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

Surg Endosc DOI 10.1007/s00464-015-4136-7

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 Poster Presentations

Ó Springer Science+Business Media New York 2015

P001 - Abdominal Cavity and Abdominal Wall


Effects of Chosen Operation Techniques on Recurrence Rates About Incisional Hernia

First Results of One General Surgical Clinic About Laparoscopic Incisional Hernia Repair: Problems

N. Ozlem

N. Ozlem

Samsun Education and Research Hospital, Samsun, Turkey


Introduction: Incisional hernia after abdominal surgery is an important problem. Objectives: We aimed to evaluate the long-term recurrence rate in patients operated with primary repair-onlay-sublay mesh repair techniques for incisional hernia. Material/Patients and Methods: We studied a serial of 75 patients retrospectively, operated due to incisional hernia in between 2003–2008 in Ankara Atatu¨rk Training and Research Hospital General Surgery Department. The patient’s age, sex, location and size of the defect, previous operation type (emergency or elective), operation findings, duration of hospitalization, early and late complications and recurrences were recorded. 14 (18,7 %) patients have primary, 24 (32 %) patients have onlay, 37 (49,3 %) patients have sublay hernia repair. There is no statistically significant difference between 3 groups in mean ages, previous operation types and weights. Results: there are recurrence 42,9 % of patients in primary repair group, 45,8 % in onlay group, 21,6 % in sublay group. There is a significant difference between onlay and sublay repair group. Surgical site infections in onlay group increases statistically significant the recurrence rate. Conclusion: Retromuscular Mesh Placement avoids contact between the mesh and abdominal viscera and has been shown in long-term studies to have a respectable recurrence rate (14 %) in large incisional hernias. Prospective analysis of onlay technique is not available, but a retrospective review has reported recurrence rates of 28 %. Our rate is 45,8 % and about two-fold higher than the literature rates. Primary repair can be done, for instance, with a direct suture technique, but recurrence rates are high. Recent literature advises the use of mesh repair. Although in our research there is no statistical significant difference between sublay and primary repair technique in recurrence rates. We have good outcomes in incisional hernia patients who have sublay hernia repair technique.

Aims: Minimal invasive surgery (MIS) for incisional hernia repair is still debated. Some studies showed LIHR is associated with less postoperative pain, comparable postop complications, low recurrence rate, safety, good long term results, lower ssi incidence, but some others reported, it is not better than open technic in term of recurrence. Method: We aim to present first 17 patient experiences on LIHR; 17 of 22 patient included. This study stopped in 22 months. Four patients are male, 13 female. Their mean age was 55.7(36–76). Mean follow-up period are 8.1 (1–22) months. Mean hernia defect size 7.5 cm (4–15), 6 patients have multiple fascial defect. Mean length of stay (LOS) 3.1 day (1–8), BMI = 33.7 (mean), range 24–48). ASA score is mean 2.05 (1–3), operative time is 160.5 ± 82 min (mean). 14 patients have comorbidities. First oral intake was mean 1.05 day. Two surgeon a performed all operations. Antibiotic prophylaxis were made routinely. Eight patients have recurrent, 9 have incisional hernia. Parietex-Composite mesh (covidien) were used. The mesh was anchored with four transfascial full-thickness sutures to the anterior abdominal wall, fixed with spiral tacks using the double-crown technique. At follow up the recurrence rate, satisfaction with the surgical results on a scale (0 = no satisfaction, 10 = very satisfied) were determined. For statistical analysis, possible associations between therapeutic, prognostic parameters, hernia recurrence were examined univariately by means of Student’s t, Fisher’s exact test. The data are reported as means with standard deviations (SDs), ranges. Results: 4 Seromas without need for intervention developed, in 2 patients postoperative ileus occured. Total complications range are 35 %. The satisfaction with the overall result of the operation was a mean value of 5.7 (0–10) in the laparoscopic group. In the interview, 60 % of the patients with LIHR would choose the laparoscopic approach for repair of their hernias again. Conclusion: The main benefits of MIS include a reduced risk of wound complications, less pain, faster recovery, a rapid return to normal activity. we did not have any wound complication. The other benefits of MIS did not assessed. LOS of our patients were longer than Bisgaard’s, shorter than Ferrarie’s. Recurrence rate of these patients were 5.8 %, Wolter et al. reported, a rate of 8.6 was. Kurmann reported, 15.9 % of recurrence rate was. Our study limitations: short term period follow-up, retrospective design, that contains the small group of patients. Satisfaction rate of our patients is not perfect; 5.7. Wolter et al.’s patients satisfaction mean level being 8.2 in LIHR. Our mean operative time was longer than Ferrari’s, Wolter’s, but shorter than Kurmann’s. It needs to design a prospective randomised study.

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Unusual Cause of Isolated Pneumomediastinum in a Laparoscopic Total Extraperitoneal Hernia Repair

Early Experience with a New Anatomical Mesh for EndoLaparoscopic Inguinal Hernia Repair

C. Lau, T.Y. Teng, Y.M. Kan

I. Wijerathne, N. Agarwal, D. Liem, D. Lomanto

Jurong Health, Singapore

National University Health System, Singapore

Introduction: Pneumomediastinum is an extremely rare complication after laparoscopic inguinal hernia repair. Few cases have been reported and almost all involve concomitant pneumoperitoneum either from the transabdominal pre-peritoneal (TAPP) approach or an inadvertent peritoneal breach during the total extraperitoneal (TEP) approach. Non-surgical etiologies include the Macklin phenomenon and difficult intubation. Our paper describe the first reported case of an isolated pneumomediastinum secondary to laparoscopic carbon dioxide gas tracking along the extraperitoneal space to the endothoracic fascia. Case Presentation and Discussion: An adult patient underwent a routine elective left TEP inguinal hernia repair. General anesthesia and extubation were uneventful. Postoperatively, he complained of left sided chest pain and desaturated a few hours later. Subcutaneous crepitus was felt along the left inguinal region extending superiorly along the left flank to the left chest. Computed Tomographic (CT) imaging of the thorax and abdomen demonstrated a pneumomediastinum contiguous with gas dissection through the extraperitoneal plane of the fascia transversalis, via the anterior gaps of the diaphragm between the sternal and costal diaphragmatic origins. No pneumothorax or pneumoperitoneum is seen. The patient was treated conservatively and discharged well on postoperative day 2. Conclusion: This case highlights extraperitoneal gas dissection as an unusual cause of pneumomediastinum in laparoscopic extraperitoneal inguinal hernia repairs. Surgeons should be cognizant of this rare occurrence and urgent CT scans are needed to aid management.

Aims: The concept of anatomical mesh is still new to the practice and the few available do not require fixation that may increase post-operative pain. Our objective was to verify the safety and feasibility of a new anatomic mesh with a unique multi-dimensional design. Methods: This is a prospective observational case series. C-Qur CentriFX mesh was used in 12 consecutive patients with inguinal hernia that underwent laparoscopic hernia repair. A standard 10.5 9 16 cm size was used in all patients. Information on patient demographics, hernia description according to EHS classification, operative findings and technique, postoperative complications including pain scores and recurrence were recorded during postoperative period at 6, 12 hours and at discharge then during follow-up visits at 1 week, 1, 3 and 6 months. Visual Analogue Scale (VAS) was used to assess the pain. Results: 20 meshes were used in 4 unilateral and 8 bilateral inguinal hernia in 12 male patients with a mean age of 61 years. According to EHS classification the size and number of defects were L1 = 8, L2 = 5, L3 = 2, M1 = 2, M2 = 7, M3 = 4, F1 = 2 and R = 2. Six patients had multiple fascial defects on at least one side. Standard 3 port totally extraperitoneal (TEP) approach was used in 10 patients while single incision trans-abdominal pre-peritoneal (TAPP) approach was used in 2 patients. Mean operative time for unilateral hernia was 49 mins (range 42–64 mins) while in bilateral hernia it was 85 mins (range 44–132 mins). 1 patient had a left scrotal hematoma and another patient presented with local peritonitis due to small-bowel perforation on post-operative day-3 and underwent emergency laparotomy for repair of perforation and mesh removal. Both patients subsequently recovered well. Post-operatively, mean VAS at 6 hours was 0.75 (range 0–3), at 12 hours 0.58 (range 0–2) and at discharge 0.17 (range 0–2). None of the patients reported pain during the follow-up visits. No recurrence was reported. Conclusion: Our early experience with the new anatomical mesh is similar and comparable to the other meshes available in the current practice, without the need for fixation. A longer follow-up may be required for further assessment of this mesh.



Complete Ileal Obstruction Due to Richter Hernia at Port Site Following Laparoscopic Cholecystectomy: A Case Report

Laparoscopic Ventral Hernia Repair: Clinical Outcome and Complications

Ch. Angkurawaranon, T. Akaraviputh, V. Chinswangwattanakul, A. Methasate, A. Trakarnsgna, J. Swangsri

I. Wijerathne, D. Liem, R. Goel, C. Wei Keat, D. Lomanto

Siriraj Hospital, Bangkok, Thailand Aims: Laparoscopic cholecystectomy (LC) is a common minimally invasive procedure. One of the recognized complications of laparoscopic surgery is port site hernia. The presence of a Richter hernia at the port site is uncommon. We report a rare case of Richter hernia at port site which occurred shortly after laparoscopic cholecystectomy. Methods: A 71-yr-old female who underwent LC was recruited. On 3rd post-operative day, she developed nausea and vomiting. The imaging studies showed distal small bowel obstruction. She underwent mini-exploratory which showed a short segment of ileal in the 12-mm trocar site. The ileal segment was reduced. Results: The procedure was successfully performed without any immediate surgical complications. Richter hernia was corrected and she was discharged one week later Conclusion: Despite Richter hernia is rare, the occurrence of ileal obstruction caused by this hernia after LC should be considered.

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National University Health System, Singapore Aims: Early reports on laparoscopic ventral hernia repair (LVHR) promised to lower both complication and recurrence rates. We aim to report our long-term experience in LVHR and to evaluate its long-term efficacy and clinical outcome. Methods: From October 2003–July 2012, clinical data of 208 patients with symptomatic ventral hernia who underwent laparoscopic mesh repair in our institution were retrospectively collected. Post-operatively followed-up at 1 week, 1 month, 6 months, 1 year and yearly intervals thereafter. Intraperitoneal onlay mesh technique was used in all cases. Four cardinal points of the mesh secured using non-absorbable sutures and positioned to overlap the edges of the defect by at-least 5 cm with the antiadhesive surface facing the bowel. The mesh was further fixed using a stapling fixation device in a double crown technique. Results: Of the 208 patients, 75 % were females (n = 156) and 25 % were males (n = 52) which included 80 primary and 128 incisional hernias. 18 patients had recurrent incisional hernia. Mean size of the defect was 6.21 cm (±4.6). The mean duration of surgery was 115.7 min (±74.3). Parietex-Composite mesh (Covidien-USA) was the mesh type used for the majority of cases followed by the GoreTex-Dual-mesh (W.L. Gore & Associates, Inc, USA). Laparoscopic repair was successful in 98.1 % of cases (n = 204). Conversions (4) were attributed to dense intra-abdominal adhesions and to bowel injury (2). Mean hospital stay was 3.19 days. VAS pain score at 24, 48 and 72 hrs was 5.5, 4.6 and 2.7 respectively. The operative complication rate was 4 % (n = 9). The recurrence rate was 4.3 % (n = 9) with a mean follow-up time of 21.5 months. Conclusion: In our experience laparoscopic ventral hernia is safe, effective and feasible compared to open approach.

Surg Endosc



Sils Repair of Nuck Canal Cyst: The First Case in Literature

Laparoscopy Cholecystectomy - About 365 Cases Managed at National Center Hospital Nouakchott - Mauritania

¨ zkurt1, I.S. Sarici2 E. O 1

Bitlis State Hospital, Bitlis, Turkey; 2Kadirli State Hospital, Osmaniye, Turkey

Introduction: Cyst of the canal of Nuck is a very rare condition especially in adults. There are only few articles about this condition and most of them are in pediatric ages. In this case report we aim to present an adult patient who was diagnosed as nuck canal cyst and operated by single incision laparoscopic technique. To our knowledge this is the first nuck canal cyst case in the literature which was operated by SILS technique. Case Report: A 36-year-old female was referred to Bitlis State Hospital general surgery department for a lump in right labia majus. She had an intermittent pain for over 20 years. She had no concomitant disease. In physical examination there was a 4 9 5 cm lump over right labia majus. The lump was becoming distended by straining. No other abnormality was detected. Ultrasonography revealed 5.2 9 4.2 9 5 cm anechoic cyst with no internal flow in doppler examination and a narrow stalk connected to abdominal cavity. Surgery was decided by the diagnosis of nuck canal cyst. The patient was operated with SILS technique via umbilicus from a 20 mm length incision. After aspiration of the cyst simple suturing to the neck of the cyst was conducted by 2/0 silk suture laparoscopically. In the first and sixth month control there was no recurrence. Discussion: Cyst of the canal of Nuck is a very rare condition especially in adults. There are only 21 articles about this issue in the literature and most of them are about pediatric patients. Although there are very few cases not more than 5 in the literature who were operated laparoscopically, our case is the first case conducted by SILS technique. Result: Nuck canal cyst is a very rare condition in adult females. It should be considered for differential diagnosis with groin hernias. Despite it can be managed by conventional laparoscopy it can also be managed by SILS technique as effective as conventional technique.

A.M. Driss1, S.A. Boukhary2, S.A. Zeydane2, A.B. Moctar2 1 Medicine Faculty, Nouakchott, Mauritania; 2National Center Hospital, Nouakchott, Mauritania

Purpose: The authors report a retrospective study of 365 cases of gallstones. The aim of this study was determine the feasibility, operative risk and patients’ benefit of laparoscopy in general surgery department of the national hospital in Nouakchott, Mauritania. Patients and Methods: Over five years 365 cases were included. Databases were statistically analyzed by SPSS and the variables studied were: age, gender, ethnicity, previous history, clinical biology, US and CT-Scan, type of intervention, mean operating time, conversion, and postoperative length of stay. Results: It is 340(93.2 %) womens and 25(6.2 %) mens, the average age was 40 years (18–80 years). The arab ethnicity is dominant 350 (95.9 %) patients. Fifteen diabetics (5.4 %) and 15 (5.4 %) HTA. Gallstones uncomplicated were observed in 230 patients (63 %), cholecystitis in 135 (37 %). Clinically the pain of RUC was the most common symptom and was isolated in 270 (74 %) cases. Biologically hyperleukocytosis was found in five (6.8 %) cases and cholestasis in 3 (10.8 %) cases. 360 patients underwent ultrasound (98.5 %), the CT-scan in 15 (4.1 %). 2 Types surgeon positions (between the legs and left the patient) were reported in the records, the trocars used were generally 4 in number (two 10 mm and two 5 mm). The Verres needle was rarely used and the technique of umbilical trocar to open was the most frequent. The conversion rate was 2.7 % (10 cases). The use sometimes a bag crafted locally. 155 patients underwent a suction drain and the mean duration of surgery was estimated at 142 mn (55–330 mn). No deaths were reported and 2.8 % morbidity rate marked by: bile leakage, hematoma, infection and hernia umbilical trocar site. The average length of hospital stay was 2 days (1–9j). Associated pathologies was dominated by goiter and urinary tract. There were five pregnancies and five nourishes. The result of pathology was found in only 165 (45.20 %) cases with 35 (21.21 %) cases of acute cholecystitis and 130 (78.78 %) of chronic cholecystitis Conclusion: Cholelithiasis is common in Mauritania, its management still requires awareness laparoscopic surgeons and patients because it is feasible in our context, but human resource and materials are limited. Keywords: Gallstones; Cholecystitis; Laparoscopy; Ultrasound.



Laparoscopic Transabdominal Inguinal Hernia Repair in Community Hospital Settings: A General Surgeon’s Last 10 Year Experience and Follow Up

Recurrences and Adhesions After Physiomesh Implantation Closer to Understanding the Mechanisms

F. Agresta, C. Tordin

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

ULSS19 Del Veneto, Adria, Rome, Italy Laparoscopic TAPP approach for Inguinal hernia repair is well documented as an excellent choice in numerous studies, especially when the surgeon is experienced. In this report we evaluate a cohort population of patients followed up in the last 10 years for a trans abdominal (TAPP) laparoscopic inguinal repair focusing on the feasibility, safety and benefits of having general surgeons perform it in Community Hospital Settings. Materials and Methods: Between January 2003 and March 2013, a total of 533 patients, at ‘Civil Hospital’ in Vittorio Veneto (TV) first and later at Civil Hospital in Adria (RO), underwent Trans- abdominal laparoscopic inguinal hernia repair. The total hernias repaired was 1000. Results: The overall mean operative time was 43.50 (±13.2). All the procedures were done on a Day Surgery basis, except three. There were no conversions to open repair or deaths in our series. We had 2 cases of small bowel occlusion and 8 relapsing hernias (0.8 %), which we preferred to treat with an anterior approach. The mean follow-up is 59.4 (±5.6; range 3120) months. No patients reported severe pain at 10 days, 3.9 % (21 cases) reported mild pain at 3 months follow up. There were no reports of night pain at 30 days. About 90 % of the patients had a return to physical-work capacity within two weeks, the remaining within 30 days maximum. All patients’ were completely satisfied at the 3-month follow up. Conclusions: The analysis of the short and long -term post-operative outcomes of our experience enabled us to conclude that in a proper setting, TAPP is feasible, effective, safe and beneficial for patients. It should be incorporated into general surgeon’s armamentarium for the management of patients with hernia disease as just as another tool to be used selectively when indicated, as long as adequate training is obtained and proper preparation observed.

M. Pawlak1, M. Smietanski1, K. Bury2 1

Aims: Long-term mesh related complications are increasingly reported as using synthetic meshes has become the gold standard for almost every abdominal wall defect. In this study we would like to share our experiences with the use of Physiomesh in the IPOM operation and to draw attention to the particularly important complication appearing in the observed group of patients. Using our theoretical models we also try to explain the mechanism behind it. Material and Methods: In last 3 years almost 100 Physiomesh implants were used for IPOM repair in our department. 72 were included into the database and monitored in the postoperative period. Recurrences and other symptoms requiring hospital readmission were noted and analysed. Reasons and mechanisms of recurrence, time and place of its occurrence and intraabdominal adhesion formation on the mesh were described. Results: In the minimum 6-months follow-up 4 patients were readmitted to the hospital due to recurrence and one due to subileus like symptoms. All the patients were reoperated. In all cases dense adhesions were found on the majority of the mesh surface. In all cases recurrence were present in the long axe of the mesh in the line of PDS stripe built into the mesh. Tackers were still presented in the abdominal wall fascia, showing the rupture mechanism of connection failure. Recurrences occured after 6 months, at the time point when stiff PDS stripe underwent degradation. Conclusions: Stiffness of the mesh in PDS axe could be an independent factor causing recurrences. Special attention must be paid when fixing the mesh in this line. The phenomenon of adhesions is not explicable in the light of our study, still must be a topic of further investigation.

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New Technique of Endoscopic Surgical Treatment of Postoperative Intercostal, Lumbar Hernias and Neuromuscular Defects

Evaluation of Laparoscopic Ventral and Incisional Hernia Repair with ePTFE Mesh in Japanese Patients

N.L. Matveev, A.I. Ukhanov Moscow State University of Medicine and Dentistry, Moscow, Russia

A. Tsuruta, T. Hirai, M. Nakamura Kawasaki Medical School, Okayama, Japan

Incisional intercostal hernias are rare pathology. Impairment of diaphragm, intercostal muscles and nerves, and possibility of colon or liver incorporation into hernia sac turn open surgery of such hernias into hard and traumatic intervention, because of difficulty of creation of retromuscular bed for adequate sized mesh. Laparoscopic or retroperitoneoscopic access is not effective in such situations, as a part of hernia orifice is above the level of diaphragm. They are also ineffective in cases of large incisional lumbar hernias and neuromuscular defects, which have much higher prevalence. We developed an endoscopic intermuscular plasty of such defects, in which the dissection is done in artificial cavity, created between external and internal oblique muscle. The limits of the bed for a mesh are: external edge of rectus muscle medially; iliac crest caudally; right external oblique muscle insertion site on VIIIth rib cranially, with an exit to insertion sites of serratus anterior and latissimus dorsi; and junction of internal oblique, transverse and latissimus dorsi tendons in lateral/dorsal direction. Hernia contents is dissected free and reduced into abdominal cavity. Hernia orifice is closed by V-LOCTM 180 2-0 continuous suture. In the bed, the polypropylene mesh of corresponding size is fixed by ProtackTM spirals, according to \ double crown [ technique. In case of neuromuscular defect without hernia, the mesh is stretched in longitudinal direction by the threads, passed through the skin near iliac crest and lower ribs. The operation is technically simple; composite mesh is not needed. Dimensions of abdominal cavity do not limit the extent of a bed for a mesh. The only structures, which could be damaged during dissection, are the lateral skin branches of segmental nerves. However, wide overlapping of innervation zones and presence of anterior skin branches preserve skin sensitivity. Contact with abdominal contents is minimal. Endoscopic approach allows to avoid the problems with SSI. Good blood supply of muscles surrounding mesh, and reduction of hernia sac lower probability of seroma formation. The technique described was used in six patients. Mean operation time was 110 min. At follow-up averaged 11 months (4–20 months), no complications and relapses were found.

Introduction: Primary ventral hernias include umbilical, epigastric, and spigelian hernias and make up approximately 5–6 % of all abdominal wall hernias. Incisional hernias are a common complication of abdominal surgery, occurring in as many as 20 % of laparotomy cases. We performed a retrospective study to determine the middle-term recurrence and complication rates following laparoscopic ventral and incisional hernia repair (LVHR) with DualMeshÒ, an expanded polytetrafluoroethylene (ePTFE) mesh in Japanese patients. Methods: We compared open mesh repair of ventral and incisional hernias (OR) and LVHR. We also analyzed the shrinkage rate of ePTFE mesh. We included 45 patients (21 OR, 24 LVHR) who underwent mesh repair for primary ventral and incisional hernias between January 2008 and December 2012. In LVHR, after introducing the trockers we performed adhesiolysis and confirmed the type of hernia (shape, size, defect number). We then placed ePTFE mesh intraperitoneally, pursuing a 3 cm overlap, which was prepared with eight-point sutures using 1 nylon on the mesh circumference. The mesh was initially fixed with transfascial sutures and then fixed to the abdominal wall with tackers at 1 cm intervals circumferentially. All patients were followed up for at least 6 months. We evaluated the rate of recurrence as well as post-operative and middle-term complications. Additionally, 13 patients in Group L were followed with post-operative abdominal computed tomography (CT) imaging. Threedimensional images were reconstructed for calculation of the transverse length of the implanted ePTFE mesh. The ePTFE mesh area was calculated by integrating each individual transverse length obtained on CT imaging, and the calculated area was compared with the original mesh size in order to study the shrinkage rate. Patients’ characteristics did not significantly differ between the two groups. Results: Mean operating time (min) was 152.7 for OR and 143.1 for LVHR (p = 0.25). Postoperative hospital stay (days) was 13.4 for OR and 6.8 for LVHR (p = 0.01). Postoperative complication rate was 28.6 % for OR and 12.5 % for LVHR (p = 0.03). In LVHR, the mean ePTFE mesh shrinkage rate was 10.6 %. Conclusions: LVHR has advantages compared with OR, and the post-insertion shrinkage rate of ePTFE mesh was permissible.



Role of Laparoscopy in Evaluation and Management of Lower Abdominal Pain

Management of Abdominal Paraganglioma: A Prognostic Score for Laparoscopic Approach

K.A. Talpur, A.M. Malik, A.K. Sangrasi, J.N. Qureshi, A.A. Laghari, B.S. Syed

C. Bergamini, A. Sturiale, G. Alemanno, R. Somigli, C. Santi, A. Bruscino, P. Prosperi, A. Valeri

Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan

General Emergency and Minimal Invasive Surgery Unit, Firenze, Italy

Objectives: The purpose of study was to evaluate and manage the different surgical lower abdominal pathologies which are usually difficult to diagnose and treat by routine clinical workup. Methods: The study was conducted at Liaquat University of Medical and Health Sciences Jamshoro and private hospitals of Hyderabad Pakistan. 106 patients with symptoms of lower abdominal pathology were included in study from July 2010 to June 2013. Results: 106 patients either with prior clinical diagnosis or without preoperative diagnosis were submitted for laparoscopic evaluation and assessment of pathology and proper treatment accordingly. Patients mainly presented either with pain in right iliac fossa (41.51 %), pain around umbilicus (23.58 %) or pain in lower abdomen (30.18 %) as main presenting complains. Laparoscopy revealed simple appendicitis (27.35 %), complicated appendicitis (20.75 %), different varieties of abdominal tuberculosis (26.41 %), and gynecological diseases (14.15 %) as main pathologies. Conclusion: Laparoscopy is of great help to evaluate and manage the different lower abdominal surgical conditions which are usually difficult to diagnose on clinical evaluation. It also prevent majority of cases from formal laparotomy procedures.

Paragangliomas are rare neural crest-derived tumors that can arise both from sympathoadrenal and parasympathetic paraganglia. The latter are often located beneath the cervical ganglia, whereas the former are usually intra-abdominally distributed. Their clinical presentation is quite variable, ranging from asymptomatic cases (incidentaloma) to catecholamine hypersecretion or compressive syndromes. The gold standard treatment of abdominal paraganglioma is the complete surgical excision. The feasibility of laparoscopy has been evaluated by many interesting papers. However, the mini-invasive excision of paraganglioma is far from being validated, principally due to the high rate of conversions and the low level of evidence of studies available. In order to avoid such conversions as far as possible, we aim at ameliorating the criteria for a laparoscopic eligibility. Thus, we prospectively apply to our series of patients an arbitrary quantitative clinical-radiological score system which includes the main clinical-pathological predictive factor for laparoscopic failure. The values of such score, in fifteen patients who underwent laparoscopic resection of abdominal paragangliomas, were compared to the outcome parameters such as blood loss, operating time and conversion. The conversion rate was of 6.7 %. The worst results were obtained for each single parameter when the score was of [4. All converted patients reported a score value of[6. We, therefore, maintain that this score system may be an efficient tool to predict the outcome of the laparoscopic approach and to ameliorate the selection of eligible patients in order to avoid surgical conversions. The main bias of the study is due to the small number of patients. Consequently, we maintain that further prospective-randomized studies are needed.

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Can Multidisciplinary Support Increase Laparoscopic Outcome of Pancreatic Surgery, Also in Low-Medium Volume Centers?

Urinary Bladder in Recurrent Hernia After TAPP Procedure: Report of 2 Cases

C. Bergamini, G. Alemanno, A. Sturiale, R. Somigli, C. Santi, A. Bruscino, P. Prosperi, A. Valeri

G. Augustin, P. Matosevic

General Emergency and Minimal Invasive Surgery Unit, Firenze, Italy Aims: Some surgical procedures are related with a statistically better outcome in high volume Centers. This concept has been particularly highlighted in pancreatic surgery, whereby a strong relation between hospital, surgeon-related working volume and results has been found. Our hospital, can be considered a high volume Center for pancreatic surgery with more than 30 procedures a year but each of its 5 surgical units taken alone has a lowmedium volume activity, performing from 1 to 8 laparoscopic left pancreatic procedures a year. The aim of the study is to evaluate the results of laparoscopic left pancreatectomy (LLP) in a low-medium volume unit supported by a multidisciplinary approach and a major high volume hospital. Methods: A research in the departmental database was carried out to point patients who underwent LLP. From January 2004 to December 2012, 12 LLP were performed in our unit. Surgical technique: 4 patients underwent LLP spleen-preserving, meanwhile 8 patients underwent laparoscopic spleno pancreatectomy (LSP). All patients were transferred to a surgical intensive care unit for 24 to 48 hours after surgery. Results: Mean operative time was 127 min +- 21 min, mean hospital stay was 8 days +4 days. No perioperative mortality rate. Four patients had early pancreatic fistula, treated with medical therapy, 3 patients had late peri-pancreatic abscess treated with trans-abdominal percutaneous drainage, One patient had hematemesis, due to gastric erosion, which was treated in emergency setting with endoscopic operative procedures. Finally 1 patient had pancreatitis, and was admitted in Intensive Care Unit for one day, without necessity of oral intubation. Histological analyses showed 4 cystic mucinous tumor and 8 pancreatic ductal adenocarcinomas. Conclusion: It has been suggested that after 10 LLP carried out by the same surgeon there was a significant decrease in blood loss and length of hospital stay. Despite there is no widely accepted definition of the number of LLP necessary to define a high, medium or low volume center, according to our experience, good results in such type of surgery can be obtained also in low-medium volume units if a multidisciplinary support is guaranteed by a major high volume hospital.

University Hospital Center Zagreb, Croatia Aims: Report of 2 cases of urinary bladder hernia in recurrent hernia after TAPP procedure and review of the literature Methods: Authors analyzed 150 consecutive cases (2010–2012) after TAPP procedure (indications for the operation were bilateral or recurrent hernias) during follow-up of 12 months. The patients were evaluated clinically every 3 months regularly or if the patients came due to symptoms. All patients with atypical symptoms were evaluated with abdomina ultrasound and CT scan. Results: Three patients had recurrent hernia (2 %). Two patients that present with symptoms and signs of recurrent groin hernia had also urinary symptoms. Both patients had difficulties during voiding when the hernia bulged and were without urinary symptoms when ‘the bulge was absent’. Conclusion: Three of 150 patients developed recurrent hernias after TAPP procedure. Two of three patients had urinary bladder in the hernia sac. Authors present cases and discuss the possible incidence and mechanisms of this condition



TAPP Using Needlescopic Instruments for Inguinal Hernia in Adults

Incisional Hernia After Laparoscopic Colorectal Surgery is There Any Factor Associated?

A. Urakami, K. Shigemitsu, M. Takaoka, J. Hayashi, Y. Naomoto

E.E. Sadava, J. Kerman Cabo, M.A. Galvań, E.G. Grzona, A.G. Canelas, M.E. Bun, N.A. Rotholtz

Kawasaki Medical School, Okayama, Japan Introduction: Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is associated with a decrease in postoperative pain, shortened hospital stay, and decrease in chronic pain. Moreover, laparoscopic surgery performed with needlescopic instruments (less than 3 mm in diameter) has more advantages than conventional laparoscopic surgery. However, there are few reports of TAPP for inguinal hernia repair using small caliber instruments. This report reviews our experiences with TAPP using needlescopic instruments in 20 patients from April 2012 to Dec 2013. Methods: We performed TAPP as the method of choice in 95 % of all patients presenting with inguinal hernia. To perform the TAPP, 2-mm instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 2-mm trocars. After reduction of the hernia sac and dissection of the preperitoneal space, we placed polyester mesh (Parietex folding mesh) with staple (Absorbatack) fixation. The peritoneum was closed with 3-0 Polysorb in continuous sutures. Results: The mean operative time was 78 min for unilateral hernias. There was no conversion to open repair. Three patients (15 %) used postoperative analgesics. Regarding intraoperative complications, we observed no bowel injuries or major vessel injuries. Postoperative complications occurred in 1 patient (5 %), who had a retained seroma. There was no incidence of chronic pain or mesh infection. Conclusions: TAPP using needlescopic instruments was a safe and useful technique for inguinal hernia repair. Large prospective, randomized controlled trials will be required to establish the benefit of needlescopic instruments

Hospital Alemań, Capital federal, Argentina Aims: Laparoscopic approach may reduce the incidence of incisional hernia. However, there is scarce data concerning laparoscopic colorectal surgery. We aimed to evaluate related factors and incidence of incisional hernia following this approach. Methods: A retrospective analysis of consecutive patients who underwent laparoscopic colorectal surgery in a single center was performed. Patients with a minimum follow up of 6 months, and also converted to open surgery were included. Uni- and multi-variate analysis were performed using the following variables: age, gender, type of surgery (left, right, total or segmental colectomy), associated diseases (diabetes and chronic pulmonary obstructive disease), previous surgery, operative time and body mass index (BMI). Right (middle line incision) and left (left lower quadrant incision) colectomy were also compared. Results: Over a 12 year period 1051 colorectal surgeries were performed. The incidence of incisional hernia was 6 % (n = 63). Mean follow up was 54 months. Univariate analysis showed that BMI [ 30 kg/m2 (p: 0.004, OR: 2.5 [1.3–4.7]), operative time [ 180 minutes (p \ 0.005, OR: 2.1 [1.2–3.6]) and conversion to open surgery (p: 0.01, OR: 2.4 [1.1–5.0]) were related to incisional hernias. Only BMI had a statistically significant relation with the incidence of ventral hernia in multivariate analysis (p: 0.008). No statistical difference between right and left colectomy was observed (5.7 % vs. 5.0 %). Conclusions: The incidence of incisional hernia after laparoscopic colorectal surgery seems to be acceptable. BMI over 30 Kg/m2 is strongly associated to this complication.

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Totally Endoscopic Approach in Ventral Hernias. The Role of Subcutańeous Access

Minimal Invasive Totally Endoscopic Surgery in Rectus Diastasis with Umbilical Hernia Associated

J. Bellido1, J. Gomez Menchero1, A. Bellido Luque2, J. Suarez Grau1, J. Garcıá Moreno1, I. Duran Ferreras1, J. Guadalajara Jurado1

J. Bellido, J. Garcıá Moreno, J. Suarez Grau, J. Gomez Menchero, I. Duran Ferreras, J. Guadalajara Jurado

Riotinto Hospital, Minas de Riotinto, Huelva, Spain, 2Quiroń Sagrado Corazoń Hospital, Seville, Spain

Riotinto Hospital, Minas de Riotinto, Huelva, Spain

1

Introduction: Laparoscopic ventral hernias repair has been proved to be an excellent access to minimize postoperative complications. Subcutańeous access to ventral hernia repair is a new way to solve it. We present the experience of single institution. Materials and Methods: The aims were to assess prospectively the feasibility of totally endoscopic approach in ventral hernia, identifying the advantages and drawbacks. Cohort Prospective study. Between January to May 2012 Patients older than 18 with primary and incisional ventral hernias are included in the study. Ventral hernias size more than 5 cms and incarcerated hernias are excluded. 15 patients fulfill the inclusion criteria. 6 umbilical hernias, 4 umbilical incisional hernias, 2 Spieguel hernias and 3 subumbilical incisional hernias. In primary and incisional umbilical-subumbilical hernias, suprapubic access is used. One 10 mm trocar and two 5 mm trocars are placed in suprapubic position. the pneumoperitoneum is created using 8 mm Hg. The supraaponeurotic space is opened using cautery to free the adhesions of the fatty tissue. Once the hernia sac is reached, it’s reintroduced to intraabdominal cavity, and the preperitoneal space is opened to place the mesh on it. In Spieguel hernias, three trocars are placed in subcutańeous positions in the same flank of the hernia. Composite mesh is used in all cases (VentralexTM hernia patch Bard Ò). The clinical follow-up was 1-7-30-180-360 days. An ultrasound at 1° postoperative month is used to identified radiological seromas o recurrences. Postoperative complications and recurrence rate are evaluated. Results: Seroma was the most frequent complications. It was identified in 4 patients (26 %). All seromas were classified Type 1, lasting less than 1 month. No surgical site infection or recurrences are seen during the follow-up (8 months). Mean postoperative pain at 1° day was 4 (3–5), at 30 day was 1 (0–2). No chronic pain is identified. Aesthetics results at 6° postoperative month using a VAS for scar: 8 (7–9). Conclusions: Using totally endoscopic approach by subcutaneous access, the main disadvantages of laparoscopic surgery can be avoided. This new access provides good results in terms of pain, recurrence rate and aesthetics results.

There are many patients who have an umbilical hernia and Rectus diastasis simultaneous. If only the hernia is corrected, we will repair the hernia on a anatomically weak tissue, so the rate of hernia recurrence may increase. Therefore, it would be suitable to correct both conditions at once. We propose minimally invasive access using a subcutaneous approach. We present a 45 years old with umbilical hernia 4 cm size and diastasis recti (subxiphoid 3 cm, 4 cm supraumbilical and 4 cm subumbilical size) 3 trocars in suprapubic position are placed. Supraaponeurotic space is created until the umbilical region. Hernia sac is then released and is reintroduced into the abdominal cavity. After that, the preperitoneal space is created and subcutaneous dissection continues until the subxiphoid region. A composite mesh is used and placed in preperitoneal position secured by two points at the edge of the defect. Complication is achieved using nonabsorbable suture endostich V -loc n ° 0. Subsequently the navel is fixed to the fascia and suction drain is placed. The postoperative time course without complications. The drain is removed at 4° day. After 6 months the patients is completely satisfied with the results. No hernia o diastasis rectus recurrence is seen at first year follow-up. Conclusion: Totally endoscopic approach by subcutaneous access is a good way to solve both umbilical hernia and rectus diastasis without complications. This minimal invasive access provides high aesthetics results.



Novel Concept of Approach to Parastomal Hernia Repair - Hyper Technique (Hybrid Parastomal Endoscopic Re-Do)

Implementation of the Novel Trans-Abdominal Partial ExtraPeritoneal (TAPE) Technique in Laparoscopic Lumbar Hernia Repair

K. Bury1, M. Szczepkowski2, P. Pawel2, M. Maciej3 Medical University of Gdansk, Poland, 2Bielanski Hospital, Warsaw, Poland, 3Ceynowa Hospital, Wejherowo, Poland

J. Sun, X. Chen, J.W. Li, Y. Zhang, F. Dong, M.H. Zheng

Background: Parastomal hernia ia a specific type of incisional hernia related to the presence of any type of enterostomy. It is a common complication, rate reported by various authors varies from 3 to 39 % for colostomies and 9 to 22 % for ileostomies. There are few surgical treatment options - relocation of the stoma or repair using or not using prothetic material via laparoscopic or open approach. The quality of evidence for the various surgical techniques for parastomal hernia repair is low and precludes firm conclusions. Patient and Methods: A prospective single center and single surgeon study was assess to evaluate new technique for parastomal hernia repair. Six consecutive patients were operated using new HYPER procedure. A combined technique using using all advantages of laparoscopic and classical approach. The HYPER procedure is based on four steps: 1. laparoscopic adhesiolysis 2. Open stage consists of release of stoma from stomal canal, dissection and excision of the hernia sac, the placement of the mesh in the peritoneal cavity and narrowing hernial gap by sutures. 3. Coming back to laparoscopic approach for proper mesh placement and fixation. 4. Final neo-stoma formation. According to EHS Classification 4 patients had type III and 2 had type IV of parastomal hernia. All six patients had colostomy. Mean follow-up time was 3 months. The mean operating time was 145 min. The mean stoma size diameter was 4,58 cm. The mean size of the DynaMesh IPST mesh was 446 cm. The mean hospital stay was 6.5 days. Surgical complication occured in one case: small haematoma with no need for reintervention. No other medical complications or hernia recurrence occured during follow up time. Conclusion: HYPER procedure for treatment of parastomal hernias proposed by authors is safe and feasible surgical technique with high patient satisfaction rate and low number of complications in early postoperative course. The hybrid procedure seems to be a promising method for parastomal hernia repair and needs further studies.

Background: To investigate the feasibility of the novel trans-abdominal partial extraperitoneal (TAPE) technique in lumbar hernia repair. Method: The TAPE technique was applied to 13 patients with lumbar hernia from May 2009 until September 2013. The surgical technique was described in details and follow-ups were performed for further evaluation. Results: The mean age of the 13 patients was 68 ± 8 years, with the average BMI 25.5 ± 1.1 kg/m2. The etiology study showed that 12 cases after surgical operations and 1 case after trauma. The average size of the hernia defect was 86.8 ± 46.4 cm2, while the mean size of the mesh implanted was 275 ± 61.2 cm2. The mean operative time was 59.2 ± 8.2 min. There was no intra-operative visceral injury in this serial of cases. There was no conversion case and all patients accepted the TAPE technique successfully. The VAS was 3.8 ± 1.9 and 2.2 ± 1.6 on POD1 and POD3, respectively. The mean postoperative hospital stay was 4.0 ± 1.3 (3–7) days. The median follow-up time was 21 months. All patients returned to unrestricted movement within two weeks after surgery. During the follow-ups, no complication as bulge, seroma, hematoma, wound infection, abscess in surgical area and chronic pain, nor recurrence was observed. Conclusion: According to the experience of this series of investigations, we found the TAPE a feasible and easy-to-learn technique in the treatment of lumbar hernia.

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Ruijin Hospital, Shanghai, China

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Learning Points from Descending Colon Perforation from Optical Port Placement and Laparoscopic Repair of Colonic Perforation

Successful Incorporation of a Biological Mesh in a Complex Abdominal Wall Repair: A Case Report

C.H. Tan1, J. Rao2

L. Swafe, A. Sudlow, V. Velchuru

1

2

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

Indication for Surgery: Incisional hernia repair Diagnostic Study: CT abdomen and pelvis Position: Supine Trocar Placement: Left abdominal wall, LHC, LIF Summary: A 60-year-old lady underwent laparoscopic repair of incisional hernia. During the first port insertion with an optical port, the descending colon was inadvertently perforated through and through. It was noticed that there was persistent bleeding from port site away from the surgical field. With a high index of suspicion, an epigastric port was placed to visualise entry site of the first port. Colon perforation of the descending colon was discovered with minimal soilage. Perforation was repaired with interrupted sutures in 2 layers reinforced with epiplocae over repair site. The incisional hernia defect was closed with sutures; no mesh was placed in view of bowel spillage. Results: The patient was discharged well on post-operative day 5. There was no postoperative complication. Conclusion: Perforation of intraperitoneal organs during optical port placement is a known complication. Visualisation of the port entry site is essential if suspicion arises. Additional ports may be placed to visualize initial entry into the abdomen. Colonic perforation can be repaired laparoscopically safely by an experienced laparoscopic surgeon. Intraperitoneal mesh should not be placed in such circumstances. Learning Points: There needs to be a high index of suspicion should bleeding occurs in other sites other than the surgical site. Additional ports can be inserted to visualise site of bleeding properly. Placement of the initial optical trocar should not be placed too laterally, risk of injury to bowel. LHC within rectus muscle can be a safe place, with the different layers of abdominal wall easily identified. In the event of contamination, intraperitoneal mesh should not be placed in a hernia operation. Suture repair should be considered. Laparoscopic colonic perforation repair can be performed safely by an experienced laparoscopic surgeon

James Paget University Hospital, Great Yarmouth, United Kingdom Introduction: Abdominal wall dehiscence and laparotomy wounds cause significant patient morbidity and financial burden to the NHS. Techniques including component separation have been employed to optimally manage the issue. Aims: The aim of the case report is to present a positive outcome following the use of noncross-linked porcine acellular dermal matrix to repair and reinforce a large complex abdominal wall defect in an obese woman. Methods: A 70-year-old obese (BMI-38) woman presented with a three day history of colicky abdominal pain and distension with decreased stoma output. Previously, had a Hartmann’s procedure for perforated diverticular disease followed by laparotomy for adhesions. She was a diabetic and on steroids for rheumatoid arthritis. Examination revealed gross abdominal distension with no peritonitis. CT showed multiple ventral hernias, complex parastomal hernia with small bowel obstruction. Laparotomy and adhesiolysis was undertaken, abdominal wall approximation and component separation was not possible (due to loss of domain and weakness), hence an onlay composite mesh was placed. On day 14, a complete wound dehiscence with wound infection required a re-laparotomy, a large 25 9 25 cm biological mesh was used as an interposition material to bridge the defect. Results: The wound required further superficial debridements. Patient recovered well and at follow up (8 months), there was good granulation tissue on the mesh (no hernia) with a skin wound defect of 5 9 4 cms. Conclusion: We conclude that porcine acellular dermal matrices can be used to successfully bridge large defects in complex abdominal wall reconstructions. Neovascularization and cellular regeneration can occur, despite the large defect.



Clinical Outcomes of Laparoscopic Inguinal Hernia Repair (TAPP), Focused on Choice of Mesh in Size

Transanal Reverse Proctectomy with Laparoscopic Assistance for Rectal Carcinoma - Short-Term Results

N. Higashino

A.O. Rasulov, Z.Z. Mamedli, V.M. Kulushev, S.S. Gordeyev, D.V. Kuzmichev, H.E. Djumabaev

Takatsuki General Hospital, Takatsuki, Japan As a big advantage of laparoscopic hernia surgery (TAPP), the possibility of the detailed diagnosis into the trap based on the observation out of the abdominal cavity is mentioned. For example, the duplication hernia pathological change (Japanese hernia society hernia classification IV type) to be diagnosed by the trap and the hernia on the opposite side corresponds this. Furthermore, in addition to a hernial orifice, the situation of the abdominal wall can serve as a leading view which suggests the possibility of a recurrence. Experience is required to master diagnoses with vision of ? weakness of the Hesselbach’s triangle or lateral triangle in an outside inguinal hernia. And a mesh will be chosen based on this accompanying diagnosis. In our department, the mesh is chosen in general on the basis of a hernia classification. In the hernia classification I-1 or II-2 (hernial orifice less than 3 cm in diameter), the comparatively small mesh (the major axis of about 11 cm) according to the size of the orifice is chosen. A comparatively big mesh (the major axis of about 15 cm) will be chosen in order to cover the portion, when the above weakness is accepted. Although TAPP was performed to 426 case 538 lesions from April, 2009 to September, 2013, 166 lesions of indirect hernia with orifice less than 3 cm and 54 lesions od direct hernia with orifice less than 3 cm were included. In 58 pathological changes (34.9 %) and 29 pathological changes (53.7 %), respectively, the comparatively big mesh is used among these, the high incidence of weakness of the Hesselbach’s triangle or lateral triangle is convinced.

N.N. Blokhin Cancer Research Center, Moscow, Russia Aims: to investigate the feasibility and oncological adequacy of reverse transanal mesorectal excision (TME) using transanal endoscopic microsurgery or transanal port with laparoscopic assistance. Methods: 2 Males and 6 females with rectal carcinoma (cT2-4N0-2Mo) located in 3–10 cm from anal verge were operated with reverse TME technique. Mean age was 50 yrs (30–66), BMI 22,7 (20,7–38,6). In 7 cases rectal dissection ‘bottom-to-up’ was carried out with 4-cm in diameter rigid rectoscope; in 1 patient - with SILS-port. After full-thickness circumferential rectal resection with purse-string occlusion rectoscope or SILS-port has been inserted and TME was performed using a ‘bottom-up’ approach till entering abdominal cavity. High ligation of inferior mesenteric artery and splenic flexure mobilization was carried out laparoscopically. Specimen was removed transanally. For the first four cases laparoscopic assistance was following completion of transanal mobilization of the rectum and it took about mean 6,5 hrs (5,4–7,2). In subsequent 4 cases both approaches had been started simultaneously by 2 teams so that the procedure in whole lasted mean 4,7 hrs (4,5–5,0). Protective ileostomy, successfully closed after 2 month, was created in all cases Results: Operation time markedly decreased if transanal and laparoscopic approaches were carried out simultaneously. In one obese patient with BMI - 38,6 operation was converted to ‘open’ surgery after completion of transanal TME due to technical difficulty. Blood loss was minimal (30 ml - except converted one). Coloanal anastomoses were handsewn in case of ISR (2 out of 8) with J-pouch, 3 ‘side-to-end’ coloplasty (1 with a circular stapler and 2 handsewn) and 3 ‘straight’ (2 stapler and 1 handsewn (converted). Distal margin (in average - 2,0 cm (0,5–5,0)) was negative in all cases. In one case urinary retention occurred postoperatively,. Patients were discharged on mean 7-th (range, 6–8) postop day. Conclusion: Reverse TME is feasible and meets the oncologic requirements and may become an alternative method to open and laparoscopic TME in the future, especially in cases of morbid obesity or narrow ‘male’ pelvis. Further investigations are needed to confirm the effectiveness of method.

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Video Presentation on Combined Laparoscopic and Thoracoscopic Repair of Diaphragmatic Hernia

Obturator Hernia; The Laparoscopic Approach

A.M. Oo1, D.B. Aneez1, A.N. Koura1, C.H. Tan2 2

1

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

R. Moldovanu1, N. Vlad2 1

Hospital Les Bonnettes, Arras, France; University of Medicine and Pharmacy Iasi, Arras, France; 2University of Medicine and Pharmacy Iasi, Romania

Aims: We present a video of a patient who successfully underwent a combined laparoscopic and thoracoscopic repair of diaphragmatic hernia. Methods: Transabdominal or transthoracic open repair of diaphragmatic hernia results in the large wound which in turn results in the morbidity. The laparoscopic and thoracoscopic repair of diaphragmatic hernia is safe and the recovery is faster. Results: A 51-year-old Chinese male with 4 9 5 cm left diaphragmatic Bochdalek’s hernia containing omental fat underwent for combined laparoscopic, thoracoscopic mesh repair in Tan Tock Seng Hospital. The patient was placed in semi right lateral position (45 degree), 2 9 10 by 12 mm ports and 2 9 5 mm ports were inserted. Hernia contents together with sac was reduced laparoscopically and hernia defect closed primarily with ethibond 2/0 stitches. Left thoracoscopic ports x 3 were inserted and paritene mesh was fashioned and anchored to the diaphragm using secure strap. Gortex mesh was then fashioned into 10 9 7 cm and anchored to the diaphragm using ethibond sutures laparoscopically. Chest drain was put into the thoracic cavity. Patient recovered well and discharged on 3rd post-op day. Conclusion: Combined laparoscopic and thoracoscopic mesh repair of the diaphragmatic hernia is technically challenging but safe and feasible.

Background: Obturator hernia (OH) is a relatively rare disease and its diagnosis is always challenging. In asymptomatic patients the diagnosis is frequently overlooked; the laparoscopic approach for the treatment of groin hernia allows however the diagnosis and repair. Aims: To evaluate the transabdominal pre-peritoneal (TAPP) procedure for the diagnosis and treatment of obturator hernia. Material and Methods: A prospective review of 300 patients who underwent TAPP procedure for groin hernia was conducted. Results: The men/women ratio was 256/44. The mean age was 55.29 ± 15.83 years old (17 to 92; median: 57). The mean BMI was 25.44 ± 3.83 kg/m2 (16 to 36.83; median: 25). The hernia was unilateral in 69.3 % (n = 208) and bilateral in 30.7 % (n = 92). In 53.26 % the contralateral hernia was occult and diagnosed during the procedure. The incidence of OH was 17 % (n = 51): type I, 92.15 % (n = 47), type II, 5.88 % (n = 3) and type III 1.96 % (n = 1). There is found that OH is associated with female gender (P = 0.001; OR: 2.42, 95 %CI: 1.45–4.09), bilateral groin hernia (P = 0.034; OR: 1.71; 95 %CI: 1.04–2.82), femoral hernia (P = 0.0001; OR: 4.31; 95 %CI: 2.14–8.63) and age over 60 (63.04 ± 13.59 vs 53.70 ± 15.82; P = 0.0001). The operation time was 46.17 ± 22.98 minutes (20 to 180; median: 45). The procedure was performed ambulatory in 58 % (n = 174). The overall postoperative morbidity rate was 5.3 % (n = 16): seroma in 4 % (n = 12) and hematoma in 1.3 % (n = 4). The recurrence rate was 1 % (n = 3). Conclusions: OH is more common than previously and classically reported. TAPP procedure is an effective technique to diagnose and treat OH.



Minimally Invasive Surgery of Calculous Cholecystitis

A Case of De Garengeot Hernia

1

2

1

A.I. Shevela , V.V. Anischenko , S.V. Gmyza

1 Institute of Chemical Biology and Fundamental Medicine, Siberian Branch of RAS, Novosibirsk, Russia; 2Novosibirsk State Medical University, Novosibirsk, Russia

The purpose of our study was to evaluate the results of surgical treatment of chronic calculous cholecystitis with different modern approaches. We carried out a comparative analysis of the results of surgical treatment in 146 cases of calculous cholecystitis. All patients in the study were women. Among these patients transluminal (transvaginal) access was used in 25 cases, a single-port access in 36 cases and a standard laparoscopic approach in 85 cases. Were investigated perioperative period and immediate postoperative period (duration of surgery, intraoperative complications, the using of additional trocars, conversion to standard laparoscopic or traditional ‘open’ cholecystectomy) and the period of 12 months after surgery. We evaluated patient satisfaction by curing process and treatment results, quality and adequacy of anesthesia, cosmetic outcome, quality of life, disability periods. In the early postoperative period in patients undergoing cholecystectomy performed by different approaches, there are differences concerning the intensity of pain, flow of funds for analgesia, length of stay in the recovery room, duration of hospital treatment. Long-term results of surgical treatment of patients after cholecystectomy performed by different approaches are similar and are characterized by the absence of complications. In assessing the quality of life in the long term the best results were obtained after the use of technology NOTES. Transluminal and single-port laparoscopic cholecystectomy should be used in patients with chronic cholecystitis in remission without evidence of choledocholithiasis. If the patient has large gallstones or has a hernia in the umbilical region, you can choose a single-port access. Arguments in favor of transluminal surgery are female gender, chronic lesions of the anterior abdominal wall (psoriasis, shingles, chronic dermatitis, etc.) and the patient’s wish to achieve the best possible cosmetic result after surgery. To ensure safety of technology, the single-port and three-port of laparoscopic approaches, we recommend that you use in conjunction with ultrasonic dissection.

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F. Shahzad1, P.D. Cruz2, S. Hussain2, M. Walsh2, M. Aremu2, A. Siddiqi2 Portlaoise Midland Regional Hospital, Portlaoise, Ireland; 2Midland Regional Hospital, Portlaoise, Ireland

1

Introduction: Croissant de Garengeot’s hernia is a rare condition and occurs mostly in females. The presence of an appendix in a femoral hernia is uncommon, and the presence of appendicitis is even more infrequent. The presence of appendix in femoral hernias as an incidental finding occurs in about 0.9 %, and the incidence of appendicitis is 0.08 %– 0.13 %. Case Report: A forty nine year old woman presented in the emergency department with an acutely painful lump in her right groin; Examination revealed a non-reducible, tender right femoral hernia with redness of the overlying skin. Laboratory blood investigations including white cell count and C - reactive protein were normal. Plain Film of the Abdomen was normal. Intra-operative findings were a femoral hernia sac containing an acutely inflamed appendix. The patient had appendicectomy and repair of the femoral hernia via the infrainguinal incision. Histology confirmed acute inflammation of the appendix and patient made an uneventful recovery and was discharged home on the third postoperative day. Conclusion: De Garengeot hernia is a rare condition, hence the frequent misdiagnosis. It should be considered in patients with signs of strangulated femoral hernia.

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Jejunal Perforation Following a Gaelic Football Game

Endoscopic Cholangiopancreatography and Bowel Obstruction: Rare Association Due to Lengthy Air Insufflation in a Patient with Prior Abdominal Adhesions

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2

2

F. Shahzad , P.D. Cruz , M. Aremu , A. Siddiqi

2

1

Portlaoise Midland Regional Hospital, Portlaoise, Ireland; 2Midland Regional Hospital, Portlaoise, Ireland Introduction: Small bowel injuries are uncommon following blunt abdominal trauma with overall reported rate of occurrence of small bowel injury after blunt abdominal injury as 0.7 %. Case Report: A 15 year old boy presented in the emergency department with lower abdominal after been kicked by the knee of an opponent player during a Gaelic football game. Initial evaluation revealed minimal epigastric and lower abdominal tenderness which became generalized with rebound tenderness 16 hours later. CT abdomen showed free intraabdominal air and fluid. Laparotomy revealed 6 cm perforation in the antimesenteric border of the proximal jejunum, one foot from the duodeno-jejunal junction. Resection of the involved segment of jejunum with end to end anastomosis was performed. Conclusion: Traumatic jejunal rupture is rare in sport games, but should always be considered in a player with blunt abdominal injury

M. Rodriguez Lopez1, J.I. Blanco1, M. Gonzalo1, R. Velasco1, S. Mambrilla1, M. Bailon1, R. Martinez1, F. Labarga2, E. Asensio1, A. Said1, J.C. Sarmentero1, B. Perez-Saborido1, M.A. Montenegro3 1

Rio Hortega University Hospital, Valladolid, Spain; 2Complejo Asistencial de Palencia, Palencia, Spain; 3Hospital Comarcal de Medina del Campo, Valladolid, Spain Background: Procedure time during endoscopic retrograde cholangiopancreatography (ERCP) might be lengthy requiring large volume of air insufflation. Room air is conventionally used for this purpose, though potential disadvantages are described because of its non-absorbable condition, leading to temporary abdominal distension and pain. More severe complications are exceptional. We report an unusual case of complete small bowel obstruction, secondary to prolonged air insufflation during ERCP. Clinical case: 60 year-old man admitted for right upper quadrant abdominal pain, fever and jaundice. Ultrasonography revealed a widely dilated common bile duct and choledocholithiasis. His medical history included appendicectomy ten years ago. ERCP was performed, including sphincterotomy and lithiasis removal, what lasted 65 minutes with ambient air insufflation. After this procedure, the patient presented persistent abdominal colicky pain and tenderness. Plain X-ray demonstrated gastric and small bowel loops massively dilated. Conservative management was useless and laparoscopic surgery was decided, revealing dense adhesions located at both lower quadrants of the cavity as well as diffuse distension of small bowel. Enterolysis was completed without conversion. Postoperative period was uneventfully and the patient was discharged on the third day. Conclusion: Prolonged insufflation with ambient air during ERCP usually leads to mild and self-limited abdominal discomfort. The progressively introduction of carbon dioxide for this procedure will potentially avoid this rare complication.



Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair Under Epidural Anesthesia

Prosthetic Hernia Repair: Long and Short Time Complications

F. Varcus, C. Tarta, M. Papurica, A. Coman, F. Lazar County Hospital Timisoara, Romania Introduction: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair has proved efficacy, can be learned with proper training, and causes less postoperative pain, better cosmesis, and earlier return to work. The one major factor preventing the widespread acceptance of TEP is the requirement for general anesthesia (GA). In our study we assessed the use of epidural anesthesia in TEP. Material and Methods: Twenty-four male patients, all with unilateral hernia defect, underwent operation. Hernia size was small, reducible; ASA risk class was I and II. Median age was 52 years, 32–62 years. One 10 mm trocar was inserted near the umbilicus, 2 others 5 mm trocars between umbilicus and pubic bone. At the beginning of the operations the operatory space was achieved with dissection using the finger and the camera, without a balloon. Results: All 24 cases were started with epidural anesthesia, 4 of which (16,67 %) were converted to GA; the other 20 (83,33 %) were completed under epidural anesthesia. All cases were successfully completed laparoscopically and there were no conversions in classical procedures. There were no intraoperative incidents. There was no significant difference between the cases conducted under epidural anesthesia (69.6 ± 29 min), and those converted to GA (64.3 ± 17.3 min). The conversions to GA was done because of the accidentally pneumoperitoneum (with subsequent shoulder-tip pain), which require the mechanical ventilation for the management of hypercapnea. No straining was noticed. One patient needed further local peri-umbilical anesthesia. Conclusion: TEP under spinal anesthesia is feasible and save. In our experience pneumoperitoneum with hypercapnea was the only factor who interplay leads to conversion to GA. A strong surgical-anesthesiology collaboration is mandatory to obtain good results.

I.V. Komarchuk Kharkiv Medical Academy of Postgraduate Education, Kharkov, Ukraine Background: Application of synthetic materials for treatment of ventral hernias and wide selection of hernia repair techniques have been a prerequisite for development of specific complications. This study was focused on complications of the prosthetic hernia repair (PHR) performed by different materials and methods. Methods: We reviewed prospectively collected data for all patients who were treated for PHR complications from Jan 2007 to Dec 2013 at our hospital. PHR was performed routinely in various surgical hospitals in Ukraine and worldwide. The patients were divided into two groups: Group 1 - patients who had complications efficiently treated by conservative methods, Group 2 - patients who had complications treated surgically. Results: The total number of patients was 68, average age 49 years, 40 women and 28 men. The complications developed after 2 months to 10 years after PHR. Group 1 comprised 21 patients (position of mesh: onlay - 12; sublay - 6; IPOM - 3): 10(47.7 %) cases of seroma, 8(38 %) - infiltration of hernia repair zone, 3(14.3 %) - eruption of transfascial suture. Therapeutic treatment of complications was effective in 20 (95.2 %) patients. In one case (4.8 %), a giant seroma required puncture aspiration of fluid. Group 2 comprised 47 patients (position of mesh: onlay - 30; sublay - 10; IPOM - 7): 20(42.6 %) - for cutaneous fistula, 3(6.4 %) - for enteric fistula, 15(32 %) - for the anterior abdominal wall phlegmon, 4(8.5 %) - for mesh migration, 5(10.6 %) - for acute intestinal obstruction. Partial removal of the mesh was performed in 40(85.1 %) cases, total removal - in 7(14.9 %), resection of portion of the small intestine was performed in 6(12.8 %) patients. There was 1(4.8 %) case of recurrence for the 6 years of follow-up in group 1 and 23(48.9 %) cases - in group 2. Conclusions: Application of modern techniques for hernia repair does not exclude the possibility of postoperative complications, which related from the materials and methods used.

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Adhesiolysis During Laparoscopic Cholecystectomy in Patients with Previously Operated Abdominal Organs

Pharmacological Management of the Postoperative Adhesions Prevention

R.V. Bondarev, A.A. Orekhov, A.L. Chibisov, V.V. Lesnoy

V.Ye. Vansovich, D.V. Novikov

State Medical University, Lugansk, Ukraine

National Medical University, Odessa, Ukraine

Aims: To determine the volume of laparoscopic adhesiolysis (LA) during laparoscopic cholecystectomy (LCE) in patients previously operated on the abdominal organs (POPAO). Methods: The analysis of the results of treatment of 61 patients who underwent LCE, LA done between organs adhesions formed after the earlier surgeries on POPAO. Men - 8 women - 53. Age from 38 to 72 years. LCE in chronic calculus cholecystitis - n = 50, in acute cholecystitis - n = 11. Adhesions (SP) I-II degree - n = 29, third degree - n = 23, IV degree - n = 9. Introducing the first trocar point determined according abdominal sonography, or administered by the method of the trocar Hassan. When the aircraft were separated adhesions dissector and clips, colliotomy performed with scissors and bipolar coagulation. Results: LA was performed only in the limited area where LCE performed, to create access to the gallbladder. In remote areas of the surgical site LA was not performed. Complications during and after surgery were observed. Conversion was in 2 patients with grade IV POPAO. The reason for conversion: a massive joint venture in the abdominal cavity (n = 1), after LA, LCE abundant diffuse bleeding from the gallbladder bed in the liver (n = 1). Conclusions: LCE in patients with SP after previous surgeries on POPAO is appropriate and does not depend on the extent of the joint venture. LA held before LCE reduces traumatic surgery to reduce the risk of recurrence of adhesions and thereby improve the quality of patients life.

Aims: Surgical interventions spectrum increasing appears to introduce the new problem for the surgeons working in different fields of medicine - postoperational intraabdominal adhesions (IAA) formation. The aim of the work is the experimental background of NOinhibitors complex administration for the IAA treatment. Methods: Experimental trials were performed using male Wistar rats weighting from 250 till 300 g. Experimental adhesions (EA) were modeled after rats’ peritoneum trauma. Lipoic acid and pentoxifylline alone and combined i.p. administrations started 30 min after EA inducing and lasted throughout 5 days, once per day. Blood plasma proteolytic activity (cathepsins D, L and B, trypsin, metallic-proteinase, carboxypeptidase A and B concentrations) were determined 1, 2, 3, 6, 12, 24, 36 hrs, 2 and 5 days after EA modeling. Results: Bothlipoic acid and pentoxifylline alone and combined i.p. daily administration resulted in significant influence on proteolytic enzymes activity in conditions of EA formation. The data obtained are in favour of combined lipoic acid and pentoxifylline antiadhesive activity which significantly prevailed over the same in case of these compounds single usage. The following raw of the used peptides efficacy in conditions of the used EA model one could see: lipoic acid + pentoxifylline [ lipoic acid [ pentoxifylline. Peptides’ maximal antiadhesive efficacy was registered on the 6 hrs interval after EA inducing. Conclusions: Thus, the data obtained showed principal possibility for IAA treatment using the compounds with NO-suppressing mechanism of action. Additionally to perspectives of clinical introduction it shows the fundamental result explaining the NO-mediating pathophysiological mechanism of adhesions. Finally, our data served as the experimental background for lipoic acid and pentoxifylline combined administration antiadhesive activity clinical testing.



Single Port Laparoscopy in a Hostile World

A Novel Sticking Method of Hyaluronic Acid/ Carboxymethylcellulose Membrane (Seprafilm) in Laparoscopic Surgery

A. Ronan, F. Narouz, D.K. Hill Beaumont Hospital, Dublin, Ireland Background: Single port laparoscopy (SPL) is most often portrayed as a rarified technique which may provide marginal cosmetic benefit over conventional multiport laparoscopy. With experience, we have found it increasingly useful as a means of initiating access by mini-laparotomy (which is then sealed for laparoscopy) in a hostile abdomen or indeed circumstance and especially when there is a significant likelihood of laparotomy being the most appropriate operative modality. Methods: Over the past 36 months, we used this approach in situations where laparoscopy may be of potential valuable but it was unclear whether it would be prudent or even possible. In each case, a site on the abdominal wall was selected for open access via a 3–5 centimeter incision. After such fascial incision, a decision was made to either proceed straight to laparotomy or to progress with a speculative attempt at laparoscopy depending on the condition of peritoneal cavity. In the latter situation, the wound was captured for laparoscopy with a ‘Surgical Glove Port’. Results: Twenty one patients (seven males, median age 60.5 years) with a hostile abdomen or circumstance had their surgery initiated by this procedure. Ten had small bowel obstruction (four of whom were due to adhesions) while six had recurrent Crohn’s disease (4 with prior laparotomy). Two patients right colonic volvulus and two had acute mesenteric ischaemia with frank intestinal gangrene while one patient had recurrent gallstone pancreatitis having had five previous laparotomies (including for adhesiolysis). Interestingly two patients were found to have tumors causing luminal obstruction with preoperative clinical and radiology findings indicating adhesional obstruction in one case and superior mesenteric artery embolus with ischaemia in the other. Overall, fourteen operations (67 %) were completed laparoscopically while seven were converted direct to laparotomy with therapeutic intent. In no case was an enterotomy formed or undue delay or expense incurred during initial access. Conclusion: We now view single port-type access as preferential to the off-midline blindstab incision often advocated for patients with prior laparotomy or indeed redo open Hassan access at a scarred umbilicus.

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D. Lee, S. Tsuchida, S. Shirakawa, M. Awazu, Y. Ueda, Y. Harada, T. Wakahara, H. Ashitani, Y. Hasegawa, A. Toyokawa Yodogawa Christian Hospital, Osaka, Japan Aims: Despite laparoscopic surgery is thought to form less postoperative adhesion compared with laparotomy, the procedure may cause adhesive ileus and result in prolonged hospital stay, or occasionally reoperation. Since around 2000, several studies have reported the laparoscopic sticking method of Hyaluronic acid/carboxymethylcellulose membrane (Seprafilm) into the body cavity for adhesion prevention. However, these were not simple and technically difficult to stick on intended site. We report a novel sticking method of Seprafilm in a simple way. Methods: We powderized Seprafilm by sterilized electric mill and mortar and dissolve it in saline in liquid form and sprayed the liquefied Seprafilm on intended site via laparoscopic trocars. We used this technique for adhesion prevention in a 69-year-old male case. He suffered from rectal cancer and underwent laparoscopic low anterior resection. We also resected the nodule located in liver segment 3 suspicious for metastasis at the same time. Before removal of trocars, we sprayed the liquefied Seprafilm into the right subphrenic space and Morrison’s pouch in consideration of the reoperation for liver recurrence. Results: It was easy to liquefy Seprafilm and spray on intended site via laparoscopic trocar. The case developed no complication associated with adhesion such as ileus for two years postoperatively. Conclusion: Our method may provide an easy and fine way to stick Seprafilm on intended site, and allow adhesion prevention with shorter operative time.

Surg Endosc



Radical Laparoscopic Operations in Oncology: Our Experience

Laparoscopic Surgical Treatment of Chilaiditi Syndrome on Continuous Ambulatory Peritoneal Dialysis

S.V. Baydo, A.B. Vinnytska, A.V. Zhygulin, D.A. Golub, S.I. Pryndyuk, V.J. Palitsa, O.A. Dmitrenko

K. Shinmura

Zina Memorial Lissod Cancer Hospital, Kiev, Ukraine

Showa University Fujigaoka Hospital, Yokohama, Japan

Aims: The use of laparoscopic access in cancer surgery is constantly increasing. It became a standard for some procedures: laparoscopic hysterectomy, colon resection, laparoscopic gastrectomy for early cancer in Japan. We want to report our experience in performing radical oncologic operations laparoscopically. Methods: In this study we analysed 1196 consecutive laparoscopic operations performed in our oncologic clinic. There were 550 (46 %) radical surgeries for various cancers among them: colorectal resections - 173, gastrectomy with D2- lymphadenectomy - 48, esophagectomy - 5; anatomical resection of liver - 3. There were 225 operations for gynaecological malignancies, including 72 radical hysterectomy (Piver III–IV) with pelvic and paraaortal lymphadenectomy. For urologic cancer we performed 87 interventions: radical nephrectomy - 54, partial nephrectomy - 28, prostatectomy - 5. We have experience of 9 pelvic exenteration with the formation of uretero-ileoconduit for recurrent and complicated pelvic tumors. Simultaneous operations (cholecystectomy, hernioplasty) were performed in 81 patients (14.7 %). Results: The number of removed lymph nodes, as an indicator of radicalism, was: after pelvic lymphadenectomy for gynecologic cancer - 19.6, after colorectal resections - 18.4, after gastrectomy - 17.8. The average duration of the operation was: simple hysterectomy with pelvic lymph node dissection - 122 minutes, Wertheim-operation - 204.3, total gastrectomy - 284, anterior resection of rectum - 167. Complications after surgery occurred in 133 patients (11.1 %). Severe complications (grade III–IV (Dindo, 2004)), i.e. life-threatening (stroke, myocardial infarction) and requiring reoperation (anastomotic leakage, intestinal obstruction) were in 45 (3.7 %). The complication rate depends on the complexity and duration of the intervention: the lowest rate - 8.7 % was after gynecological operations, the highest - after gastrectomy - 24.3 %. Conversion performed in 5 patients (0.4 %). Postoperative mortality was 0.5 % (6 patients died). Conclusions: With a number of advantages for both the patient (less abdominal wall trauma, pain, blood loss, early recovery) and surgeon (excellent visualization) laparoscopic oncosurgery improves immediate postoperative results (complications, mortality, length of stay) compared with open without compromising oncological principles. The undoubted advantage of minimally invasive technologies is the ability to perform simultaneous operations in different parts of the abdominal cavity without increasing access trauma.

A case is 56 years old Japanese female complaining abdominal pain with vomiting after meal. She underwent hysterectomy due to hysteromyoma three years ago. She has also suffered from IgA nephropathy and introduced Continuous Ambulatory Peritoneal Dialysis (CAPD) due to IgA nephropathy two years ago. Chilaiditi syndrome was diagnosed by X-p and computer tomography (CT). CT and plain X-p revealed small bowel in the hepatodiaphragmatic space, so she was diagnosed Chilaiditi syndrome. At first conservative treatment was conducted. Her abdominal symptom was improved. However, abdominal pain after meal has been repeated after one month. Finally we decided surgical treatment, but she hoped continuation of CAPD and minimally invasive surgical procedure. Thus, we selected laparoscopic surgery. Intra-abdominal findings showed that restiform structures were observed between liver and abdominal wall, and those structures involved bowel adhesion and incarceration that could be caused of repeated abdominal pain. Adhesion of small bowel and restiform structures were treated under laparoscopic guidance and postoperative course was uneventful. Chilaiditi syndrome is a rare form of abdominal symptom caused by the interposition of the colon or small bowel into the hepato-diaphragmatic space. Chilaiditi syndrome involving the small bowel is prone to cause abdominal pain with strangulation of the intestine, therefore careful follow-up that took an operation into consideration is necessary. It is worth considering laparoscopic surgery in the case of operating Chilaiditi syndrome without dilatation of intestine.



Impact of Previous Abdominal Surgery on Surgical Outcome of Transabdominal Preperitoneal Hernia Repair

Recycling the Selfexpandable Mesh in the Laparoscopic Repair of Small Ventral Hernias: A Series of 33 Consecutive Patients

Y. Ushimaru, Y. Kato, T. Kimura, N. Matsuoka, H. Suzuki, Y. Kakimoto, A. Toyoda, M. Inoue, Y. Endo, O. Murakami

Sint Jan Hospital Bruges, Bruges, Belgium

Yao Tokushukai General Hospital, Yao City, Osaka, Japan Background: The feasibility of transabdominal preperitoneal inguinal hernia repair (TAPP) in patients with previous abdominal surgery has not been established. The author conducted this retrospective study to evaluate the safety and feasibility of TAPP in patients with previous abdominal surgery. Method: All 411 consecutive patients undergoing TAPP between April 2010 and June 2013 were included in this study. All patients were divided into three groups. The NPS (no prior surgery) group is absent of previous abdominal surgery (n = 275). The UAS (upper abdominal surgery) group includes patients with previous upper abdominal surgery (n = 24). The LAS (lower abdominal surgery) group contains patients with previous lower abdominal surgery regardless of upper abdominal surgery (n = 112). Considering the operation data, the above 3 groups are further divided into two groups: hemilateral and bilateral hernia. Results: In patient characteristics, age and sex are significantly different between the 3 groups in hemilateral hernia group and BMI in bilateral group by multivariate analysis. Operation time (NPS-UH: 88.1 vs UAS-UH: 91.7 vs LAS-UH: 88.3 (min), NPS-BH: 123.2 vs UAS-BH: 127.8 vs LAS-BH: 142.4 (min)), Length of hospital stay (NPS-UH: 4.0 vs UAS-UH: 3.9 vs LAS-UH: 4.3 (days), NPS-BH: 4.3 vs UAS-BH: 4.0 vs LAS-BH: 4.1 (days)), did not show significant differences. Conversion to femoral repair was observed in 2 cases in the LAS group, but did not reach significant differences. Adhesion were observed in 17 patients (NPS group; 6.2 %), 15 patients (UAS group; 62.5 %), 72 patients (LAS group; 64.2 %), and adhesiolysis were required in 8 patients (NPS group; 2.9 %), 4 patients (UAS group; 16.7 %), 53 patients (LAS group; 47.3 %), respectively, which showed significantly differences between 3 groups. No differences were observed between the three groups in terms of analgesic use, postoperative complications and recurrences. Conclusions: Feasibility and safety of TAPP in patients with previous abdominal surgery has been demonstrated in this study. TAPP hernia repair in patients with previous abdominal surgery regardless of surgical site may become a standard alternative.

S. van Cauwenberge, E. Reynvoet, T. Feryn, B. Dillemans

Introduction: Nowadays the use of a mesh is mandatory, in all types of hernia. To avoid wide tissue dissection for small defects, selfexpandable patches for intraperitoneal placement were launched on the market. However, recent reports describe failure of this technique as this implies blind placement and good deployment cannot be controlled. We present an adapted approach, placing these patches laparoscopically. Methods: This is a retrospective review of all patients in which the selfexpandable mesh was used to repair small ventral hernia. It concerns a polypropylene mesh with an ePTFE layer and a polyethylene terephthalate (PET) polymer ring as memory system. In our series the patch was placed by laparoscopy over the fascial defect and fixed with resorbable tacks. A standardized technique was performed in all cases. Results: A total of 33 patients was treated confirm this technique from July 2011 to December 2013. Fifteen were incisional hernias and 18 were primary ventral hernias; 14 umbilical and 4 epigastric. There were no conversions. The mean operative time was 58.04 (+/- 29.5) minutes, in five cases the procedure was followed by an abdominoplasty. Mean hospital stay was 2.6 (+/-0.99) days. Postoperative follow-up was complete for 27 patients (82 %) with a mean follow-up of 15.4 months. Early postoperative complications consist of 5 seromas, all resolved spontaneously. Wound infection rate was zero. Seven patients described pain during the first six weeks, which resolved spontaneously in all patients except in one. At long-term, no recurrences were seen. Mean VAS (visual analogue scale) is 1.18/10 at long-term. Four patients (15 %) describe discomfort while bending with foreign body sensation and a VAS score of = 4. Discussion: Laparoscopic placement of selfexpandable patches guarantees excellent visualization and correct mesh deployment. This approach should be considered as a valid alternative for the open technique in small ventral hernia repair.

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Reduced Port Laparoscopic Surgery for Inguinal Hernia: TEP with Single Incision

A Novel Technique of Single Incision Endoscopic Totally Extraperitoneal Hernia Surgery Under Local Anesthesia

T. Nagahama1, M. Kitamura2, H. Ganno1, H. Amagasa1, H. Kamikoduru1, M. Ando1, K. Arai1

N. Wada, T. Furukawa, Y. Kitagawa

Toshima Hospital, Tokyo, Japan; 2Kitamura Family Clinic, Sagamihara, Japan

Keio University School of Medicine, Tokyo, Japan

1

Introduction: Single incision laparoscopic surgery for inguinal hernia is not so popular than cholecystectomy since TAPP procedures need suture or ligation that is technically difficult due to restriction of forceps handling. Since suture and ligation is not necessary for TEP, TEP may be suitable procedure for single incision hernia repair. Purpose: We will evaluate and report our initial series of TEP with single incision. Methods: Procedure was carried out through 2 cm long skin incision made at umbilicus. Trocar was inserted into retro muscular space through silicon rubber lid (EZ access Hakko corporation Japan) fitted to wound retractor. Dissection of pre-peritoneal space was done by Laparoscopic coagulating scissors. After reduction of hernia and isolation of vas deference, polyester mesh and absorbable tacker were used to cover inguinal wall. Results: From March 2012 94 patients received TEP with single incision. 38 patients had bilateral hernia (bilateral direct 14, bilateral indirect 13, direct and indirect 11) and rest 56 patients had unilateral hernia (direct 14, indirect 42). Duration of procedures for unilateral lesion ranges from 30 min to 108 min (average 55 min). Those for bilateral lesion ranges from 25 min to 168 min. (average 83 min) All patient could discharge within 2 days after surgery without any adverse event except 11 cases of seroma. Average duration of initial 20 procedures was 55 min for unilateral lesion and 102 min for bilateral lesion. But for the most recent 20 procedures average duration was improved to 47 min for unilateral lesion and 60 min for bilateral lesion. Those results were similar to the result for open hernioplasty carried out during same period. (Unilateral 46 min bilateral 80 min) Discussion: Our result of TEP with single incision demonstrated acceptable result. At the initial phase limitation of coaxial handling more affected treatment for indirect hernia. But it could be overcome as we have experienced procedures. Conclusion: Our result demonstrated that TEP hernia repair with single incision was feasible procedure.

Introduction: Laparoscopic hernia repair is considered to be minimally invasive. Pneumoperitoneum, however, usually requires muscle relaxation and general anesthesia. We have developed a novel technique for single-incision endoscopic totally extraperitoneal (TEP) hernia surgery which is feasible even under local anesthesia. This procedure does not require the use of dissecting balloon or tacks for mesh fixation. Methods: From January 2012 to September 2013, a consecutive group of 53 patients with bilateral inguinal hernia was included. We used 0.5 % lidocaine with epinephrine (1:100,000) as a local anesthetic. An incision of 30 mm in the lower abdomen was made and a wound protector with sealing silicon cap was placed. Three 5 mm trocars were inserted through the cap. A 5 mm flexible laparoscope was employed. A flat self-fixating mesh with resorbable microgrip was installed and spread over the entire myopectineal orifice of Fruchaud with enough overlap. Results: The age (mean ± SD) was 66 ± 11 and male sex was 93 %. The operating time was 174 ± 40 min. Total lidocaine dose was 125 ± 52 mg. All patients were awake but sedated with intermittent intravenous pethidine (54 ± 18 mg) and flunitrazepam (0.4 ± 0.3 mg). Surgical complications were not observed except for 15 cases (28.3 %) of minor seromas. Pneumoperitoneum due to peritoneal tear was occurred in 4 cases (7.5 %) and managed with laparoscopic suturing devices. During median follow-up of 11 months, we observed no hernia recurrence. Conclusions: Short term outcomes were similar to those of conventional TEP or open hernia repair. Surgical invasiveness would have been reduced because the area of preperitoneal dissection is smaller in this procedure than in the umbilical approach. Postoperative recovery was rapid and patients can walk soon after surgery. This novel procedure may be a promising strategy to reduce the invasiveness of hernia repair.



Role of Laparoscopy in the Management of Diaphragmatic Hernias

Laparoscopic Surgery of Renal Cysts with an Ultrasonic Scalpel

M. Parı´s, S. Blanco, E. Raga, A. Sańchez, A. Munõz, M. Hernańdez, J. Sańchez, A. Criado, F. Sabench, D. del Castillo University Hospital of Sant Joan. Rovira i Virgili University, Reus, Spain Aims: Traumatic diaphragmatic hernias are rare, and most of them are as a result of a blunt trauma. Diagnosis is often difficult because symptoms are nonspecific, whether abdominal or respiratory, and often they are unobserved during the acute phase of injury. It is a disease with high morbidity and mortality, and there have been described several surgical approaches for its repair. The use of laparoscopy is still debated, especially in acute trauma, but may be indicated in its chronic form. Methods: We report the case of a young man (35 years old), that after a motorcycle accident, suffered multiple trauma with multiple rib fractures, lumbar and abdominal contusion and hemothorax without evidence of acute abdomen. A CT scan described the mentioned injuries and a small subhepatic collection. Results: The patient was treated with a chest tube and, after a good evolution, was discharged without symptoms. Within 8 months, he began with symptoms such difficult and painful digestions. A new thoracoabdominal CT scan and a barium swallow study were performed; both showed a large diaphragmatic hernia with a great portion of stomach inside. Given the clinical situation and the patient’s hemodynamic stability, it was decided to repair the defect laparoscopically, reducing herniation containing 70 % of the stomach, omentum and upper splenic pole. A ParieteneÒ mesh, fixed with absorbable tackers, was placed and reinforced with fibrin sealant. In addition, a pleural drain was introduced to treat pneumothorax occurred during surgery. Postoperatively, the patient recovered without complications. In postoperative controls, the patient remains asymptomatic. Conclusions: Traumatic diaphragmatic hernias can be very serious, either in the acute phase, or in complications such as intestinal strangulation. Early detection is essential for immediate treatment. The value of laparoscopy in these cases grows if the surgical team is expert in laparoscopy, but its role in acute diaphragmatic hernias is far from being the standard for their added risks due to pneumoperitoneum. However, those patients who have a long-standing hernia and who are hemodynamically stable are ideal candidates to undergo endoscopic treatment. In this case, laparoscopy has allowed satisfactorily the reduction of the content of the hernia.

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K. Khamidov, M.P. Magomedov, G.P. Gazimagomedov, M.A. Magomedov DGMA, Makhachkala, Russia Aims: The aim of this work is to improve the results of minimally invasive treatment of patients with simple kidney cysts. Materials and Methods: 48 Patients with symptomatic simple renal cysts were operated on using the laparoscopically, 20 patients of them were operated on with an ultrasonic scalpel, 4 patients of them with ultrasound-guided puncture and sclerotherapy. There were 32 women and 20 men. The age of patients ranged from 14 to 72. In all cases there were single cysts which 27 patients had in the right kidney, and 25 patients had in the left kidney. The size of cysts ranged from 6 to 18 cm. The diagnosis was confirmed by the ultrasound and computer-aided tomography. The average duration of laparoscopic surgery was 30 min. There were not any transitions to the traditional laparotomy. The patients were activated on the second day after the operation, the drain was removed on the second or third day after the operation. Malignant transformation was not detected in any histological studies. The simple renal cyst occurs predominantly in middle-aged and older. Ultrasonography allow to set the correct diagnosis overwhelmingly and to determine the indications for surgical treatment. Results: Our experience of laparoscopic surgery in the treatment of renal cysts allows us to consider minimal invasiveness, accountability and efficiency as the main advantages of this technique. Maximum resection of the cyst wall is easily performed during operations on kidney cysts, the remaining edges are coagulated all along to prevent bleeding, and an ultrasonic scalpel significantly reduces blood loss and duration of surgery. Our experience has confirmed not only the safety of the operation, but the clinical benefit in the late postoperative period. All patients after checkup had no recurrence of the cyst, and there was the improvement of renal function and blood pressure stabilization. These objective data combined with the disappearance of subjective symptoms noted before the surgery. Conclusion: Laparoscopic excision of simple renal cysts with an ultrasonic scalpel is an effective, safe and promising treatment of renal cysts.

Surg Endosc



Laparoscopic Inguinal Hernia Repair: The Inexpensive Way

Indication of Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernia in Adult

M.N. Latakgomo, M.Z. Koto Dr George Mukhari Hospital, Pretoria, South Africa Introduction: Laparoscopic repair is increasingly becoming popular method of addressing groin hernia problem. It allows widest coverage of myopectineal orifice, resulting in lowest recurrence rate in experienced hands. Associated with less operative pain; best and quick patient recovery; early return to work and normal activities. Aims: To present our cost-effective laparoscopic approach Methods: Inclusion: Patients presenting with diagnosis of inguinal hernia, Informed consent. Exclusion: Hernia with complications ie strangulations, Incarceration, peritonitis; contraindication to general anaesthesia. We used re-useable instruments with no commercial balloon to create space. Total extraperitoneal approach using a 3D mesh, fixed using a protractor. Data was prospectively collected using standard forms that were completed at end of surgery. Patients followed up at clinic after discharge; 2 weeks; 1 month; then on demand; to be recalled at 1 year. Determination of secondary outcome: Complications, conversion to another procedure. Organization: Surgery was performed by/in the presence of consultant surgeon. Results: Data from January 2009 to date. 137 Patients (130 Males, 7 Females). 129 Patients underwent Total Extraperitoneal Approach (TEP). 8 Patients were converted to Transabdominal Preperitoneal Approach (TAPP) due to technical difficulties Hernia type: (Direct n = 58, Indirect n = 79). Position: (Left n = 56; Right n = 66; Bilateral n = 15). Recurrent: 12 TAPP conversions: 2 early recurrences due to mesh migration/poor placement. 6 Patients had torn peritoneum with large air leaks. Recurrences: 2 early recurrences detected before discharge (following day). Patients underwent TAPP repair and recovered uneventfully. Mesh operative time: 90 minutes. Average hospital stay: 1,5 days. Complication: Penile/Scrotal haematoma: 6(8 %): managed conservatively. Seroma: 11(16 %): aspirated and resolved. Bowel injury: 1(1,5 %): Mortality (Post operation MI): 1(1,5 %) 2 WEEKS: No recurrence. 1 Month: No recurrence Conclusion: Laparoscopic repair is a safe procedure in good, well trained hands. TEP has lowest recurrence rate and least associated with complications. TEP highly feasible using low cost instrumentation

H. Yamamoto Okayama Medical Center, Okayama, Japan Introduction: In recent year, laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia in children appears to be safe, effective and reliable and may also reduce the incidence of metachronous contralateral hernia. But the indication of LPEC for inguinal hernia in adult case is still contravertial. So we investigated the age and the type of inguinal hernias in our hospital to decide the indication of LPEC in adult. Method: From April, 2004 to November, 2013, 2491 inguinal hernias were operated in our hospital. And we investigated all hernias with distribution about age and sex. ?In adult cases (15 years old or older), we compared type of hernia and onset age with all 67 woman cases and 120 most recent male cases. Result: 1,587 male and 904 female were operated. The case under 14 years old: 957 boys and 833 girls. The male distribution graph shows two peaks (0–4 y and 75–79 y) but, as for the female, only one peak (0–4 y). ? In 67 women cases, 8 internal inguinal hernia and 59 external inguinal hernia were observed. The youngest age of the internal inguinal hernia was 59 years old. On the other hand, in the most recent 120 men cases, 35 internal inguinal hernias and 93 external inguinal hernias were observed. The youngest age of the internal inguinal hernia was 26 years old. In the male case, increasing the ratio of the internal inguinal hernia is the main cause of two peaks characteristics. Conclusion: Male case, there are two peaks of onset age, it result not only from patent processus vaginalis but also weakness of the hernia floor. But in women case shows only one peak that means the reason of women’s inguinal hernia is more likely for patent processus vaginalis. So LPEC method may indicate for younger female external inguinal hernia.



Laparoscopic Hernia Repair for Recurrent Inguinal Hernia

Laparoscopic Transabdominal Preperitoneal (TAPP) Hernia Repair Via Minimal Parietal Wounds (2 mm, 5 mm, 2 mm)

A.U. Umezawa, T. Watanabe, Y. Seki, K. Hashimoto, K. Kasama, Y. Negishi, Y. Kurokawa

A. Kamei, E. Kanehira, T. Tanida, M. Nakagi, A. Hieshima

Yotsuya Medical Cube, Tokyo, Japan

Medical Topia Soka, Soka, Saitama, Japan

Aims: To determine the effectiveness and complications of the laparoscopic technique in the treatment of recurrent inguinal hernia. Methods: The medical records of 20 patients (22 hernia sides) who underwent laparoscopic hernia repair for recurrent inguinal hernia were reviewed. Results: Of 20 patients, 19 were male and one was female with a mean age of 57 years. They had previously received open Kugel mesh repair (Kugel) in 7 patients, mesh plug repair (MP) in 5 patients and other method (uncertain) in 8 patients. Of 7 Kugel patients, 4 were migration and 3 were dislocation of the mesh. Of 22 sides of recurrent hernia, 9 sides were direct, 11 were indirect, one was femoral and one was combined hernia. Nineteen patients were received laparoscopic transabdominal preperitoneal hernia repair (TAPP) and another who was the case of recurrence of pediatric inguinal hernia was received laparoscopic totally extraperitoneally preperitoneal hernia repair. Mean operation time was 107 min (range, 49–191 min) for unilateral hernia and 198 min (190–218 min) for bilateral hernia. There were no intraoperative complications and no morbidity. There was one conversion TAPP to open MP, because of the old mesh. Conclusions: The advantage of laparoscopic hernia repair is accuracy of diagnosis. Technical failures in the previous repairs were the main factors contributing to recurrence, especially in Kugel. The dislocated old mesh which protruded into the abdominal cavity complicates surgical manipulation. In MP cases and migrated mesh cases, the old mesh or plug remained on the abdominal wall will facilitate operative procedure. For recurrent inguinal hernia, TAPP is the best way to easily access to the hernia site and superior to manage peritoneal defects. Laparoscopic hernia repair appears to be safe and effective in the treatment of recurrent inguinal hernia.

We developed a new operative method for laparoscopic transabdominal preperitoneal (TAPP) hernia repair, performed via two 2 mm punctures and a 5 mm port (TAPP-252). The operative technique and the initial clinical outcomes of TAPP-252 are herein reported. We have performed TAPP-252 in 10 adult female patients. To facilitate TAPP-252 5 different kinds of newly developed needle instruments with a diameter of 2 mm were used; a rigid laparoscope, a grasping forceps, an electrocautery, a needle driver, and a scissors. The 2 mm laparoscope played an important role to utilize the 5 mm port, which enabled insertion of such as an ultrasonically activate device, a tacker, a mesh, gauze, and a sewing needle. The average operation time was 49 minutes. The perioperative morbidity was nil. The cosmetic results seemed excellent in all patients. TAPP-252 was safely performed with minimal destruction of the abdominal wall. A further investigation should be necessary to assess the patient selection or long-term outcomes.

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The Umbilicus - A True ‘Natural Orifice’

‘Mes-Star’ Manunet II - European Research Project: Biological Characterization of Composite Mesh and Correlation to Anisotropy as Reference Study

M. Asakuma, K. Komeda, Y. Inoue, T. Shimizu, F. Hirokawa, Y. Miyamoto, M. Hayashi, K. Memura, Y. Otsuki, K. Uchiyama Osaka Medical College, Takatsuki City Osaka, Japan Aims: A recent development in minimally invasive surgery (MIS) is single port surgery, where a single large multi-port trocar is placed in the umbilicus. We have done 428 cases of single port surgery via the umbilicus since Jun 2009. All medical schools require that students complete an anatomy course as part of the medical curriculum. However, there is limited instruction regarding the detailed parts of the ‘umbilicus’. In several famous anatomy atlases, the umbilicus is not dissected at all and is merely represented as a button. The true nature of the umbilicus is very much a black box. Methods: Five cadavers were obtained from the Osaka Medical College medical student anatomy class. In each cadaver, the umbilicus was dissected in the anatomy laboratory, to demonstrate all the layers between the skin and peritoneal cavity. A detailed dissection was performed, focusing on the exact center of the umbilicus, in order to ascertain whether there exists a ‘natural orifice’ or a fascial defect. Results: In all cadavers, a small defect of fascia was identified just below the center of the umbilicus. Yellow fatty tissue is present just below the skin in the exact center of the umbilicus. This yellow fatty tissue tends to be regarded as subcutaneous fatty tissue, but this is actually pre-peritoneal fatty tissue. A probe placed exactly in the middle of this defect passes easily through into the abdominal cavity. Conclusions: Traditionally, many surgery text books recommend avoiding direct umbilical incision. In the last 3 decades, with widespread use of MIS, umbilical incision is commonly used to achieve less pain and better cosmetic results. Anatomical knowledge of the umbilicus is therefore important. This study consistently revealed a natural defect of fascia in the center of the umbilicus. Therefore the umbilicus can be called a true ‘natural orifice’. It is important to recognize and utilize this defect effectively to minimize unnecessary tissue trauma during MIS.

F. Vozzi1, I. Guerrazzi1, C. de Maria2, C. Buemi3, C. Chiaravalloti3, C. Domenici1, G. Vozzi2 1

Institute of Clinical Physiology, Pisa, Italy; 2Interdepartmental Research Centre, E. Piaggio, Pisa, Italy; 3Dipro Medical Devices s.r.l. (DIPROMED), San Mauro Torinese, Italy Aims: The scope of the study is to evaluate the interaction of composite mesh with the biological environment in order to obtain a reference study for further developments of new products during the MES-STAR project. To achieve this goal it is fundamental understand the biomechanical features of natural tissue that the prosthesis should mimic and the biological response to prosthesis by host, obtaining several data for future necessary modifications. Methods: A composite mesh CMC, furnished from Dipromed, was seeded with Human BJ Fibroblast to test cytotoxicity and cell growth trend. Furthermore, on this the inflammatory profile (IL-6 and IL-10) was quantified as also the collagen type I and type III production was highlighted with immunohistochemistry. These results were related to mechanical properties of composite CMC mesh, in particular to Young modulus and to its anisotropy. Results: Material is totally biocompatible (90 % viability), with a good cell growth trend on macroporous polypropylene layer after 21 days of culture. The inflammatory profile shows an initial secretion of anti-inflammatory IL-10 and a final increase of pro-inflammatory IL-6. Immunocytochemistry highlighted an increase of Collagen type III production respect to type I. Moreover, CMC prosthesis presents an anisotropy similar to that of natural tissue, that can promote tissue integration. Conclusion: The CMC mesh shows an good cellular growth on macroporous side, indicating a satisfying rate of cell adhesion, confirmed by high rate of therapy hernia success. The polypropylene film shown a proper interaction with the surround biological environment. The increase of IL-6 cytokine and Collagen type III secretion are perhaps led to stiffness of mesh, so it will be important in the future to design and realise prosthesis, made of biomaterials and with mechanical features that mimic those of natural healthy tissue. All these elements must be take in account as decision making in the MES STAR research project.



Colorectal Cancer in Pregnancy

How Often Biliary Fistulas Can be Found in Hydatid Cyst of the Liver

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J. Grundy , C. Chow , I. Goh , A. Thomson

Queen Elizabeth II Hospital, Coopers Plains, Australia; 2Royal Brisbane Hospital, Brisbane, Australia; 3Mater Adults Hospital, Brisbane, Australia; 4Queensland University of Technology, Brisbane, Australia 1

Colorectal cancer in pregnancy is a rare condition affecting less than 1 in 13000 pregnancies. The diagnosis can be devastating and unfortunately is often delayed due to the similarity between the symptoms of pregnancy and those of malignancy, with consequent poor outcomes for the mother. The challenges faced by both the patient and the clinicians involved, are formidable, with little in the way of consensus as to management strategies. A recent small case series from Australia is presented and compared with the published literature. Traditionally, peritoneal access to resect colorectal malignancy in the pregnant patient has been via laparotomy. A case is presented here describing the laparoscopic technique used in the resection of a colorectal malignancy in a pregnant woman of 25 weeks gestation.

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K. Khamidov, M.P. Magomedov DGMA, Makhachkala, Russia Aim: The aim of this work is to improve the diagnosis of biliary fistula results in hydatid cyst of the liver. Materials and Methods: The problem of diagnosis and treatment of biliary fistulas, which frequency at the liver hydatid cyst varies according to different authors from 6 to 63 %, remains an urgent problem of the abdominal surgery. We observed 162 patients with hydatid cyst of the liver, that were operated from 1996 to 2013. The age of patients ranged from 14 to 76, 98 women (60.5 %), 64 men (39.5 %). Laparoscopic echinococcectomy liver was performed in 61 patients, traditional laparotomy was performed in 101 patients. For the diagnosis of biliary fistula in the laparoscopic echinococcectomy the residual cavity inspection was conducted with the oblique laparoscope optics usually after the phase of the aplatisation of hydatid cyst. Performing traditional laparotomy to improve the audit of the residual cavity of the liver we developed and applied endovideoscopy of the residual cavity of the liver, which was carried out after the completion of the antiparasitic treatment and evacuation of the cysts. Results: Biliary fistulas were found in 42 (25.9 %) patients, and they were more frequent met in the dead maternal gidatide and festering cysts (84.3 %). A high percentage of detection of fistulas tsistobiliarnyh, 25.9 % (in complicated echinococcosis 84.3 %) can be explained by such advantages of endovideoscopy of the residual cavity of the liver as magnification of the image on the monitor screen and complete unfolding of the walls of the fibrous capsule. That allows to identify the smallest fistula, including erosive stage of their formation. Conclusion: Endovideoscopy improves significantly the audit of residual cavities of the liver and facilitates the identification of fistulas tsistobiliarnyh, that allows to improve the results of treatment of patients with hydatid cyst of the liver.

Surg Endosc



Five Years Experience of Laparoscopic Hernioplasty: Evaluation of Composite Prosthesis Totally in Polypropylene

Complications of Laparoscopic Appendectomy - Five Year Review

M. Giaccone, S. Pilecci, M. Camandona, G.M. Tiranti, G. Gasparri

F. Galgoćzyova´, J. Rejholec, J. Moravı´k

San Giovanni Battista Hospital, Torino, Italy

Nemocnice Decıń o.z., KZ a.s., Decıń, Czech Republic

Aims: The goal of this study is a critical analysis of the main issues of laparoscopic treatment. An independent retrospective cohort study was conducted using laparoscopic approach in the ventral and incisional hernia repair, comparing the data obtained from our case histories with the evidence from the literature. Methods: A cohort of 110 patients undergoing laparoscopic hernioplasty for primary ventral or incisional hernia, was enrolled from June 2008 to June 2013 at the S. Giovanni Battista Hospital in Turin. The 72,8 % of patients were affected of incisional hernia, whereas the 27,2 % of ventral hernia. Were applied not-absorbable composite meshes of different materials, fixed with glue, clips or both. The 51 % of patients are treated with CMC, polypropylene double layers composite mesh, (DIPROMED s.r.l-Turin, Italy); whereas the 49 % with other marketed prostheses (OTHERS). Surgical complications observed were classified into two categories: peri- or intra-operative and postoperative. Disease recurrence was recorded separately. Follow-up time was between 6 and 60 months. The statistical analysis of the results was performed using ‘MedCalc’; all data were subjected to the ?2 test, while continuous variables were subjected to ANOVA One-way analysis of variance. Results: The complication rate was determined following the literature, evaluating the disease recurrences and the other complications occurred. In this study population there has not been postoperative mortality. The long term follow-up showed good results with only 3 recurrences observed using OTHERS. No recurrence occurred with CMC. After placement of the prosthesis nobody presented wound infection or systemic complications. The statistical study of the patients characteristics showed a significant trend between the number of defects and post-operative complications: these were higher in patients with multiple defects. Conclusion: The correct methods in laparoscopic surgery produce an effective repair exposing the patient to complications significantly lower compared to repairs in the open surgery. Our records has a recurrence rate of 2,7 % and showed results comparable with other studies, in addition to count on the follow-up of longer period. Patient who underwent laparoscopic hernioplasty with CMC, has experienced less pain thanks to good tolerance of the biomaterial, good handling, ease to fixing and transparency.

Aims: Laparoscopic appendectomy is nowadays a common surgical procedure. According to several studies the number of complications - as surgical site infections - is reduced with laparoscopic approach, but the rate of intra-abdominal complications is increased in laparoscopy compare to open appendectomy. The aim of this study is to ascertain quantity of complications in laparoscopic approach. Methods: A retrospective chart review of patients undergoing appendectomy during a 5-year period was performed to evaluate frequency of different sort of per-operative and post-operative complications. Those who underwent open appendectomy were excluded. Results: Laparoscopic appendectomy was performed in 411 patients of 426 who underwent appendectomy from 2008 to 2012, 31 of them required conversion. 83,3 % of appendectomies were performed in acute appendicitis. The mean age of patients was 25 years (range 4–86 years), gender rate 188 male, 223 female. Per-operative complications occurred in 10 patients including bleeding of appendicular artery and deserosalization of small bowel or caecum. In half of these cases conversion was required. Some post-operative complication occurred in 57 reviewed cases. Surgical site infection of different severity (including seroma or flegmona of the wound) appeared in 7,4 %. Intra-abdominal abscess (IAA) or hematoma occurred in 2,1 %, one in a patient with Crohn disease diagnosed after appendectomy. One IAA was managed with percutaneous drainage, one required laparoscopic revision, the others were treated conservatively. Post-operative peritonitis was ascertained in one patient, laparoscopic revision and lavage was performed without discovering the cause of peritonitis. Ileus occurred with frequency of 1,6 % and was managed conservatively. Conclusion: Laparoscopic appendectomy used in a treatment of appendicitis has its advantages of a minimally invasive procedure as superior abdominal cavity visualisation, better cosmetic outcome and lower rate of surgical site infection. Based on a comparison of our results and of reviews published in literature presence of an intra-abdominal abscess after laparoscopic appendectomy is not increased compare to open procedure.



Laparoscopic Repair of Lateral Relaxation of the Abdominal Wall with Nerve Entrapment

Retroprosthetic Seroma After Laparoscopic Ventral Hernia Repair: Incidence, Risk Factors and Clinical Significance

S. Morales-Conde, M. Rubio-Manzanres, A. Barranco, M. Socas, A. Navas, I. Alarcoń, R. Avila, M. Sanchez, J.M. Cadet, J. Padillo

S. Morales-Conde1, G. Suarez-Artacho1, M. Sanchez-Ramirez2, I. Alarcoń1, A. Barranco1, H. Cadet1, F.J. Padillo1, M. Socas1

University Hospital Virgen del Rocio, Sevilla, Spain

University Hospital Virgen del Rocıó, Sevilla, Spain; 2Hospital Universitario Puerta del mar, Cadiz, Sevilla, Spain

Aims: Laparoscopic ventral hernia repair (LVHR) has been established as a well-accepted option in the treatment of complex hernias. Lateral relaxation of the abdominal wall is challenge for surgeons since the results obtained are poor. Laparoscopic approach of this entity has been described by our group with excellent results. This approach also offers the possibility of describing findings that could be related to pain as the combination of the lateral relaxation with nerve entrapment, as we described in this case. Methods: We reported the case of 78 old man, with clinical history of previous surgery of the back with autotransplant of the left iliac crest through a preperitoneal infraumbilical incision. Since surgery, he described an asymmetry of the abdomen together with pain. Physical examination showed relaxation of the left abdomen although no abnormalities of the area were observed in the CT-scan. Results: Patient underwent laparoscopic surgery finding a neuromuscular relaxation of the left flank of 13 9 13 cm, together with a small defect of 2 9 2 cm next to cranial part of the iliac crest with fatty tissue inside entrapping one of the nerves of the area. The fatty tissue was removed from the small defect and nerve was released from the scar tissue. The neuromuscular defect was repaired using a e-PTFE mesh of 20 9 30 cm, being fixed with double crown of tackers, adding transfascial sutures to fixed the rectus muscle. There were no postoperative complications. The onset of oral tolerance occurred at 1st day and discharged on the 3th day, progressively decreasing the pain in the area and improving his quality of life. Conclusions: LVHR could be a good option in patient with complex incisional hernias, as lateral relaxation, offering the opportunity to find different entities, such as nerve entrapment, that could be related to the pain described by the patients.

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Background: The seroma generated between the abdominal viscera and the prosthesis (retroprosthetic seroma), after laparoscopic ventral hernia repair (LVHR) with the implant of a intraperitoneal mesh is an unknown entity with few references in the literature. Our objective is to analyze its incidence, risk factors, clinical repercussions and course of retroprosthetic seroma during the first 3 months post operation. Study Design: Prospective, descriptive study in patients undergoing LVHR using the double crown technique. After surgery, the patients had follow-ups on the 7th day and the 1st and 3rd months post operation with clinical examination and abdominal CT scan. The study endpoints were: Incidence and volume of retroprosthetic seroma, clinical repercussions, relationship to BMI, prosthesis size and the existence of preprosthetic seroma. Results: Fifty patients underwent LVHR using the double crown technique and were included in the study. The incidence of retroprosthetic seroma during the 3 months’ followup was 46 %, there being a progressive process of spontaneous reabsorption. In just one patient (2 %) there were clinical repercussions as a result of the seroma. No statistically significant relationship was found with BMI and preprosthetic seroma. A statistical relationship was found between the size of the prosthesis and the risk of suffering retroprosthetic seroma in the 3rd month post operation (p = 0.048). Conclusions: Retroprosthetic seroma is an entity produced in 46 % of patients undergoing LVHR with few clinical repercussions (2 %). In most cases it develops in the 1st week post operation and then undergoes a reabsorption process that is usually complete by the 3rd month post operation. The size of the prosthesis delays the reabsorption process.

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Experimental Ground for Tissue Sealing Method: Of the Front Abdominal Wall Wound

Abdominal Mass Excision Through Single-Port

E. Mylovydova1, V. Boyko1, V. Lelytsya2, V. Sushkov1, P. Babkina3 1 Government Institution Institute of General and Urgent Surgery of NAMSU, Kharkiv, Ukraine; 2Kharkiv National Medical University, Kharkiv, Ukraine; 3Lugansk State Medical University, Lugansk, Ukraine

Aims: Prevention of visceral-parietal adhesions of laparotomic wound. Methods: Rats, used in this study, were divided into the main and control groups. The control group had front abdominal wall wound sealed with silk sutures; tissue sealing method IK-300M1 (analogue LigaSure, USA) was used on second (main) group. Wound sealing of front abdominal wall was assessed in 14 days by the second surgery; the pictures of sutured wound and histological materials were taken for the evaluation of tissue inflammation and grade of adhesions. Results: In the main group adhesions have occurred only in one rat suffering from eventration, others had no signs of adhesions. Evaluation of the front abdominal laparotomic wound of control group has discovered the following: two rats had omentum adhesions, the rest of the group suffered from even more severe adhesions to sutures. Histological assessment of the main group (treated with tissue sealing method) has discovered minimal tissue inflammation, granular tissue growth and macrophageal reaction. Histological assessment of the control group appeared to have extended tissue reaction with acute inflammation. Granular tissue had many foreign body giant cells and macrophages. Muscle fibers were in condition of bionecrosis. Blood vessel walls appeared to be thickened and had signs of hyalinization. Conclusions: Thermal tissue sealing method proved to cause less tissue inflammation and more reparative changes according to histological and macroscopic evaluation. Thermal tissue sealing method leads to the reduction of post surgery adhesions and tissue inflammation, which can lead to reduction of intestinal obstruction caused by post surgical adhesions.

¨ . Firat, S. Ersin, A. Gu¨ler, T. Sezer, H. Yildirim, A. Uguz, O C. Hoscoskun Ege University School of Medicine, Izmir, Turkey Aims: In this study, we describe a 30-cm cystic mass excision performed by using glove technique, single-port system. Methods: A 48 years old female patient with complaint of abdominal pain and abdominal distension for a year was inspected. Upon a 30 cm mass originating from right ovary was detected in radiological examination, the patient was hospitalized for operation. The patient underwent a single port mass excision. Results: Abdomen was entered with approximately 2–3 cm incision passing through umbilicus and a single port glove system that we had prepared. It was detected that mass was nearly 30 cm long reaching transverse colon and umbilicus superiorly. Since mass was blocking movements of laparoscopic devices, content of mass is aspirated via taking out of abdomen through incision. Soon port was replaced and mass was excised using ligasure. No drain is placed. Patient was discharged 2 days after surgery. The histopathological diagnosis was mucinous cystadenoma. Conclusion: In addition to the advantages of conventional laparoscopic surgery, single-port laparoscopic surgery serves excellent cosmetic results. However, cost of the industry type single-ports are higher. Single-port system that we have prepared with the materials in the operating room is cost-effective and easy to use.



Initial Experience with Application of Local Anesthetics in Laparoscopic Appendectomy

Is Single Port Laparoscopic Inguinal Hernia Repair Really Required?

C. Custovic1, P. Pandza1, D. Delibegovic2, K. Krupalija1, M. Mahmutovic1

¨. U ¨ . Firat, S. Ersin, C. Hoscoskun ¨ nalp, O T. Sezer, H. Yildirim, O

1

General Hospital Sarajevo, Bosnia-Herzegovina; 2Clinical Centre Tuzla, Bosnia-Herzegovina

Aims: Laparoscopic appendectomy is most common surgical procedure done in emergences. We wanted to see effect of local anesthetic - lidocaine which was injected and dispersed during laparoscopic appendectomy. It is a pilot project of bigger study with application of many local anesthetics and there clinical outcomes which we began and will do in next years. Methods: 60 patients were included in study. 30 patients got local anesthetic and other 30 are control group. At the beginning of the operation on the site of each port (two 10 mm and one 5 mm) we injected 5 ml of local anesthetic, and after finishing lap. Appendectomy at the site of appendix and surrounding tissue we dispersed 10 ml of lidocaine with nebulizer. After the operation we made control of laboratory results, VAS and McGill score. Results: There is no differences in laboratory results between these groups. In VAS (visual analog scale) we found slightly better results in patients in researching group. Pain was lesser on port sites and slightly on site of appendectomy. There were no complications due to administration of local anesthetic. Conclusion: Application of local anesthetic during laparoscopic appendectomy has some advantages in early postoperative pain control examined with VAS and McGill score.

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Ege University School of Medicine, Izmir, Turkey Aims: While surgical operations performed through single port provides excellent cosmetic outcomes for patients, in terms of surgeons, they cause difficulties technically, longer operating time and need more experience. In case of inguinal hernia repair, single incision surgery raises the risk of a new hernia. The smaller incision reduces the risk of hernia but operation is harder then or vice versa. We believe these problems can be overcomed by using the glove technique we modified, which enables smaller incisions. Methods: From July 2012 to May 2013, 18 patients with inguinal hernia underwent singleport laparoscopic transabdominal preperitoneal repair. Data were analyzed retrospectively. Results: Among them, 3 had bilateral inguinal hernia. Among unilateral hernias, 9 were on right side whereas 6 were on left, 9 were indirect hernia whereas 6 were direct hernia. For bilateral inguinal hernias, 3 were indirect and 1 was direct type of hernia. Additional port placement was necessary for one patient which have bilateral inguinal hernia. The average length of fascia was 1.8 cm. The mean duration of hospital stay was 20 hours. No recurrence or umbilical hernia was observed in the early postoperative period. Patients have described as excellent cosmetic satisfaction at first month control. Conclusion: The single-port glove technique that we modified is cost-effective and provides more space for instruments. Providing smaller fascia incisions, it also reduces postoperative umbilical hernia risk. We think that single-port laparoscopic hernia repair can be performed with smaller umbilical incisions in experienced hands.

Surg Endosc



Current Results of Our Experience with Laparoscopic Mesh Repair of Incisional Hernia-Can it be the First Line Treatment?

Prospective Study Comparing Subcuticular Skin Suturing vs Skin Clips After Laparoscopic Surgery

B.V. Martian1, I. Diaconescu1, C. Tudor1, M.R. Bratu1, I. Dogaru2, G. Andrei1, I. Vacaroiu1, A. Spatariu1, M. Beuran1

M.H. Majeed

Emergency Clinical Hospital, Bucharest, Romania; 2Regional Hospital Constanta, Constanta, Romania

Our Lady of Lourds Hospital Drogheda, Ireland

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Aims: The aim of our study was to determine if laparoscopy is a better choice for the treatment of incisional hernia compared to open surgery. Materials and Methods: This was a retrospective study of patients undergoing a laparoscopic (LHR group) or open (OHR group) mesh repair for incisional hernia. All interventions were performed by the same surgical team in a standardized manner. Using SPSS v19 we analyzed preoperative data (demographics, BMI, gender ratio, abdominal wall defect dimensions), perioperative data (operation time) and postoperative data (hematoma, seroma, wound and mesh infection, inpatient stay). Patients were reevaluated after 3, 6 and 12 months for recurrence and other complications. A p-value smaller than 0.05 was considered statistically significant. Results: There were included 96 patient (54 in LHR and 42 in OHR) with no significant differences in gender and BMI status. The average of abdominal wall dimension in LHR group was much smaller than for the OHR. The operative time of laparoscopic interventions was almost equal to open surgery at the base of learning curve but at the peak of the learning curve became shorter (p \ 0.05). Patients in LHR group had a smaller inpatient period and rate of infection while there were no differences in hematoma or seroma formation rate. At 3 months follow-up laparoscopy had equal rate of recurrence with open surgery but at 6 and 12 months recurrence rate for LHR was substantial smaller than for OHR. Conclusion: According to our results laparoscopy can be the treatment of choice for incisional hernia with better results in the postoperative period, noting that large hernias can’t be easily managed by minimally invasive surgery.

Background: after laparoscopic procedures skin is closed with different methods. Subcuticular absorbable sutures and skin clips are two most commonly used methods. We compared these two methods in prospective study over the period of three years. Aims: Compare the wound infection, Hematoma, cost and patient satisfaction for two methods Methods: over the period of three years 495 patients were included in study including laparoscopic cholecystectomy, colorectal procedures, laparoscopic appendectomy and laparoscopic hernias. Immunosuppressed and patients with Intra abdominal sepsis were excluded from study Results: There was more wound hematoma and pain in subcuticular sutures group and it was significant. There was no difference for the cost and patients satisfaction in two groups Conclusion: skin clips gives good result after laparoscopic procedures avoiding hematoma and wound complications associated with subcuticular sutures in laparoscopic procedures.



Abdominal Wall Biomechanics During Cough And Deep Breathing Movements

Laparoscopic Experience of Diagnosis and Removal of an Atypical Right Iliac Fossa Mass

H. Qandeel, P.J. O’Dwyer

R.J. Hughes, V.V. Vijay

Glasgow University, Glasgow, United Kingdom

Princess Alexandra Hospital Harlow, Harlow, United Kingdom

Aims: Cough has the maximum effect on daily physiological abdominal movements. Little is known about the actual lengths of abdominal wall during movements and if it would impact on the mesh’s size chosen in laparoscopic ventral hernia repair. This study aims to measure the lengthening of different lines across the abdomen during cough (C) and deep breathing (DP). Methods: Three-dimensions videos were taken of the abdomen of 12 volunteers (3 females: 9 males). Digital Image Correlation technique was used to determine the extent of strains along 6 lines (longitudinal & transverse) marked on their abdomen at rest, cough (C) and deep breathing (DP) movements. Original length of each line was defined when abdominal muscles were paused in relaxed position after exhalation and this length (at rest) was considered as a reference for lengthening calculations during at (C) and (DP) on that line. Results: Patients’ median age = 50 yr (25–75) and Body Mass Index (BMI) mean = 26.8 (21.4–36). The mean lengthening detected on longitudinal lines was 1.7 cm during (DP) and 1.2 cm during (C). The mean lengthening detected on transverse lines was 0.4 cm during (DP) and 0.2 cm during (C). The change in line’s length during (C) and (DP) compared to the rest position was statistically significant across all lines except for the lower abdomen transversely. The P-values were at midline (0.014 & 0.009), right paramedian (0.007 & 0.003), left paramedian (0.006 & 0.003), transverse line at umbilical level (0.022 & 0.014), transverse line in upper abdomen (0.009 & 0.009) and transverse line in lower abdomen (0.181 & 0.100); for the (C) and (DP) respectively. Conclusions: Better understanding of abdominal wall dynamic strains and lengths changes during daily physiological activities may help surgeons to choose the appropriate size and orientation of mesh in order to reduce the risk of hernia recurrence.

Aims: To demonstrate the laparoscopic experience and the technique needed for investigation and removal of an atypical right iliac fossa mass Methods: A 25 year old female, with a background of agenesis of uterus and a suspected congenital disorder presented with a 6 month history of right iliac fossa pain. Clinical examination was unremarkable and biochemical markers showed no evidence of inflammation or infection. An initial CT scan revealed ovoid lesion lying posterior to the caecum which patchily enhances in its inferior aspect. Venous drainage was to the inferior vena cava at the anatomical position of the left renal vein. Its overall appearance was suggestive of a right kidney remnant. A left kidney was identified in the normal anatomical position and both ovaries were identified pelvis. A later radionuclide uptake renal scan demonstrated the only functioning renal tissue was in the normal positioned left kidney. Diagnostic laparoscopy was performed, with patient in the trendelenburg position under general anaesthetic, with 3 port sites at infraumbilical, left lateral and suprapubic. Standard equipment as for laparoscopic appendectomy was used including a 30 degree laparoscope. Small bowel and caecum were mobilised to the left iliac fossa and the lesion was identified within the right paracolic gutter. its mesentery dissected from the base posterior and lateral abdominal wall with the aid of scissors and diathermy and its blood supply ligated with hemoclips and diathermy. It was removed from the abdomen through with the aid of umbilical incision and retrieval bag. Results: Histopathology results revealed ovarian tissue with associated haemorrhagic corpus luteum No renal structures identified, no evidence of malignancy. Patient recovered uneventfully from surgery and right iliac fossa discomfort was alleviated. Conclusions: Laparoscopy is essential for diagnosis and management of atypical right iliac fossa pain, despite imaging suggesting the mass in this case was agenic right kidney, it is crucial to be aware of many other causes of right iliac fossa masses including additional ectopic ovaries, and particularly in patients with congenital disorders.

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Laparoscopic Excision of a Large Infected Mesenteric Cyst

Laparoscopic Incisional Hernia Repair - Early vs. Late Experience and Economic Aspects

A.V. Ariyarathenam, S. Aroori Plymouth Hospitals NHS Trust, Plymouth, United Kingdom Aims: This DVD presentation demonstrates a rare case of laparoscopic excision of a large symptomatic infected mesenteric cyst. Patient & Methods: This in-house DVD production with voiceover presents a laparoscopic excision of a mesenteric cyst arising from the root of the mesentery. A 35 year old male patient was investigated for severe upper abdominal pain. Several investigations including an Endoscopic ultrasound (EUS) and fine needle aspiration cytology (FNAC) showed a large cystic lesion with signs of bleeding and infection in the root of the mesentery. At laparoscopy, the cyst was in close relation to duodeno-jejunal flexure, transverse colon, and superior mesenteric artery (SMA) and vein. The cyst was successfully excised laparoscopically with a small remnant left behind, which was closely adherent to the superior mesenteric artery. Outcome: The patient made a good recovery from surgery and was discharged on postoperative day 5. The post-operative histology confirmed a lympho-epithelial cyst. At two months following surgery he is well with no abdominal pain. Conclusions: Laparoscopic excision of complicated mesenteric cyst can be performed safely with excellent outcome.

I.O. Avram1, M.F. Avram1, D. Koukoulas2, A.M. Ungureanu1, S. Olariu1 UMF Victor Babes Timisoara, Saarbru¨cken, Germany; 2Spitalul Municipal Lugoj, Lugoj, Romania

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Study Objective: We aim to analyse the results in laparoscopic treatment of parietal defects during the learning curve and after completion of the learning curve and to compare them with results obtained with the classical technique. Material and Methods: We analyzed 75 patients with incisional hernias operated in our Clinic, divided into 3 groups of 25 Patients. All abdominal parietal defects were of similar size. Group A was operated by surgeons during the learning period of the laparoscopic method, Group B was operated by surgeons with experience in the laparoscopic IPOM, while the control Group C was oerated by the classic method (open sublay technique). Mean follow-up was of 24 month. We studied the clinical, the intra- and postoperative complication rate and postoperative evolution, the duration of the procedure and the conversion rate. We also analyzed the costs of hospitalization and postoperative medication. Results: Conversion rate in group A was 32 % (1 case due to technical reasons, 5 case due to extensive adhesive syndrome and 2 case due to bowel injury). Conversion rate in group B was 40 % (1 case due to bowel injury, 9 cases due to bowel injury). Duration surgery for incisional hernias was 125–165 minutes in group A and 95–135 minutes for group B; duration of surgery for group C was 55–120 minutes). and for eventrations 100–220 minutes. During our follow-up period of 1 year we noted 1 recurrence in group A, no recurrence in group B and 3 recurrences in group C. We recorded 5 postoperative complications in group A (one early bowel obstruction due to an internal hernia resolved laparoscopically and 4 seromas), 7 postoperative complications in group B (seromas) and 4 postoperative complications in group C (3 seromas, 1 wound infect). Duration of hospitalization was significantly lower for groups A and B with a significantly lower need for analgesics and faster mobilization of the patients. Conclusions: Laparoscopic approach is safe and effective alternative in treatment parietal defects, with reduced rates of complications, longer duration of the operation, but unfortunately with higher costs.



Laparoscopic Approach of Large Ovarian Cystic Tumors

Single-Incision Transabdominal Preperitoneal Hernia Repair Using Tumescent Anesthesia

B.A. Popescu, S. Paun, B. Gaspar, I. Negoi, B. Stoica, I. Tanase, M. Lica, C. Turculet, M. Beuran

I. Ito, N. Nakao, N. Ohashi, H. Nagata, T. Nonami

Bucharest Emergency Hospital, Bucharest, Romania

Aichi Medical University, Nagakute, Japan

Introduction: the first laparoscopic removal of a giant ovarian cyst was reported in 1996. Since then, laparoscopic techniques have evolved and now the laparoscopic approach is considered the gold-standard for benign ovarian cysts. In the literature cysts that are more than 10 cm on imagistic findings are considered large. Huge ovarian cysts are conventionally managed by laparotomy but laparoscopic treatment of cysts larger than 20 cm has been reported Method: We present 2 patients with large ovarian cystic tumors whom underwent surgery in Emergency Hospital Bucharest - Surgery Clinic Results: Case 1. The patient G.I. aged 25, under birth control pill for 2 years, but discontinued in the last 2 months is admitted for pain in the lower abdomen with sudden onset that lasted for the last 5 hours. The abdominal ultrasound showed a 11/7,3 cm pelvic heterogenous cystic tumor, with 17 mm liquid in the Douglas pouch. The patient underwent laparoscopy that showed haemoperitoneum (200 ml blood) and a huge left ovarian cyst measuring 20/15 cm containing aprox 1000 ml blood. Left laparoscopic oophorectomy was performed. Case 2 The patient G.D. aged 58, previously diagnosed by ultrasound with ovarian cyst is hospitalized for pain in the lower right quadrant. Abdominal ultrasound showed an right ovarian cyst measuring 11 cm. Laboratory overall workup was normal including CA125 and CEA. The patient underwent laparoscopy that revealed a huge left ovarian cyst measuring 20 cm, adherent to the parietal peritoneum, containing 700 ml thick murky fluid, with a 8/6 cm hard tumor in the lower ovarian pole with no signs of invasion but with uneven consistency. Due to malignant resemblance conversion to laparotomy was decided that showed a septated left ovarian with blood clots and a 8 cm fibroma. The patient underwent total hysterectomy with bilateral adnexectomy. Both patients had a simple postoperative evolution. Conclusions: With the advances in technique it is now possible to remove giant cysts laparoscopically. The size of the cyst, multiple tumors, technical difficulties or incidental malignant findings may however require conversion. Unfortunately, there isn’t enough data available regarding the management ovarian cysts larger than 20 cm.

Transabdominal preperitoneal hernia repair is one of the common procedures used to repair inguinal hernia. But single-incision transabdominal preperitoneal hernia repair (SITAPP) is very difficult to perform. There are two difficulties, the first is to peel away the peritoneum on the ventral side, and the second is to close the peritoneum with stitches. The instrument is at a right angle to the axis when peeling off the peritoneum on the ventral side. The narrow angle between the two instruments makes it difficult to suture the peritoneum. It was easier to peel away the peritoneum by injecting a local anesthetic agent into the preperitoneal cavity, making for easier peeling and less pain. We use the V-LocTM (Covidien) to close the peritoneum because it eliminates ligation. A thread does not loosen because it has self-anchoring. These ideas and devices make for shorter operating time. In this presentation, we show a video on how to perform this SITAPP procedure.

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P074 - Amazing Technologies

Laparoscopic Parastomal Hernia and Left Inguinal Hernia Repair - Same Operative Time

Reduced Port Cholecystectomy Using Two Trocars and Adjustable Endo-Retractors

B.A.P. Popescu, C. Turculet, F. Iordache, I. Grintescu, D. Ene, M. Beuran

L. Boni, E. Cassinotti, G. David

Emergency Clinical Hospital Bucharest, Bucharest, Romania Aims: Parastomal hernias are still a challenge for the general surgeon. There are a lot of debates regarding the treatment or the prevention of parastomal hernias. In the USA there are performed between 87.000–135.000 ileostomies and colostomies per year. The incidence of parastomal hernias is higher in the permanent ones. Methods: We present the case of a patient of 61 years old, admitted for a large parastomal hernia and an concomitant left inguinal hernia. The patient had an abdomino-perineal resection for low rectal cancer performed 2 years, prior to our admittance. We chose to resolve both hernias using a laparoscopic technique in the same operative time. We placed the patient supine and used 3 trocars, 2 of 10 mm and one of 5 mm on the border of the right abdominus muscle. We used a dual mesh of 30/20 cm fixed with titanium tacks in a Sugarbaker modified technique for the parastomal hernia and a TAPP approach for the left inguinal hernia. Results: The operative time was of 130 minutes with minimum blood loss. He resumed transit in the second postoperative day. There were no complications after surgery and the patient was released in the fourth postoperative day. Follow up after three years found no recurrence of both hernias. Conclusions: The modified laparoscopic Sugarbaker technique is the preferred treatment for parastomal hernias in most of the hospitals due to its low recurrence and morbidity rates and for the possibility to approach other hernias (midline incisional, inguinal). Yet, we tend to agree with the present studies that conclude that the prevention of parastomal hernias, by placing a mesh at the time of the first operation, may be the safest procedure with the lowest recurrence rates.

Minimally Invasive Surgery Center, Varese, Italy Background: Laparoscopic cholecystectomy is the most common procedure performed in gastro-intestinal surgery. During the recent years with the aim of reducing the trauma NOTE and Single Port Surgery have been proposed but they both have some technical limitations that makes these approach challenging Aim: the aim of this video is to show the technique for reduced post cholecystectomy using (2 port) and new adjustable endoretractors Project Description patient is placed in standard position one 10 mm trocar is placed in the umbilicus and one 5 mm in the epigastrium, using 2 adjustable endoretractors to lift the fundus and retract the infundibulum without creating any gallbladder perforations, the triangle of Calot can be exposed and cholecystectomy performed archiving the ‘critical view of safety’. Preliminary Results: This technique is promising to reduce the number of trocars without compromising the standard technique



Mental Health and Physical Health Monitoring

Comparing Robotic, Laparoscopic and Open Cystectomy: A Meta-Analysis

L. Popescu, L. Dvorkin North Middlesex University Hospital, London, United Kingdom Background: Mental wellbeing has a significant impact on the recovery and length of stay of patients during their admission to a general hospital and after surgical intervention. Methods: In the prospective audit we identified the appropriate use of current mini tools in assessing mental health in our hospital. Over a period of 2 weeks we audited all the clerking proformas filled in on admission. Results: As the audit findings were below the expectations, and the AMT was poorly recorded on admission, we adjusted the current mini tool, including sections regarding past psychiatric history, mood, cognition, and mental capacity. Conclusions: There is evidence that mental health issues are unrecognised and not fully addressed by medical and nursing staff in general hospitals. Early recognition of any cognitive impairment and decline in activities of daily living can improve the quality of life in the patients developing mental illness, reducing the socio-economical impact.

T. Fonseka, S. Froghi, K. Ahmed, P. Dasgupta, M.S. Khan King’s College London, London, United Kingdom Background: Comparison must be made between robotic-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) to assess superiority. Aim: To perform a meta-analysis to compare surgical and oncological outcomes between RARC, LRC and ORC. Project Description: A Systematic review of the literature was conducted, to collate all studies comparing RARC, LRC and ORC. Data on surgical and oncological outcomes were extracted. Subsequently a meta-analysis was performed using a random effects model. Results: 1,735 cases were analyzed, with 997 (57.5 %) undergoing ORC, 117 (6.74 %) LRC and 621 (35.8 %) RARC. Forest plots showed RARC had significantly lower length of stay, estimated blood loss and complication rate compared to ORC. RARC had no better surgical outcomes than LRC, only a longer operative time. LRC had better surgical outcomes than ORC. There were no statistically significant differences regarding oncological outcomes comparing RARC to ORC and LRC to ORC.

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Laparoscopic Low Anterior Resection with Prolapsing Technique for Lower Rectal Cancer

Cognitive Task Analysis Performance of Surgical Trainees Using an Open Hernia Repair Simulator: An Educational Trial

T. Mukogawa, H. Ishikawa, Y. Tsuji, K. Nakamura, S. Ko, A. Watanabe

O. Rae, Khatib, Sarker, Bello

Nara Prefectural Nara Hospital, Nara, Japan Aim: Laparoscopic low anterior resection for lower rectal cancer has some technical problems such as rectal irrigation, appropriate distal transection of the rectum and safe anastomosis. To overcome these problems, we performed four cases of laparoscopic low anterior resection with prolapsing technique. Procedure: Total mesorectal excision (TME) and systematic lymph node dissection are performed routinely. The proximal colon is transected intra-corporeally with an endoscopic stapler. The stump of the proximal colon is grasped by Babcock forceps, pulled out and prolapsed through the anus. The distal rectum is irrigated and transected under direct vision extra-corporeally. The stump of the distal rectum is pushed back into the pelvis through the anus and anastomosis is achieved with a double-stapling technique under laparoscopic view intra-corporeally. Conclusion: Our limited experience suggests that laparoscopic low anterior resection with prolapsing technique is useful procedure to get surgical distal margin safely and definitely for lower rectal cancer.

St. Mary’s Hospital, London, United Kingdom Background: Open inguinal hernia repair is a key procedure for trainees for progression. Simulation is becoming increasingly used to train surgical trainees. Aim: Evaluate effect of interactive open surgery simulation on the CTA performance of trainees via educational trial. Project Description: 32 doctors foundation trainees and core surgical trainees were randomised to receive 1 of 4 interventions for learning about an open inguinal hernia repair (interactive open simulation (G1), non-interactive open surgery simulation (G2), a video tutorial (G3) or control {surgical textbook} (G4)). The outcome measures were cognitive knowledge and overall global rating, assessed through trainee interview. Preliminary Results: Trainees in G1 achieved significantly higher CTA performance scores for knowledge of an open Lichtenstein inguinal hernia mesh repair compared with trainees in G3 (p \ 0.001) and G4 (p \ 0.001). A similar significant finding was found for the general performance scores compared with trainees in G3 (p = 0.001) and G4 (p = 0.048).



Deadly Urethral Bleeding of the Obturator Artery

Serious Gaming Can be a Valid Method to Train Clinical Decision-Making in Surgery

T.H. Lee, T.Y. Huang Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan We presented a patient developing a pelvic fracture with complete posterior urethral disruption in a vehicle accident. He received endoscopic realignment and orthopedic surgery at the same time. However, delayed massive urethral bleeding with hypovolemic shock happened 1 month later. Computed tomographic scan demonstrated contrast extravasation at penile root. Active bleeding from bulbourethral was revealed endoscopically while electrocauterization could not play a role in controlling bleeding. Consequent angiography revealed a pseudoaneurysm from the right obturator artery; embolization obliterated the pseudoaneurysm successfully. No further similar hematuria episode was noted during follow-up. Pseudoaneurysm is a rare etiology among traumatic urethral bleeding. Posttrauma urethra pseudoaneurysm remains a diagnostic and endoscopic challenge as standing in a urologist’s shoes. Angiography with selective embolization is beneficial to this circumstance.

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M. Graafland, M.F. Vollebergh, S.M. Lagarde, M Van Haperen, W.A. Bemelman, M.P. Schijven Academic Medical Centre, Amsterdam, The Netherlands Background: Serious gaming is a novel approach to postgraduate training, delivering serious content in a fun and challenging way. The game ‘Medialis’ was developed to train clinical decision-making regarding biliary tract disease. Aim: This study investigates participant’s perspectives on the serious game, and it’s discriminatory ability between different levels of expertise. Project Description: Decision scores and decision speed were compared between 41 surgeons, surgical residents, interns and students. Participants completed a questionnaire. Preliminary Results: Surgeons solved more cases (mean 77 %) than residents (67 %); interns (60 %), master- (50 %) and bachelor students (39 %, p \ 0.01). Trainees performed significantly better in the second play session than in the first (median 72 % versus 48 %, p = 0.00). Questionnaire results showed that participants found it fun (90.9 %), challenging (84.9 %) and recommend the game to educate colleagues (81.3 %). Serious gaming has the potential to increase adherence to education, both in surgical training and medical school.

Surg Endosc



A Case of Splenic Metastasis of Ovarian Cancer Treated by Complete Laparoscopic Splenectomy and Transvaginal Specimen Extraction

Laparoscopic Transabdominal Preperitoneal Hernia Repair (TAPP)

Y. Takase Gunma University, Gunma Pref., Japan

¨ . Sezer2, F. Ozgur2, A. Guler2, C. Hoscoskun2, A.Ismayilov1, O 2 I. Solak , S. Ersin2, T. Yoldas2, I. Azer1 1

Ege university school of medicine, Department of general surgery, Izmir, Turkey; 2Ege University, Izmir, Turkey

Case is 61-year-old woman diagnosed with right inguinal node and splenic metastasis for ovarian serous cystadenocarcinoma. First at 3 ports, we extracted the right inguinal lymph node. Posterior wall of the inguinal canal became fragile, we restored it using a plug for inguinal hernia repair. We added 2 ports still in supine position, and displaced the spleen from retroperitoneum. We lifted it using snake retractor, and disconnected the hilum with automatic suturing device. Next, we incised the posterior wall of vagina intraperitoneally with ultrasonic coagulotomy device, inserted and spread it using wound retractor. Aeroperitoneum was maintained by cap covered over wound retractor, inserted bag into abdominal cavity via vagina and extracted the specimen transvaginally. The vaginal wound was sutured laparoscopically. she had no operative complications and was able to ambulate actively at first day after surgery because postoperative pain was slight. Totally laparoscopic splenectomy with TVSE in supine position was safe and feasible. This technique may be very minimally invasive surgery for female with splenic disease.

Introduction: In this study we collected retrospectively 80 patients that operated laparoscopic transabdominal preperitoneal repair Material and Method: January 2009 between may 2013 total 80 patients who had been operated with the diagnosis inguinal hernia. Within this group 29 cases were bilateral, 24 cases right inguinal hernia and 27 cases were left inguinal hernia. In this group average age were 49,8. Result: In this group average age 49.7. Among these patients were 7 female 73 male. we observed recurrence only three patients. The average residence time in the hospital was 23 hours. Conclusion: In hernia repair laparoscopic tap can be used safely.



FLEPP (Flexible Endoscopic Pre-peritoneoscopy) for Inguinal Hernia Repair - Novel Use of Flexible Endoscope Platform

Tamis for Low Rectal Cancer: A New Approach

P.W. Dhumane1, G.F. Donatelli2, H. Chung3, B. Dallemagne4, J. Marescaux4 Lilavati Hospital And Research Center, Mumbai, India; 2Hoˆpital Prive´ des Peupliers, 8 Place de l’Abbe´ G. Henocque, 75013 Paris, France; 3Yonsei University College of Medicine, Seoul, Korea; 4 IRCAD/EITS, I, Place de l’hopital, University of Strasbourg, France 1

A variety of NOTES (natural orifice transluminal endoscopic surgery) hernia repair techniques have been described. At IRCAD (Strasbourg, France) we aimed for utilizing transumibilically introduced conventional double-channel flexible endoscope for performing preperitoneoscopy -FLEPP (flexible endoscopic preperitoneoscopy) and inguinal mesh placement. A conventional double-channel endoscope (Storz Endoskope, Tutlingen, Germany) with conventional flexible endoscopic instrumentation, including a grasper and insulated-tip diathermic knife (IT-knife2-KD-611L; Olympus Optical; Tokyo, Japan) were used. This video demonstrates good vision provided by this platform. Blunt dissection by side-to-side movement of endoscope tip and precise electro-cautery dissection using endoscopic instruments, helped us identify all the preperitoneal structures without causing any damage. Bilateral preperitoneal spaces could be explored by this single 1.5–1.8 cm transumbilical access using FLEPP. 9 x 7 cm2 oval polypropylene mesh could be easily delivered in the inguinal region and was placed so as to cover the myopectineal orifice simulating total extra-peritoneal (TEP) inguinal hernia meshplasty.

M.A. Zappa, E. Giorgini, G.P. Giusti, A.I. Antonini, A. Porta Fatebenefratelli Sacra Famiglia Hospital, Erba (Como), Italy Background: A 78 years old man affected by sub stenosing sigmoid and intra mucosal rectal cancer was submitted to anterior resection of the rectum with a double approach: laparoscopic and trans-anal. Pre-operative CT scan didn’t show abdominal-thoracic metastases. Aim: to improve mesorectal rescission and to make easier the ultra low colo-rectal anastomosis. Project: Laparoscopic left hemicolectomy was performed with classical approach. Then the single port device was fixed to the anus verge to create the pneumoperitoneum. Fullthickness section of the rectal mucosa 4 cm above levator layer allowed us to enter in the pelvic space. After mesorectal dissection we reached the abdominal cavity. Hand-sewn ultra-low colo-rectal anastomosis was performed through the anus. Results: The post operative course was uneventful. The patient was discharged in 5 day in good general conditions. Histological findings revealed pT2N0 (0/22) for the sigmoid cancer and pT1N0 (0/15) for the rectal cancer.

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Influence of pH, Dose Volume, Human Pancreatic Juice and Bile on 64CU Absorption From the Rat Closed Duodenal–Jejunal Loop

A Method for Measuring Copper Absorption Using a Short-Lived Isotope (64CU)

P.R.S. Tasker, J.M. Braganza, H.L. Sharma, M. Case Manchester Royal Infirmary, Swansea, United Kingdom Background: Rat pancreatic juice (P.J.) inhibited 64Cu absorption in the rat closed duodenal-jejunal loop against isotonic saline control. Aim: The same loop was re-examined by testing for pH influences and by repeating the 64Cu 2 h instillation using human P.J. (from a patient with a fistula) and human gall bladder bile. Project Description: Using antimony electrodes to measure resting pH values in the loop lumen, the influence of instillations of single-shot alkaline and acid buffers was examined. After finding an influence of dose volume, the loop procedure was adjusted. Preliminary Results: Due to a strong alkaline tide single-shot test solutions had only transitory effect on pH. 64Cu absorbed related to the extent of loop filling. Using the modified loop, 64Cu absorption at one ml was twice that at 0.5 ml. Higher volumes showed no further increment. Diluted human bile decreased 64Cu absorption by 62 % but P.J. from the patient did not.

P.R.S. Tasker, J.M. Braganza, H.L. Sharma Manchester Royal Infirmary, Swansea, United Kingdom Background: In chronic pancreatitis (CP) more copper was secreted in the bile. Aim: To measure copper (Cu) absorption in volunteers. Project Description: Non-caeruloplasmin (Cp)-64Cu in the serum was separated absorbed onto charcoal column. After an oral dose of the isotope 250 lCi, a plasma appearance curve for Non-Cp 64 Cu was constructed over 10 h. On a separate occasion, 125 lCi 64Cu was injected. 64Cu absorption was deduced by deconvolving oral serum non-Cp 64Cu appearance curve from IV disappearance component. Preliminary Results: Eight normal subjects (five men and three women) absorbed 40.8 ± 9.5 % (Mean ± S.D.) (Range 24.3 to 53.7. 64Cu absorption from 350 ml water plateaued at ten hours; 50 % absorption in 1 hours, and 95 % in 7 hours. 64Cu absorption from 350 ml 7.14 % casein was 31.4 % (male) and 32.1 % (OC- female). No absorption presented in the first 1-h, 50 % in 3.4 h and 91 % in 7-h.



The Influence of pH in Proximal Small Bowel Perfusion on 64CU Absorption in Anaesthetised Rats

LigaSure Maryland: A New Approach in Colorectal Laparoscopic Surgery

P.R.S. Tasker, J.M. Braganza, H.L. Sharma, M. Case

M.A. Zappa, C. Musolino, E. Giorgini, A. Porta

Manchester Royal Infirmary, Swansea, United Kingdom

Fatebenefratelli Sacra Famiglia Hospital, Erba (Como), Italy

Background: In the rat, pancreatic juice inhibited 64Cu absorption in the closed duodenojejunal loop. Pancreatic insufficiency increased liver copper and pancreatic extract reversed this. Aim: To investigate the influence of intraluminal pH. Project Description: The loop, with pancreatic-biliary duct ligated, was opened, and perfused for two hours at different pH levels. Firstly a pH-stat re-circulation technique on single rats and then a triple rat buffered single pass system were used. Preliminary Results: Method one: 64Cu retention was 36.61 (±5.61) % (n = 6) (% body count per g perfusate count) at pH 6 and 22.98 (±3.09) % (n = 4) at pH 8 (Mean ± SD). Method two, using a MOPS, MES and HEPES (MMH) buffer with glucose, liver 64Cu retention was 33.95 (±7.84) % (n = 7) at pH5, 28.02 (±5.02) % (n = 3) at pH 6, 20.54 (±3.65) % (n = 5) at pH7, and 16.43 (±3.60) (n = 7) at pH8. The more acid the luminal pH the more copper was absorbed.

Background: our department has been chosen to prove the validity of a new technological tool in laparoscopic colorectal surgery. Ligasure Maryland allows enhanced blunt dissection, improve tip visualization, reduce instrument exchanges. This device is not yet available for sale. Aim: to optimize outcomes in laparoscopic surgery, to reduce complications peri-and postoperative. Project: Laparoscopic colorectal surgery was performed using the LigaSureTM Maryland. LigaSureTM Maryland jaw combines one-step sealing with the functionality of a Maryland dissector, atraumatic grasper and cold scissors. In this surgery this instrument has proved to be efficient, versatile, multifunctional. Results: LigaSureTM Maryland in our experience has been shown to significantly reduce operative blood loss, procedure time, length of hospital stay.

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VerisetTM, A Novel Haemostatic Patch, can be Easily Applied and Achieves Complete Haemostasis in Laparoscopic Liver Resection - A Preclinical Trial

Recurrent Giant Adrenal Cyst: Simpler Laparoscopic Technique

P. Schemmer1, K. Howk2, J. Fortier2 Ruprecht-Karls-University, Heidelberg, Germany; 2Covidien, Mansfield, United States of America

J.S. Deed, T. Sathis Kumar, M Sadoon, I. Gujaral, M S.Al Hossni, T. Husain Zulekha hospital, Sharjah, United Arab Emirates

1

Aim: The control of bleeding remains a challenge after laparoscopic liver resection. VerisetTM haemostatic patch recently received CE Mark for use in both open and laparoscopic solid organ and soft tissue procedures. This study was designed to test its performance when applied laparoscopically. Methods: Twelve pigs underwent laparoscopic liver resection. VerisetTM patch (5 cm 9 10 cm) was delivered via a 10-mm trocar and compared to similar delivery of the control, SurgicelTM Nu-KnitTM Absorbable Haemostat (7.6 9 10.2 cm). Haemostatic efficacy, device handling, and performance were assessed. Results: The median time to haemostasis was 2 minutes after VerisetTM patch application and 3 minutes after the control. At second-look laparoscopy, both devices were present. VerisetTM patch remained adhered to the resection site in 8/8 (100 %) cases, but the control was not adhered in 2/4 (50 %) cases. Handling and performance satisfaction for VerisetTM patch was rated higher than the control.

Background: The location of adrenal in close proximity to vital vascular structures and partial overlap by liver makes its surgery technically demanding. 60–70 % cysts of adrenal are pseudocysts which most commonly present with pressure effects due to size. Aim: To demonstrate simple laparoscopic technique for handling giant right adrenal cyst. Project Description: 36 years Nigerian female presented with cough, right upper quadrant heaviness and aspiration attempted 1 year back. Radiological workup showed 13 cms cyst with likely origin from right adrenal. Diagnostic aspiration suggested benign nature. Laparoscopic right adrenalectomy with cystectomy was done and following modifications made technique simpler: Per-operative aspiration made available working space (initially obscured due to massive size), dissection from inferior vena cava and liver simpler and provided access to planes between surrounding structures. Use of ultrasonic shears and vascular clips Preliminary Results: Uneventful recovery, early discharge and unremarkable 6 months follow-up. Technique uncomplicated and possible routine application.



Liver Retraction with Versalifter BandÒ for Single Port and Multiport Gastric Bypass And Sleeve GastrectomyProspective Pilot Study

Reduced Port Cholecystectomy: Better Triangulation J.S. Deed1, V. Sabharwal2, P. Bhatia3, A. Chauhan4 Zulekha hospital, Sharjah, United Arab Emirates; 2Jeewan Mala Hospital, Delhi, India; 3Sir Ganga Ram Hospital, Delhi, India; 4BLK Super speciality hospital, Delhi, India 1

R. Zorron, C. Bothe, E. Junghans, T. Junghans Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany Background: Retracting the liver in bariatric surgery is a crucial part and often represents the need for a second assistant or an expensive retractor. Aim: No-trocar liver retraction using VersaLifter BANDÒ may overcome the difficulties in retracting voluminous livers by a single application at the beginning of the procedure. Project Description: All patients from both genders with body mass index (BMI) between 41–55 Kg/m2 with indication for bariatric surgery were prospectively documented. Instead of usual retraction, the device was applied in two points of the anterior parietal wall of the abdomen and stretching the band under the left lobe of the liver. Preliminary Results: BAND-Technique was performed in all cases without using a trocar for liver retraction or conversion. Mean op-time was 119 min for LSG and 144 min for LRYGB. Postoperative leak was observed in one patient. The novel system showed feasibility and safety, allowing reduction of surgical ports in bariatric surgery.

Background: Few challenges of reduced port surgery are loss of triangulation, crowding and swording of instruments, inadequate retraction and exorbitant cost of instrumentation Aim: To demonstrate inexpensive, innovative technique to overcome challenges of reduced port surgery Project Description: Reduced port cholecystectomy with following setup: -Umbilicus accommodated a 10 mm and a 5 mm instrument (camera/dissector/clip applicator) -Optional percutaneous mini-instrument (1.8 mm) on right side for fundal retraction -Puppeteering suture- entry through epigastrium- figure of eight around Hartmann’s pouchexit through right side at level of umbilicus. It’s essential roles are: -Provide triangulation without extra instruments hence avoid swording and crowding-Anterior and inferior retraction (rather than superior) of Hartman’s to open the Calot’s triangle for dissection-Dynamic movement of Hartman’s to allow alternate anterior and posterior dissection-Firm counter-traction of Hartman’s to allow precise dissection-Maintain reduced port strategy without additional ports Preliminary Results: 67 patients, mean operative time 53 minutes, no complications, one year followup- satisfactory. Simple technique, easy to reproduce

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P092 - Anaesthesiology


Effects of Depth of Neuromuscular Blockade and Insufflation Pressure on Surgical Conditions: Study Rationale and Design

Curare Free Anaesthesia for Laparoscopic Cholecystectomy

J. Rosenberg1, M. Blobner2, J. Mulier3, N. Rahe-Meyer4, T Woo5, P. Grobara6, M. Li5, A. Szegedi5 1

Herlev Hospital, University of Copenhagen, Herlev, Denmark; Klinik fu¨r Anaesthesiologie der Technischen Universita¨t Mu¨nchen, Munich, Germany; 3AZ Sint Jan Brugge-Oostende, Bruges, Belgium; 4 Franziskus Hospital Bielefeld, Hannover Medical School, Bielefeld, Germany; 5Merck, Whitehouse station, United States of America; 6 MSD, Oss, The Netherlands 2

Aims: The purpose of this pilot trial is to investigate the potential benefits of sustained deep neuromuscular blockade (NMB) on surgical conditions during laparoscopic surgery. Reports suggest that sustained deep NMB may allow use of lower insufflation pressures, with potential benefits including increased abdominal wall muscle relaxation, fewer involuntary patient movements, and reduced post-operative pain. Sustained deep NMB may also provide a clearer visual field with increased ease of surgical access and manipulation, and facilitation of closure. Deep NMB may be reversed at any time with sugammadex, a selective relaxant-binding agent, which rapidly reverses rocuronium- and vecuronium-induced NMB. Methods: This randomised, controlled, parallel-group, blinded trial (NCT01728584) will compare use of deep (targeted 1–2 post-tetanic counts [PTC] [range: 1–5 PTC]) or standard (targeted trainof-four [TOF] ratio 10 % [range: TOF count 2–3 to TOF ratio 20 %) NMB, in combination with low (starting at 8 mmHg) or standard (starting at 12 mmHg) insufflation pressure. Approximately 120 male and female patients, aged = 18 years undergoing laparoscopic cholecystectomy will be enrolled. Rocuronium will be given for tracheal intubation and NMB maintenance. The anaesthesiologist will ensure the surgeon remains blinded to the NMB depth and insufflation pressure applied. At end of surgery, NMB will be reversed with sugammadex 2 or 4 mg/kg, according to depth of NMB. Primary endpoint is the surgeon’s overall satisfaction with the surgical conditions as rated at end of surgery using a numerical scale from 0 (poor, needs intervention) to 10 (excellent). Key secondary endpoint is the patient’s overall reported pain within 24 h, also measured by a numerical scale from 0 (no pain) to 10 (severe pain). Endpoints will be analysed using Analysis of Variance, including factors depth of NMB, level of insufflation pressure and surgeon; with gender added for the pain analysis. Post-operative consumption of analgesics will be assessed. Results: The first patient was randomised in January 2013. The study is ongoing at 11 sites, with 76 patients enrolled as of November 2013. Conclusions: This pilot trial should help identify potential surgical benefits of combining deep NMB with low insufflation pressure in patients undergoing laparoscopic procedures.

G. Armellin, F. Agresta ULSS 19 ADRIA (RO), Adria, Italy Aims: The administration of neuromuscular blocking drugs (NMBDs) may cause residual paralysis that is associated with potential morbidity and the reversal of neuromuscular blockade, even though is correctly done, is not without risks. During laparoscopic cholecystectomy, however, NMBDs reduce intraabdominal pressure, postoperative pain and allow a better operative theatre. In this study we test the hypothesis that muscle relaxants are not always necessary for laparoscopic cholecystectomy with a ProSeal Laryngeal Mask Airway (ProSeal LMATM). Methods: One hundred-twenty adult patients scheduled for elective or urgent laparoscopic cholecystectomy were enrolled in the study. A Target Controlled Infusion general anaesthesia was used. ProSeal Laryngeal Mask Airway was inserted and pressure-controlled ventilation mode was used. Peak airways pressures were recorded before and during the pneumoperitoneum. Peritoneal insufflation pressure was kept between 10 and 12 mmHg. Low dosages NMBDs were used if the pressure-volume curves revealed an obstructive pattern, despite adequate level of anaesthesia or if the surgeon requested a better relaxation of the patient. Results: Surgical conditions were good in every case but in 12 patients (15 %) who needed a mild curarization. Mean peak airway pressure before pneumoperitoneum was 14.6 ± 3.2 cm H2O while during pneumoperitoneum was 19.9 ± 4.3 cm H2O. Nausea and vomiting were present in 18 patients (15 %). None of the patients had clinical evidence of aspiration. Conclusions: Avoiding tracheal intubation has many potential advantages. In this study ProSeal LMA permitted an adequate ventilation and good operative conditions for laparoscopic cholecystectomy. 15 % of the patients needed a mild curarization mostly for the difficulty to create a good operative theatre. At the end of the operation we always showed a very smooth emergence from anaesthesia without laryngospasm, cough and desaturation. In the postoperative period the incidence of nausea and vomiting was low.



Anesthesia Via Sevofluranum with Prolonged Epidural Blockade Decreasing Complications During and After Laparoscopic Sanitation in Patients with Abdominal Sepsis

Intermittent Propofol Sedation for Intragastric Balloon Removal

S.V. Satsuta, R.V. Bondarev

Ahepa Hospital, Thessaloniki, Greece

State Medical University, Lugansk, Ukraine

Objective: The BioEnterics Intragastric Balloon [BIB] has been considered as a safe and effective, less invasive, method for weight loss. However, sedation demands are greater when it is removed, especially upon withdrawal from the stomach. In the present study we describe the type of sedation we used for BIB removal. Patients and Methods: The study included 408 obese individuals treated with a BIB for weight loss who received sedation for BIB removal. They were 119 males/289 females, with a mean age of 39.6 ± 11.26 years, a mean BMI of 36.79 ± 8.1 at the time of removal and a mean ASA score of 2.17 ± 0.45; eighty nine out of 408 suffered from hypertension, 30 from diabetes mellitus, 17 from coronary artery disease, 222 were heavy smokers and 138 out of 408 received long-term medication. The first approach to the patient was on the day of the procedure [physical examination, informed consent], while the procedure took place in the operating theatre. Propofol was used as a sedative, in an intermittent administration manner, the patients being under constant ECG monitoring, pulse oximetry and noninvasive arterial blood pressure measurement, while oxygen was administered via nasal cannulas throughout the procedure. Results: The mean volume of propofol used was 352 ± 152 mg [19.7 ± 5.5 mg/kg BW or 187.9 ± 63.4 lg/kg/min], the procedure lasted 18.7 ± 7.11 min. Twenty one patients [5.14 %] exhibited signs of upper airway obstruction, managed by airway maneuvers with no need to terminate the endoscopic procedure. None of the patients required mask ventilation. All patients had an uncomplicated recovery and were discharged from the hospital within an hour under instructions to avoid driving. Conclusion: Intermittent propofol administration is a safe and effective ‘totally personalized’ means of sedation for intragastric balloon removal.

Aims: Granting of own results of research of efficiency of application of combined general anesthesia with Sevofluranum (stand method) with prolonged epidural blockade (EB) at anesthesiology maintenance of laparoscopic sanitation (LS) at patients with abdominal sepsis (AS). Methods: It is spent prospective, randomized research at 40 patients with AS, the become complicated sharp poured peritonitis. Middle age has made 50 years. Risk of anesthesia for all patients corresponded to the III class to the ASA scale, and was due to the basic pathology. All patients were operate in the conditions of the general balanced combined Sevofluranum anaesthesia with artificial ventilation of lungs: 24 patients (I group) without EB and at 16 patients (II group) the general anaesthesia combined with prolonged EB at level ?h8–9. Preference gave to statement epidural catheter before induction to the general anaesthesia. Used a ‘step-by-step’ induction EB of the 0,5 % solution of bupivacaine entered in small volumes of 2–3 ml with an interval 10–15 min under the constant control the arterial blood pressure and heart rate. Essential fluctuations of hemodynamics and the oxygen status at patients during anaesthesia it was not marked. Average duration of anaesthesia was 45 min. In the postoperative period all patients received comparable intensive therapy according to modern protocols which was invariable throughout all research. Average duration of prolonged EB was 74 hrs. Results: The analysis of results has shown, that at patients of II group, restoration of function of intestines occurred appr on 24–30 hrs earlier, provided optimum intra- and postoperative analgesia, did not demand appointment of opioids and also allowed to carry out painful manipulations (bandaging, change of drainages, catheters etc.). Conclusions: General Anesthesia with Sevofluranum with prolonged EB is an optimum component of anesthesiology maintenance and postoperative intensive therapy of laparoscopic sanitation at patients with abdominal sepsis.

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K. Kotzampassi, V. Grosomanidis, B. Fyntanidou, G. Stavrou, K. Kotzampassi

Surg Endosc

P096 - Basic and Technical Research


Study on The Efficacy of Adhesion Preventive Materials in Experimental Models of Laparoscopic Surgical Adhesion

Increased Intra-Abdominal Pressure Induces Kidney Dysfunction in Experimental Model of Heart Failure: Nephroprotective Effects of Phosphodiesterase-5 Inhibition

M. Ito Fujita Health University, Aichi, Japan Objective: A comparative study using experimental animal models was conducted on the efficacy of adhesion preventive materials for the prevention of adhesion in laparoscopic surgery. Subjects and Methods: After bilateral cornual resection had been performed laparoscopically in young female pigs, they were divided into 6 groups according to the following treatments applied to the stumps to compare the effects of adhesion preventive materials among the groups: no adhesion preventive material (control), oxidized cellulose (TC7), liquid fibrin glue (FG), hyaluronic acid sheet (HC/CMC), fibrin glue sheet (TO193), and combination of TC7 and FG. On the 14th postoperative day, second-look laparotomy was performed to evaluate adhesion formation at the right and left uterine horn stumps. For evaluation of adhesions, an adhesion scoring system that we developed (Adhesion Score-I; AS-I) and the established adhesion scoring system (revised version by Diamond et al. 1984; AS-II) were used. Results: In the control group, adhesion of organs around the uterus, such as the bladder and intestine, was observed in all animals, and the mean AS-I and AS-II were 5.5 and 9.5, respectively. Postoperative adhesion formation in the TC7, FG, and TO193 groups was lower than that in the control group, and the mean AS-I and AS-II were, respectively, 2.0 and 7.8 in the TC7 group (p \ 0.05), 0.7 and 1.3 in the FG group (p \ 0.05), and 1.8 and 3.8 in the TO193 group (p \ 0.05), showing significantly reduced adhesion formation. The mean scores in the HC/CMC group were 4.8 and 10.5, respectively, showing no significant difference from the control group. Moreover, the mean scores in the TC7 + FG group, in which a combination of adhesion preventive materials was used, were 3.2 and 13.3, respectively, showing no additive effect on prevention of adhesion. Conclusion: TC7, FG, and TO193 were confirmed to have an adhesion preventive effect, and the effect was especially pronounced in FG. In this study, no adhesion preventive effect was obtained with concomitant use of TC7 and FG, or use of HC/CMC.

W. Abboud1, Z. Abassi2, N. Abu-Saleh2, H. Awad2, B. Bishara1, W. Abboud1 1

Rambam Health Campus, Haifa, Israel; 2Technion.IIT, Haifa, Israel

Background: The deleterious effects of elevated intra-abdominal pressure (IAP) on the kidneys are widely recognized in abdominal compartment syndrome, visceral edema and laparoscopic surgery. Previously, we demonstrated that rats with congestive heart failure (CHF) exhibited exaggerated sensitivity to the adverse renal effects of elevated IAP compared with sham controls. Aims: In the present study we tested whether IAP induces acute kidney injury (AKI), and whether phosphodiesterase-5 (PDE5) inhibition ameliorates the adverse renal effects of elevated IAP in rats with CHF. Methods: Following a baseline period, rats with high- and low-output CHF induced by the placement of aorto-caval fistula or LAD ligation, respectively, and sham-controls were subjected to consecutive IAPs of 7, 10, or 14 mmHg for 45 min each by CO2 insufflation. Urine flow (V), Na+ excretion (UNaV), glomerular filtration rate (GFR), renal plasma flow (RPF) and NGAL excretion were determined. The effects of pretreatment with Tadalafil (10 mg/day, PO) on the adverse renal effects of elevated IAP were examined in these rats. Results: While IAP of 7 mmHg in sham-controls did not affect V, UNaV, GFR and RPF, IAPs of 10 and 14 mmHg produced dose-dependent reductions in these parameters. Basal kidney function and renal hemodynamics were lower in both low- and high-output CHF rats. When subjected to 10 and 14 mmHg, CHF rats exhibited exaggerated declines in V, UNaV, GFR, RPF and increased NGAL excretion compared to sham controls. Pretreatment with Tadalafil ameliorated the deleterious renal effects of high IAP in both CHF models. Conclusions: Rats with CHF are vulnerable to the adverse renal effects of pneumoperitoneum. Tadalafil abolishes renal dysfunction and AKI induced by high IAP, supporting a therapeutic role for PDE5 inhibition in laparoscopic surgery in CHF states.



Evaluation of Intracorporeal Knotting and Metallic Clipping of the Appendicular Stump in Laparoscopic Appendicectomy

Complications Caused by Laparoscopic-Assisted Double-Stapling Technique Anastomosis at Our Department

H. Abou Ashour, M.S. Ammar, M. Abd El Samie, A.A.H. Zein Eldin

K. Kure, K. Honzyo, R. Ichikawa, H. Ro, S. Itou, J. Aoki, R. Takahashi, Y. Okazawa, K. Mizukoshi, M. Kawai, K. Takehara, S. Munakata, Y. Tashiro, K. Niwa, S. Ishiyama, K. Sugimoto, M. Takahashi, Y. Yaginuma, Y. Kojima, M. Michitoshi, A. Atushi, Y. Tomiki, S. Kazuhiro

Minoufiya Faculty of Medicine, Shibin al kom, Egypt Background: Laparoscopic appendicectomy has gained popularity specially among laparoscopic surgeons due to the advantages of minimal access surgery and simplicity of the technique. Together with endoloop, Various techniques are tried to secure the base of the appendix. Some laparoscopic surgeons apply ligature or clips owing to its lower cost and feasibility. In this study we applied intracorporeal ligature (knotting) or metallic clips for secure closure of the base of the appendix during laparoscopic appendicectomy. Aims: of the work: Evaluation of the application of both techniques, together with recording of any specific complications related to each. Material and Methods: Through the period from Feb. 2010 to Nov. 2013, in Minoufiya university hospital and other private hospitals, 200 laparoscopic appendicectomy patients were included in this prospective study. 117 patients were females and the average age was 27.4 years. Patients were divided into 2 equal groups (A and B), group A were those who underwent intracorporeal knotting of the base and group B where metallic clip closure technique was the alternative. Results: The mean operative time in group A was 45 min and 37 min in group B (p \ 0.05). The mean hospital stay in group A was 2.07 days and group B was 2 days and was not significant p [ 0.05. Complications varied between port site wound infection, delayed intestinal sounds and there were no significant differences or major complications. Conclusion: In our study, both intracorporeal knotting and metallic clip closure technique were successful, feasible and economic in securing the appendicular stump, except for wide, severely edematous or gangrenous base where metallic clip closure technique was not appropriate.

Juntendo University, Faculty of Medicine, Tokyo, Japan Introduction: Laparoscopic-assisted surgery for colorectal cancer is becoming more common with increasing numbers of colorectal cancer cases and advances in surgical techniques including stapled anastomosis. Here, we will report on our investigation of complications caused by double-stapling technique (DST) anastomosis at our department. Subjects: Of 991 patients who underwent laparoscopic-assisted colorectal cancer resection over the period from December 1993 through December 2013 at our department, we investigated the 435 (43.9 %) cases that underwent internal DST anastomosis. Results: DST-related intraoperative complications were noted in 27 (6.2 %) cases. These complications were caused: by anal side digestive tract transection operation in 6 cases; when connecting the anvil to the instrument in 6 cases; during DST anastomosis in 6 cases (uncut cases caused by CS: 4 cases); and after DST anastomosis in 9 cases. These complications were treated by changing the anastomosis technique (e.g. end-to-side anastomosis) or, for uncut cases, by methods such as transanal transection of the uncut section under direct vision. Moreover, at our department, when the anastomosis region is near the peritoneal reflection, the site is confirmed endoscopically and a leak test is also performed. Of the 103 (23.7 %) cases that underwent the leak test, 1 case was positive and therefore underwent ileostomy. No postoperative complications were observed in any of the 27 patients who suffered intraoperative complications Conclusions: We found that many of the complications that occurred during endoscopicassisted DST anastomosis were caused by intraoperative fire operations. Our results suggested that in addition to being well-versed in handling the stapling device, it is important that physicians select appropriate anastomosis techniques that place less burden on the anastomosis site and use methods such as endoscopy to confirm the anastomosis site.

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Technical Safety in Usage of the Laparoscopic Coagulating Shears

The Pneumoperitoneum Establishment: A Critical Review

T. Kubota, Y Izumiya, D. Ichikawa, S. Komatsu, K. Okamoto, H. Hitoshi, A. Shiozaki, H. Konishi, M. Nakanishi, Y. Kuriu, H. Ikoma, Y. Murayama, R. Morimura, C. Sakakura, E. Otsuji Kyoto Prefectural University of Medicine, Kyoto, Japan Background: In recent years, the progress in an energy device is remarkable with the spread of laparoscopic surgeries. Now, use of laparoscopic coagulating shears (LCS) became an indispensable device for gastrointestinal surgery. However, when you are unfamiliar to use of it or depend on its function too much, unexpected damage could be occurred. Objective: To grope how to use of LCS for technical safety. Materials and Methods: We used Harmonic scalpel as a LCS (Johnson and Johnson, Cincinnati, OH, USA). Experimental procedures were performed in accordance with ‘Guidelines for proper conduct of animal experiments,’ prepared by the Science Council of Japan. I) Measurement of temperatures; when cutting a living tissue (pig’s mesentery) by LCS extracorporeally, time-dependent change of the tissue temperature was measured by various conditions and parts. II) Intravascular pressure test; coagulating and cutting of the blood vessel was carried out in various conditions, and the strength of sealing was evaluated by measuring the intravascular pressure. Results: I) When we measured the change of tissue temperature around the tip of LCS during activation, it was 40–50 degrees for 4 sec after the beginning of coagulation, but, after that, it became 70 degrees at the maximum power. At the intermediate power, it reached 80 degrees 8 sec after the beginning of coagulation. At that time, the temperature right near the active blade was over 100 degrees. II) When coagulating and cutting blood vessels, the bleeding did not occur even if it cut it by insufficient hold. In the intravascular pressure test, the strength of vessel sealing was higher in incompletely exposed vessels than in incompletely exposed vessels. Also, when sealing the vessel doubly, it was found that the strength of double sealing vessel was rather weaker than single sealing vessel and breakthrough bleeding occurred if the activating time at the proximal part of the double sealing stump was too long. Conclusion: We surgeons should understand the characteristics of the LCS enough and pay careful attention to heat damage.

P101 - Basic and Technical Research Laparoscopic Plasticity of Trocar’s Hernias A.V. Pepenin, I.V. Ioffe, A.V. Alekseev, N.A. Pepenin State Medicla University, Lugansk, Ukraine Aims: To estimate results of use laparoscopic IPOM plastics at patients with trocar hernias. Methods: There were two groups of patients. First group: 15 patients whom used the laparoscopic IPOM plastic. Second group: 25 patients whom used the ‘open’ plasticity of hernial gate is cases of trocar’s hernias. At laparoscopic IPOM plastic of trocar’s hernias we used the composite meshes Proceed, Physiomesh (Ethicon). At ‘open’ methods applied the Ultrapro meshes (12 patients) on sublay technique and Parietex composite (13 patients) on IPOM technology. Results: According to our clinic, the greatest number the trocar’s hernias is formed at overumbilical access. At our patients the trocar’s hernias at subumbilical access we didn’t observe. The average duration of operation time at sublay plasticity made 45 ± 5 min., the main expenses of time left on preparation of a place for implantation of a mesh. At ‘open’ IPOM – 30 ± 5 min, the main expenses of time left on mesh fixation. At laparoscopic IPOM -15 ± 4 min, the main expenses of time left on adhesiolysis. At an assessment of technical aspects of performance of operations we came to conclusion that at ‘open’ techniques the main difficulties take place at a stage of a dissection of abdominal layers and mesh implantation. At laparoscopic IPOM the main difficulties can arise at adhesiolysis. The postoperative period in the first group was much easier due to the lack of a pain syndrome. Complications in the first group weren’t. The stationary period was 3–4th days. Conclusions: At the trocar hernias of M2W1 expedient to use to IPOM plastic. In comparison with other methods of plasticity, this technology is more simple, reduces time of operation and terms of stay in a hospital, makes to easily the postoperative period, doesn’t cause wound complications.

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G.L. Baiocchi1, D. Prando2, N. Agresta2 1

University of Brescia, Italy; 2Adria Hospital, Adria, Italy

Since it represents the first step in any laparoscopic procedure, the technique of pneumoperitoneum establishment and optical trocarinsertion has been subjected for longtime to study and debate. The main 3 techniques available are the open laparoscopy (OL), the Veress needle laparoscopy (VN) and the direct trocar insertion (DTI) technique. Several major (vascular and visceral injury, gas embolism and failed entry) and minor (extraperitoneal insufflation, trocar site bleeding, infection and hernia) complications may occur. Many retrospective studies, 29 RCTs, 6 systematic review and 2 Cochrane have addressed this topic. However, owing to some methodological limitations (the main of which is the limited samples as compared to the very low complications rate), a significant difference in major complications has never been demonstrated, even though it appears reasonable that OL and DTI with optical trocar would allow for a lower complication rate and above all for a quicker recognition of the eventual complication; from the available data, OL and DTI have a lower rate of failed entry and extraperitoneal gas insufflation, while DTI is the faster technique. In the present paper, a comprehensive review of the Literature upon this topic is presented, together with an organic revision of access techniques and of their complications.

P103 - Basic and Technical Research Laparoscopic Colectomy for Colorectal Cancer Using Needlescopic Forceps R. Takahashi, S. Ito, R. Ichikawa, K. Kure2, J. Aoki, Y. Okazawa, K. Mizukoshi, M. Kawai, K. Takehara, S. Munakata, K. Niwa, S. Ishiyama, K. Sugimoto, M. Takahashi, Y. Kojima, M. Goto, Y. Tomiki, K. Sakamoto Juntendo University Faculty of Medicine, Tokyo, Japan Aims: The concept of reduced-port surgery has been proposed in laparoscopic surgery. In our department, we have introduced the use of needlescopic forceps in laparoscopic colorectal cancer surgery. We report our clinical experience of laparoscopic surgery using Endo ReliefTM. Methods: The study subjects were 26 patients who underwent laparoscopic colorectal cancer surgery using needlescopic forceps in our department between August 2012 and December 2013. The Endo ReliefTM is new type of needlescopic forceps. The tip of new forceps has the same shape and size as that of conventional 5-mm forceps; however, the forceps have a shaft measuring 2.4 mm in diameter. After the insertion of a camera port (12-mm) at the umbilicus, two 5-mm (or 12-mm and 5-mm) operator ports were inserted through the upper and lower abdomen, and two needlescopic forceps for the assistant surgeon were inserted into the upper and lower abdomen at the opposite side. Results: The surgical procedure was ileocecal resection in 4 cases, right hemicolectomy in 8, partial colectomy in 2, sigmoid colectomy in 4, anterior resection in 3, intersphincteric resection in 3 and abdominoperineal resection in 2. Needlescopic forceps were used for direct puncture in 14 cases and via a 3.5-mm trocar in 3. There was no complications due to using the needlescopic forceps. All surgical procedures using the needlescopic forceps were performed safely and without the change the needlescopic forceps for the conventional 5-mm forceps. Conclusion: The End ReliefTM has cosmetic and less painful advantage, because the skin damage is only 2.4 mm in diameter, and it can be used without a trocar. The needlescopic forceps is strong to keep the grasping tissues. However, the shaft is easy to bend just a little, when the heavy tissues such as the mesorectum are lift up. Needlescopic forceps are feasible of reduced-port surgery for non-obese colorectal cancer patients.

Surg Endosc



Transanal Natural Orifice Specimen Extraction for Laparoscopic Colorectal Surgery

A Direct Measure of Copper Absorption in Heathy Volunteers

J.S. Hsieh, C.J. Huang, H.M. Chan, T.J. Huang

P.R.S. Tasker, J.M. Braganza, H. Sharma Manchester Royal Infirmary, Swansea, United Kingdom

Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Aims: The technique of transanal natural orifice specimen extraction (NOSE) following laparoscopic resection for colorectal cancer has been used to evaluate the safety and effectiveness for extracting the surgical specimen. Methods: Patient selection for transanal specimen extraction and intracorporeal anastomosis was based on the tumor size and distance of rectal lesions from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed. A rectoscope (Karl Storz, Tuettlingen, Germany) used for transanal endoscopic microsurgery was convenient for NOSE procedure. Results: Laparoscopic resection with NOSE was successful in all of the 22 patients. Median operating time was 178 min (range, 130–250 min) and the mean length of hospital stay was 6.5 d (range, 2–15 days). One patient had postoperative ileus resulting in a prolong hospital stay and another had trocar site infection. There were no postoperative complications or surgery-associated death. The mean size of the lesion was 3.1 cm (range, 2.2–6.2 cm), and the mean number of harvested nodes was 16.3 (range, 10–25). During a mean follow-up period of 14 months, there were no functional disorders associated with the transanal specimen extraction. Conclusion: Ttransanal extraction in laparoscopic colorectal surgery is a safe and effective procedure. Natural orifice specimen extraction prevents possible incision-related morbidity.

Aims: A computer-assisted deconvolution method was used to study 64Cu absorption in healthy volunteers on their habitual diet. This group of twelve adults comprised of six men and six women, three of whom were on oral contraceptives (OC +). Method: All subjects had stopped ingestion of any meal after 6 p.m. the previous day. After an overnight fast, oral 64Cu in 350 ml of water was imbibed and an appearance curve was constructed from the non-caeruloplasmin 64Cu serum activity in sequential blood samples over 10 h. After subtraction of 64Cu-caeruloplasmin from total sample activity, the noncaeruloplasmin-64Cu data were normalised. On a separate occasion, after injected 64Cu, a disappearance curve was similarly constructed. A deconvolution program was used to separate the disappearance component of non-caeruloplasmin 64Cu from the oral appearance data. Results: The mean 64Cu 10-h absorption (±SD) for a single subject validation tests was 44.3 (±8.4) % (n = 9). Cumulative 10-h absorption for all twelve subjects was 43.7 (±10.2) %. With no evidence to support copper absorption from the stomach in man, variation in the initial peak after oral 64Cu and delay in caeruloplasmin rise seemed to relate to the influence of gastric emptying on absorption. With 50 % occurring in first 1 h and 94 % by 7 h, the 10 h cumulative 64Cu reached a plateau. Excluding OC + subjects, 64Cu absorption was 42.3 (±9.7) % (Mean ± SD) (n = 9), and serum copper and caeruloplasmin, 64Cu-caeruloplasmin synthesis and 64Cu urinary excretion were all similar suggesting equivalent copper status in spite of preparation on their habitual diet. Conclusion: Because of venous sampling on each arm of the test balanced out the influence of copper status, this study reflected directly the influence of mucosal copper status. The mean absorption for male 44.2 (±8.6 %) and female 43.1 (±12.4 %) subjects did not differ except in the greater variance of the female group. Without oral contraceptives (OC +) data. These studies further affirmed the reliability of this method in the measurement of accumulated 64Cu absorption with time. Ten hours was sufficient time for the curve to plateau and appeared to qualify completed absorption in subjects starved overnight.



A Method for Measuring Copper Absorption Using a Short-Lived Isotope (64CU)

The Learning Curve: An Optimal Model for Pancreatic Surgery

P.R.S. Tasker, J.M. Braganza, H. Sharma Manchester Royal Infirmary, Swansea, United Kingdom

S. Tyutyunnik1, I.E. Khatkov1, V.V. Tsvirkun1, R.E. Izrailov1, S.A. Domrachev2, A.O. Atroshchenko1, I.Y. Feydorov1 1

Moscow Clinical Scientific Center. MSUMD, Moscow, Russia; Moscow state university of medicine and dentistry, Moscow, Russia

2 64

Aims: Clinical studies were carried out to validate the measurement of Cu absorption by a computer-assisted deconvolution. Method: After an oral dose of 64Cu (250 lCi), a plasma appearance curve was derived over 10 h from sequential blood samples. On a separate occasion after an injected dose of 64Cu (125 lCi), a plasma disappearance curve was similarly constructed. To remove the caeruloplasmin component in each curve, serum samples after counting were mixed in solution with sodium diethyldithiocarbamate and passed through activated charcoal columns; this separated non-caeruloplasmin-64Cu from 64Cu-caeruloplasmin contained in the eluate. Serum activity not bound to caeruloplasmin was determined by subtraction of the weight-corrected activities of 64Cu-caeruloplasmin from the complete sample. Both curves of non-caeruloplasmin data were normalised to relate the data to the same dose level. Deconvolution of this data determined cumulative 64Cu absorption. Subjects had to be on their habitual diet for three days prior to test. Their last meal had to be taken before 6 p.m. Overnight starvation preceded both I.V. and oral tests. The dose was delivered at 9.00 am the next day. Results: Column validation tests consisted of quantitative elution of caeruloplasmin, full adsorption of non-caeruloplasmin bound 64Cu, and protein spectrum in the eluate, which was unaltered. Unless 64Cu-caeruloplasmin was present practically no activity would appear in the eluate using either plastic (containing more than 130 mg charcoal) or the glass columns (containing more than [ 200 mg charcoal). In one subject (investigator data), three oral tests against three I.V. tests: Oral 1/I.V. 1 (1,1) = 51.17 % against I.V. 2 (1,2) = 52.44 % against I.V. 3 (1,3) = 46.41 % Mean ± S.D. = 50.0 ± 3.2 Oral 2 (2,1) = 50.30 % (2,2) = 51.71 % (2,3) = 45.75 % Mean ± S.D. 49.3 ± 3.1 Oral 3 (3,1) = 34.39 % (3,2) = 35.21 % (3,3) = 31.22 % Mean ± S.D. 33.6 ± 2.0 Conclusion: Mean accumulated 10-h absorption with this single subject was the same for first two oral tests. A late evening meal taken prior to the third oral test in spite of overnight starvation reduced absorption.

Background: Learning curve is deemed to be the right tool in representing surgical experience for different laparoscopic procedures. Purpose: To find the most optimal model for laparoscopic pancreatic surgery for patients with benign and malignant tumors of pancreatic head and periampullary area. To figure how many procedures have to be done to get the ‘learning plateau’. Patients and Methods: From January 2007 to July 2013 60 pancreaticoduodenectomies were performed by total laparoscopic approach. The operative time was used as the main characteristic for creating the learning curve. Operative time was counted from the first incision to the last skin stitch. Different linear and non-linear models were used for analysis. For statistical analysis Multiple R-squared, R2, Shapiro-Wilk test, Q-Q Plot and p-value were used. Results: The optimal model for sixty total laparoscopic pancreaticoduodenectomy was found through applying variety of different non-linear models. Main trend in operative time reduction was found initially just with simple linear model. According to the linear model the operative time decreased for 47 min with each 10 LPD procedure. No less than sixty consecutive LPDs have to be done to get the ‘learning plateau’. Shapiro-Wilk test for Wright model: W = 0.968, p = 0.1346. Shapiro-Wilk test for Exponential model: W = 0.9551, p = 0.0337. Conclusion: Learning curve is an efficient way to monitor surgeons’ performance in repetitive procedures.

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P110 - Clinical Practice and Evaluation

Ishaemic Preconditioning as a Protective Method: Against Oxidative Stress Caused by Increased Abdominal Pressure

Endoscopic Surgery in Patients with Pacemakers. Where is the Danger?

A. Leventi1, E. Argyra2, A. Avraamidou2, A. Marinis2, S. Asonitis2, D. Perrea3, D. Voros2, K. Theodoraki2

A.V. Sazhin, T.V. Nechay, A.E. Tyagunov, S.V. Mosin Russian state medical university, Moscow, Russia

1

Medway Maritime Hospital, Gillingham, Kent, United Kingdom; 2 Aretaieion University Hospital, Athens, Greece; 3Medical School of Athens, University of Athens, Greece Aims: Increased intra-abdominal pressure (even at the levels used in laparoscopic surgery) is associated with tissue ischaemia, ischaemia reperfusion injury and oxidative stress. Ischaemic preconditioning (IP) is a method successfully used so far in liver and transplant surgery to attenuate the effects of ischaemia and reperfusion. In this experimental study we tested if IP could modify oxidative stress induced by extremely high intraabdominal pressures in order to test the efficacy of this method in extreme conditions. Methods: Twenty five female pigs were studied in three groups: a control group, a pneumoperitoneum group (pressure of 30 mmHg) and an ischemic preconditioning group (initially subjected to preconditioning of 25 mmHg for 15 min and desufflation for 15 min and then to pneumoperitoneum as in P group). Blood samples were obtained at identical time intervals in the three groups. Total oxidative capacity, total antioxidative capacity and total nitric oxide (NO), Nitrite and Nitrate concentrations were measured. Results: IP was protective by increasing significantly total antioxidative capacity and protective mediators like Nitrite. Although associated with a trend towards lower total oxidative capacity statistical significance was not met. Conclusions: IP increased antioxidative capacity and the levels of protective mediators in a model of intra-abdominal hypertension. The fact that IP was still effective at extremely high pressures, reinforces the interest on this method as a protective tool against oxidative stress associated with increased abdominal pressure, but further studies are needed to clarify its exact mechanism of action and potential clinical applications.

Implanting pacemaker is often regarded as a contraindication to manipulation using monopolar electrocoagulation (ME). Application of ME in endoscopic surgery is inevitable both in endoluminal procedures and laparoscopy. The influence of ME currents on an electronic circuit of the device and problem of myocardial damage as a consequence of heating of the electrode tip by passing current while ME are often contrived and insufficiently studied. Aims: To establish the conditions for the occurrence of the effect of near-electrode tissue heating in poster experiments and in experiments on cadavers, and evaluate the safety of endoscopic and laparoscopic surgery using ME in patients to devise a secure algorithm. Materials and Methods: The temperature effect in near-electrode tissues was modulated In Mathcad. It turned out to be 100 C° in 10 seconds and the impact on the electrode voltage 20 W depth of damage reaches 2.9 mm it is known that damage of cardiomyocytes heated above 50 C° are irreversible. Bench testing were carried out in an electrolyte solution. The bull’s heart with pacemaker and electrodes of coagulator were placed in electrolyte. Several relative positions of the coagulator electrodes with respect to the stimulation electrodes were investigated. ME was performed in different capacities, modes and duration of exposure. Experimentally the possibility and conditions for heating of tissues was confirmed. Subject to developed secure algorithm 70 endoscopic procedures were performed using the ME in patients with pacemaker. There were 20 intraluminal and 50 laparoscopic surgeries. Results: There were no any cardiological complications while and after surgeries. One patient died. No morphological damages of the heart were found on autopsy. Findings: ME can be recommended in patients with pacemaker subject to the algorithm and adequate preoperative examination. Passive electrode plate should be placed in a safe position in accordance with the ME area of application. Duration of exposure should be limited to 3 seconds and 50 watts.



Short-Term Results of Laparoscopic Surgery in Very Elderly Colorectal Cancer Patients

Laparoscopic Versus Open Resection for Rectal Cancer (RA and RB) Based on 10 Year Data: Results of Our Hospital Study in 217 Rectal Cancer Patients

S. Yamagishi, M. Momiyama, Y. Izumisawa, A. Nakano Fujisawa City Hospital, Fujisawa City, Japan Background: Laparoscopic surgery has been shown to improve short-term outcomes compared with open surgery in colorectal cancer patients. However, there are a few reports that describe the efficacy of Laparoscopic surgery in the very elderly population. The aim in this study was to verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in very elderly patients. Methods: The data of the patients who underwent surgical resection for colorectal cancer between April 2010 and December 2012 were retrospectively collected. The clinical backgrounds and short-term outcomes of very elderly patients (80 years of age or older) who underwent laparoscopic surgery (Lap) were compared with those of very elderly patients who underwent open surgery (OS). Results: Of the 48 very elderly patients with colorectal cancer, 20 patients underwent OS and 28 patients had Lap. There were no differences in patient characteristics between the two groups. No patients were converted from laparoscopic to open. In the short-term results, there were significant differences in the amount of blood loss (OS 212 vs. Lap 31.3 mL), duration of surgery (179 vs. 232 min), resumption of a liquid diet (4.4 vs. 3.1 days), number of dissected lymph nodes (15.9 vs. 22.4) and rate of curative resection (75 vs. 100 %). There were no significant differences in the pathological margin, length of postoperative stay (12.4 vs. 10.1 days), and rate of complications (20.0 vs. 16.7 %). Conclusions: Laparoscopic surgery in very elderly colorectal cancer patients did not result in a difference in radical cure compared with open surgery, and the short-term results except the duration of surgery were excellent. It is an effective procedure for very elderly patients with colorectal cancer.

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A. Matsumoto, K. Arita, M. Tashiro, S. Haruki, S. Usui Tsuchiura Kyodo General Hospital, Tsuchiura city, Japan Purpose: The aim of this study was to compare the long-term outcome of laparoscopicassisted (LAP) versus open (OR) resection for nonmetastatic rectal cancer. Materials and Methods: From January 2003 to December 2012 all patients (217 patients) with adenocarcinoma of the rectum (Ra and Rb) were assessed for entry. Adjuvant chemotherapy and postoperative follow-up were similar in both groups. Primary end point was disease free survival and secondary end points were overall survival, complications, variables related to recovery and the quality of life. Results: One hundred and fifty-eight patients entered the study (72 LAP group and 86 OR group). There was a tendency of higher overall survival (St 0: p = 0.1573, NS. St 1: p = 0.9240, NS. St 2: p = 0.0981, NS. St 2A: p = 0.0969, NS. St 2B: p = Inf. St 3: p = 0.1224, NS. St 3A: p = 0.4795, NS. St 3C: p = 0.5828, NS.) for the LAP group. There was a tendency of higher disease free survival (St 0: p = 0.1573, NS. St 1: p = 0.6104, NS. St 2B: p = Inf. St 3: p = 0.0904, NS. St 3A: p = 0.2945, NS. St 3B: p = 0.0868, NS. St 3C: p = 0.4788, NS.) in the LAP group. Overall survival was higher (St 3B: p = 0.0486) in the LAP group. Disease free survival was higher (St 2: p = 0.0473. St 2A: p = 0.0397) in the LAP group. Circumferential resection margin was significantly negative (p = 0.022) in the LAP group. Local recurrence and recurrence rates were significant lower (p = 0.001–0.002) in the LAP group when compared with OR group. Operation time was longer (p = 0.0141) in the LAP group. But blood loss was lower (p \ 0.0001), fluid intake was faster (p \ 0.0001), hospital stay was shorter (p = 0.0056) in the LAP group. The occurrence rates of bowel obstruction and wound infection were lower (p = 0.001–0.012) in the LAP group. There were no differences in resection margin (p = 0.1007–0.6178, NS.), in the rate of anastomotic leakage (p = 0.356–0.824, NS.), in the reoperation rate (p = 0.207, NS.) and in 30-day mortality (p = 0.193, NS.). Conclusions: LAP is more effective than OR in the treatment of rectal cancer.

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Value of a Dedicated Specialist Nurse Practitioner in Implementation of Enhanced Recovery Programme (ERP)

Short-Term Outcome of Laparoscopic Versus Open Surgery for Elderly Colon Cancer Patients

P.K. Dhruva Rao, S. Howells, P. Haray

K. Tsukamoto, N. Matsubara, M. Noda, T. Yamano, D. Yamagishi, N. Beppu, M. Hamanaka, M. Kobayashi, N. Tomita

Prince Charles Hospital, Merthyr Tydfil, United Kingdom Aims: To assess the value of a dedicated Specialist Nurse Practitioner (SNP) in implementation of Enhanced Recovery Programme (ERP) and improving compliance to ERP. Methods: A review of a prospectively maintained database of ERP since introduction in Oct 2010 to Dec 2012 was undertaken. Our default position is to include all patients on the ERP. The database recorded compliance to various aspects of the ERP. Compliance with the Clinic, Preadmissions, Pre-operative, Intra-operative and Post operative elements of ERP was analysed before and after the appointment of a dedicated SNP in October 2011. Based on the percentage of objectives achieved, compliance to the programme were graded as Good ([80 %), Average (50–80 %) and Poor (\50 %). Results and Discussion: A total of 330 patients underwent colorectal operations (88.7 % were laparoscopic) in this time period including 282 major resections. The compliance with the programme has steadily improved since the appointment of the dedicated SNP. With increasing compliance to ERP, the proportion of patients being withdrawn from ERP fell from 46 % to 30 % patients (p \ 0.01) with an ongoing downward trend. Overall length of stay has also improved from a median of 6 days to 5 days although not reaching statistical significance. In addition, the nurse has been able to identify deficiencies in our data recording processes which have been addressed. Conclusion: The appointment of a dedicated SNP has had a positive impact in implementation and monitoring of ERP and with ongoing increase in compliance.

Hyogo College of Medicine, Nishinomiya, Japan Aims: The aim of this study is to compare the short-term outcomes of laparoscopic surgery (LAP) and open surgery (OS) for elderly colon cancer patients in a single institute in Japan. Methods: Retrospectively collected data from 120 patients who underwent curative resection for primary colon cancer aged 76 years or older at Hyogo College of Medicine between January 2008 and December 2012 was analysed. In this study, patients with rectosigmoid cancer were included, but patients with rectal cancer and stage 4 colon cancer were excluded. The patients were divided into LAP and OS group, and compared in the clinical characteristics and post-operative early outcomes between the two groups. Postoperative complications were scored according to the Clavien-Dindo scale (Grade 1 to 5), and the Charlson index was used as a pre-operative comorbidity score. Chi-square test and Mann-Whitney U test were used for data analysis of categorical variables. Statistical significance was set at a p value less than 0.05. Results: Eighty seven patients underwent OS and 33 patients underwent LAP. There was no significant difference either in gender, age, Charlson index, diabetes mellitus, ASA grade, tumor location, surgical procedure and number of dissected lymph node between two groups. Advanced cancer was observed more frequently in OS group (P \ 0.001), however cancer stage was not statistically significant factor influenced post-operative complications. Compared to OS group, hospital stay was significantly shorter (13 vs. 10 days, p \ 0.001), operating time was significantly longer (171 vs. 223 min, p = 0.002) and blood loss was significantly less (140 vs. 35 ml, p \ 0.001) in LAP group. There was no significant difference in post-operative complications according to Clavien-Dindo scale in both groups. Conclusions: In conclusion, laparoscopic surgery can be performed safely in elderly patients with colon cancer.



A Simple and Effective Method of Applying Tachocomb (TachoShil) to Uncontrollable Bleeding in Laparoscopic Surgery

Review of Obturator Hernia-Retrospective 10-Year Study in a Single Institution

Y. Miura, N. Toyota, S. Shiota, H. Kishimoto

Y.P. Wong, K.F. Wong, S.K. Leung

Masuda Red Cross Hospital, Masuda-shi Shimane-ken, Japan

Tuen Mun Hospital, Hong Kong, Hong Kong

Oozing type bleeding might be easily controlled by simple compression with gauze or coagulation by diathermy but bleeding from vascular injury is a hazard and possibly leads to open conversion. TachoCombR is known to be an effective material for uncontrollable bleeding although adequate insertion method through trocar is not established. We designed an easy and effective way of conveying TachoCombR through trocar and subsequent proper compression. Hemostasis to the pulsating bleeding from the gall bladder bed during laparoscopic cholecystectomy is presented. A small gauze of 15 cm 9 3 cm is folded into 6 layers making a 2.5 cm 9 3 cm piece. The head of the 12 mm trocar is detached and a 5 mm forceps is introduced through it. The folded gauze is put over the TachoCombR of 10 mm square in size and the forceps bites the center of the gauze and the TachoCombR together. After the inside of the trocar is wiped off the blood, the TachoCombR-gauze unit is inserted through the trocar and the head of the trocar is reunited to maintain pneumoperitoneum. The gauze previously put on the bleeding point for compression is promptly replaced by the TachoCombR-gauze unit and that gauze is put over it again for one-minute compression. The bleeding that could not be controlled by simple compression over 50 minutes was resolved by application of this method twice and the compression time required was 2 minutes. In experimental cystic arterial injury in pig, hemostasis could also be achieved by application of this method twice. In this animal lab, TachoShilR was used instead of TachoCombR for supply reason. Insertion and compression with the TachoCombR-gauze unit can be done as a sequence so that fragmentation or dislocation of the TachoCombR is prevented, which is a key to secure hemostasis. This simple method of grasping the hemostatic agents over the gauze requires no special tools and is better tried when open conversion due to bleeding is considered.

Obturator hernia is a rare type of abdominal hernia. It typically affects thin and old lady. Its high mortality is often attributed to the obscure presentation and delayed diagnosis. This article aims to review the diagnosis and management of obturator hernia in our hospital, and to identify factors associated with better survival. Method: We reviewed all patients who were diagnosed to have obturator hernia from 2003 to 2013. Results: A total of eighteen patients were diagnosed to have obturator hernia during the ten-year period. Seventeen (94 %) of them were female, and the median age was 83. The median BMI was 16.1 kg/m2. The commonest presentation was intestinal obstruction (72.2 %), followed by thigh pain (22.2 %). In 55.6 % of patients, diagnosis was made by computerized tomography (CT). For the remaining patients, diagnosis was only made intraoperatively. All patients underwent surgery. The median time from admission to surgery was 3 days. Bowel ischemia was found in 55.6 % of patients. Post-operatively, 27.8 % of patients received intensive care. Post-operative 30-day mortality rate was 38.9 %. One patient suffered from recurrence of the obturator hernia but she refused further surgery. The use of CT, shorter ‘admission to surgery’ time and the absence of bowel ischemia did not correlate with the 30-day mortality. Post-operative intensive unit (ICU) care was the only factor identified to associate with better survival (p = 0.002). Conclusion: Obturator hernia remains a disease entity with high mortality. Post- op ICU care improves survival.

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Laparoscopic Colorectal Surgery Leads To Increased Overall Survival When Compared to a Conventional Open Approach

Important Left Hand Technique for Transabdominal Preperitoneal Inguinal Hernia in Left Inguinal Hernia

P.A. Neijenhuis1, M. Buurma1, M. Reimers2, H.M. Kroon1

Y Ishiyama, Y. Hirano, M. Hattori, Y. Hashizume

1

2

Rijnland Hospital, Leiderdorp, The Netherlands; Leids University Medical Centre, Leiden, The Netherlands Introduction: Over the past decade laparoscopic surgery has become increasingly popular in the treatment for colorectal malignancies. Short-term results are equivocal and skepticism regarding safety is rapidly diminishing. To date however, not much is known about its effect on the long-term outcome. Therefore, we conducted this study to evaluate the impact of a laparoscopic approach on the survival of patients operated in our hospital. Methods: We conducted a retrospective analysis of our prospectively collected colorectal cancer database, including all patients who underwent a resection between 2004 and 2011. Patients were divided into two groups based on surgical technique: an open versus a laparoscopic approach. Peri-operative data were collected as well as follow-up, recurrence rates and survival data. Results: A total of 774 patients underwent a colorectal resection for a malignancy. The open approach was performed in 259 patients and the laparoscopic approach in 515 patients. Rectal cancer patients were also included, 60 abdominoperineal (APR) resections were performed and a total of 165 low anterior resections (LAR). These patients received preoperative (chemo)radiation according national guidelines. Groups showed an equal distribution for pre-operative characteristics. After a median follow-up of four years, multivariate analysis showed a resection performed by a laparoscopic approach as an independent prognostic factor for disease-free survival (hazard ratio [HR] 0.737; 95 %CI 0.55-.099; P = 0.046) as well as for overall survival (HR 0.595; 95 %CI 0.43–83; P = 0.002). Conclusions: In our experience a laparoscopic approach is associated with both an increased disease-free survival as well as a longer overall survival in the multivariate analyses. Therefore, when there are no contra-indications for laparoscopic surgery, surgeons performing colorectal surgery should offer this approach to their patients as the technique of choice.

Fukui Prefectural Hospital, Fukui, Japan Aims: Transabdominal preperitoneal inguinal hernia repair (TAPP), one of the laparoscopic repair procedures for inguinal hernia, enable visualization of the inguinal region on both sides. However, there were little reports in the procedure, especially left inguinal hernia. We report the procedure of the tip in left inguinal hernia. Methods: We performed TAPP in patients with left inguinal hernia by using left hand technique. In this report, we will present an overview of left inguinal hernia with an operative video including how to incise, dissect, and excise by left hand. A laparoscopic approach was performed for inguinal hernia using three-trocar technique. The important tip here is to exposure cooper ligament in TAPP. One is the tip of pulling medial umbilical fold to the inside by right hand. The other point is to dissect the tissues by left hand technique. This technique can control the line direction as to exposure cooper ligament. This technique requires intensive training for example laparoscopic suturing technique by left hand. Results: In this retrospective study the records of left inguinal hernia patients at the Fukui Prefectural Hospital, Fukui, Japan were reviewed. From January 2013 to December 2013, 6 cases were performed by using left hand technique. No case was converted to open surgery. There were no cases intraoperative and postoperative complications or deaths. No recurrence was detected. Conclusions: Although the left hand technique is a technically difficult procedure, we expect to contribute to better quality of life in inguinal hernia patients.



Validation of PNI (Prognostic Nutritional Index) Score in Digestive Tract Cancers

Double Tract Reconstruction After Proximal Gastrectomy, Procedure and Early Clinical Results

M. Khalfallah, A. Sbai, A. Changuel, Y. Chaker, I. Bouasker, R. Nouira, C. Dziri

K. Kobayashi1, K. Kojima2, M. Inokuchi3, K. Kato3, H. Sugita3, S. Otsuki3, A Kamiya3, Y. Sato3, M. Nakagawa3, H. Yanaka3, K. Higuchi3, K. Sugihara4

Hoˆpital Charles Nicolle, Tunis, Tunisia

1

Introduction: Tumor markers such as CA 19-9, CA 125, ACE, and aFP are used as markers for post-operative follow-up and also as prognostic factors for patients suffering from cancer of the GI tract [1]. However, their high cost and their low specificity reduce their preoperative prognostic interest [1]. The immunological and nutritional status of patients influences the post-operative course of patients operated on for a malignant tumor of the GI tract [2,3]. The aim of our study was to validate the PNI for all the GI tract cancers. Material and Methods: This retrospective study collected data from patients operated on for GI tract cancer at the surgical unit B of Charles Nicolle hospital in Tunis between January 1st, 2008 and December 31, 2012. Were included patients aged more than 18 who had been operated on for a cancer of Esophagus, stomach, small intestine, pancreas, colon, rectum and duodenal papilla. Patients suffering from a digestive cancer but non operated on have not been included. Patients with no available albuminemia and/or full blood count were excluded. The main outcome measure was the early post-operative death (within 10 days). The secondary was early post-operative complications. We have performed a descriptive statistical analysis and a ROC curve analysis. Results: 75 women and 102 men were enrolled, with a sex ratio of 1,36. The mean age was 61,9 ± 15. Our study included 65 cancers of the colon, 49 cancers of the rectum, 40 cancers of the stomach, 7 cancers of the pancreas, six cancers of the small intestine and 6 cancers of the ampulla of Vater. Post-operative mortality and morbidity rate were respectively 11,9 % and 23,7 %. The ROC curve allowed us to validate the PNI with a threshold level of 37 (sensitivity 70 %, specificity 76,6 %, positive predictive level 25,8 % and negative predictive level 88,2 %). As concerns digestive cancers separately, we have validate the PNI for the cancer of stomach and colon. Conclusion: We have validated the PNI for digestive cancers and more particularly for the cancer of stomach and colon. PNI is a pre-operative predictive factor of mortality.

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Tokyo Medical and Dental University, Tokyo, Japan; 2Center for Minimally Invasive Surgery, Tokyo Medical and Dental University, Tokyo, Japan; 3Department of Gastric Surgery, Tokyo Medical and Dental University, Tokyo, Japan; 4Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan We will show purely laparoscopic reconstructions after laparoscopic proximal gastrectomy (LPG), and we’ll present it’s early clinical results. Procedure: The anvil of the circular stapler (ECS25) and the tip of the detachable ENDOPSI were inserted into the abdominal cavity from the umbilical wound. The lid was attached to the retractor and re-pneumoperitoneum was done. The gripper of the detachable ENDOPSI was inserted form the left lower port and was attached to the tip of the device. The detachable ENDO-PSI was hung on the esophageal stump, and a nylon 2-0 straight needle was let through the esophagus wall. Stump of the esophagus was cut. The detachable ENDO-PSI was removed from the esophagus. The tip, which was detached from the gripper, was left in the position that does not become the obstacle. The anvil was inserted and fixed to the esophagus using knot pusher. Next, a side-to-side jejunogastrostomy was performed using an Echelon Flex 60 with a 60/3.5-mm blue cartridge. Finally, a Roux-en-Y anastomosis was performed through the mini-laparotomy using Echelon Flex 60 with a 60/2.5-mm white cartridge. The distance between the esophagojejunostomy and the jejunogastrostomy was about 15 cm. The distance between the jejunogastrostomy and the Roux-en-Y anastomosis was about 20 cm. Result: The median operation time was 304 min (236–441); median estimated blood loss, 51.5 mL (0–325); median postoperative hospital stay, 9 days (7–30). Patients resumed an oral diet on postoperative days 3 to 7. The early complications occurred in 2 patients, included 1 case of pancreatic fistula (Clavien-Dindo grade IIIa), 1 case of aspiration pneumonia (Clavien-Dindo grade II). There is no mortality case. Conclusions: We have performed Double tract reconstruction after LPG for 12 cases of proximal cancer lesions. Early results revealed good postoperative course. Its clinical applicability must be validated by mid to long-term results and QOL.

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Clinical Outcomes of Colonic Stenting: Is There a Need for a Colonic Stent Register?

Feasibility of Single-Site Laparoscopic Colectomy for Right-Sided Colon Cancer

L. Swafe, A. Sudlow, R. Lal, V. Velchuru

M. Uemura

James Paget University Hospital, Great Yarmouth, United Kingdom

Osaka University, Osaka, Japan

Introduction: Patients with obstruction secondary to malignancy may benefit from decompressive colonic stenting- either as a bridge to surgery or for palliation of symptoms in those who are not surgical candidates. Aims: The aims were to evaluate the safety, success and outcomes of stenting in a district general hospital. Methods: All patients undergoing stenting from January 2002 to June 2013 were included. Information regarding demographics, indication for stenting, technical success and outcomes (symptom relief, mortality and morbidity) was collected from patient notes. Results: Stenting was attempted in 30 patients with one for bridge to surgery and the remainder for palliation. Average age was 78.3 (range: 58–100) years. Technical success was obtained in 83 % and 11 were done as emergencies. 30-day mortality in stented patients was 24 % (6/25). Complications included two perforations and two cases of stent migration. Symptom relief was clearly documented in 32 % (8/25). Conclusions: The majority of stenting was done for palliation of symptoms, offering good symptomatic relief in a significant proportion of patients not suitable for surgery. Although the procedural success rate was high, it is difficult to evaluate outcomes given the lack of formal follow-up. A national stenting register would allow more detailed analysis of results.

Background: Single-site laparoscopic colectomy (SLC) is an emerging concept that, compared with conventional multiport laparoscopic colectomy (MLC), yields reduced postoperative pain and improved cosmesis. Complete mesocolic excision (CME) is a novel concept for colon cancer surgery that provides improved oncologic outcome. We conducted a prospective case-control study to evaluate the feasibility and safety of SLC with CME for right-sided colon cancer. Methods: Prospectively collected data of patients with stage I-III right-sided colon cancer who underwent SLC (n = 69) or MLC (n = 69) between June 2008 and March 2012 were analyzed. Patients who underwent SLC were, in terms of clinical characteristics and tumor location, matched as closely as possible with those undergoing MLC. Short-term outcomes were compared between the two procedures. Results: Overall perioperative outcomes, including blood loss, number of lymph nodes harvested, length of the resected specimen, and complications, were similar between the two procedures, whereas postoperative pain was significantly lower with SLC. Operation time was significantly shorter in the group treated by SLC than in the group treated by MLC (168 ± 32 vs. 179 ± 32 min, respectively; p = 0.046). SLC was completed successfully in 94 % (65/69) of cases. Conversion rates were 1.4 % (1/69). The umbilical scars were nearly invisible 3 months after the procedure, and most patients reported being quite satisfied with the cosmetic outcomes. Conclusions: SLC with CME for right-sided colon cancer is feasible when performed by experienced surgeons in selected patients. Excellent cosmesis and reduced postoperative pain as well as oncologic clearance can be expected. A large-scale, prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over MLC with CME.



Postoperative Disorders After Transabdominal Preperitoneal (TAPP) Repair at the Entry Stage of Introducing the Laparoscopic Procedure

Is Early Discharge of Patients Post Laparoscopic Roux en Y Gastric Bypass Safe?

T. Matsubara, G. Kigawa, T. Wakabayashi, K. Kizima, Y. Harada, K. Shinmura, K. Yokomizo, Y. Kitamura, K.. Sakuraba, J. Tanaka

The Ottawa Hospital Civic Campus, Ottawa, Canada

Showa University Fujigaoka Hospital, Yokohama, Japan Aims: Laparoscopic inguinal hernia repair results in an earlier return to normal activities than open hernia repair. There are few reports of comparing the transabdominal preperitoneal (TAPP) repair and transinguinal preperitoneal (TIPP) repair concerning the postoperative disorders when the entry stage of procedure. We have introduced TAPP in May 2013 and evaluated about the postoperative disorders compared with TIPP which had been the first choice of hernia repair in our hospital from 2009. Method: We adopted TAPP to 25 adult patients with primary unilateral inguinal hernia, and evaluated the complications after surgery compared with those of 318 patients who adopted TIPP. Pain assessments were scored by 0–10 cm of visual analogue scale (VAS) at rest and on movement. Discomfort and touch sensation were assessed by four-point verbal rating scale. Results: The patients’ characteristics (age, gender, ASA score, BMI, hernia classification and preoperative pain score) were similar between the groups. Patients who received TAPP expressed significantly less pain on movement at 3 POD (p = 0.01) and at rest at 1 month after surgery (p = 0.03). However there was no difference about the discomfort at 1 month after surgery between the groups (42.1 % in TIPP and 34.8 % in TAPP). The touch sensation was significantly lower in the TAPP group than in the TIPP group (13.0 % and 39.8 %, respectively, p = 0.01). In the TIPP group, iliohypogastric nerve, Ilioinguinal nerve and genital branch of the genitofemoral nerve were identified during the procedure in 69.4 %, 84.3 % and 73.5 %, respectively. Patients to be identified all three inguinal nerves were 44 %, considered as the standard level (Hernia 15: 239–249, 2011). Resection of a suspected injured nerve was performed on 7.5 % of patients. Conclusion: Even though the evaluation has performed during only few months after TAPP introduced, TAPP showed advantages in reducing the pain at rest and on movement, expecting early recovery than patients who underwent TIPP.

R. Wu, F. Haggar, A. Neville, J.D. Yelle, I. Raiche, J. Mamazza

Introduction: Bariatric surgery has experienced a significant rise to combat the obesity epidemic. However, the timing and related safety of early discharge after laparoscopic Roux en Y gastric bypass (LRYGB) is still debated, and the safety of early discharge (\24 hours) after surgery remains unclear. The objective of this study was to examine the impact of early discharge on surgery related readmission following LRYGB. Methods: Retrospective review of patients undergoing LRYGB from September 2009 to March 2011 at the Ottawa Hospital was performed. Discharge readiness was determined by adequate analgesia achieved with PO medication, patients tolerating fluids, voiding well, ambulating without assistance and absence of tachycardia. Fisher exact tests or chi-squared tests were used for categorical variables and student t tests for continuous variables to compare differences between patients discharged on post-operative day (POD) 1 (\24 hours) and those discharged on POD 2 or 3. Results: A total of 638 patients (520 females and 114 males) were included. Thirty-four patients were discharged on post operative day 1 (\24 hours) and 604 patients were discharged on day 2 or 3 (standard DC). The 30-day readmission rates were not different between early DC and standard DC (p = 1.0). There were two re-admissions in the early DC group (5.88 %) as compared to 47 readmissions in the standard DC group (7.78 %). The two groups (early DC versus standard DC) were comparable in terms of mean age (44.38 years old versus 45.72, p = 0.49), sex (77 % female versus 82 %, p = 0.36), mean BMI (48.21 versus 59.44, p = 0.28), perioperative risks as indicated by the American Society of Anesthesiologists (ASA) score (71 % versus 79 % ASA 3, p = 0.05), and total number of concurrent intraoperative procedures (11.8 % versus 10.6 %, p = 0.83). Conclusion: Early discharge from hospital within 24 hours after LRYGB appears to be safe and does not adversely affect readmission. Fast tracking patients post surgery may result in significant hospital cost savings and a reduction in waiting lists.

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Clinical Effectiveness of Endoscopic Ultrasound Guided Interventional Services in a District General Hospital

Endoscopic Surgery in a Developing Country: A Private Hospital Practice

K. Wanigasooriya, C.V. Thompson, M. Almond, P. Wilson

E. Ray-Offor1, C. Akinla2

Heart of England NHS Trust, Birmingham, United Kingdom

1 University of Port-Harcourt Teaching Hospital, Port-Harcourt, Nigeria; 2Paragon Clinics & Imaging, Port-Harcourt, Nigeria

Aims: We aim to assess how our recently introduced endoscopic ultrasound (EUS) intervention service has impacted on patient management within our institution. Method: EUS interventional services were introduced within our institution in August 2010. A database of all patients undergoing these procedures is being maintained. To evaluate the clinical effectiveness of the new service we analysed the first 26 months of data to establish how often the EUS procedure altered patient management. A positive impact on management was defined as confirmation of diagnosis facilitating progression to next step in management, resolution of symptoms or clinical improvement. Results: A total of 120 patients underwent EUS guided interventions. The majority, 84 (70 %) patients underwent EUS guided fine needle aspiration (FNA). Other procedures performed included coeliac plexus block (n = 2, 1 %), EUS guided biopsy (n = 4, 3 %), pseudocyst drainage (n = 25, 21 %) and abscess drainage (n = 4, 3 %). 84 % of patients who underwent EUS guided pseudocyst drainage had complete cyst resolution. 70 % of EUS guided FNAs yielded a diagnosis which therefore had an impact on management. Furthermore, a 50 % success rate was observed after coeliac plexus block and 100 % of patients who underwent EUS guided biopsy received histologically confirmed diagnosis. Conclusion: EUS interventional services make a genuine difference to patient management in the district general hospital setting. We believe that interventional EUS should form part of the standard endoscopic service provided by secondary care.

Endoscopic surgery is a notable advancement in surgical care. Its growth in developing countries is desirable. Effective private initiatives augmenting the poorly funded government tertiary health facilities may be a pragmatic route to the popularity of this surgical practice. Aims: To review the challenges encountered in the effective practice of endoscopic surgery in a developing country-Nigeria. Patients and Methods: All consecutive patients referred to a General Surgeon for endoscopic procedure in one of the few private hospitals with an Endoscopy unit in PortHarcourt metropolis and entire Niger Delta region of Nigeria from February 2012 to January 2014. The sociodemographics, endoscopic procedure, outcome and challenges encountered were documented. Results: A total of 90 endoscopic procedures were performed during the study period. There were 54 males and 36 females. Fifty-three upper gastro-intestinal endoscopies, 23 lower gastro-intestinal endoscopies (8 injection sclerotherapies) and 14 laparoscopic surgeries (5 cholecystectomy, 2 appendicectomy, 1 herniotomy, 1 salpingectomy, 1 Lapassisted -orchidopexy, 2 adhesiolysis and 2 diagnostic laparoscopy) were done. The scarcity of endoscopic consumable and trained support personnel were the two major challenges encountered. Conclusion: An increase in effective private initiatives offering endoscopic surgery in developing countries, availability of cost-effective consumables and training of support staff are recommended for growth of endoscopic surgery.



Comparison of Total Laparoscopic Left Colectomy with Transanal Specimen Extraction Versus Laparoscopic Assisted Colectomy with Minilaparotomy

Revisiting the Microbiology of Appendicitis in the Laparoscopic Era

S. Saad1, D. Politt1, C. Lindlohr1, C. Brockhaus2, S. Sauerland2 Clinic Gummersbach, Gummersbach, Germany; 2Institute for Quality and Efficiency in Health Care, Cologne, Germany

U.O. Cardona Nun˜ez Clinica Saludcoop, Cali, Colombia

1

Total laparoscopic left colectomy (TLC) with transanal specimen extraction avoids a minilaparotomy and has the potential to reduce postoperative wound-related morbidity (pain, infection, hernia) compared to conventional laparoscopic assisted colectomy (LAC). Aims: We compared short-term patient outcome in terms of operating time, hospital stay, complication rate and postoperative pain between TLC and LAC in a retrospective study at a German Academic Teaching Hospital. Methods: TLC was performed in 112 patients, LAC in 56 patients. Indications for left colectomy were diverticular disease, rectal prolaps, benign and malignant tumors up to 4 cm. Operative colon dissection was performed using 3 to 4 ports. In TLC the specimen was extracted via the anus with the help of a TEO-rectoscope, in LAC a minilaparotomy of 5 cm was used. Colonic anastomosis was done with a circular stapler in end-to-side or endto-end fashion. Various parameters of technical performance and patient outcome were recorded. Results: Patient characteristics like gender, BMI, age and ASA classification showed no difference between the groups. Mean operating time for TLC (124 min) was significantly longer (p = 0.026) compared to LAC (110 min). However considering the learning curve of TLC operating time decreased to 104 min in the last 50 operations. Discharge from hospital was significantly longer (p = 0.004) after LAC (9 days) compared to TCL (7.8 days). Time to bowel movement was significantly shorter (p = 0.032) after TCL (1.88 days) vs LAC (2.29 days). Additional pain medication to the standard pain regimen (NSAR drugs only) was necessary in 14 % of TLC and in 60 % of LAC patients (p \ 0.001). No difference was found between both groups in length of the removed bowel specimen and complication rate. Conclusion: For patients undergoing minimally invasive left colectomy TLC is a safe operation and provides a superior patient outcome compared to LAC.

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Microbiology of acute appendicitis managed laparoscopically is reviewed. Differences exist between the perforated an suppurative forms. Data can guide antibiotic prophylaxis and management in the postoperative period. Experience with 50 patients is described in a 12-month period on 3-Level two hospitals in Cali Colombia.

Surg Endosc



Visceral Fat Area and Body Mass Index in Laparoscopic Surgery for Colorectal Cancer

Case Studies of Benign Solitary Pulmonary Nodule Resected by Video-Assisted Thoracoscopic Surgery

Y. Kojima, K. Sakamoto, Y. Tomiki, A. Okuzawa, M. Goto, H. Komiyama, M. Takahashi, Y. Yaginuma, H. Kamiyama, S. Ishiyama, K. Sugimoto, M. Kawai, K. Takehara, S. Munakata, J. Aoki, Y. Okazawa, R. Takahashi, K. Mizukoshi, R. Ichikawa, S. Ito, K. Kure, K. Honjo, H. Ro

M. Naruke

Juntendo University Faculty of Medicine, Tokyo, Japan Aims: Laparoscopic surgery is increasingly used for obese patients and difficulties with surgery and complications have emerged in some cases. In this study, we investigated the effects of high visceral fat area and body mass index (BMI) in patients who underwent laparoscopic surgery for colorectal cancer. Subjects and Methods: The subjects were 81 patients who underwent laparoscopic surgery for colorectal cancer in our department between April 2011 and April 2013, in whom the visceral fat area could be measured by CT (53 males and 28 females, mean age: 63.3 years old). The patients were divided into groups based on a cut-off value for the visceral fat area of 100 cm2 or a BMI of 25 kg/m2. Gender, age, operative time, blood loss, length of small incision, intra- and postoperative complications, and length of postoperative hospital stay were investigated. Results: The number of male patients was significantly greater in the high visceral fat group. The incidence of intraoperative complications was also significantly higher in this group. The operative time was longer, blood loss was higher, and the number of dissected lymph nodes was smaller in the high visceral fat group, but the differences were not significant. In the analysis based on BMI, the length of the small incision was significantly longer in the high BMI group. No other items differed significantly between the high and low BMI groups. Discussion: These results suggest that visceral fat measurement is more useful than BMI for prediction of the operative time, blood loss, number of lymph nodes requiring dissection, and intraoperative complications in laparoscopic surgery for colorectal cancer. BMI may be more effective for prediction of the length of the small incision. These indices may also be useful for selection of devices for use in laparoscopic surgery.

EIJU General Hospital, Tokyo, Japan Aims: Solitary pulmonary nodules of indeterminate etiology are being detected frequency by computed tomography (CT). We retrospectively review our experience of benign nodules resected for diagnosis by video-assisted thoracic surgery (VATS). Methods: From 2011 to 2013, the 55 patients with suspicious solitary malignant nodule underwent VATS pulmonary resection as the primary diagnostic method. All nodules were detected on CT. Their VATS procedure consisted of lobectomy, segmentectomy and wedge resection according to site and size of nodule. The peripheral nodule was localized by preoperative percutaneous hook wire marking or digital palpation with a finger through thoracoscopy access ports during operation. The clinical features of solitary benign nodule was investigated by their size, site, CT finding. Results: A benign diagnosis was obtained in 10 patients (18 %). 8 nodules were suspected to be primary lung cancer and 2 nodules were suspected to be pulmonary metastases at the time of VATS. The pathological diagnoses were granuloma (Mycobacterium avium and Cryptococcosis) in 4 patients, lung abscess and inflammatory scar in 2 patients, lymph node and Sclerosing Hemangioma in 1 patient. The benign nodules ranged from 0.6 cm to 4.5 cm in diameter (average, 1.94 cm). VATS anatomical resection procedure was required for 6 patients to diagnose. On CT, 9 benign nodules that showed isodensity revealed similar Hounsfield unit values (median, 27HU). The rest of the benign nodule showed Groundglass opacity. Conclusion: Although the number of cases was small, measured Hounsfield unit of solitary CT-isodensity nodules may be helpful to predict for diagnosis.



Evaluation of Laparoscopic Surgery for Elderly Rectal Cancer Patients

Modified Laparoscopy-Assisted Proximal Gastrectomy with Preservation of Abdominal Esophagus can Reduce Reflux Esophagitis for Upper Third Early Gastric Cancer

K. Hara, S. Yamaguchi, J. Tashiro, I. Toshimasa, K. Hiroka, S. Asami Saitama Medical University International Medical Center, HidakaCity, Japan Aims: The surgical results of laparoscopic surgery for elderly rectal cancer were analyzed. Methods: Between April 2007 and December 2013, 282 patients of more than 65 years-old who underwent laparoscopic rectal cancer surgery at our hospital were retrospectively analyzed concerning patient characteristics, surgical related factor, short-term outcomes of surgery, hospital mortality rates, and recurrence rate. 282 patients were divided relatively younger group (65 to 74 years, Group A), moderate group (75 to 84 years, Group B), very elderly group (85 years over, Group C). Results: There were 186 patients in Group A, 83 patients in Group 13 patients in Group C. Mean age of each group were Group C = 69/78/86 years-old. Preoperative comorbidity was observed in Group A/B/C = 64.5/78.3/69.2 %, respectively, and Group B was significantly higher than Group A (P = 0.024). As for the ASA Physical Stage, there were significant differences; Group C was the highest, and Group B was higher in comparison with the Group A. (P \ 0.001) Group A and B were similar stage distribution. However, there were more stage I and less stage IV in Group C.(P = 0.018) Regarding surgical related factors, mean blood loss and mean operative time did not differ in each group. Neither group had a difference for procedure, but ISR was not performed in Group C. The construction rate of diverting stoma were Group A/B/C = 46.8/41.9/61.5 %, colostomy construction tended more in Group C compared Group A (P = 0.08). The rates of radical D3 lymphadenectomy were Group AC = 81.2/64.0/23.1 %, and significantly lower Group C (P \ 0.001) The rates of postoperative complications were; Group C = 26.9/38.4/ 38.5 %, significantly less Group A compared with Group B (P \ 0.001). Mean postoperative hospital stay did not differ. Hospital mortality rates recognized Group and C by one case. The recurrence rate were; Group C = 8.2/18.6/7.7 %, Group B was significantly higher than Group A (P = 0.013). Conclusion: The surgical results of laparoscopic surgery for elderly rectal cancer were similar in each group, except postoperative complications and hospital mortality rates.

Y.J. Huh, H.J. Lee, S.Y. Oh, K.G. Lee, Y.S. Suh, S.H. Kong, W.H. Kim, K.U. Lee, H.K. Yang Seoul National University Hospital, Seoul, Korea Aims: The aim of this study was to evaluate the functional and oncological outcomes after modified laparoscopy-assisted proximal gastrectomy (mPG) in comparison with total gastrectomy (TG) or conventional PG (cPG), with special reference to reflux esophagitis. Methods: We reviewed the medical records of 192 patients with early gastric cancer (EGC) who underwent PG and those of 157 patients with EGC who underwent TG retrospectively. mPG was performed by laparoscopy-assisted method, whereas TG and cPG were done by open methods. In mPG, we intended to preserve a longer portion of the intra-abdominal esophagus and hepatic branch of the vagus nerve. Clinicopathological characteristics, outcomes, nutritional status and survival were analyzed. The mean follow-up period was 37.6 months. Results: The proportion of mPG among PG cases was 18.2 % (n = 35). The differences in cancer stage between the groups were not significant. As short-term outcomes, postoperative complications developed in 31.2 %, 15.9 %, and 20.0 % of patients in the TG, cPG, and mPG groups, without significant differences. The complications included dysphagia (TG vs. cPG vs. mPG, 0 % vs. 7.0 % vs. 0 %) and anastomosis leakage (TG vs. cPG vs. mPG, 1.9 % vs. 0 % vs. 8.6 %). Among long-term complications, reflux was the most common, but its incidence rate decreased gradually (TG vs. cPG vs. mPG, 0 % vs. 19.5 % vs. 11.4 % at 3 months, 0 % vs. 11.6 % vs. 4.8 % at 1.5 years). However, most reflux cases in mPG were classified as Los Angeles classification grade A or B. In cPG and mPG groups, decreased vitamin B12 levels were not detected in 98 (62.4 %) and 30 patients (85.7 %). Severe anemia was detected in 41 (26.1 %), 10 (6.4 %), and 3 patients (8.6 %) in the mPG, TG, and cPG groups. Similarly, hypoalbuminemia was detected in 34 (21.7 %), 10 (6.4 %), and 2 patients (5.7 %) in 3 groups. The recurrence-free survival rates were not significantly different. Conclusion: mPG may be functionally feasible in the treatment of upper third EGC, with acceptable morbidity. In PG, reflux was relatively more common than in TG, but its incidence rate gradually decreased. Moreover, mPG showed a tendency for lower incidence of reflux than that in cPG.

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Lymph-Node Yield In Laparoscopic vs. Open Right Colectomy for Colon Cancer

Laparoscopic Dissection Technique of Para-Aortic Lymph Node 16A2-LAT for Esophagogastric Junctional Cancer

L. de Napoli1, L. Fregoli1, D. Bottari2, V. Matteucci2, M. Biricotti2, A. Aghababyan2, A. Bertolucci2, N. Furbetta2, P. Miccoli1, M. Chiarugi1

N. Shinno, Y. Miyazaki, S. Takiguchi, Y. Kurokawa, T. Takahashi, M. Miyata, M. Yamasaki, K. Nakajima, M. Mori, Y. Doki Osaka University, Suita city, Japan

1

Department of Surgical, Medical, Molecular Pathology and Critical Care, Pisa, Italy; 2Postgraduated School of Surgery, University of Pisa, Pisa, Italy

Aims: Examination of at least 12 lymph nodes (LNs) has been established as the standard of care for adequate staging of colon cancer. Age, patient body mass index (BMI), tumor location and stage, surgical approach and technical skillness may all affect the number of nodes retrieval during curative surgery for colon cancer. This study aimed to assess the number of LNs yielded after laparoscopic and open right colectomy for cancer. Methods: We review a series of 51 patients which underwent elective right colectomy for stage I–III cancer of the caecum-right colon in the last five years. Twenty-six of them had a laparoscopic assisted right colectomy (LARC), 25 a open right colectomy (ORC). There were no statistically significant differences for age, gender, BMI, tumor stage and grading between the two treatment groups. Surgeries were performed by the same team and surgical specimens were prepared and examined by the same pathologist. Results: Overall, a median of 23 LNs (IQR 14.7) were identified. Specimens contained a median of 21.5 LNs (IQR 14) after LARC vs. 23 LNs (IQR 15.5) after ORC (p = ns). Meanly, the number of metastatic LNs was 0.3 after LARC and 1.4 after ORC (p = 0.02) with a LN ratio of 0.015 and 0.059 respectively. Twenty-five out 26 patients undergone LARC (96 %) and 24 out 25 patients undergone ORC (96 %) met the criteria for adequate staging of colon cancer (=[12 LNs harvested). Conclusion: LARC is a safe and effective method of treatment for cancer of the caecum and of the ascending colon. Respect to ORC it carries no risk of inadequate nodal retrieval.

Background: In case of radical operation for esophagogastric junctional cancer, we dissect para-aortic lymph node 16a2-lat and we introduced laparoscopic lower esophagectomy, fundectomy and double tract reconstruction since July 2012. Aims: We report four cases of laparoscopic para-aortic lymph node 16a2-lat dissection and examine the procedure. Cases: Male/female = 3/1, median age = 64.5(40–75) and pre-therapeutic length of esophagus invasion was 2 cm (0–5). All four cases took two courses of neo-adjuvant chemotherapy with DCS (docetaxel, cisplatin and TS-1) before operation. Pre-operative stage was ?B/?C = 3/1. The 16a2-lat lymph node was approached by dissecting posterior lobe of mesocolon or Gerota’s fascia at left side of celiac artery. Result: Operative duration was 515(390–750) minutes and total blood loss was 325(250–500) ml. Only one case needed excision together with pancreatic tail and spleen. We used circular stapler (21 mm/25 mm = 1/3) for Esophago-jejunal anastomosis and had no severe complications. The count of dissected 16a2-lat lymph node was 4(0–5). All cases underwent R0 resection. Conclusion: In spite of some problem such as field of view, laparoscopic dissection technique of para-aortic lymph node 16a2-lat may be safe and feasible.



Reduced Port Surgery for Rectal Cancer, with Using Endograb

Laparoscopic Appendectomy. A Study of 655 Consecutive Cases

H. Samura, T. Kinjyo, Y Irei, T. Nishimaki

P. Papp, V. Vereczkei

University of Ryukyus, Nakagami-gun, Japan

Medical University of Pećs, Pećs, Hungary

Introduction: Advances in laparoscopic surgery is very fast. Single port Surgery, Reduced port surgery and Needle scopic surgery has been developed as less invasive surgery for patients benefits. Ultimate less invasive surgery is a Normal Orifice Transluminal Endoscopic Surgery (NOTES), but NOTES is immature and very difficult procedure at this time. Then, now the lowest invasive surgery must be a less invasive laparoscopic surgery combined with hybrid NOTES. We used to do the 4-port laparoscopic surgery for rectal cancer, but until now, we have started the operation of 3 ports using the EndoGrab recently. In case of lower rectal cancer, or additional resection of uterus and ovary with rectal cancer, resected organs were extracted through normal orifice (Hybrid NOTES). Aims: To improve the procedure, we evaluate result of our Reduced Port Surgery (RPS) compered with conventional laparoscopic surgery for rectal cancer. Method: since Jun 2013, eight patients underwent lower rectal surgery as RPS. Our reduced port surgery for rectal cancer was performed by 3-port and one EndoGrab. 12 mmPort for camera was placed umbilicus and 12 mm port at right lower abdomen, 5 mm-port at right upper abdomen. Use Endograb as an assistant forceps. At first, grab sigmoid mesocolon to dissect sigmoid mesocolon from retro peritoneum and exposure Inferior mesenteric artery (IMA) and left colic artery (LCA) then preserves LCA superior rectal artery was cut. Retract SRA to right side by Endo Grab, mesentery was cut just the front of marginal vessels. SRA or rectal mesentery was retracted to head side for dissection of rectum. Result: Eight patients include Low anterior resection (4), Inter sphincteric resection (2), Abdomino perineal resection (2). As additional procedure include lateral lymph node dissection (3), hysterectomy and bilateral salpingo-oophorectomy (1), Extended perineal resection (1). And two case were became hybrid NOTES operation. Because of additional procedure takes long time, the mean operation time was 582 minutes, and mean blood loss was 358 ml. Except additional procedure, mean operation time was 226 minutes and mean blood loss was 106 ml. no adverse events related to RPS was occurred. Conclusions: RPS using EndoGrab seemed to be a simple and easy, useful maneuver.

Introduction: Since Kurt Semm first described the laparoscopic approach to appendectomy in 1983, this method has become a common and accepted approach for the management of acute appendicitis. Patients and Method: In this retrospective study we report on our 6 years’ experience with this type of approach. Between January 2007 and May 2013 we operated on 655 patients (294 men, 361 women, mean age 36.7 years), admitted with clinical signs of appendicitis. Results: The operation was completed by laparoscopy in 594 cases (90.7 %) the other 61 cases were converted. No deaths were recorded. Four (0,6 %) post-operative complications occurred: 2 cases with periappendicular infiltration and fever and 2 cases with intraabdominal abscess. All were successfully treated conservatively. Mean procedure time was 55 minutes (15–150 minutes). Mean duration of hospitalisation was 3.2 days (range 2–5 days). In 23 cases laparoscopic appendectomy was performed due to severe right lower-quadrant pain (LRQP), without any laboratory signs of inflammation. Among these cases appendicitis was reported in 31 % by histology. Out of all cases in seven patients (1 %) unexpected malignancy were proved by histology, and further operation were needed. Conclusion: Laparoscopic appendectomy is safe and feasible in the majority of cases. In cases with RLQP even without lab signs of inflammation we recommend laparoscopic appendectomy when no other cause for the pain can be identified.

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Preoperative Endoscopy Localization Error in Patients with Colorectal Cancer

Colorectal Cancer Urgent Referrals: Time for a Change?

F. Saleh, T. al Abbasi, C. Jimenez, T. Jackson, A. Okrainec, F. Quereshy University Health Network, Toronto Western Hospital, Toronto, Canada Introduction: Preoperative repeat endoscopy in colorectal cancer patients is considered by many to be an integral component of surgical planning. We have previously shown our institutional repeat endoscopy rate to be approximately 40 % when the initial endoscopist is not the operating surgeon. Little is known, however, about the utility of repeat endoscopy, particularly as it pertains to reducing localization errors, complication risk, and prospective delay to definitive treatment. Methods: A retrospective review of 299 consecutive patients undergoing surgical resection for colorectal cancer was performed from January 2008 to December 2011. Patients were included if the initial endoscopist was different than the operating surgeon. A localization error was recorded if the final tumor location identified during surgery was in a different anatomical segment than that identified by the initial colonoscopy. Descriptive statistics were used to define the patient population and the Chi-squared test was used to compare categorical variables. An error rate with a 95 % % confidence interval was obtained using the exact binomial distribution. Results: A total of 10 patients had incorrect tumor localization at initial endoscopy, equivalent to a 3.3 % error rate (95 % CI 1.6 %-6.1 %). There were no localization errors in any of the preoperative re-endoscopies (122/299, 40.5 %). Re-endoscopy was found to be protective against localization errors (p \ 0.05). Of the 10 localization errors, 5 were identified at reendoscopy resulting in a change in preoperative planning and were confirmed during the operation. Three of the 10 localization errors were performed at the study institution, and half were performed by academic endoscopists. Overall, there were no major complications of bleeding or perforation from the initial or repeat endoscopies. However, re-endoscopy was associated with an increase in median time to surgery (103 days versus 41 days, p \ 0.01). Conclusion: There is a small but important localization error rate in preoperative endoscopic evaluation of colorectal tumors. Re-endoscopy appears to be safe and may potentially identify and correct these errors and help with preoperative planning at the expense of delaying surgery. Further research is necessary to find ways to improve localization and identify which patients would benefit from re-endoscopy.

Y.A. Al-Abed, M. Fong, S. Rana, M.G. Tutton Colchester Hospital University, Colchester, United Kingdom Aims: In the UK, the department of health had introduced the ‘two week rule’ (TWR) referral system to allow patients presenting with symptoms suspicious of colorectal cancer (CRC) to be referred by their general practitioners to see a colorectal specialist within 14 days. This process is thought to speed up the process of diagnosis and treatment of colorectal cancer and there have been high profile campaigns to advertise this. The aim of this study is to evaluate the number of new patients diagnosed with CRC under this system and assess whether it reflects the change in the pattern of referral over a four-year period. Methods: Retrospective analysis of prospectively collected data of all patients referred to colorectal clinics under the TWR referral system was carried out. Results of all patients including endoscopy, radiology and histology were analysed. Patients with confirmed colorectal cancer were entered into specially designed outcome pro-forma. Total number of TWR colorectal target referrals including all positive cases of cancer per month were fed into an excel data sheet and results were analysed using SPSS V.19.0. Results: Over a four year period (April 2009–July 2013-52 months), total number of TWR referrals was 6853 cases, of which 513 patients (7.4 %) were positive for CRC. There is a significant rise in the number of TWR referrals per month from 2009 to 2013 (91 to 202, p = \ 0.01). There is significant and steady fall of total annual positive cancers from 2009 to 2013 (9.5 % to 5.5 % respectively). Conclusion: In this study, it is clear that the total number of referrals on TWR pathway have doubled over the last four years and despite this large increase, the results are not mirrored by the total number of cancer cases diagnosed. Moreover, the real number of cancer cases diagnosed remains almost unchanged. This questions whether high profile advertisements and increasing use of specific cancer referral targets actually improves the detection of colorectal cancer patients and whether this is a cost effective way of trying to improve outcomes.



Emergent Laparoscopic Surgery in a Tertiary Spanish Hospital: Review of Our Series

Laparoscopic Versus Mini-open Appendectomy in a Low-Budget Health System

M. Rodriguez Lopez, J.I. Blanco, A. Said, M. Gonzalo, R. Velasco, S. Mambrilla, M. Bailon, E. Asensio, R. Martinez, J.C. Sarmentero, P. Pinto, D. Pacheco, B. Perez-Saborido, J.L. Marcos Rio Hortega University Hospital, Valladolid, Spain Aims: Several reports have shown benefit for laparoscopic approach in numerous emergent surgical diseases. Because of that, we have analysed our series of emergent laparoscopic procedures during the last 3 years, in terms of temporal figures and patients outcomes, performed at General Surgery Department (Rio Hortega University Hospital, Valladolid, Spain). Methods: All patients admitted due to surgical disease who underwent emergent laparoscopic surgery from January 2010 to July 2013 were enrolled. Retrospective bivariated analysis of 17 variables has been performed. Endpoint: identifying factors associated with post-operative stay, surgical site infection (SSI) and severity of complications (Clavien’s classification). Statistical analysis: SPSS 18. Results: During this period, 191 patients underwent laparoscopic procedure and increasing temporal trend has been noticed. Mean age: 44.3 years (R = 13–92). Most common procedures: appendicectomy (77.5 %), cholecystectomy (12 %). Conversion rate: 4.2 %. Median Surgical Intensive Care Unit (SICU) stay: 0 days (R = 0–58). Median time until oral intake (TUOI): 1 day. Median postoperative stay: 3 days. No postoperative complications: 77 %. Lack of SSI: 88.5 %. Severity of complications: Clavien II, 13.6 %; III, 4.2 %; IV, 1 patient out of 191, and Clavien V, 2 patients. Re-admission rate: 3.7 %. Statistical differences have been found between: 1. Postoperative stay and: age, etiology, A.S.A. scale, conversion, presence of complications (including SSI), their severity (Clavien) and reoperation rate. There is strong correlation with TUOI (r = 0.92, p \ 0.001) and SICU stay (r = 0.86, p \ 0.001). 2. SSI and: etiology, conversion, re-operation, re-admission rate. 3. Severity of complications and: age, etiology, A.S.A. scale, SSI, re-admission rate. Conclusions: We have progressively increased emergent laparoscopic approach with wellachieved skills, due to our low conversion rate, selecting young and previously healthy patients. Factors associated with our endpoint variables do not differ much from literature. In spite of a short series, our global outcomes are acceptable, though they can be improved.

I.O. Avram1, M.F. Avram1, D. Koukoulas2, A.M. Ungureanu1, S. Olariu1 UMF Victor Babes Timisoara, Saarbru¨cken, Germany; 2Spitalul Municipal Lugoj, Lugoj, Romania

1

Aims of the Study: Laparoscopic appendectomy has been reported to have similar outcomes to open repair, but implies higher cost for disposable equipment and longer OR time. In our low-budget health system (mean 300–340 EUR/treated patient) minimally-invasive surgery is still under-developed and only a few centers perform routinely other procedures than laparoscopic cholecystectomy claiming much higher costs. Material and Method: We performed a retrospective analysis of 50 laparoscopic appendectomies and 50 mini-open appendectomies performed in our center between 2008–2012. The cost of anaesthesia, OR-time, medication and disposable equipment or materials was calculated manually for each patient. For the cost of hospital stay we used the daily hospital standard for our surgical clinic. In order to estimate the cost of the recovery period we used the mean annual salary for our country. Results: Our National Insurance House reimburses for a appendectomy open or laparoscopic) about 190–210 EUR (corresponding to a DRG value of 0.5797), while the costs for a laparoscopic appendectomy were between 174–578 EUR (mean 224,7 EUR); mean costs for open appendectomy were 171–355 EUR (mean 256,8). There was no significant difference between recovery period after both methods and similar need of postoperative medication. The complication rate was also similar in both groups. Conclusions: From the point of view of the hospital laparoscopic appendectomy is not feasible, it generates higher costs than reimbursed by the National Insurance House. Postoperative pain and recovery period were also similar.

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P142 - Day Surgery

Trocar Site Complications are Avoidable in Laparoscopic Colorectal Surgery

Is the Irish Health System Ready for Day Case Laparoscopic Cholecystectomy?

J. Ngu, K.R. Lim, K.K. Sng, C.K. Chong, S.M. Tan

M. Salama, A. Kharif, A. Nasr, M. Aremu, I. Ahmed

Changi General Hospital, Singapore, Singapore

Our Lady of Lourdes Hospital, Drogheda, co. Louth, Ireland

Background: With greater awareness of the benefits and widespread acceptance of minimal access techniques in colorectal surgery, we have seen an increase in the proportion of colorectal procedures being performed laparoscopically. Initial publications highlighted the risks of trocar site complications like visceral injury, tumor recurrence and herniations. We aim to demonstrate that such complications can be minimised by appropriate surgical technique and improvements in trocar design. Materials and Methods: A computer search of our institution operative database between 2008 and 2013 was performed using the keywords ‘laparoscopic’, ‘colon’, ‘rectum’, ‘colorectal’ and ‘colectomy’. Colorectal procedures performed by one of four trained surgeons in the department using laparoscopic techniques were included in our analysis. Their operative notes were used to compile data on the site, size, number, and type of trocars. Medical records were reviewed for postoperative outcome and port site complications during follow-up. Results: 165 patients underwent laparoscopic colorectal procedures in our institution over the past five years. The increasing trend over the study period reflected the rising popularity of minimal access techniques and the development of expertise in this field of surgery. Almost all first ports were inserted via open technique. Subsequent trocars were invariably inserted under direct visualization by the laparoscope, avoiding injury to vascular and visceral structures. There were no significant complications associated with trocar insertion. Trocar diameters ranged from 5 mm to 12 mm, and consisted mainly of dilating noncutting designs. None of the patients developed trocar site hernias. Among patients who underwent laparoscopic procedures for malignancy, there were no incidences of trocar site recurrence or metastases. These included trocar sites that were subsequently extended for purposes of specimen extraction. Conclusion: Improvements in port insertion and laparoscopic surgical techniques have ensured the avoidance of trocar site complications. Such complications add unnecessary morbidity to minimal access procedures, and standardized practices should be inculcated in our surgical trainees in order to prevent their occurrence.

Ambulatory Surgery 23 hours (AS 23) Laparoscopic cholecystectomy has now become routine practice in the USA as well as many centres in Europe. The patients come in the day of their operations and are discharged the following morning after a night of monitoring. It offers convenience to patients and cost saving to the health care institutes. Aims: To review our current practice of (AS 23) Laparoscopic Cholecystectomy and to evaluate our readiness for the next level of ambulatory care in our institutions. To determine its applicability and safety as well as patient’s satisfaction. Methods: Data were collected retrospectively for 2 years (June 2010–June 2012) for patients who had elective Lap. Cholecystectomy. Standard Laparoscopic Cholecystectomy and anaesthetic protocols were used as well as standard criteria for discharge were employed. Results: Between June 2010 to June 2012, 354 patients were admitted to our As 23 ward and had elective Lap. Cholecystectomy. Out of 354 cases, 336 (94.9 %) were discharged next morning and 18 cases stayed for more than 24 hours (7 drains, 5 conversion, 1 empyema, 1 lap. Cholecystectomy and closure of cholecysto-gastric fistula. Other causes were abdominal pain, nausea, vomiting, urinary retention and slow mobility) Conclusions: Ambulatory surgery 23 Laparoscopic Cholecystectomy is safe, applicable, convenient to the patients and cost saving to the health care system. It allows wider range of patients to be accommodated.

P141 - Day Surgery

P143 - Day Surgery

Gastrointestinal Stromal Tumor of Stomach: A Gentle Enemy of the Surgeon. Our Experience in Confronting the Disease

True Day Case Rate of Laparoscopic Inguinal Hernia Repair and a Review of Factors Contributing to Unexpected Stay in a District General Hospital

S. Bard1, N. Menasherov1, S. Morgenstern2, M. Stein1, F. Greif1, H. Kashtan1 Beilinson Hospital, Petah-tiqwa, Israel; 2Institute of Pathology, Petah-tiqwa, Israel 1

Background: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract (GI) and manifested 1–2 % of all GI malignancies. Tumors originate from the interstitial cells of Cajai and characterized by overexpression of KIT protein (tyrosine kinase). It can affect any part of GI tract. Stomach is considered the most common site (60 %). Tumor size, mitotic rate, anatomical locations are directly related to potential malignancy, surgical approach, oncological treatment and recurrence rate. Surgical resection is considered to be the best treatment. Methods: Histologically or immunohistochemistry proved GIST of stomach who were operated at Rabin Medical Center and at Kaplan Medical Center from 2004 to 2013 were retrospectively collected. Data of tumor size, location, margin status, pathological characteristics, surgical approach, surgical outcome and long-term follow up were analyzed. Results: During the period of study, 31 patients underwent surgery due to gastric GIST. The most common presentation was upper gastrointestinal bleeding. Their localization was different. Most of the tumors were localized at the proximal part of stomach. The median tumor size was 5.5 cm. Laparoscopic approach was the preferred technique whenever feasible. Most of the resected tumors were with low mitotic rate and were identified as GIST with low to moderate risk of malignancy. All tumors were completely resected with free surgical margins. The median follow up period was 4 years. Conclusion: Gastric GIST is a snake in the grass and its diagnosis is often incidental by endoscopy and CT scan. The most notable symptoms are gastrointestinal bleeding. Treatment of choice is laparoscopic resection unless advanced GIST is diagnosed. The most important technical point is to avoid tumor rupture during removal.

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A. Solodkyy, Q. Azeem, S. Gergely, F. Difranco, A. Harris Hinchingbrooke Hospital, Huntingdon, United Kingdom Aims: Laparoscopic inguinal hernia repair (LIHR) is ideal for a day case surgery. It is recommended that 75 % of these operations should be day cases both for optimal patient outcomes and cost-effectiveness. There is still ambiguity of presentation in the literature between so-called ‘23-hour’ stay and true day cases where the patient goes home on the day of their operation. The aim of this study was to assess our own rate of true day case (TDC) surgery and review factors that prevent same-day discharge. Methods: Prospectively collected data of all elective LIHR performed in a District General Hospital over a 3-year period. All patients had telephone follow-up with a single surgical practitioner at 4–6 weeks after operation. Data included demographics, operative data, length of stay and reasons for unplanned overnight stay (UOS). Results: 500 patients underwent LIHR. Mean age is 57(18–96). 454 (90.8 %) patients were planned day case, 46 patients (9.2 %) were booked for overnight stay. In fact 397 (79.4 %) patients were discharged on the same day and 57 (11.4 %) stayed overnight unexpectedly. Mean operating time was 66 (20–152) minutes. Within this group 364 (72.8 %) cases were unilateral and 136 (27.2 %) cases bilateral hernia repairs. Only 3 (0.6 %) patients were converted to open surgery. Urinary retention and late surgery are significant risks for UOS. Conclusions: Day case LIHR is a feasible, safe and cost effective method of treatment. In this study the true day case rate of 79.4 % is lower than most published series but this is a larger series than most and we believe this more accurately represents the true day case rate in an unselected group. Most studies have strict exclusion criteria for day case surgery which may unnecessarily increase their planned overnight bed occupancy. Unexpected overnight stays are often unavoidable but this may potentially be reduced by patient preparation and operation scheduling. Strict exclusion criteria such as BMI and ASA grade can be safely modified to help increase day case rate. This will improve patient experience and have a cost benefit by reducing the added bed pressures and financial costs of an overnight hospital stay.

Surg Endosc

P144 - Different Endoscopic Approaches


Early Results of Endoscopic Nipple-Sparing Mastectomy for Breast Cancer and Immediate Reconstruction with a Tissue Expander

A Study of 82 Cases of Single-Incision Laparoscopic Appendectomy

N. Sakamoto, Y. Tsunoda, E. Fukuma Kameda Medical Center, Kamogawa City, Chiba, Japan Aims: Endoscopic mastectomy is reportedly associated with smaller scars and greater patient satisfaction. The purpose of this retrospective study was to examine the early results of endoscopic nipple-sparing mastectomy and immediate reconstruction with a tissue expander (E-NSM with TE) and to investigate the safety of this procedure. Methods: A retrospective study was performed using a consecutive series of 59 E-NSM with TE in 56 patients with breast cancer but without skin, nipple, and lymph node involvement. Surgical procedures; First, dissection of the reverse side of breast is performed using Vein Retractor through axillar skin incision. Next, skin flap is created through the periareolar incision. At the boundaries of the breast, the previously dissected reverse side of the breast is exposed. The excised breast tissue is pulled out through the incision. Then, submuscular pocket is created. At the lateral side, serratus fascia is elevated to cover the smooth type TE completely. A suction-drain is inserted and skin is closed. Results: Fifty-six percent of the tumors were invasive cancer, and 44 % were ductal carcinoma in situ. Mean operative time and mean blood loss were 233 minutes and 200 ml, respectively. The overall complication rate was 37 % (22/59) and included nipple necrosis (14/59, 14 %), major infection requiring the removal of the TE (4/59, 6.8 %), minor infection (2/59, 3.4 %), and TE ruptures (2/59, 3.4 %). The TE was exchanged with a prosthesis at around six months or later after the surgery in 71 % (42/59) of the patients. After a median follow-up period of 25 months, one local recurrence (1.7 %) occurred in this series. Conclusion: E-NSM with TE is a safe and acceptable procedure in select patients requiring a mastectomy.


T. Takagi, N. Koizumi, Y. Nakase, K. Fukumoto Nishijin Hospital, Kyoto, Japan In our hospital, we have been performing stylized single-incision laparoscopic appendectomy (SILA) using a multi-channel port, EZ Access Port (Hakko, Japan), since April 2010. We investigated its effectiveness in 82 cases, taking the operative time and complications into consideration. (Subjects) Preoperative diagnoses were based on clinical findings, blood examination, and abdominal CT. All patients were able to undergo general anesthesia. Those with a history of open lower abdominal surgery were included if preoperative abdominal CT showed the absence of intestines under the umbilicus. Methods: EZ Access Port was placed after a 15 to 20-mm vertical umbilical incision. If visibility was poor because of intestinal distension, small forceps were additionally inserted into the lower abdomen, and a drainage site port was added if postoperative drainage was necessary because of a prominent abscess. The appendix was separated from surrounding tissue, and localized abscesses were suctioned laparoscopically. The ileocecal region was mobilized if necessary so the appendix could be moved to the umbilical level, and procedures outside the abdominal cavity commenced after confirming its mobilization. The root of the appendix was directly observed, and its incised end was buried with purse-string suture in the same way as in conventional open surgery with a small incision. Finally, bleeding absence was checked laparoscopically and abdominal lavage was performed. Results: The appendix was mobilized to the umbilical level in all cases. The average operative time was 50.2 (25–109) minutes, and there were no complications. Surgical site infection (SSI) and paralytic ileus were observed in 5 (6.1 %) and 1 (1.2 %) case, respectively. Completion was possible in 76 cases (92.7 %). In 4 cases, additional ports for drainage were added, elongation of the umbilical incision was required in 2 cases, and ileocecal resection was performed. Conclusion: Our procedure was as favorable as conventional multi-incision laparoscopic appendectomy regarding the operative time, and offered comparable timeliness for emergent application. Single-incision laparoscopic appendectomy may become the first choice as it can be performed economically and safely, and it is more cosmetically favorable than open surgery or multi-incision laparoscopic appendectomy.


Laparoscopic Appendectomy with Hand-Made Loop

Simple and Easy Technique for the Placement of Seprafilm During Laparoscopic Surgery

B. Mayir, T. Bilecik, C.O. Ensari, U. Koc, U. Dogan, T.M. Oruc, R. Eryilmaz

Y. Sumi, K. Yamashita, K. Kanemitsu, S. Kanaji, M. Yamamoto, T. Imanishi, T. Nakamura, S. Suzuki, K. Tanaka, Y. Kakeji

Antalya Training and Research Hospital, Antalya, Turkey

Kobe University, Kobe, Japan

Introduction: Acute appendicitis is the most common abdominal pathology requiring emergent surgical procedure. For treatment, laparoscopic surgery is commonly performed. For closure of stump of appendix, different procedures are used. Aims of this study is to evaluation of the results of patients in whom stump of appendix was closed with hand made loop during laparoscopic appendectomy (LA). Material and Methods: Patients in whom stump of appendix was closed with hand made loop during LA were included in the study. Reports of patients were collected from patient files retrospectively. Laparoscopic appendectomy was applied through 3 ports. Two loops were placed to stump of appendix. Root was a modification of Tayside loop that has been described in literature and has shown to be safe. Results: 70 patients were included in study. 28 of them (40 %) were female, 42 of them (60 %) were male. Ages range from 13 to 60 (average age is 30). During postoperative period, one surgical wound infection and two intraabdominal abscess were detected. There was no leakage from stump of appendix in any patients. Discussion: One of the most important component of cost of LA is technique of closure of stump. Stapler, endoloop, various clips or hand-made loop could be used for closure. We recommend hand made loop usage for closure as an easy, safe and cheap method.

Laparoscopic surgery is a minimally invasive surgery and the incidence of postoperative small bowel obstruction (SBO) is not high. However, SBO is a disease that detracts from the benefits of laparoscopic surgery due to the need for additional therapies or prolongation of hospital stay. Seprafilm is effective in reducing adhesions and preventing the occurrence of SBO. However, it is very difficult to place the Seprafilm during laparoscopic surgery compared to open surgery. Therefore, it is necessary to develop an inventive approach due to the structure of the material. Herein we report a simple and easy method. It consists of placing a piece of Seprafilm with holder paper in the Reduction Sleeve. It does not need any special preparation or training. We are firmly convinced that this method can easily overcome the problems that the Seprafilm is vulnerable to tear and difficult to spread out in the abdominal cavity.

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Percutaneous Transhepatic Biopsy by Choledochoscope in Intrahepatic Biliary Tumors

Endoscopic Stenting Versus Laparoscopic Diverting Stoma in Management of Emergency Colorectal Cancer Obstruction

D.D. You1, Y.S. Won2, I.Y. Park3, K.H. Kim4, D.G. Kim5

K.M.A. Elgendy, A.A. Almuhrij, A.M. Salem

1

2

The Catholic University of Korea,, Suwon, Korea; The Catholic University of Korea, St. Vincent’s Hospital, Suwon, Korea; 3The Catholic University of Korea, Bucheon St. Mary’s Hospital, Bucheon, Korea; 4The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, Uijeongbu, Korea; 5The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea Intraductal papillary mucin-producing neoplasm (IPMN) of the bile duct is a rare disease. The precise diagnosis of biliary IPMN is not easy, especially in intrahepatically located, by conventional endoscopic retrograde cholangiopancreatography. We report two cases of intrahepatic IPMN diagnosed before operation by using percutaneous transhepatic choledochoscopic biopsy. A female-63 year old patient admitted to our hospital complaining of right upper quadrant abdominal pain and fever. Abdominal computed tomography (CT) scan showed both common bile duct and both intrahepatic bile duct dilatation and endoscopic retrograde cholangiopancreatography showed a mucin like soft mass projection after endoscopic sphincterotomy yet biopsy did not reveal malignancy. Further evaluation with magnetic resonance imaging (MRI) suggested biliary IPMN or distal CBD cancer involving the right hepatic duct. Percutaneous transhepatic biliary drainage (PTBD) catheter was inserted and choledochoscopic biopsy was done revealing adenocarcinoma in the peripheral right hepatic and common hepatic duct. A 52 year old man admitted to our hospital due to intrahepatic duct dilatation on annual abdominal sonographic check-up. Liver CT scans revealed distal CBD narrowing near the ampulla and there were longitudinal filling defects on both IHD and CHD on ERCP, after EST pus like discharge was found. Biliary parasitosis was suspected due to his history of ingestion of raw fish liver and praziquantel trial was started. After a follow loss of 20 months the patient was readmitted due to jaundice. Liver CT and ERCP showed mass like findings at the common hepatic duct with both intrahepatic duct dilatation. MRI findings suggested biliary IPMN or atypical cholangiocarcinoma. Choledochoscopic biopsy after PTBD was done revealing intraductal tumor in the peripheral right hepatic duct. Before operation, the pathology and the extent of the tumor were confirmed and surgical strategy was easy to set up to right hemihepatectomy with caudate lobectomy. Both patients were discharged with no postoperative major complication.

King Fahd Specialist Hospital, Dammam, Saudi Arabia Aims: The study aims to compare the endoscopic stenting with laparoscopic stoma creation regarding the complications and outcome in cases of emergency colorectal cancer obstruction as bridge to surgery or as palliative treatment. Methods: Retrospective analysis of the cases with emergency obstruction due to colorectal cancers from January to December 2012. The patients were followed up to 6 months, regarding early and late complications of the procedure. Results: 31 patients presented with emergency obstruction, 6 excluded due to loss of follow up. 15 patients underwent stenting with success achieved in 13 patients and 2 patients proceeded to laparoscopic stoma creation in addition of 10 patients who directly to referred to laparoscopic surgery. 20 out of 25 patients were males, with mean age of 47.2 years old (29–87). For the indications of decompression, 44 % (n = 11) as a bridge to neoadjuvant chemoradiation therapy then surgical resection, 52 % (n = 13) for palliative care and 4 % (n = 1) case as a bridge to surgical resection. 1 case in the right colon, 3 cases in the left, 12 in the rectum, 4 in sigmoid, 5 case in the rectosigmoid. 6 out of 13 stented patients were bridged to neoadjuvant therapy (46 %), and one directly to surgical resection (8 %), and 6 patients were for palliative (46 %). 5 patients out of 12 laparoscopic diverted patients (42 %) and 7 patients were for palliative (58 %). Of the stented patients, one patients suffered early complications (8 %) in the form of perforation and 4 patients suffered late complications (31 %) [stent migration (n = 3) and tumor growth (n = 1)]. For the laparoscopic group, 4 patients suffered early complications (33 %) in the form of ileus (n = 2) and wound infection (n = 2) and one long term complications (8 % - prolapse). Conclusions: Late complications of the stenting make it less favorable option for the long term palliative care where laparoscopic stoma can be offered as it has manageable earlier and rare late complications. For patients with intention to cure by neoadjuvant therapy and surgical intervention, stenting can provide a better option as a bridge by relieving of the emergency obstruction and better quality of life.



Trans-Phrenic Peritoneoscopy as Novel Approach for Abdominal Organs During Thoracic Surgery: ‘Beyond Notes’ Concept

Value of Laparoscopic the Repair of Pediatric Recurrent Inguinal Hernia

S. Kainuma, S. Miyagawa, S. Fukushima, A. Saito, A. Harada, M. Hirota, Y. Miyazaki, N. Sawabata, T. Watabe, G. Horitsugi, K. Toda, J. Hatazawa, M. Okumura, K. Nakajima, Y. Sawa Osaka University Graduate School of Medicine, Suita, Japan Aims: The NOTES (natural orifice transluminal endoscopic surgery) concept leads us to new insight concerning uses of flexible endoscope in various surgical specialities. Intra-abdominal procedures, such as abdominal exploration, biopsy, or omentopexy, are occasionally indicated during thoracic surgery, which can be detrimental to patient’s fragile state. To avoid a simultaneous laparotomy, we devised a novel endoscopic approach termed trans-phrenic peritoneoscopy (TPP) for minimal access to abdominal organs from the thoracic cavity. Here, we evaluated the feasibility and safety of TPP-omentopexy in a porcine model. In addition, we assessed its potential effectiveness for enhancing cell-sheet based regenerative medicine in a myocardial infarction (MI) model. This is the first reported pre-clinical pilot trial of a trans-phrenic endoscopic procedure based on a concept beyond NOTES. Methods: One month after MI induction induced by an ameroid constrictor, a left thoracotomy was made and a standard laparoscopic port was placed on the left diaphragm to access the abdominal cavity, then a flexible gastrointestinal endoscope was advanced under low-pressure pneumoperitoneum. The omentum was identified, partially grasped with endoscopic forceps, and brought up into the thoracic cavity via the diaphragm. Finally, autologous somatic tissue-derived cell-sheets were implanted over the impaired myocardium, followed by placing the omentum over the sheets. Results: TPP-omentopexy was successfully accomplished in 2 ischemic heart failure model animals (left ventricular ejection fraction \ 40 %) within 22 and 27 minutes, respectively, in the presence of low intra-abdominal pressure (4–8 mmHg) and with stable hemodynamic status. There were no TPP-related complications. A necropsy 1 month after the procedure revealed the intact omentum-flap and its pedicle, with no evidence of diaphragmatic hernia. Vessel communication between the omentum and myocardium was identified using selective India ink angiography and histological analysis. Serial cardiac MRI and quantitative PET examinations also showed substantial reverse cardiac remodeling with improved myocardial perfusion, suggesting a synergetic effect of cell-sheet implantation and omentopexy. Conclusion: TPP-omentopexy was feasible and safe with a low-pressure pneumoperitoneum. The omentopexy was durable and had a synergetic impact on cell-sheet therapy. Such a successful marriage may provide new insight into less-invasive endoscopic intervention and regenerative therapy, particularly in critically ill patients.

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R. Shalaby1, A.l Ahmad2 Al-Azhar University, Cairo, Egypt; 2Al-Azhar University Hospital, Cairo, Egypt

1

Background: Open repair of recurrent inguinal hernias [RIH] in infancy and childhood is difficult and there is definite risk of damaging the vas deferens and testicular vessels. Laparoscopic repair of RIH has the benefit of avoiding the previous operative site. The aim of this study is to present the value of laparoscopy in the repair of RIH either after open or laparoscopic hernia repair with stress on technical refinements to prevent recurrence. Patients and Methods: This is a retrospective study of laparoscopic repair of recurrent inguinal hernia. Records of patients that have been subjected to laparoscopic inguinal hernia repair for RIH were reviewed and evaluated. All patients were subjected to laparoscopic repair of 42 recurrent hernial defects. The main outcome measurements of this study included; operative time, intra and post-operative complications, recurrence, hydrocele formation, iatrogenic ascent of the testis and testicular atrophy. Results: In this study 38 children with 42 recurrent hernial defects were operated upon laparoscopically. They were 34 male and 4 females with a mean age of 2.54 ± 1.989 years (range = 0.58–10.00 years). In 34 hernial defects the recurrence occurred after open herniotomy, while in 8 hernial defects it occurred after laparoscopic repair. All procedures were completed laparoscopically without any conversion. There were no intra or postoperative complications during this study. Mean operating time was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes for bilateral inguinal hernia. All patients achieved full recovery without intra or postoperative complications and were discharged on the same day of admission. Two patients developed hydroceles that responded well to conservative management. At 1 year follow up, there was no recurrence, no testicular atrophy or iatrogenic ascent of the testis. Conclusion: Laparoscopic repair of recurrent inguinal hernia in infancy and childhood, developed after either open or laparoscopic repair, avoids entering a Òbrotic inguinal canal, making the procedure easier, safer and shorter. It is a good alternative option in recurrent childhood hernia

Surg Endosc



Endoscopic Anti-reflux Valve (WEB) Creation in Gastric Tube Reconstruction Surgery

Five Cases of Single Incisional Intragastric Surgery Using a Glove Port for Gastric Submucosal Tumor Resection

Y. Yanagimoto

T. Yamauchi

Osaka University Graduate School of Medicine, Osaka, Japan

Uwajima City Hospital, Uwajima, Japan

Aims: Gastric tube reconstruction in esophagectomy is the standard procedure for patients with resectable esophageal cancers. Postoperative reflux of gastric content, however, often leads to serious consequences such as aspiration pneumonia and malnutrition. Known conservative treatments e.g. reassessment of life style, eating habit, and oral administration of antacid agents, have been reported only partially effective. The diaphragm or ‘web,’ created in the gastric tube, may theoretically work as ‘anti-reflux’ valve. The aim of this study was to evaluate feasibility, safety and potential effectiveness of endoscopic web creation in porcine gastric tube using recently released endoscopic suturing device. This is the world’s first pilot preclinical trial of endoscopic anti-reflux web creation in gastric tube reconstruction. Methods: This was an acute preclinical pilot study approved by IACUC in our institution. Crossbred female pigs with body weight of approx. 35 kg were used (n = 3). Prior to web creation, the gastric tube was fashioned using surgical staplers. A semi-circumferential web was created endoscopically by approximating mucosal-muscular layers at 9 and 3 o’clock using 2-0 DemeLENE applied via a double-channel flexible endoscope (GIF-2T-240TM, Olympus, Japan) with suturing device (OverStitchTM, Apollo, USA). A screw-type grasping forceps (Tissue HelixTM, Apollo, USA) was used to involve muscular layers. A reinforcing stitch was added to bridge the gap posterior to the first approximation. The performance of the web was morphologically (fluoroscopy) and functionally (pH monitoring with artificial gastric juice) assessed by inducing reflux in various postures (-20 to +20 degrees). Results: The web was successfully created without any intraoperative complication. The median operating time was 33 (28–116) minutes. The height of the web was accounted for 60 (53–60) % of the gastric tube lumen. In morphologic assessment, a significant reflux was observed in reverse-Trendelenburg’s position before the procedure, while not detected in Trendelenburg’s position after the procedure. In functional study, the cardiac pH dropped even in head-up position before the procedure, while not dropped at any angle after the procedure. Conclusions: Endoscopic anti-reflux web creation using OverStitch was feasible, safe and potential effective in porcine acute models. Its durability and long-term effectiveness need to be assessed using surviving animals.

Background: Intragastric surgery is a useful method for treating early gastric cancer and gastric submucosal tumors, such as gastrointestinal stromal tumors, in the cardia region, which are difficult to resect using endoscopic mucosal resection or endoscopic submucosal dissection. The procedure is usually performed by fixing the gastric wall to the abdominal wall using multiple balloon ports and insufflating the gastric cavity. However, port-related problems, such as air leakage from the port site or balloon breakage, often occur. Aim: This study aimed to introduce a new method of intragastric surgery in which a single incisional glove port is used. Methods: We performed five procedures of intragastric surgery using the single incisional glove port method to fix the gastric wall to the abdominal wall in order to resect gastric submucosal tumors. An incision measuring 4 cm was made in the umbilicus, and the gastric wall was lifted. The lap protector Ò(S type, FF0605S) was used to fix the gastric wall to the abdominal wall. A size 5.5 glove was placed on the lap protector, and 5-mm and 12-mm ports were inserted. The tumor was lifted and resected intragastrically using the auto suture stapler (Endo GIA Universal StaplerÒ), while confirming the tumor endoscopically. Results: In all cases, no port-related problems were encountered, and the forceps were easily manipulated using the glove port, which had a wide range of movement, allowing the gastric submucosal tumor to be successfully dissected. The tumors measured less than 30 mm in diameter and were located in the upper gastric portion near the esophagogastric junction. The mean operative time was 76 minutes, and the mean estimated amount of blood loss was 57 ml. In all cases, the patient’s postoperative course was uneventful. Conclusions: The single incisional glove port method is useful for performing intragastric surgery.



Initial Experience in Single-Incision Surgery by Glove Port Device: A Search of Safety, Repeatability and Affordability

Treatment of Endoscopic Submucosal Dissection and Single Incision Laparoscopic Surgery for Synchronous Occurrence of Gist of the Stomach and Early Gastric Cancer

G. Martin Martin, M. Jimenez Segovia, J.M. Moron Canis, F. Molina Romero, J.C. Rodriguez Pino, F.X. Gonza´lez Argente´ Hospital Universitario Son Espases, Palma de Mallorca, Spain Aims: with the intention of contributing to the development of less invasive surgery but reproducible, safe and logistically feasible, we present our initial experience with the use of the device Glove Port (GP) in the context of single incision surgery which also involves the first series published in our country with this device. Methods: 42 patients diagnosed with symptomatic cholelithiasis or acute appendicitis underwent laparoscopic single incision surgery with the device GP during 12 months from September 2012. We present the steps to prepare the GP device and its use. The following parameters were collected: demographic characteristics of patients, intervention type, operative time, need for conversion, intra-and postoperative complications, need for analgesia, early oral feeding, ambulation, hospital stay and development of incisional hernia during the period tracking. The data collection was conducted a telephone survey of satisfaction. Results: The most performed procedure is cholecystectomy in 36 (86 %) patients followed by appendectomy in 6 (14 %). A previous procedures adds another simultaneous in four (9 %) patients. The operation time is 65 (120), 52 (34) and 118 (246) minutes for cholecystectomy, appendectomy and combined processes respectively. The onset of oral tolerance and ambulation was achieved the day of surgery in 34 (79 %) and 33 (77 %) patients respectively. Median hospital stay is 1 (27) days. All patients in the series would return to operate this route and considered in its most aesthetic result as good. Conclusions: Endoscopic surgery by GP device is a safe alternative available and reproducible. Maintains the potential benefits of laparoscopic surgery through one incision. Its main advantage is the lower cost compared to other commercially available devices.

Y. Watanabe, S. Ohki, T. Yazawa, T. Nakajima, T. Momma, S. Suzuki, S. Takenoshita Fukushima Medical University, Fukushima, Japan Introduction: Recently, treatment of gastric tumor have been more less invasive according to endoscopic submucosal dissection (ESD) and laparoscopic surgery. Synchronous occurrence of epithelial neoplasia and gastrointestinal stromal tumor (GIST) in the stomach is uncommon. Only rare cases have been reported in the literature. We report in here that a case of gastrointestinal stromal tumor (GIST) of the stomach coexisted with early gastric cancer. Patient and Methods: A 60 s years old male presented with submucosal tumor (longest diameter, 40 mm) arising in gastric corpus greater curvature and coexisted with early gastric cancer in gastric antrum. EUS-FNA and immunostaining revealed GIST. Computed tomography revealed no metastatic lesion. Results: We performed ESD for gastric cancer and histopathological examination confirmed curative resection. Subsequently, we performed a single incision laparoscopic surgery for GIST. Operation time was 116 min and blood loss was 5 ml. Histopathological and immunohistochemical examination revealed low risk GIST. The post operative course was uneventful and hospital stay after surgery was 9 days. There has been no recurrence up to present. Conclusion: A single incision laparoscopic surgery and ESD were useful and less invasive treatment for GIST of the stomach coexisted with early gastric cancer.

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Bilateral Simultaneous Thoracoscopic Sympathectomy in Prone Position for Palmar Hyperhydrosis: Four Years Outcome and Quality of Life for University Students

Endoluminal Full-Thickness Suture Repair of Gastrotomies: A Survival Study

H. Ismail, A. El Samadoni Cairo University, Cairo, Egypt Background: Hyperhydrosis is a disorder that is characterized by excessive sweating of palms of the hands, axillae and feet in disproportion to that required for thermoregulation. The principal characteristic of this disease is the intense discomfort of patients, which affects their social and professional life specially in those depending on hand work. Aims: Improvement of professional and social life style of university students complaining of palmar and axillo-palmar hyperhydrosis through bilateral simultaneous thoracoscopic sympathectomy. Methods: Between October 2009 and September 2013, a prospective study of endoscopic thoracic sympathectomies for palmar and axillo-palmar hyperhydrosis was undertaken based on case histories and prospective pre and postoperative assessment. Sixty four patients, age range (18 to 25) years. All patients were students in Cairo University. All had primary hyperhydrosis, grade III and IV according to Hyperhydrosis disease severity scale HDSS. Bilateral simultaneous thoracoscopic sympathectomy in prone position was done in all cases. Excision of T3 was done in 32 cases, T3 and T4 in 13 cases and T3 sympathectomy was done in 19 cases. Results: All patients had immediate cessation of Hyperhydrosis (grade zero). The postoperative hospital stay ranged from 12 to 24 hours. No complications were detected except for mild Compensatory sweating that was not troublesome to most of patients. It was seen in 20 % of patients where ganglion excision was done (sympathectomy), compared to 5 % in those where sympathectomy was performed. Intercostal tube was required in one patient for only 12 hours. Postoperative pain was controlled by regular analgesics as diclofenac. Recurrence rate in the follow up period ranging from 6 months to 4 years was negligible in comparison to other methods of treatment such as Botulinum toxin injection. Conclusion: In view of low morbidity and zero mortality rate of this surgical technique, it is considered as one of the best methods of treatment for palmar and axillo-palmar hyperhydrosis. Patients who depend on handwork such as university students gain marked improvement in their quality of life after the operation.

P. Halvax, L. Swanstro¨m, M. Diana, S. Perretta, S. Cho, Y.Y. Liu, Y. Nagao, J. Marescaux IRCAD and Image Guided Minimally Invasive Surgical Institute (IHU Strasbourg), Strasbourg, France Aims: Treatment of perforations and complications related to surgery and flexible endoscopy are increasingly performed endoscopically. It is critical to be able to perform a secure full thickness gastro-intestinal (GI) tract closure. The aim of this presentation is to document the safety and efficacy of endoscopic closure of a large gastrotomy using an endoscopic suturing device. Methods: All procedures were done under animal welfare and ethics approved protocols. Under general anesthesia, 3 cm full-thickness gastrotomies were created endoscopically on various areas of the gastric wall in four 50 kg porcine models using a needle-knife cautery. The scope was then introduced through the gastrotomy to confirm full-thickness incision and to check for any external damage. An endoscopic suturing device (OverStitchTM, ApolloMedical) was fitted to the end of the double channel upper endoscope, a tag needle was loaded, and the endoscope was carefully inserted into the stomach. Suturing was started at either end of the incision. Retraction was obtained using both suction and a helical tissue grasper to insure full-thickness purchases on the gastric wall. Previous experiments had established that figure-of-eight sutures are the most efficient and effective suture pattern for secure closure. All stitches were placed to achieve full-thickness apposition. When the sutures were in place, the tag needle was released, the thread was pulled and with a cinching device the sutures were locked down. An air leak test was performed and the animal was then transferred back to the shelter for a ten-day surviving period. Results: Endoscopic suturing was achieved between 39–70 mins, for each incision 4–6 sutures were used. No complications occurred during the procedure. All animals did well post operatively and gained weight. At sacrifice, all gastrotomies were definitively closed. There were dense adhesions surrounding the suture site of one of the animals. Careful inspection did not identify any leaks. Conclusions: We demonstrate that modern endoscopic technologies have evolved to the point of allowing safe and reliable full-thickness closure of large enterotomies. This seems to open the door to an expanded role of endoscopic treatments of a variety of GI diseases both endoluminal and transluminal.



Flexible Endoscopic Single Incision Extraperitoneal Implant and Fixation of Peritoneal Dialysis Catheter: Proof of Concept in the Porcine Model (with Video)

Single Port Operations in Surgery and Urology

Y.Y. Liu, M. Diana, P. Halvax, S. Cho, A. Legner, A. Alzaga, L. Swanstro¨m, B. Dallemagne, J. Marescaux IRCAD and Image Guided Minimally Invasive Surgical Institute (IHU Strasbourg), Strasbourg, France Background: Peritoneal Dialysis (PD) offers an increased quality of life when compared to Hemodialysis (HD). However, a high rate of catheter migration and malfunction has been reported with the standard open placement technique, in which the catheter is placed in the pelvic space without anchoring. Aims: To assess the feasibility of a novel single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation. Materials and Methods: Six pigs were involved in this experimental study. A loop of Vicryl 2/0 was sutured on the tip of a PD catheter. In 3 pigs, a 2 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting the rectal muscles. A standard twochannel gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again and endoscopic clips were used to fix the tip of the catheter, by anchoring the Vicryl loop. In 3 pigs, the PD catheter was inserted laparoscopically with a two-port approach: a 10 mm port for the optic and a second 10 mm operating port through which the catheter was inserted. The catheter’s tip was fixed using a laparoscopic clip on the Vicryl loop. Outflow rate was measured by instilling 1,000 cc of saline through the catheter and recording the time and quantity of fluid recovered by gravity. A strain-test to assess the force required to detach the clips was performed using a digital dynamometer. Results: Mean operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (27 min, range 25–35 vs. 21 min, range 20–23). Outflow was comparable in both techniques. Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76). Conclusions: Flexible endoscopic extraperitoneal tunneling allows for a minimally invasive singleincision PD catheter placement and fixation. This technique is simple and could well reduce the risks of catheter migration.

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D.N. Panchenkov1, A.V. Baranov1, M.E. Bekhteva1, Y.u.V. Ivanov2, N.A. Soloviev2, A.A. Nechunaev1, A.I. Zlobin2 1 A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia; 2Federal Research Centre of Specialized Medical Care and Medical technologies FMB, Moscow, Russia

Introduction: At last years in addition to traditional laparoscopy surgeons have began to perform operations using a single access method. The aim of our study was to analyze single port (SP) operations and compare them with traditional laparoscopic surgery. Materials and Methods: During the period from 2011 to 2013 years we carried out 56 SP operations, including 36 cholecystectomies, 3 resections of liver cysts and 17 resections of renal cysts. The first group of patients was surgical patients. Among them there were 13 men and 26 women. The average age of patients was 47 years (33 to 72 years). The second group of patients was urological patients. Of these there were 11 women and 6 men. The average age of patients was 60,5 years (44–74 years). All interventions were performed by one team of surgeons with extensive experience in performing laparoscopic surgery. To access the abdominal cavity they used SilsPort (Covidien) and Triport (Olympus). Results: In the first group of patients the mean operative time was 55 min. There were not any intraoperative complications. Insurance drainages were set at 15 cases and removed at 1,25 day (1–2 days) after the operations. There were not any complications at early postoperative period. Index of postoperative pain was 1–2, using of narcotic analgesics were not required. Postoperative hospital stay - 5,7 (4–6 days). In the second group of patients the mean operative time was 100.8 min (85–195 min). Insurance drainages were set at 4 occasions and removed on 2,5 day after surgery (1–4 days). Index of postoperative pain was 1–2, using of narcotic analgesics are not required. Postoperative hospital stay - 4,1 (4–5 days). Conclusion: Number of intra- and postoperative complications, index of postoperative pain, time of the drains’ removal, as well as postoperative hospital stay are not differ from traditional laparoscopic interventions. We consider that such operations are possible if surgeons have enough experience in laparoscopic surgery and if it is necessary to achieve maximum aesthetic effect, as well as the patients’ wishes.

Surg Endosc



Twenty-Five Years of Endoscopic Tissue Sealing After Anastomotic Leakage

Laparoscopic Approach with Modified Hasson Technique, Decreasing the Risk of Injury (‘Cali Technical’), 1000 Cases

K. Kotzampassi, E. Eleftheriadis

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

Ahepa Hospital, Thessaloniki, Greece

1 Clinica Farallones - Clinica SaludCoop, Cali, Colombia; 2Clinica Farallones - Hospital Universitario del Valle, Cali, Colombia; 3 Hospital Universitario del Valle - Clinica de Occidente, Cali, Colombia

Background: Anastomotic leakage after gastrointestinal surgery is a difficult to managed complication, since conservative therapy and/or surgical reoperation may be unsuccessful with increased morbidity and mortality. The endoscopic use of tissue sealants seems a promising alternative to avoid surgery. Method: We present conclusively our 25-years’ experience with tissue sealing, in a series of 63 patients referred to our Endoscopic Department after a gastrointestinal anastomosis leakage. 37 males and 26 females were admitted 5 days [range 2 to 18] after diagnosis of anastomotic dehiscence; 48 of the upper and 15 of the lower gastrointestinal tract, experienced a drainage volume ranged from 50 to 2400 mL. Results: Tissue glue was applied perorally in 37 patients, per anus in 10, through the fistula tract [fistuloscopy] in 8, and through a combination of approximation routes in another 8 cases. Biological glue [fibrin] was used in 47 patients, cyanoacrylate glue in 8 cases and both types of glue in another 8 patients. The total volume of fibrin applied was 2 to 36 mL [median 12 mL], in a median of 4 sessions [range 1 to 9], 0.5 to 4 mL [median 1.5 mL] for cyanoacrylate, in a median of 2 sessions [range 1 to 4], and, whenever a combination of glues used, a volume of 12 to 40 mL of fibrin plus 1 to 4 mL of cyanoacrylate, in a median of 9 sessions [range 4 to 14]. The median hospital stay after initiation of gluing was 14 days, ranged from 8 up to 32 days. Clinical and technical success rate was 96.8 % [61 out of 63 patients]. Conclusion: Tissue glue application seems a valuable clinical tool that would prevent further surgical interventions and associated morbidity and mortality after a gastrointestinal anastomosis dehiscence. However, must remain in mind that repeated sessions and large volumes of sealants are in many cases necessary.

Laparoscopy is the most common technique of Minimally Invasive Surgery. Although that is usually safe, some complications may occur, including injuries to the blood vessels (0.9 per 1000) and the bowel (1.8 per 1000). Initial approach, can be done by two techniques: closed technique, using a Veres needle or open technique in which the insertion of a trocar is made under direct visualisation. Until 2008, had no differences in complications between the two techniques. In the last revision made in 2012, significant benefits were noted with the use of open technique when compared to the Veress Needle. The second one was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury. Open technique has been described by Hasson in 1971. However the safety of this technique, is the time taken for dissection is much higher than in other techniques, also the amount of surgical instruments needed. Our technique, called ‘Tecnica de Cali’, aims to preserve the virtues of Hasson technique, simplifying some steps and the number of instruments used, including a new element: the elevation abdominal wall. In all cases, a longitudinal incision is done across the navel, which is made on its two side edges with Kelly forceps and then dissected to the cavity with a third Kelly clamp. After viewing the abdominal cavity, a suture in U is performed. This suture remains lax and issued at the end of the procedure to close definitively the fascia. Next step is the introduction into the hole created a separator Senn Miller or Langenbeck; with this separator the abdominal wall is elevated between 5–7 centimeters, separating it completely from the viscera and potentially decreasing the risk of injury. In our series, no vascular or bowel injury occurred. Extraperitoneal insufflation happened in one case; trocar site bleeding in seven cases; trocar site infection in twenty cases, related subgroup of appendectomies; minor injuries in the mesentery occurred in 5 patients. In conclusion, the ‘Cali Technique’, It is a safe, fast and economical method of approach to laparoscopy without major complications and minor complications less than expected in the current literature



Modern Methods: Of Endoscopic Hemostasis and Effectiveness in Treatment of Acute Duodenal Ulcer Bleedings

Tips and Tricks in the Evolution and Standardization of Intracorporeal Anastomosis in Single Incision Surgery

E.N. Shepetko, V.V. Yefremov, M.G. Boyarskaya, V.V. Shapovaluk

I. Alarcon-del Agua, S. Morales-Conde, A. Barranco-Moreno, J. Can˜ete, R. Avila-Pin˜ero, H. Cadet, F.J. Padillo-Ruiz, M. SocasMacias

National Medical University Named After O.O. Bogomolets, Kiev, Ukraine Aims: Comparison of efficacy of endoscopic hemostasis methods in treatment of acute duodenal ulcer bleedings. Materials and Methods: The treatment results were analyzed for 1630 patients with duodenal ulcer bleedings which were treated in Kyiv City center of gastrointestinal bleedings during 2004–2008. 1577 of them was treated conservatively ?nd 53 were operated. Endoscopic hemostasis was performed in 1096 patients. Results: The application hemostasis with preparation \Caprofer[ is most often applied (88.96 %), diathermo-coagulation - in 5.11 % of cases (p = 0.00001, p \ 0.05), argon plasma coagulation - in 2.37 % (p = 0.00001, p \ 0.05), the combined hemostasis (diathermo-coagulation with preparation \ Caprofer [) in 3.47 % of cases (p = 0.00001, p \ 0.05). After application endoscopic methods of a hemostasis relapse of an ulcer bleeding has occurred all in 4.74 % of cases. Relapse bleeding in a hospital after application of Caprofer occurred in 5.13 % of cases, after diathermo-coagulation - in 3.57 % (p = 0.6041, p [ 0.05); after the combined methods (diathermo-coagulation with Caprofer) bleeding relapses were not detected (p = 0.2363, p [ 0.05), as well as after argon plasma coagulations (p = 0.1525, p [ 0.05). Conclusions: 1. The combined methods of the hemostasis are the most effective, and their efficiency reaches 96–100 % at technologically correct application. 2. The endoscopic injection hemostasis with the tranexam acid is a safe and effective method which needs to be used more widely in clinical practice. 3. At endoscopic stigma FIIA–FIIB it is recommented to apply argon plasma coagulation as a monomethod, and as a component of combined endohemostasis. 4. Application of modern effective endoscopic hemostasis methods and intravenous proton pomp inhibitor reduces lethality at conservative treatment of relapse bleeding in 1.94 times (p = 0.0152) in the basic group of patients in comparison with the control group. 5. There are the reasons for high-dose intravenous proton pump inhibitors therapy during 5 days after the patient hospitalization for relapse bleeding prevention.

University Hospital Virgen del Rocio, Seville, Spain Background: Lack of standardization has been one of the main critics against single port surgery since the initially development of this new approach. Different ways and devices to perform this surgery have been proposed and specifically design for single port surgery. Material and Methods: We present our experience performing intracorporeal anastomosis in Single incision Laparoscopic Roux-en-Y By pass and right hemicolectomy. Many technical aspects have been developed. Specific suture devices, barbed sutures and traction devices are used to perform the anastomosis looking for the standard manner of perform it. Conclusion: Standardization of technique is mandatory to obtain similar results to conventional laparoscopic interventions. Efforts must be focus in perform anastomosis in a safe, rapid and reproducible way.

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Evaluation of Gut Anastomosis with Endoscopic ICG System

Ingenuity of Laparoscopic Transhiatal Approach for Esophagogastric Junction Cancer/Left Diaphragm Oblique Incision Method: By Linear Stapler

T. Nobuhisa Red Cross Hospital, Himeji, Japan Aims: We report a dramatically quick and easy assessment of blood flow of gut anastomosis. Endoscopic indocyanine green fluorescence angiography (EIFA) is an angiography that is performed by using Endoscopic ICG System with indocyanine green (ICG). Materials: ICG, Endoscopic ICG System. Methods: Fluorescence images were obtained by the Endoscopic ICG System, produced by KARL STORZ-ENDOSCOPE, that is equipped with a low-cut filter as a light source for emission of ICG. The fluorescence images were digitalized for the display after the injection of ICG. The Endoscopic ICG System is quite easy to start up. EIFA was performed in the patients who underwent esophagogastrostomy, gastroduodenostomy, small-intestinal anastomosis and colon anastomosis. Results: Within 1 minute after the injection of ICG, fluorescence images were visually demonstrable by Endoscopic ICG System. Real-time blood flow of the anastomosis was observed clearly by NIFA. Conclusions: It takes only 1 minute to perform EIFA. EIFA enables only blood flow to shine, so it is visually easy to assess the bloodstream at anastomosis. Moreover, EIFA makes it possible to decrease anastomotic leakage.

M. Yamamoto1, S. Takiguchi2, Y. Miyazaki2, T. Takahashi2, Y. Kurokawa2, M. Yamasaki2, H. Miyata2, K. Nakajima2, M. Mori2, Y. Doki2 1

Osaka University Graduate School of Medicine, Osaka, Japan; Osaka University Hospital, Osaka, Japan

2

Aims: In recent years, a treatment policy for esophagogastric junction cancer has been considered and the reports for necessity of lower mediastinal lymph node dissection are occasionally found. Although we make efforts to secure operative field for mediastinal manipulation by thoracotomy, it would lead an issue for large invasion. On the other hand, it is considered that a laparoscopic surgery possibly could secure operative field as being comparable to that of open chest surgery up to surgeon’s ingenuity if utilizing a feature of proximity magnifying observation. At our hospital, after executing preoperative chemotherapy to advanced esophagogastric junction cancer, we execute fundusectomy, transhiatal lower esophagus resection, and lower mediastinal lymph node dissection. In addition, when executing mediastinal dissection as incising diaphragm crura, we incise a left diaphragm with linear stapler. Sufficient lower mediastinal lymph node dissection can be executed by obtaining favorable operative field with integration of chest cavity, mediastinum, and abdominal cavity, and also working space. Furthermore, a staple line becomes Merck mark at the time of diaphragmatic repair by dissecting diaphragm with linear stapler, then the diaphragm also can be easily repaired without cutting. Methods: We targeted 6 cases with surgery of esophagogastric junction cancer executed after July 2012. The ratio of male/female was 4:2, median age was 62 years old (36–75), and esophageal infiltration length before treatment was 1.5 cm (0–5). Results: We have completed the surgery for all cases laparoscopically. The surgical duration was 479 minutes (390–750) and the hemorrhage volume was 250 ml (130–500). One case was for resection of adjacent organs (body and tail of the pancreas and spleen). The result of pathological tissue recognized lymph node metastasis in 5 cases, and one of those cases was mediastinal lymph node metastasis. R0 surgery was executed for all cases. One case of each intraabdominal abscess and pneumothorax was recognized as postoperative complication. Their hospitalization period was 22 days (17–54). Conclusions: For esophagogastric junction cancer, the above-mentioned approach can be useful as securing operative field and repairing diaphragm; therefore, we will continuously examine the postoperative treatment results with accumulating the cases from now on.



The Three Dimensions Laparoscopic Approach. Our Experience in Metabolic and Bariatric Surgery

Developments in Single-Incision Laparoscopic Appendectomy as Performed in Our Department

F. Martıńez-Ubieto1, A. Jimeńez-Bernado´2, A. Cabrerizo3, J. Martıńez-Ubieto1, A. Pascual-Bellosta4, L. Munõz-Rodriguez4, A. Valencia-Romeo1

T. Nakamura, T. Nagaoka, Y. Nakagawa, T. Okada, T. Yamauchi, N. Ishida, Y. Imai, H. Kiyochi, K. Okada, T. Sakao, S. Kajiwara Uwajima City Hospital, Uwajima City Ehime Prefecture, Japan

1

Hospital Viamed Montecanal, Zaragoza, Spain; 2Hospital Clıńico Universitario, Zaragoza, Spain; 3Hospital de Tudela, Tudela, Spain; 4 Hospital Universitario Miguel Servet, Zaragoza, Spain We present our personal experience with the first twenty cases operated on by 3D laparoscopic approach. We have used the devices of three companies with different cameras and optics systems. the most important aspect is the gaining of depth dimension, specially important in laparoscopy. Tasks as the position of the needle, the suture, the solution of problems improve with the new vision. We emphasize the security in the technique with 3D laparoscopic surgery. The learning curve is really short.

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Introduction: Single-incision laparoscopic surgery is a scarless technique and is performed through a single small incision hidden in the umbilicus. Single-incision laparoscopic appendectomy (SILA) was introduced in our department in August 2011, and SILA without establishing pneumoperitoneum (gasless SILA- GL-SILA) has been performed since May 2013. The aims of this study were to describe the way in which SILA is performed in our department and to compare the clinical features of GL-SILA and conventional SILA (C-SILA). Methods: The procedure began with a short incision on the umbilicus and placement of a wound protector. In GL-SILA group the umbilical hole was lifted, the mesoappendix was grasped, and the appendix was pulled out through the umbilicus without establishing pneumoperitoneum; appendectomy was then performed using the same method employed in open appendectomy. In C-SILA group a surgical glove was fixed to the outer ring of the wound protector. Three 5-mm ports were placed for individual fingers. Pneumoperitoneum was established, and the appendix was pulled out; appendectomy was performed in the same way. The surgical duration, blood loss, complications, and length of hospitalization were retrospectively examined. Results: 40 SILA cases between August 2011 and December 2013 were included in this study. The GL-SILA group included 11 patients and the C-SILA group included 22 patients (16 with catarrhal, 15 with phlegmonous, and one with gangrenous appendicitis). No complications were noted in either group. In the remaining 7 patients (6 with gangrenous and one with perforated appendicitis), the procedure was converted to the one during which the other incisions were made. The median patient ages were 12 and 15.5 years in the GL-SILA and C-SILA groups, respectively. The median surgical duration was significantly shorter in the GL-SILA group (35 min) than in the C-SILA group (56 min). In the GL-SILA and C-SILA groups, median blood losses were 3 and 4 ml, respectively, and median lengths of hospitalization were 4 and 5 days, respectively. Conclusion: SILA is a useful technique for catarrhal or phlegmonous appendicitis, with an obvious cosmetic benefit. GL-SILA is safe and feasible in select patients.

Surg Endosc


P171 - Education

The Patient, the Technology and the Crisis: Every Cloud has a Silver Lining

Integration of Surgical Outcomes into Laparoscopic Surgery Education: Eight Years’ Experience from a Single Institution in China

F. Furbetta Clinica, Leonardo, Pisa, Italy

H. Liu, T.Y. Mou, Y.F. Hu, L.Y. Zhao, Y.N. Wang, H.J. Deng, J. Yu, G.X. Li

Aims: The patient has to be cured with the less invasive more effective procedure, the technology offers astonishing solutions to gifted, wise hands, the crisis dictates the right priority of a surgical procedure. Lack of well-organized team and technological resources to balance deficient competence are the downside of the modern surgeries. It’s worth focusing on staged, redundant examinations and procedures like in gallstone surgery, less invasive access instead of less invasive procedure like in SILS (single access laparoscopic surgery) for old-fashioned hiatal hernia repair, colonic resection with staplers to cover technical deficiency. The crisis asks for cooperation, organization and priorities and capitalizes on own low cost brain and skills. Material and Methods: Three frequent and paradigmatic surgical fields according to my best practice and suggestion are: 1) cholelithiasis/common bile duct stones: pre-operative hematologic check and ultrasound; intraoperative cholangiography; surgical team specialized and skilled for one time endo-laparoscopic treatment. In my experience since 1997 a well organized team guarantees this gold standard of treatment 2) hiatal hernia repair above pars condense (HHapc) (personal technique): new era of less invasive procedure instead of less invasive access (SILS) tied to business and cosmetics. Since 2005 we propose this less invasive new technique 3) colonic operations and misuse of staplers: staplers to permit reproducibility of open procedure; stapler as first row of two layer bowel closure. Since 1998 we used staplers with the same indication in open as in laparoscopy Conclusion: Crisis can reset our working style: technology to improve our performances rather than make up for lack of human resources. The frequent biliary lithiasis underlines the rational of an endoscopic surgeon to balance and integrate laparo-endoscopic potentialities and to cut down pre and post-operative checks and staged risky operations. HHapc stresses laparoscopic advantages for less invasive procedure opposed to SILS, between cosmetics and business. What about staplers to compensate for laparoscopic inability to reproduce open vascular ligation or intestinal suturing? We all are here because the companies are there but we should dictate who and what is useful to the public health.

Aims: Laparoscopic surgery has become popular in China over the past decade and its trainings still have a great importance. Our institution is one of the leading centers with specialty in laparoscopic gastrectomy (LAG) for gastric cancer in China. Like the Western forerunners, our educational methods also involved interactive theoretical and video sessions between faculty and course participants, hand-on training on mini-pigs in experimental lab, mentorship program and so on. However, few efforts were made to improve the quality of surgical care through education and training in China. We report here our eight-year experience of using the patient outcomes data in the training of laparoscopic surgeons. Methods: From 2004 onwards more than 2,560 trainees with various surgical skill levels enrolled and learned techniques in our center. To provide surgical outcomes data, we retrospectively collected the data for all 878 patients with gastric cancer who were underwent LAG between 2004 and 2010 by ten surgeons from ten leading upper GI centers, who were trained in our center previously. The postoperative complications were classified according to the Accordion Severity Grading System. Results: In this eight-year period ten selected surgeons who had a background of performing over 30 LAGs in their respective hospitals were included for analysis. The operating time was 242 ± 101 minutes and was highly dependent on the surgeon’s experience for LAG. Overall, the rate of postoperative complications was 14.1 % and varied greatly between then ten surgeons. Of these cases with postoperative complications, 34 were mild complications, 79 moderate complications, 9 severe complications and 3 deaths. Conclusions: The patient-centered outcomes data can be fully applied in laparoscopic surgery education, due to the fact that the data are the most effective method to engage surgeons in quality improvement. Thus, surgical training should embrace the use of outcomes data in the training process. In the upcoming academic year, our outcomes-based program will introduce semi-annual reports for senior surgeons.


P172 - Education

Surgeon’s Upper Extremity Muscle Activity: Single Incision Versus Conventional Laparoscopic Surgery

Learning Curve Analysis During the First Year Of Peroral Endoscopic Myotomy in the Czech Republic

A. Morandeira-Rivas, C. Moreno-Sanz, L. Millań-Casas, M. Clerveus, C. Alhambra-Rodriguez de Guzman, L. Antinolfi, J. Cortina-Oliva, M.L. Herrero-Bogajo, F. Sańchez-de Pedro, G. Tadeo-Ruiz, J. Picazo-Yeste

D. Dolezel1, J. Martinek2, J. Spicak2, O. Ryska1

Mancha Centro General Hospital, Alca´zar de San Juan, Spain Aims: The aim of this study was to compare muscle activity in the surgeon’s upper extremity between single incision (SILC) and conventional (CLC) laparoscopic cholecystectomy. Methods: Eight surgeons, right handed and experienced in laparoscopic surgery, performed one conventional and one single incision laparoscopic cholecystectomy in a cadaveric porcine model. Electromyography (EMG) signals were obtained from right upper extremity muscles using triple surface electrodes in each muscle group, including trapezius, triceps, biceps, and forearm flexors and extensors. EMG results were expressed as percentage of the maximal voluntary contraction. Results: Mean percentage of maximal voluntary contraction between the two approaches was comparable for all muscle groups, the trapezius muscle showing the highest muscle activity. Trapezius 42.3 ± 4.7 SILC vs. 45.3 ± 6.7 CLC, biceps 15.7 ± 5.5 SILC vs. 15.4 ± 5.4 CLC, triceps 8.8 ± 4.6 SILC vs. 10.9 ± 5.6 CLC, forearm flexors 17.6 ± 7.6 SILC vs. 13.7 ± 5 CLC and forearm extensors 16 ± 2.2 SILC vs. 17.6 ± 3.6 CLC. Conclusion: Single incision laparoscopic cholecystectomy has similar levels of muscular activity in the dominant upper extremity muscle groups when compared with the conventional laparoscopic approach. Ergonomic recommendations for conventional laparoscopic surgery should be also applied in single incision

Nanfang Hospital of Southern Medical University, Guangzhou, China

1 Central Military Hospital Prague, Czech Republic; 2IKEM, Prague, Czech Republic

Aims: Peroral endoscopic myotomy (POEM) is still considered experimental procedure in the Czech Republic. We analyzed learning curve for POEM procedure during the first year of our clinical experience. Methods: Prospective cohort study from a single center involved 30 patients (18 men, 12 women) undergoing POEM. All procedures were performed by one experienced endoscopist after training on 10 pigs. The first clinical procedure was supervised by expert in the field. All patients had a diagnosis of esophageal achalasia based on endoscopic, manometric and radiologic examinations. We divided patients into three consecutive groups of ten. We set length of procedure (LOP) in minutes divided by length of myotomy (LOM) in centimeters (cm) as an appropriate measure (LOP/LOM) of progression in time. Analysis of learning curve was based on LOP/LOM and technical errors (mucosectomy and carbon dioxide extravasation). Results: POEM was successfully completed in all patients (aged 47,3 ± 14,5 years; BMI 24,9 ± 3,7 kg/m2) without any serious intraoperative complications. The mean hospital stay was 2,5 ± 0,7 days. The mean LOP was 87,5 ± 20 minutes. The mean myotomy length was 12,1 ± 2,9 cm. The mean LOP/LOM (7,7 ± 2,7 minutes/cm) decreased (P-value \ 0,001) with increasing experience: first group (9,9 ± 1,8 minutes/cm); second (7,7 ± 2,7 minutes/cm); and third (5,5 ± 1 minutes/cm). An inadvertent mucosectomy was created in 3 patients (10 %), and was treated immediately with clips. Decreasing incidence of mucosectomy in groups (0,2; 0,1; 0) was not significant (P-value = 0,75). Thirteen patients (43 %) required decompression of capnoperitoneum and additional 7 patients (23 %) experienced subcutaneous emphysema with spontaneous resolution. Both types of carbon dioxide extravasation was not influenced by learning (P-value = 1). Plateau phase of learning curve (based on LOP/LOM) has fully stabilized since the 14th patient (24th procedure including animal training). Conclusion: Significant learning curve of POEM during the first year in the Czech Republic was recorded in decreasing LOP and faster myotomy creation. Inadvertent mucosectomy and carbon dioxide extravasation were not influenced by learning. Primary POEM training on at least ten pigs shortened achievement of plateau phase to 14 clinical procedures. Supported by projects: NT13634-4/2012 and MO-1012.

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P173 - Education

P175 - Education

A Bovine Torso Model for Training Colorectal Surgeons in Laparoscopic Rectal Dissection

Laparoscopic Surgery Education, Addition of Internet

B. Tang1, G. Ross1, M. Coats2, Z. Vujovic2, D. Ziyiae2, K. Campbell2 1

2

University of Dundee, Dundee, United Kingdom; Ninewells Hospital and Medical School, Dundee, United Kingdom

C. Avci1, G.B. Cadie`re2, L. Avtan3 1

Istanbul University, Istanbul, Turkey; 2Saint Pierre University Hospital, Brussels, Belgium; 3Istanbul Faculty of Medicine, Istanbul, Turkey

Aims: Porcine models, live and cadaveric, have been used extensively in laparoscopic training. They allow features of rectal surgery to be simulated but are unrealistic in terms of size, the mesorectal and rectal tissues are flimsy, fat is lacking and the dissection is insufficiently challenging. The pelvis is too small for a low stapled anastomosis. This study aimed to identify a more realistic and more challenging model of laparoscopic rectal dissection. Materials and Methods: The torso of a 30 kg calf with intact pelvis and diaphragm were purchased from a medical meat company. The shaved calf was placed on its back with sandbags used to maintain position and simulate tilt. Pneumoperitoneum was established. The key steps and techniques of laparoscopic rectal dissection and stapled anastomosis were completed by 20 trainees under supervision. Evaluation forms were completed by these participants and expert faculty. Results: Analysis of the feedback shows all found the model to be a realistic approximation in terms of anatomy, tissue colour, consistency and organ tactility, to human rectal dissection (average score of 4.3 on a Likert scale of 1(unrealistic/poor) to 5 (realistic/useful)). The feedback on the calf model for port insertion, anatomy, rectal dissection, retraction and access, stapled anastomosis were scored as 3.9, 4.0, 4.0, 4.0 and 4.3 respectively. All those with experience of both, rated the calf superior to the porcine model. 6 delegates and all 5 faculty rated the bovine was better than the porcine model used before. Conclusion: This calf torso model can be easily obtained and appears valuable as part of a multi-modal training programme for skills acquisition in laparoscopic rectal dissection and anastomosis. Some of the disadvantages of the porcine model are addressed allowing the more advanced trainees to be stretched.

Education and training are always important in practice of laparoscopic surgery. On site participation in educational activities as different courses, various scientific meetings are often useful and eficase but sometimes is not easy, takes time and expense The advancement of telecommunication technology and especially the widespread use of internet adds a new way to the effective and relatively easy education. In this regard, on line educational activities replaces more and successfully the activities on site. Last ten years, Turkish Association for Endoscopic Laparoscopic Surgery (ELCD) and Distance Educational Center of the University of Istanbul (ISTEM) apply a permanent online education program for Turkish laparoscopic surgeons, In addition, the collaboration with ‘ European School of Laparoscopic Surgery in Brussels’ whose director Prof. GB Cadie¨re, this program takes an international dimension thus the surgeons from different countries, particularly the Euro - Mediterranean benefit also. The main objective is to promote the exchange of knowledge and experience about videoscopic surgery and to establish a surgical network with a good-quality moving image over broadband internet access. With the supports of the ‘webtelesurgery.com platform’ whose administrator Prof C. Avci, having the ‘ Live Video/Audio Transmission System (IMD)’ and using ‘Digital Video Transport System (DVTS)’, the audio and video content from operation room, meeting hall can be transmitted easily to the remote sites. Surgeons applicants who have a computer and basic internet connection will be easily connected online to the operation and conference rooms, and follow in real time and even use it interactively. This kind of internet-based education we use their regularly is effective and inexpensive. Surgeons living in remote areas, distant countries, especially those with limited resources, can follow the videoscopic courses, meetings, and live surgeries organized by experienced centers, on their computer screen, in real-time and interactively.

P174 - Education

P176 - Education

Comparing New Generation Virtual Reality Simulators from Simbionix Ltd and Surgical Science AB

Web Based Live Laparoscopic Surgery Media Content: National Experience

C. Va˚penstad1, E.F. Hofstad2, G. Johnsen3, R. Ma˚rvik3, T.N. Hernes1

S. Tyutyunnik, I.E. Khatkov

1

Moscow Clinical Scientific Center. MSUMD, Moscow, Russia

The Norwegian University of Science and Technology, Trondheim, Norway; 2SINTEF Technology and Society, Trondheim, Norway; 3St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway Aims: Virtual Reality (VR) simulators are useful tools in surgical skills training. The realism of graphics and simulated haptic feedback influence training effect, performance results and how such tools are perceived. We compared two new generation simulators by asking surgeons to test them. Methods: Surgeons with different levels of experience in laparoscopy were asked to test the Lap MentorTM VR simulator from SimbionixTM LTD and the LapSimÒ VR simulator from Surgical Science AB. The systems were tested in random order. A standardized peg transfer task and an appendectomy module were performed twice on each system. After having tested the first system they answered 12 questions related to that system, and after having tested both systems they answered an additional 12 questions regarding the second system, 26 questions regarding both systems and 10 questions regarding training in general. The performances were recorded on both simulators and compared. Results: Twenty-seven surgeons participated in the study of whom fourteen tried the LapSimÒ simulator first. The surgeons recommended the use of both simulators to train procedural steps (median four on a scale from one (disagree) to five (agree) for both systems). They used on average 108 seconds on the LapMentorTM and 137 seconds on the LapSimÒ to pass the peg transfer (statistical significant difference). The simulated appendectomy scene was rated more realistic on the LapMentorTM (median four) versus the LapSimÒr (median three) (statistical significant difference), whereas the LapSimÒ userinterface was rated more intuitive (median four) than the one from LapMentorTM (median three) (no statistical significant difference). Conclusions: There are several aspects that influence the utility and the user-experience of a VR simulator. Although the peg transfer is a standardized task based on the Fundamentals of Laparoscopic Surgery program, the performance scores differ from one simulator to another.

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Purpose: To show educational value of an on-line live laparoscopic surgery broadcasting. Patients and Methods: Broadcasting advertisement were available on-line on the main website and was spread by e-mail for subscribed surgeons. There was no pre registration. There were no any fees for all surgeons and patients interested in. Archived video is available 24/7 from laptop, mobile and tablet devices without any registration. Many sites had multiple viewers. There was a surgeon who commented the procedure. All questions were sent by e-mail. Special assistant read them to surgeon and the main surgeon asked the questions in real time through the microphone in operation room. Twelve major and middle size laparoscopic procedures were shown on-line in live time from September 2011 to December 2013. Among theme were gynecological, urological, general surgery and HPB procedures. Also there were 6 edited laparoscopic video presentations and 4 on-line video lectures. We evaluated the mean time of broadcasting and number of view for on-line live surgery and for edited laparoscopic video presentations. All video files were available on-line next day after the presentation. Results: More than 7300 views for 30 months time. For on-line live surgeries mean time was 135.1 ± 55.0 min (85–216 min); mean number of view was 3965.8 ± 1943.0 views (1283–7344 views). For edited laparoscopic video presentations mean time was 8 ± 5.8 min (1–16 min); mean number of view was 2964 ± 1385 views (1569–4823 view). 64 % viewers was from Moscow and Moscow region; 10 % viewers from Sverdlovsk region and 26 % viewers from the rest of Russia. 121 people recommended the website to others via the major social network in the world. 628 people subscribed for the news. Conclusion: On-line live surgery broadcasting is modern and affordable way of sharing top quality laparoscopic surgical technique. It is the first successful on-line live surgery broadcaster in Russia.

Surg Endosc

P177 - Education

P179 - Emergency Surgery

Surgeon as a Mentor: Role of a Mentor

Hybrid Single-Port Surgery in Emergency: A Single-Center Experience

M. Ghellai National Cancer Institute, Misurata, Libia The making of a surgeon passes through three phases: undergraduate, graduate and continuous surgical education. This requires education, certification and practice regulation. In producing a surgeon beside clinical and surgical skills, surgical trainee must require a broad range of technical, interpersonal, administrative and research skills. Producing surgeons of the highest type requires more than teaching and instruction. It requires strong mentorship. Mentoring is a collaborative mutually beneficial partnership between two parties, a Mentor and a Mentee or Prote´ge´. A mentor helps you to perceive your own weaknesses and confront them with courage. The bond between mentor and Prote´ge´. enables us to stay true to our chosen path until the very end. True mentor should instill confidence, help mentees to analyze their own abilities and assess strengths and weakness but don’t solve their problems. A good mentor should motivate, empower, nurture self-confidence, teach by example, offers wise counsel and raise performance bar. The pathway to effective mentorship Starts with recognizing the importance of mentorship, identification of specific mentor, establishing goals and communication then executing the strategy. In this presentation we will define mentorship and list it’s types. Explains who needs a mentorship and distinguish between mentoring and role modeling? Mentorship benefits as well as mentor and Prote´ge´. qualities, attributes and responsibilities are listed. The process and pathway to effective mentorship is discussed. We shade light on causes of failure of mentorship process and conclude by listing some secrets to the success of mentorship. Whether we realize or not, our performance are closely observed and internally graded by the next generation of ‘could-be’ surgeons. One can only hope that one day, the mentee will become an even better surgeon than his mentors.

A.A. Faev, V.A. Zamiatin, A.V. Smirnova, S.S. Chernyavski, A.S. Leontiev Hospital Nr 29, Novokuznetsk, Russia Background: The technical complexity of operation technique restricts the use of singleport access (SPA) in urgent cases. Aims: Development of new methods of SPA-operations to facilitate their use in acute diseases of the abdominal cavity. Methods: Between February 2012 and December 2013 the operations using single incision port X-Cone (Karl Storz, Germany), 10-mm laparoscope and high definition camera was performed in 111 adult patients. We used video-assisted techniques, additional trocar insertion in complex cases for the purpose of exposure and drainage. Results: Video-assisted transumbilical appendectomy was performed in 56 patients aged 18–62 (Me 28) years. Phlegmonous appendicitis is revealed at 49 patients, gangrenous at 6, perforated - 1. Conversion to the open access required in 2 patients with retroperitoneal location of appendix. No postoperative complications were noted. SPA-cholecystectomy performed in 38 patients aged 19–80(Me 44) years. Phlegmonous cholecystitis is revealed at 35 patients, gangrenous at 3. Additional trocar insertion needed in 26 (68 %) patients for adequate traction. Postoperative complications noted in 2 (5,2 %) patients: subhepatic abscess - 1, hepatic abscess - 1. There were no mortality. SPAcholecystectomy using original traction device which consists of needle and metal loop performed in 4 patients without intra - or postoperative complications, in 1 case 5 mm additional trocar inserted. Video-assisted SPA- perforated ulcer repair via right subcostal access includes port placement in projection of bulbus of duodenum, laparoscopy, abdominal lavage, extraction of port and simple open perforation suturing via the same small access. The method was used in 12 patients with disease duration 1.5–10 (Me 6.5) hours, without postoperative complications. Additional trocar used in 4 (33 %) patients. Another video-assisted SPA: great omentum resection - 3, Meckel’s diverticulum resection - 2. Conclusion: Application of hybrid video assisted technology, additional trocar and 10 mm laparoscope facilitates the use of SPA in emergency surgery.

P178 - Education


New Teaching Materials of Three Dimensional Anatomical Images

Emergency Cholecystectomy for Acute Cholecystitis: Depends on the Onset Time

Y. Kondo, M. Nishizaki, T. Fujiwara

A. Tomida, Y. Fukami, Y. Kurumiya, K. Mizuno, E. Sekoguchi, S. Kobayashi

Okayama University Hospital, Okayama, Japan It is very important for young surgeons or residents to learn clinical anatomy in an efficient and effective way. In colorectal region, the anatomy of pelvis is complex and difficult to understand the three-dimensional relationship between vascular system and other viscera by a classical two-dimensional method. In an ordinary text of the anatomy, figures are arranged from a best angle to explain. It is usually drawn not from an assistant’s, but from an operator’s view-angle or an any easy angle to understand. A young resident has few opportunities to watch operations from operator’s points of view. The figure is not consistent with the image they have seen during operations. In order to resolve these dilemma, we develop a completely new anatomical teaching material. It offers new solutions for young surgeons in order to learn an intricate cubic structure of abdomen, especially of pelvis, by themselves. We call this new material ‘ 3D-Anatomy’ which provides five unique characteristics as follows: (1)from multi-view points, (2)on multi-layers, (3)using a human cadaver, (4)by an on-line viewer, and (5)with a three-dimensional view. This’ 3D anatomy’ can be applied to teach complicate anatomy with the feeling of being at a live operation. We introduce an example of practical use of this new teaching material for young surgeons.

Toyota Kosei Hospital, Toyota, Japan Aims: Early cholecystectomy is the treatment of choice for acute cholecystitis. However, the optimal surgical timing is controversial. The aim of this study is to assess the clinical outcome of patients with acute cholecystitis to different onset time. Methods: Between January 2011 and June 2013, a total of 146 patients with acute cholecystitis were treated. We performed emergency cholecystectomy within 72 hours of symptom onset. In cases of organs dysfunction (i.e. cardiovascular, respiratory, coagulation) or over 72 hours of symptom onset, we performed delayed cholecystectomy after a conservative treatment (i.e. antibiotics, drainage). Their medical records were retrospectively analysed. Results: Emergency cholecystectomy group included 90 patients (61.6 %) and delayed cholecystectomy group included 56 patients (38.4 %). Emergency cholecystectomy group was associated with high laparoscopic completed rate, less operative blood loss, and shorter postoperative hospital stay. Among emergency cholecystectomy group, 52 patients (57.8 %) were within 24 hours and 38 patients (42.2 %) were 24 to 72 hours of symptom onset. 24 to 72 hours group was associated with high age and high diabetes rate. Within 24 hours group was significantly reduced operative blood loss and postoperative hospital stay than 24 to 72 hours group. Conclusions: Emergency cholecystectomy for acute cholecystitis is safe and short hospital stay. Further improvement of clinical outcome is dependent on the onset time.

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Laparoscopy in the Management of Acute Abdomen

Laparoscopic Management of Complicated Foreign Body Ingestion

Y. Hamza, W. Abdelhalim, S. Ziedan Faculty of Medicine, University of Alexandria, Egypt Background: Laparoscopy is an excellent tool for dealing with peritonitis. It allows for efficient exploration for the causative pathology, dealing with it and performing a thorough peritoneal toilet. It also minimizes the extra-trauma caused by surgery in such acutely ill patient. Aims: assess the efficacy and safety of laparoscopy in the management of peritonitis. Material and Methods: 50 consecutive patients with acute abdomen scheduled for abdominal exploration were treated by laparoscopy. The abdomen was explored systemically. Once the pathology is identified, it is treated laparoscopically. Abdominal lavage is then performed. Drains inserted. Results: There were no conversions. All patients could be managed laparoscopically. 50 % of female patients with suspected acute appendicitis were found to have gynecologic pathology. There was no mortality. Complications occurred in 17 % of study patients. Conclusion: Laparoscopy is a safe and effective tool in the management of acute abdomen.

R. Wijaya, D. Chia, A. Wong, S.M. Tan Changi General Hospital, Singapore, Singapore Aims: Foreign Body (FB) ingestion remains a common acute surgical care problem. FB ingestion is occasionally complicated by abscess formation or perforation, requiring surgical intervention. Open surgical techniques are routinely employed to deal with the emergency presentation of complicated FB ingestion. There have only been isolated case reports on the use of minimally invasive surgical techniques. However, it has yet to be adopted consistently as a consideration in complicated FB ingestion. Methods: We present the largest case series to-date of 7 patients with complicated FB ingestion successfully managed with laparoscopy over a 3-year period and present the salient clinical and laparoscopic surgical technique points for the consideration of its use in similar emergency presentations. Results: In all 7 cases, the patients could not recall their FB ingestion and had normal plain radiographs. The diagnosis was made on Computed Tomography (CT) scan. Laparoscopy was successfully employed to retrieve all FBs (fish bones), de-roof abscesses and primarily repair gastrointestinal perforations. The mean operative time was 63 minutes (25–85), utilizing 2–4 (non-camera) ports. There was no operative mortality and patients were discharged on average post-operative day (POD) 5 (2–8). Conclusion: We show that laparoscopic surgery is advantageous in small diameter complicated FB ingestion requiring surgical intervention and is a safe option and should be considered in similar patients with its short operative time and post-operative length of stay.



Effectiveness of New Laparoscopic Procedure for Fundal Variceal Bleeding

Colon Perforation After Self-Expanding Stent Positioning for Obstructive Cancer: A Case Report

V.Y Grubnik, Y.u.V. Grubnik, V.A. Fomenko

C. Canziani, F. Ceriani, S. Cutaia, V. Bertocchi, F. Caravati

Odessa National Medical University, Odessa, Ukraine

Multimedica S.p.A., Castellanza (VA), Italy

Background: The most common hemorrhagic complication of liver cirrhosis is esophageal variceal bleeding, which can be controlled with endoscopic sclerotherapy or band ligation. Endoscopic control of gastric variceal bleeding often fails, resulting in massive hemorrhage with a high mortality rate. Aims: of the study was to analyse the effectiveness of a new laparoscopic procedure to control gastric variceal bleeding. Methods: From 2007 to 2013, a series of 562 patients were treated for variceal bleeding secondary to liver cirrhosis. Among them, 32 patients (5,6 %) were treated for massive bleeding from gastric varices. 14 of these patients had gastric varices mainly in the cardia and the lesser curvature with esophageal varices (gastroesophageal varices type 1). The remaining 18 patients with fundal varices were included in this study. There were 14 male and 4 female patients with the mean age of 49,8 ± 8,6 years (33–68 years). 4 patients were admitted with their first hemorrhage, the remaining 14 patients had a history of previous hemorrhage (from 2 to 5 episodes). 5 patients underwent emergency surgery, 13 patients had elective surgery. Wide devascularization of great curvature was done. Periesophageal vessels were also devascularized. In addition, the left gastric vein and artery were clipped. Resection of fundus was done by 60 mm linear stapler. To control full excision of fundal varices, intraoperative endoscopy was used. Results: Mean operative time was 94 ± 12 min. Mean blood loss was 260 ± 70 ml. There was 1 death due to leakage from staple line, sepsis and hepatic failure. Conversion to open procedure was present in 1 case due to massive bleeding from large varices in cardiac part of stomach. Mean follow-up of the patients was 18,6 months (range, 6–32). During followup, there was 1 recurrent bleeding from gastric varices, and 1 case of hemorrhage from esophageal varices. Conclusion: Laparoscopic periesophageal devascularisation and fundectomy offers an alternative method for cirrhotic patients with variceal hemorrhage from the gastric fundus.

Treatment of acute colorectal malignant obstruction, by using self-expanding metallic stents is useful for both palliative and decompressive therapy before the final surgical treatment. Usually this procedure is performed also in advanced cancers, to optimize the clinical conditions of the patients or to perform neoadjuvant therapy before surgery. Usually this is a minimally invasive procedure, relatively safe and it contributes to the improvement of quality of life of patients, avoiding the need for a colostomy. Obviously this procedure has complications, that can be soon after placement or late after insertion. Complications have been reported in up to 50 % of patients, and the most important complication can be identified in colon perforation. This situation usually needs emergency intervention, to avoid the risk of death. We report a case of a patient with obstructive advanced colon cancer, eligible to chemotherapy, treated with the positioning of a self-expanding metallic stent. Nine days after the procedure the patient came to our attention with acute abdomen, due to colon perforation. He underwent emergency surgery and a laparoscopic sigmoid resection was performed, with contextual colorectal anastomosis. Post-operative course was regular and patient was dismissed in post-operative day 10.

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Laparoscopy in Perforated Appendicitis with Generalised Peritonitis: Case Presentation

Laparoscopic Splenectomy: An Initial Experience of Management of Isolated Blunt Traumatic Splenic Injury

P.R. Sookha1, H. Charitar-Sookha2, S.S. Seewoosungkur3

T. al Qurashi1, A. Ghasoup1, O. Sadieh2, A. Saifeldin1

1 Apollo Bramwell hospital, Clinique du Nord, Riviere du rempart, Mauritius; 2Apollo Bramwell Hospital, Moka, Mauritius; 3Clinique du nord, Baie du tombeau, Mauritius

1

Are advantages of laparoscopic surgery the same in cases of perforated appendicitis with generalised peritonitis? A 47 years old patient was brought to our department with fever and moderate generalised abdominal pain. On clinical examination the patient was diagnosed with acute appendicitis. Paraclinical investigations showed moderate amount of fluid in the peritoneal cavity; in Douglas pouch, supra-hepatic, sub-hepatic and inter-ileal. WBC was 11.3. An exploratory laparoscopy was performed which confirmed the presence of purulent fluid intra-peritoneal, multiple adhesions blocking the caecum and appendix in the right iliac fossa. After suction and lavage, the adhesions were lysed to expose the caecum and the appendix. The Toldt’s fascia had to be dissected to expose the appendix and its arterial supply. The appendix was perforated at its mid-level. Appendicectomy was performed after double ligation of the base. To be noted that the WBC raised to 18.0 despite the patient being on IV meronem, but it gradually decreased. Results: The patient was discharged 6 days postoperative, the wounds were almost healed with no signs of infection. Mobilisation was started 24 hours postoperative, with the patient regaining work after 12 days. Conclusion: Perforated appendicitis is not a contra-indication for laparoscopic treatment, indeed if you have the training to perform the surgery laparoscopically it offers faster and better recovery.

Security Force Hospital Makkah, Makkah, Saudi Arabia; 2Saad Specialty Hospital, Al khobar, Saudi Arabia

Objectives: To evaluate outcome of laparoscopic splenectomy (LS) for isolated blunt traumatic splenic injury (TSI). Background: Minor splenic injuries from blunt trauma can be treated conservatively, whereas high-grade injuries require surgical treatment and usually removal of the organ. Although splenectomy is nowadays routinely performed laparoscopically for the treatment of hematological pathologies, in an emergency the operational procedure is performed through conventional laparotomy worldwide, Progress in surgical skill and new developments in equipment allow us to manage also patients with severe splenic blunt trauma laparoscopically. Patients and Methods: The study included 11 patients with isolated blunt TSI. All patients underwent full history taking, complete physical examination, CT examination for grading of splenic injury according to Moore et al. surgical interference was indicated when there was deterioration of patient’s hemodynamic parameters and/or if there is progressive or massive decrease of hemoglobin concentration. All splenectomies were performed using 3-trocar procedure through lateral approach 9 cases and two cases supine position, Intraoperative and postoperative (PO) data were collected. Results: CT examination defined 2 patient of grade V, 5 patients of grade IV, 4 patients of grade III. All patients passed uneventful intraoperative course without conversion to open splenectomy with a mean operative time of 60 ± 20.7 minutes and mean amount of total blood loss of 280.6 ± 140.1 ml. All patients required blood transfusion with mean number of blood units of 3.4 ± 1.1; range: 3–5 units. Nine patients passed uneventful postoperative course, one patients developed wound infection and one patient developed chest infection that responded to medical treatment. Mean duration of hospital stay for was 5.7 ± 2 days. All patients completed their follow-up for a mean duration of 14.1 ± 4.7 months. No follow-up complications were recorded during follow-up period. Conclusion: LS is a feasible, safe and effective therapeutic modality for cases of blunt TSI providing short recovery times and hospital stay without extensive morbidities nor mortalities. It is recommended for management of cases needing emergency surgical interference or not responding to non-operative management.

P186 - Emergency Surgery P188 - Emergency Surgery Emergent Single-Incision Laparoscopic Appendectomy Versus Interval Single-Incision Laparoscopic Appendectomy: A Retrospective Study R. Miyata, N. Kameyama, M. Tomita, H. Mitsuhashi, S. Baba, S. Imai International Goodwill Hospital, Yokohama, Japan Aims: To evaluate the validity of initial nonoperative management for acute appendicitis, followed by interval single-incision laparoscopic appendectomy. Methods: Between October 2009 and May 2013, we performed 74 single-incision laparoscopic appendectomy (SILA), of which 46 were emergency (EM) and 28 underwent initial conservative treatment, followed by interval appendectomy (IN) after three months. A 1.5 cm vertical transumbilical incision was used for SILA, followed by the glove method using Alexis wound retractorTM (XS size) with three 5-mm laparoscopic ports through the holes of cut fingertips. An additional port was inserted when required. The indication of initial conservative treatment included catarrhal appendicitis, phlegmonous appendicitis with localized peritonitis, no intestinal ileus, and no fecalith, or gangrenous appendicitis with localized peritonitis, no intestinal ileus, and more than 4 days from the onset. Results: There were no differences in patient demographic characteristics. There were also no differences in initial stage of appendicitis (abscess formation, gangrene, localized/panperitonitis, leukocyte count, C-reactive protein). The mean operative time was less in the IN group (58 ± 3 min vs. 73 ± 4 min, IN vs. EM, P \ 0.05). The time of starting oral intake was shorter in the IN group (1.4 ± 0.1 days vs. 2.2 ± 0.2 days, IN vs. EM, P \ 0.01), which resulted in shorter hospital stay (3.5 ± 0.1 days vs. 4.9 ± 0.5 days, IN vs. EM, P \ 0.05). There were no differences in blood loss, total doses of analgesics, and postoperative complications. Conversion to laparotomy were 3 (7 %) in the EM group and 0 (0 %) in the IN group without statistical differences. An additional miniport was required in 3 (7 %) in the EM group and 1 (4 %) in the IN group without statistical differences. Conclusions: Single-incision laparoscopic surgery is technically demanding. However, initial nonoperative management and 3-month interval often abolishes appendicitis completely, which contributed reduced operative time in our study. Interval appendectomy requires two steps: (1) conservative treatment and (2) interval appendectomy, obviously increasing medical cost. Given the surgical difficulty of single-incision laparoscopic surgery, the superiority of interval appendectomy might outweigh the problem of increased cost.

Comparison of the Surgical Outcomes of Laparoscopic and Open Surgery for Perforated Gastroduodenal Ulcer K. Yoshida, K. Ietsugu, K. Watanabe, K. Murasugi, S. Soga, H. Sugawara, S. Tabata, M. Kaneki, M. Sakatoku, K. Kiyohara Tonami General Hospital, Tonami Toyama, Japan Aims: Recently Laparoscopic surgery for perforated gastroduodenal ulcer has been a prevailing procedure. This procedure is likely to become a standard therapy. However, there may be an opinion that on this laparoscopic approach, a small amount of irrigation of the abdominal cavity or a small number of drains is insufficient for the treatment of peritonitis. It is the aim of this study to clarify the safety and the non-inferiority of laparoscopic surgery for perforated gastroduodenal ulcer by comparison with open surgery. Method: From January 1996 to December 2012, patients undergoing surgery for perforated gastroduodenal ulcer were included to this study. Patients were divided into two groups, laparoscopic surgery (Group L) and open surgery (Group O). A retrospective review of patient records was performed. Demographic data, amount of irrigation of the abdominal cavity, operative duration, period until drain removal, postoperative complications and duration of hospitalization in both groups were compared. Fisher’s exact probability test and Mann- Whitney’s U test were used for statistical analysis. Result: 130 patients underwent surgery for perforated gastroduodenal ulcer. Group L had 90 patients and Group O had 40 patients. In demographic data there was no statistically significant difference except age. Patients in Group L were younger (P \ 0.0001). The number of drains of Group L was one, but that of Group O was three or four. There was no statistically significant difference in operative duration (P = 0.77) and period until drain removal (P = 0.17). Group L was statistically less than Group O in the amount of saline for irrigation (P \ 0.0001), postoperative complications (P = 0.046) and duration of hospitalization (P \ 0.0001). Conclusion: Laparoscopic surgery for perforated gastroduodenal ulcer which had a small amount of irrigation and had only one drain was superior to open surgery on the surgical outcomes (postoperative complications and duration of hospitalization) and was not inferior to open surgery on operative duration and period until drain removal. Laparoscopic surgery for perforated gastroduodenal ulcer is safe and non-inferiority to open surgery.

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Emergency Laparoscopic Subtotal Cholecystectomy for Acute Severe Cholecystitis

Warfarin Induced Ischaemic Bowel Necrosis

Y. Kurumiya, S. Sekoguchi, K. Kobayashi, Y. Fukami, H. Aoyama, T. Oyama, H. Tomita, R. Shirotsuki, K. Miyamura, M. Kanamori, T. Jinno, G. Takemura Toyota Kosei Hospital, Toyota city, Japan Background: Early operation within 72 hours after the onset is suitable as operation timing that has lesser adhesion for patients with acute severe cholecystitis. An operation may be difficult for the adhesion after the onset for around two weeks. Therefore, early cholecystectomy is recommended in some guidelines. Furthermore, the early laparoscopic surgery can remove the pain of the patient quickly by the result of various RCT without increasing complications in comparison with an elective operation, and it is said that it is the superior cure that reducing medical costs, and can shorten hospitalization. However, a question occurs whether we can perform an emergency laparoscope surgery with a safely for acute severe cholecystitis. Patients and Methods: We perform as possible early laparoscopic surgery for a patient with severe cholecystitis than 2012 without performing PTGBD about the case that an operation is possible in our hospital. On this occasion, we attempted to develop a laparoscopic subtotal cholecystectomy (LSC) to perform laparoscopic surgery safely. From 2012 to 2013, laparoscopic cholecystectomy was performed in 181 patients for cholecystitis. Of these, we underwent urgent (early) operation was 42 acute cases, and finally we shifted the open surgery soon was 13 cases. I accomplished laparoscopic surgery in 29 cases. Of these, as for 25 cases, the clipping with the cystic duct was possible, but for four cases we performed LSC, when dissection of the gall bladder neck and triangle of Calot was difficult, the neck of the gallbladder was sutured despite clipping. Results: LSC cases, compared with clipping cases, preoperative total bilirubin (mg/dl) was higher (2.5 vs. 1.1) and CRP (mg/dl) (18.7 vs. 6.3). The median operating time (min) was equal (110 vs. 120), but there were many amounts of the median operative bleeding (313 vs. 44). Hospitalization did not have the difference after the operation (6.0 vs. 4.4). All four of them left the hospital 4–7 days after the operation without complications. Conclusion: In patients with an acute severe cholecystitis, emergency Laparoscopic subtotal cholecystectomy offers a simple and safe solution that prevents bile duct injuries and decreases the rate of conversion in anatomically difficult situations.

M. Salama, H. Kumar, M. Aremu Our Lady of Lourdes Hospital, Drogheda, co. Louth, Ireland Introduction: Warfarin is one of the most important drugs used in both medical and surgical practice. Necrosis and gangrene of skin and other tissues is an uncommon but serious risk of its use. Skin, limb, breast or penis necrosis has been reported. Also there are few cases of spontaneous intra mural intestinal haematoma with bowel obstruction and infarction has been reported as a rare complication of anticoagulant therapy. Case Report: We are reporting a rare case of warfarin induced bowel necrosis. 55 years old man presented with abdominal pain and vomiting for one day. He was febrile with guarding and tenderness in RIF. He was on warfarin 2 mg daily (for 10 years) for PVD and chronic leg ulcer. His blood results showed WBCS-14.3 Lactate-1.7 CRP-8.3 amylase-243 U&E, LFTS were normal. He had CT which reported mildly distended thickened loop of terminal ileum with hyperaemia in mesentery suggestive terminal ileitis. As his clinical condition deteriorated, he had laparoscopy which confirmed necrotic caecum with patches of necrosis in the terminal ileum. Right hemicolectomy with ileo-colic anastomosis was performed. Post operatively he made a good recovery and was discharged home on 2 mg warfarin. The histology of right hemicolectomy revealed ischaemic infarction of terminal ileum and caecum with sub mucosal vessels showing a varying degree of thrombus without vasculitis. He was readmitted a few days later with right lower limb DVT. Warfarin dose was adjusted as per INR. Conclusion: Warfarin induced ischaemic bowel necrosis is extremely rare. Awareness of this condition is very important for early prompt treatment.



Perspectives of Laparoscopic Surgery in the Treatment of Acute Small Bowel Obstruction: 5 Year Single-Center Experience

Warfarin Induced Skin Necrosis (WISN)

A.V. Sazhin1, S.V. Mosin1, M.A. Dzusov2, A.T. Mirzoyan2, A.E. Tyagunov1, B.K. Laipanov2 Russian state medical university, Moscow, Russia; 2Pirogov Russian National Research Medical University, Moscow, Russia

1

Aims: To analyze the results of laparoscopic surgery in the treatment of acute small bowel obstruction (ASBO) for 5 years. Materials and Methods: We perform laparoscopic operation for ASBO since 2004. For the last 5 years (2008–2012) we made 157 operations for ASBO. We believe that during this period our surgeons have already reached the ‘plateau of learning curve’ in advanced laparoscopic surgery. In 79(50,3 %) cases laparoscopy was used, in 24(15,3 %) of it we performed conversion to open surgery for different reasons. Complete laparoscopic operations performed in 55(35 %) patients. Male was 35,8 %, the middle age was 56 ± 20,9 years. Later than 24 hours from the onset there were 97(61,7 %). 75,6 % had previous abdominal surgery. Adhesive ASBO was observed in 145(92,3 %) cases, including strangulation in 57(35,0 %). Resection was required in 27(17,2 %), in other cases, the cause of obstruction eliminated without resection (adhesiolysis, enterotomy, detorsion etc). The most severe, complicated ASBO, IV–V ASA scale degree, at least one previous operation for adhesive ASBO, as well as the lack of surgeon’s laparoscopic skills was excluding criteria for laparoscopic surgery. Results: In the presence of previous midline laparotomy, the open laparoscopy was performed strictly. Trocar placements were chosen individually. Indications for conversion were any conditions, laparoscopically unrecoverable. In the group of complete laparoscopic operations, average operation time was 67,7 min (against 120,2 min in open/conversion surgery group). Postoperative hospital stay 6.9(vs. 12,5 in open/conversion surgery group). Postoperative period was favorable in 51(92,7 %) patients, in others intestinal paresis was observed. We didn’t have mortality, intraoperative complications and wound infection after complete laparoscopic operations. Pneumonia was observed in 1(0,6 %) patient. Conclusions: Over 5 years of active use of laparoscopy in ASBO we revealed an overall decrease in mortality (of average 11,62 in 2003–2007 to 5,64 in 2008–2012) and decrease in the frequency of early postoperative adhesive obstruction (from 8 in 2003–2007 to 3 in 2008–2012). These changes we associate with general increase of amount of laparoscopic operations, extensive use of early diagnostic laparoscopy and improved laparoscopic skills. Achieved share of complete laparoscopic surgery in ASBO is 35 % for 5 years (average) and 45 % in 2012.

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M. Salama, M. Aremu Our Lady of Lourdes Hospital, Drogheda, co. Louth, Ireland Introduction: Warfarin is one of the most important drugs used in both medical and surgical practice. Warfarin induced skin necrosis (WISN) is an extremely rare complication occurs in only 0.01 to 0.1 % of patients taking the drug. Worldwide only 300 cases have been reported in the literature. The associated morbidity is extremely high and failure to diagnose early or late commencement of treatment may lead to mortality. WISN is probably under reported and awareness of this condition is the key for early diagnosis and minimization of morbidity and mortality. Case Report: We describe an atypical case of late presentation of WISN in a 64 year old man, 18 months after commencing Warfarin for mechanical valve and aortic root replacement. He presented with right groin lump which was explored and revealed organised hematoma. Hematoma was excised& Its histology reported fat necrosis and marked septal inflammation, some of the blood vessels contain thrombi. One week later he developed skin necrosis of the right thigh which was debrided and he made a good recovery. Conclusion: WISN is a rare but serious complication. It is still under reported and awareness of this condition is the key for early diagnosis and minimising morbidity and mortality.

Surg Endosc



The Advantage Over Traditional Laparoscopic Appendectomy on the Results: Of Our Clinical Experience

Laparoscopic Surgery During Pregnancy

V. Tedoradze, D. Menabde, O. Gulko, A. Baziak, K. Susareishvili Republican Hospital of Batumi, Batumi, Georgia The aim of the study is a comparison of the treatment results of laparoscopic and open appendectomy on the basis of surgical materials department Batumi Republican Clinical Hospital. Work is based on a retrospective analysis of treatment of 120 patients diagnosed with acute appendicitis, which operated as laparoscopic and traditional method from 2004 to 2013. Patients were divided us by 3 group. 1 group of 40 patients with traditional appendectomy, 2-group of 40 patients with laparoscopic appendectomy extracorporal method, 3-group of 40 patients with laparoscopic appendectomy intracorporal way. The operative time group 1 when there was more than 2 and group 3. Group 1 was on average more than 1 hour, from 50 to 90 min, duration of operation group 2 on average 50–80 min As for Group 3 average duration of surgery varies from 30 to 40 minutes. Substantial intraoperative complications and lethal outcomes were not in one of the groups of patients. Out of postoperative complication of suppuration wounds, observed 1 group of cases -2 and 2 Group 1 cases, adhesive intestinal obstruction after a year 1 cases- group 1, group 3 complications are not observed. After operation the patients discharged for Groups 1 and 2 on day 4–5, as for group 3- on 2–3 day. Intensity of pain and expense of medicines 3 group was much less then than 2 and especially 1 group. Patients could have became more active 2 and 3 group immediately after the operation in 2–3 hours, compared to the patients of group 1 - traditional appendectomy activate on the second day. The total size of surgical approaches in group 1 was 60 100 mm; In group 2 was 50 -60 mm; In group 3 was 25 -30 mm; It is clear that, the size of operational access at 3 group were much less then than 1 and group 2 patients. As a result, the authors on the basis of above stated it conclude that laparoscopic approach practically eliminates suppuration wounds, the divergence of its edges, bleeding, eventration and other complications.

M. Salama, A. Paul, M. Aremu, A. Nasr, I. Ahmed, H. Kumar Our Lady of Lourdes Hospital, Drogheda, co. louth, Ireland Introduction: Non obstetric surgical problems complicate up to 2–3 % of pregnancies. Emergency surgical procedures are required in approximately 1 in 635 pregnancies. Acute appendicitis occurs with the same frequency in gravid and non-gravid females, leading to Appendicectomy in 1 out of every 2000 pregnancies. Acute cholecystitis leads to surgical intervention less frequently. Laparoscopic surgery in pregnant women has become increasingly more common since 1990. However, the safety of laparoscopy in this population has been widely debated particularly in emergent situations. Some surgeons are reluctant to employ laparoscopic approach when treating a pregnant patient with appendicitis or biliary disease. Aims: - To study the safety and outcome of laparoscopic surgery during pregnancy for nonobstetric abdominal emergency in our institution. - To compare our results with recent literature. Methods: A retrospective chart review of all pregnant women following non-obstetric abdominal operations performed in our institution, between 1/1/2010 to 31/8/2013. The operation, stage of pregnancy, complications and foetal outcome were evaluated. One case was excluded from our study (tubal pregnancy and appendicitis had laparoscopic appendectomy and right salpingectomy) Results: Out of 13668 patients who had ante natal care and delivery in our hospital between 1/1/10 to 31/8/13, 12 patients had surgery for non obstetric surgical problems. Age range was between 15–40 years. 11 out of 12 patients had appendectomy (8 had open appendectomy and 3 had laparoscopic appendectomy). One patient after laparoscopic appendectomy had a miscarriage at 13 weeks of pregnancy. 1 case had open cholecystectomy & Caesarean section performed at 36 weeks of pregnancy. Stage of pregnancy at time of surgery: 1st tri mester: - 0 2nd tri mester: - 4 3rd tri mester: - 8 Histology: 10 cases reported acute appendicitis (1 of them was gangrenous and perforated). 1 case was reported normal appendix. The gallbladder post cholecystectomy reported active chronic cholecystitis with cholelithiasis. Conclusion: Surgery during pregnancy does carry a risk of losing the baby. The risk may however be small as only one patient lost the baby after appendicectomy in our series.



Comparison of Various Options of Laparoscopic Appendectomy in the Treatment of Acute Uncomplicated Appendicitis

Single Incision Laparoscopic Versus Open Appendectomy for Acute Appendicitis in Adults

A.V. Sazhin1, A.T. Mirzoyan2, S.V. Mosin1, A.A. Kodjoglyan2, B.K. Laipanov2, M.A. Dzusov2

Y. Ishiyama, Y. Hirano, K. Doden, M. Hattori, Y. Hashizume

Russian state medical university, Moscow, Russia; 2Pirogov Russian National Research Medical University, Moscow, Russia

Fukui Prefectural Hospital, Fukui, Japan

1

Aims: To study the various options of laparoscopic appendectomy to optimize the operation. Methods: RCI study presents the results of laparoscopic appendectomy in 250 patients with uncomplicated acute appendicitis from 2009 to 2012. Including criteria: cases with no perforation, abscess, dense appendicular mass or peritonitis, age (16 to 60), no severe comorbidities. Women was 113(45.2 %). The average age was 34,75 ± 5,3. We compared various methods of dissection and stump formation. We studied the use of monopolar coagulation compared with bipolar and ultrasound dissection devices for mobilization process, as well as the use of two standard endoloops with intracorporal suturing for stump immersion and application linear stapler in equal groups of 50 patients. Criteria for comparison were: duration of the operation stages, the number of application, conversion rate, number of intraand postoperative complications. All operations were performed by experienced surgeons. Results: The time of mobilization and number of applications were significantly higher (p \ 0.05) if using dissector on inflamed mesoappendix, than in bipolar and ultrasound dissection devices groups. In monopolar coagulation and ultrasound dissection groups there were two cases of conversions due to massive intraoperative bleeding from severe inflamed mesoappendix (p [ 0,05). Leaving mesoappendix when it severe inflammation led to the development of postoperative mass in 22 % (p \ 0,001), and abscess in 2 % (p [ 0,05) compared to cases with complete mesoappendix removal. Time of stump formation was significantly higher with intracorporeal suturing (p \ 0,01), if using two endoloops and linear stapler application. The incidence of complications related to the method of stump formation was not statistically significant in all groups (p [ 0,05). Suturing was often used when high risk of stump leakage seen. Conclusions: Using monopolar coagulation, and two endoloops allowed perform laparoscopic appendectomy for uncomplicated acute appendicitis successfully in most cases, and we propose it as the standard technique of laparoscopic appendectomy. In severe inflammation of the mesentery, using ultrasound dissection is more convenient than bipolar dissection or monopolar coagulation. Complete removal of the mesoappendix resulted in the lowest incidence of postoperative mass (p \ 0,05). At high risk of leakage stump, showing her immersion in intracorporeal purse string suture or the use of a linear stapler.

Aims: Appendectomy is one of the most common emergency operations performed in the population. Single incision laparoscopic surgery has become increasingly common. The aim of this study is to compare the outcome Single incision laparoscopic appendectomy (SILA) and open appendectomy (OA) for acute appendicitis in adult. Methods: In this retrospective study the records of appendectomy patients at the Fukui Prefectural Hospital, Fukui, Japan were reviewed. From October 2010 to December 2013, 185 appendectomy were performed in our institution. Statistical evaluation included descriptive analysis of demographic data including age and body mass index, severity of appendicitis operative outcomes including operative time, complications, hospital length of stay, and cost-effectiveness. Results: This study reviewed 131 patients who underwent SILA and 54 patients who underwent OP. We did not perform traditional multiport laparoscopic appendectomy. No statistically significant difference was found between SILA and OA age, operative time complications, hospital length of stay, cost effectiveness. For SILA there were significantly higher than OA between the groups in BMI. For OA there were significantly higher than SILA in severity of appendicitis. Four patients (3.0 %) of SILA were converted to open procedure. Five patients (3.8 %) required an additional port, but no major complications occurred. No increase in the overall complication rate was associated with SILA compared with OA. Conclusion: In our study SILA for acute appendicitis was shown to be safe, feasible, and cosmetic with compared with OA. It is a safe procedure for the treatment acute appendicitis.

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A Case of Laparoscopic Appendectomy for a Morbid Obese Japanese Patient

Laparoscopic Resolution in Six Cases of Bowel Obstruction Without a History of Laparotomy

R. Suzuki, H. Matsuno, T. Yamada, T. Kobayashi, Y. Kobori, T. Doi, M. Hoshi, Y. Makari, S. Oshima, K. Ikeda, E. Kurokawa

Y. Shimizu, H. Tominaga, S. Yamashita, K. Odagiri, T. Kurokawa, N. Honmyo, M. Inoue, J. Moon, T. Irei, M. Tanemura, N. Hatanaka, W. Kamiike

Minoh City Hospital, Minoh, Japan Introduction: Laparoscopic appendectomy for obese patients reported to have better perioperative outcomes. (J Am Coll Surg 2012, J Min Access Surg 2014) Even in Japan, obese patients are gradually increasing as in other Western countries, opportunities to encounter morbid obese patients who need surgery have been brought. We report laparoscopic appendectomy for a patient with a BMI37.2. (Case) A 35-year-old Japanese male 170 cm tall and weighing 111 kg (BMI 37.2) who had past medical history with asthma and conservative treatment of appendicitis 5 years before had right lower quadrant pain for 3 days. We diagnosed appendicitis from tenderness in right lower quadrant without sign of localized peritonitis and enlarged diameter of the appendix to 8 mm in CT scan. First we started to administer antibiotics, the third day of admission laparoscopic appendectomy was performed because of second episode of appendicitis. Operation: Though transumbilical single incision laparoscopic appendectomy is our usual procedure, multiport procedure was chosen to secure safety. To avoid major vessel injury, optical method was utilized to introduce the 12 mm first port (150 mm long) through left abdominal rectus muscle at the point 3 cm lateral and 2 cm cranial from the umbilicus. Pneumoperitoneum was kept at 12 mmHg. Three 5 mm ports were added. Mesoappendix were dissected by ultrasonically activated device. The appendix was transected by stapler and retrieved in plastic bag from 12 mm port. Operation time was 96 min, blood loss was a little. Postoperative course was uneventful. Summary: In Japan, chances to encounter morbid obese patients who need surgery in daily practice are increasing, knowledge and techniques obtained in bariatric surgery are also needed in community hospitals.

National Hospital Organization Kure Medical Center/Chugoku Cancer Center, Hiroshima, Japan Introduction: Laparoscopic surgery is increasing in number but is not so commonly used for the treatment of intestinal obstruction. Specifically, in emergent situation, limited space due to dilated intestine, and various mechanisms of obstruction make laparoscopic resolution difficult. We report on six cases of bowel obstruction without a history of laparotomy and were successfully treated by laparoscopy. Patients: We had six cases. Average age was 64.0 years old and all patients visited our emergency outpatient unit with abdominal pain. In four cases, emergent operations were carried out under diagnosis of suspected strangulating obstruction. Another two cases underwent elective operations after decompression of intestine. Emergency cases (men: 0, women: 4): Although, in 3 of the 4 cases, physical examinations revealed only mild tenderness in the abdomen and laboratory findings were not contributory, abdominal CT revealed signs of closed-loop obstruction of the small bowel that resulted in our decision for an emergent operation. In 4 cases, all female, Laparoscopy revealed the cause of strangulating obstruction; fibrous adhesion to the greater omentum, broad ligament hernia, and fibrous adhesion to the pelvic organ in the other two cases. And one patient needed bowel resection. Elective cases (men: 2, women: 0): Elective operations were carried out after decompression of intestine, because abdominal CT revealed simple bowel obstruction without impairment of blood supply. Fibrous adhesion to the greater omentum was the cause of obstruction in the both cases. Discussion: The causes of bowel obstruction without a history of laparotomy were considered as follows, 1. Inflammatory adhesion: Inflammatory reaction often takes place, especially around the greater omentum and the female genitals. 2. Internal hernia: Intrapiploic hernia, broad ligament hernia, obturator hernia, etc. In general, early diagnosis of strangulating obstruction is difficult. Based on our experience, closed-loop obstruction of the small bowel on CT findings are very informative to identified the focus of obstruction. We presumed that early diagnosis made the operation easier because of less intestinal distension and preserved working space. Conclusion: We had six cases of bowel obstruction including four strangulating obstruction that were diagnosed early by precise evaluation of CT findings and successfully treated by laparoscopy.



Emergency Laparoscopic Hernia Repair (Transabdominal Preperitoneal Approach) for Incarcerated Femoral Hernias

Outcomes of Emergent Laparoscopy to Acute Appendicitis in Our Hospital

Y. Aoyama

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

Toyokawa City Hospital, Toyokawa, Japan Aims: Femoral hernias are relatively uncommon in abdominal hernias and their diagnosis is difficult by reason of anatomical structural of femoral ring. They are often incarcerated and undergone as emergency operation. Currently, laparoscopic hernia repair, especially the transabdominal preperitoneal approach (‘TAPP’), has become as a standard operative procedure in hernia repair and performed to incarcerated femoral hernias in emergency surgery. We analyzed the usefulness of emergency TAPP for incarcerated femoral hernias. Methods: We experienced 5 cases of emergency TAPP for incarcerated femoral hernia during 1 April 2010 to 31 March 2012. Result: We underwent TAPP for all 5 cases, 2 cases of male and 3 cases of female with the median age of 83.0 years old. Femoral hernias were found 3 in the right sides, 1 in the left side and 1 in both sides. In all cases, small intestine was incarcerated. 3 cases were the incarceration as Richter type. Hernia repair was performed using a mesh in all cases. However, in one of the cases, we needed to resect necrotic part of incarcerated small intestine. We found no complications or recurrences. Conclusion: TAPP in emergency operation for incarcerated femoral hernias could be carried out safely, thus we should consider using this approach for future.

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Kobe City Medical Center General Hospital, Kobe-City, Japan Aims: In our hospital, we have adopted emergent laparoscopy as a treatment for acute appendicitis regardless of whether appendiceal abscess or perforation is present. We assessed the outcomes of emergent laparoscopic surgical treatment for acute appendicitis in our hospital. Methods: From January 2010 to July 2013, 252 patients were operated emergently by laparoscopy for acute appendicitis. Laparoscopic appendectomy was carried out in 238 cases (94.4 %). Conversion to open surgery or ileocecal resection was necessary in 14 cases (5.6 %). We examined operation time, blood loss, morbidity, postoperative hospital stay of patients treated by laparoscopic appendectomy. Results: 30 patients had acute appendicitis complicated by abscess or perforation. The mean operation time was 55 minutes. The mean blood loss was 0 g. Complications were categorized according to the Clavien-Dindo classification. There were 20 wound infections (20 Grade?), 6 postoperative abscesses (3 Grade?, 1 Grade?, 2 Grade?a), 1 small bowel obstruction (Grade?), and 1 bladder injury (Grade?b). The mean postoperative hospital stay was 3 days. Conclusions: With respect to complications and hospital stay, we performed emergent laparoscopic appendectomy safely even in patients with appendiceal abscess or perforation.

Surg Endosc



Laparoscopic Repair (LR) for Perforated Duodenal and Gastric Ulcers (PDGU)

12-Years’ Experience of Laparoscopic Surgery of Acute Appendicitis in City Hospital

S.G. Shapovalyants, M.E. Timofeev, E.D. Fedorov, G.V. Konjuhov

M.E. Timofeev, S.G. Shapovalyants, E. Fedorov, I.P. Marchenko, R.V. Plakhov, V.G. Polushkin

Pirogov Russian National Research Medical University, Moscow, Russia Background: Laparoscopic treatment of perforated duodenal and gastric ulcer has been described as safe and advantageous compared to open technique but advantages are still not clear due to small number of cases in published studies. Aims: The purpose of this study was to evaluate the feasibility, efficacy and safety of the laparoscopic treatment of perforated duodenal and gastric ulcer. Methods: This retrospective study included patients who underwent laparoscopic treatment of perforated duodenal ulcer during the 17-year period from 1996 to 2012. As rule, reoperative diagnostic program included gastroduodenoscopy which defined the perforation size and presence of contra-indications for LR like piloroduodenal deformation or stenosis, requiring pyloroplasty thru midline laparotomy. The procedure included direct suture of the perforated ulcer followed by peritoneal lavage. All patients received medical treatment including Helicobacter pylori eradication and proton pump inhibitor therapy. From 11.1996 until 12.2012 LR for PDGU were performed to 212 pts., including 209 pts with duodenal ulcers and 3 with gastric ulcers (m-50, f-7; range from 18 to 60 yrs; average 34,6 ± 2,1 yrs). 45 patient presented with generalized peritonitis, which required peritoneal lavage and drainage in addition to LR. Results: Direct suture of the ulcer was successful in all cases. The mean duration of the procedure was 95 ± 23,1 minutes (range from 30 to 160 minutes). The mean postoperative complication rate was 1.88 % (4 pts). Complications included early abdominal obstruction in one case demanded laparotomy, subhepatic abscess (ultrasound guided draining was performed), suture failure diagnosed in two cases, that demanded laparotomy. There were no postoperative deaths. Conclusions: Laparoscopic suture of perforated duodenal ulcer is safe and effective. It avoids the need for laparotomy that is associated with a risk for septic and wound complications. We regard laparoscopic repair of selected patients with perforated duodenal and gastric ulcer as a safe and preferable treatment.

Pirogov Russian National Research Medical University, Moscow, Russia Aims: to study therapeutic scope of laparoscopic operations in treatment of acute appendicitis, including complicated forms. Materials and Methods: Case histories of patient, who underwent laparoscopic appendectomies (LA) for acute appendicitis including complicating forms, between 2000 and 2012 in city hospital ?31 were analyzed. Results: 1451 patients underwent LA, 224 (15,4 %) patients had complicated forms: perforative appendicitis - 55, localized peritonitis - 110, generalized peritonitis - 57, abscesses - 7. In 20 (%) patients simultaneous operations were performed: coagulation of ruptured ovarian cyst (9), adhesiolysis out of appendectomy site (6), large hydatid cyst ectomies (2), unilateral adnexectomy due to secondary salpingoophoritis caused by peritonitis (1), ovarian resection (1), myomectomy (1). In most cases dissector with unipolar coagulation was used to mobilize appendix and to cut mesoappendix. Appendicial stump was formed using 2 ligatures. To perform decollement, spring intestinal clamps, scissors, hook with unipolar coagulation and aqua dissection were used. If needed, abdominal cavity lavage and drainage were performed. 6 intraoperative complications occurred: intensive surgical site bleeding - 4, bleeding from trocar site, appendix fragmentation when ligated - 1. All complications required surgery thru local approach. There were 24 (1,7 %) postoperative complications: intraabdominal inflammatory infiltrates - 17, pelvic abscess - 2, suture lack - 1, all effectively treated conservatively and using ultrasound-guided drainage. Two complications led to lethal outcomes: acute myocardial infarction - 1, bilateral nosocomial pneumonia - 1. Conclusion: LA is effective in most cases of acute appendicitis, including complicated forms, and is associated with minimal mortality and complications rate.



Evaluation of the Laparoscopic Surgery for Oncologic Emergencies

Diagnostic Laparoscopy and Repair of Small and Large Bowel Lesions in Patient with Penetrating Abdominal Stab Wound

S. Yoshikawa, M. Fukunaga, Y. Lee, K. Nagakari, M. Sugano, M. Suda, Y. Iida, Y. Ito, M. Ouchi, G. Katsuno, Y. Hirasaki, M. Ito, D. Azuma, J. Nomoto

T. Klimovska, I. Ivanovs, G.P. Pupelis

Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan

Aims: The role of diagnostic laparoscopy in case of penetrating abdominal trauma is still controversial. When properly applied, it can offer several advantages, such as reduced short and long-term morbidity, lower rates of negative and nontherapeutic laparotomies, shortened length of hospital stay. Laparoscopy may improve diagnostic accuracy compared to focused assessment with sonography for trauma (FAST), diagnostic peritoneal lavage and computed tomography. The aim of presentation is to demonstrate the value of laparoscopic intervention in case of penetrating abdominal injury. Material and Methods: A 50 year old man was admitted to emergency department with alcohol intoxication and two stab wounds localized two cm above the umbilicus at the level of the l. axillaris anterior on the left side. The second wound localized at the level of Th3-4 and l. paravertebralis on the right side. Patient was hemodynamically stable without signs of peritonitis and complained about pain of the left side abdomen and back. FAST and computed tomography scan showed no evidence of free air or fluid in the abdominal and retroperitoneal cavity, however penetrating injury could not be excluded. Patient underwent urgent diagnostic laparoscopy. During surgical intervention 0,5 cm lesion in the wall of the descendent colon without perforation of mucosa, 2 9 3 cm large lesion of the jejunum with perforation of the mucosa, and several lesions in small bowel mesentery without signs of active bleeding was found. Laparoscopic repair of the bowel and peritoneal lesions was performed. Results: Postoperative period was uneventful, drainage was removed on 2nd postoperative day. Patient was discharged on the 7th postoperative day. His regular follow up was free of symptoms. Conclusions: Diagnostic and therapeutic laparoscopy in trauma can be safe alternative to laparotomy for the evaluation and treatment of penetrating abdominal injuries in hemodynamically stable patients.

Aims: Laparoscopic surgery has been validated for both benign and malignant diseases. Now a days, this procedure is indicated to emergency cases. Laparoscopic surgery is useful not only minimally invasiveness but also high diagnostic performance in emergency surgery which often have limited preoperative informations. In the oncologic emergencies, the one of the benefit of laparoscopic surgery is possible to the select a better surgical procedure by laparoscopic diagnosis. We evaluated the use of laparoscopic emergency surgery in the management of oncologic emergency cases. Methods: From January 2008 through July 2013, there were 13 patients who underwent surgical treatment for oncologic emergencies at our institution. Symptoms were 5 cases of intestinal perforation, 2 cases of penetration, 3 cases of bowel obstruction, 1 case of invagination, 1 case of abdominal bleeding, and 1 case of appendicitis by tumor obstruction. The performed surgical procedures were 8 cases of colectomy, 4 cases of stoma creation, 1 case of tumor resection. Curable operation was performed for 5 cases, and two stepped curable operation was performed for a case. 6 cases were selected palliative operation because of the poor general condition or the incurable malignancies. The average surgery time was 147 minutes, and the amount of bleeding was 92 ml. The average postoperative hospital stay was 30 days. The postoperative complications were observed in two cases. The average followup period was 539 days. 8 patients are alive, 4 patients were dead from cancer, and one case was dead from other disease. Over 1000 days or more after the operation has elapsed in the 3 alive cases and the one dead case. Conclusions: The results of the present study showed that the therapeutic outcomes for laparoscopic operations for oncologic emergencies were feasible. Thus suggesting that emergency laparoscopic surgery for oncologic emergencies can be performed on patients with incurable malignancies provided a thorough sufficient preoperative assessment and well skilled operation.

Riga East Clinical University Hospital Gailezers, Riga, Latvia

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Laparoscopic Resection of Perforated Duodenal Diverticulum. A Case Report

Laparoscopic Management of Trauma Patients- The New Paradiagm

L. Melberga

M.Z. Koto, V. Ndlovu, o. Matshevitch, T. Sumbana

Riga Eastern Clinical University hospital, Jurmala, Latvia

University of Limpopo, Vereeniging, South Africa

Aims: Perforation of a duodenal diverticulum is one of the most rare and potentially serious complications. The aim is to present a rare case of perforated duodenal diverticulum complicated with pneumoperitoneum, pneumomediastinum and pneumothorax with involvement of the retroperitoneal tissue surgically treated by laparoscopic resection and drainage. Methods: 68-year-old woman hospitalized urgently because of shivering, moderate abdominal pain, difficult breathing and swelling of the neck. Patient was transferred from the endoscopy department, where she underwent elective fibrogastroscopy. Radiologic examination including computed tomography (CT) of the thorax and abdomen revealed subcutaneous emphysema of the neck and large amount of the air in mediastinum, retroperitoneal and intra-abdominal space. Atypical perforation of the duodenum was suspected. Results: Right side thoracostomy before intubation was performed. During the urgent laparoscopy after mobilization of the duodenum using Kocher manoeuvre the bile content with gas was found near to descending part of duodenum and retroperitoneally. After additional mobilisation diverticulum 3 cm in diameter with perforation was visualised. Laparoscopic resection of duodenal diverticulum and drainage of the abdominal cavity and retroperitoneal space was performed. Histologic examination of the specimen proved duodenal wall diverticulum. Results: Postoperative period was uneventful, the abdominal drainage was removed on the fourth postoperative day and patient was discharge on 7th postoperative day. In 2 month follow up no complication was found. Conclusion(s): Laparoscopic resection of complicated duodenal diverticulum can be successfully done. Eventually minimally invasive techniques and multidisciplinary approach makes it easier to cure complex patients.

Introduction: Laparoscopy in management of trauma patient still remains controversial. There are increasing reports in usage of this modality in management of trauma patients. We use laparoscopic approach routinely in our unit managing these patients. The only proviso is hemodynamic stability Aim: We report our initial experience in managing trauma patients using this modality Methods: This is a retrospective analysis of prospectively collected data of trauma patients admitted at our institution who were treated laparoscopically from 01 November 2011 and 31 December 2013. The demographics, the clinical presentation, the operative findings and outcomes were all recorded. exclusion were hemodynamic instability Results: during this time 146 (132 males) trauma patients were seen. blunt trauma (n = 13), penetrating injury (n = 133) mean age 32 years (9–52 years) small bowel injury (n = 46), negative laparoscopy (n = 28) colon injury (n = 19) bladder injury (n = 4) diaphragm injury (n = 40) gallbladder injury (n = 3) liver injury (n = 3), Inferior vena cava injury (n = -1), mortality (n = 2), mean operative time 167 min (35–385 min) conversion to open n = 2 Conclusion: therapeutic laparoscopy is safe and feasible and should be the standard of care for trauma patients.



Clinical Outcome of Laparoscopic Surgery for Small Bowel Obstruction

Laparoscopic Management of Impending Small Bowel and Mesenteric Infarction

K. Nakamura, H. Kitagami, Y. Aoyama, T. Kato, H. Ushigome, T. Watanabe, A. Yasuda, M. Yamamoto, Y. Shimizu, T. Hayakawa, M. Tanaka

A.A. Hussain, A. Khan, P. Chandack, P. Sinha

Kariya Toyota General Hospital, Kariya, Japan Purpose: Evaluation of the outcome and effectiveness of laparoscopic surgery to small bowel obstruction (‘SBO’). Methods: We performed the surgery for small bowel obstruction of 139 cases from 2007 to 2012 and the elective laparoscopic surgery was attempted in 102 cases. Laparoscopy was also selected for the strangulation SBO for the diagnosis when the patient’s condition was stable and the intestinal tract was not dilated. We compared the group which was completed laparoscopic surgery successfully (Group L) with the group which was converted to open operations (Group C), based on the operative outcomes and postoperative courses. Results: We experienced 102 cases in total which consist of 46 cases of Group L and 56 cases of Group C. The main reason for the conversion was bowel ischemia. Laparoscopy was able to shorten the incision of 22 cases in Group C to less than 10 cm. The mean blood loss was 3 g in Group L while in Group C, the mean was 30 g. The average time of passage of flatus was 1 day in Group L and 3 days in Group C. The mean length of hospital stay was 7 days in Group L and 11 days in Group C. Operative complications were paralytic ileus (2 %) and pneumonia (4 %) in Group L and paralytic ileus (11 %), pneumonia (4 %) and surgical site infection (14 %) in Group C. The recurrence rates of SBO were 11 % (5 cases) in Group L and 7 % (4 cases) in Group C with the average observation period of 37 months. In Group L, there were 4 cases of recurrence at the first lesion and 1 case of recurrence at the different lesion. On the other hand, as for Group C, all recurrence took place at the different lesion. Conclusion: Laparoscopic surgery for SBO is safe and minimally invasive, when it is performed successfully. Even if it was converted to an open operation, there was a possibility of shortening of the incision by the laparoscopy. However, it is necessary to note that there is a possibility of recurrence at the first lesion even if laparoscopic surgery is performed successfully.

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King’s College Hospital NHS Foundation Trust, Orpington, United Kingdom Aims: To show the effective approach for and correct timing of intervention to manage an acute and impending infarction of mesentery and small bowel. Method: In December 2013 a 69-years old fit and well patient presented with 4 hours history of sudden severe continuous abdominal pain associated with vomiting. His pulse rate was 105/minutes, respiratory rate of 20/minute, temperature of 37.2c and a normal blood pressure. Abdomen was mildly distended, soft, and tender all over but no guarding or rigidity. His white cell count was 16 9 109/L, C Reacting protein of 92 mgs/L. The arterial blood gas analysis was normal. His renal function showed increased urea but normal creatinine. Computed Tomography scan concluded small bowel obstruction? Cause. Laparoscopy showed hemorrhagic fluid in the abdomen, subserosal hemorrhage across segment of small bowel and its mesentery and a congenital band causing bowel obstruction and impending bowel infarction because of the pressure on the mesenteric vessels. Division of the band, evacuation of the hemorrhagic fluid, peritoneal lavage and drainage of the peritoneal cavity was performed. Result: The patient had unremarkable course. Conclusion: Immediate laparoscopy is a gold standard tool for diagnosis and management of acute small bowel and mesenteric obstruction due to congenital band.

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Laparoscopic Management of Infarcted Bowel Due to Broad Ligament Internal Hernia

Laparoscopic Treatment of Iatrogenic Perforation During Endoscopic Procedures

A.A. Hussain, A. Khan, P. Chandack, P. Sinha

G. Sroka, O. Eyal, H. Mady, T. Raynes, D. Keren, A. Lavi, I. Matter

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

Bnai-Zion Medical Center, Haifa, Israel

Aims: to highlight the importance of immediate laparoscopy in the management of acute abdomen. Method: an 88 years old patient was admitted with lower abdominal pain, nausea and vomiting and constipation. She had several comorbidities including atrial fibrillation, hypertension and ischemic heart disease. She was taking several medications including warfarin. Her inflammatory markers were high, renal function was abnormal and her international normalised ratio was 3.7 on admission. The chest x-ray did not show free gas while the abdominal x-ray showed dilated small bowel loops. An urgent CT scan confirmed small bowel obstruction but no definite cause was reported. She has been resuscitated and prepared for laparoscopy which showed dilated and collapsed small bowel loops proximal and distal to an internal hernia defect in the right broad ligament. The distal entrapped 15 cm segment of ileum was infracted. The bowel is reduced and the defect is closed using vicryl suture. The small bowel was resected and side-side anastomosis was performed using Gastro Intestinal Anastomosis (GIA 60) stapler. The small bowel is delivered through a small transverse wound at the lower abdomen. The abdomen was lavaged and drained. Results: her postoperative course was unremarkable for any surgical complications. Conclusion: an urgent laparoscopy is vital for diagnosis and management of acute small bowel obstruction and strangulation due to a broad ligament internal hernia

Introduction: iatrogenic perforations during endoscopic procedures are rare (0.1 % in diagnostic procedures and 0.2 % in therapeutic procedures), but mandate operative repair in most cases. There is not enough data regarding the feasibility and safety of the laparoscopic approach in these circumstances. Methods: a retrospective analysis of all patients who’ve had an iatrogenic perforation during colonoscopy, gastroscopy or double balloon enteroscopy in our institution between May 2006 and November 2013. Procedural, perioperative and follow up data is presented as Mean ± SD. Results: during the study period 57749 colonoscopies, 29822 gastroscopies and 28 double balloon enteroscopies were performed. There were 15 colonoscopic perforations (0.025 %) and 1 duodenal perforation during double balloon enteroscopy (5.8 %). There was no perforation during gastroscopy. 12 patients were referred to the ED directly from the gastroenterology suite by the performing physician. Most patients [11/16] only underwent X-RAY imaging before being taken to surgery. Most patients [13/16] underwent laparoscopic repair of the perforation, with conversion rate of 23 %. Operating time was 93 ± 12 minutes for laparoscopy and 89 ± 6 minutes for open surgery. Length of hospital stay was 4.8 ± 1.6 for laparoscopy and 5.0 ± 1.2 for open surgery. There were no adverse events. Conclusions: laparoscopic surgery is feasible and safe as treatment for iatrogenic perforations during gastroenterological procedures. In most cases primary suture of the perforation is the treatment of choice. Comparative study and long term follow up are needed for assessment of the advantages of the laparoscopic approach.



Results of Laparoscopic Appendectomies Performed with the Use of Endoscopic Clips for Closure of the Appendix Stump

Cost-Effectiveness of Three Different Techniques Used to Close the Appendix Stump

M. Strzalka, M. Matyja, K. Rembiasz

M. Matyja, M. Strzalka, K. Rembiasz

Jagiellonian University, Krako´w, Poland

Jagiellonian University, Krako´w, Poland

Aims: Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendix stump during laparoscopic appendectomy. The aim of the study was to present the results of minimally invasive appendectomies performed with the use of endoscopic titanium clips. Methods: Patients operated on laparoscopically for acute appendicitis with the application of endoscopic clips between October 2012 and December 2013 were included in the study. We reviewed retrospectively patients’ data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication and conversion rates. Results: There were 93 patients (mean age = 33.8 years, SD = 15.23) in the analyzed group, including 60 men (mean age = 33.5 years, SD = 15.07) and 33 women (mean age = 33.9 years SD = 15.26). The average duration of the surgical procedure was 66 min (SD = 33.15). The average length of hospital stay was 3.38 days (SD = 1.62). There were 3 conversions (3.2 %), most of them in patients with retrocoecal position of the appendix. No intraoperative complications were observed in the analyzed group. Postoperative complication rate was low (6 cases, 6.5 %). No mortality was observed. Conclusions: Laparoscopic appendectomy with the application of endoscopic clips for closure of the appendix stump is safe, associated with low complication rates and should be considered as a routine technique in everyday surgical practice.

Aims: It is generally agreed that laparoscopic appendectomy is a valuable operative method. The purpose of our paper was to evaluate cost- effectiveness of three different techniques used to close the appendix stump. Methods: We conducted a retrospective study that compared three groups of patients who were operated on laparoscopically for acute appendicitis in 2013 at our institution. We used an endoscopic clip to close the appendix stump in the first group (n = 20), endoscopic stapler was applied in the second group (n = 20), and in the third group of patients the appendix base was closed with a laparoscopic suture (n = 20). These groups were matched by age, sex and BMI. Results: The average operative cost was the highest in the second group. Cost of the laparoscopic appendectomy with the application of the endoscopic clip was significantly lower (first group) and comparable to the third group. Observed differences in total hospitalization costs were associated only with the chosen appendix stump closure technique. Conclusion: Clip closure of the appendix base is an easy and cost - effective procedure. The laparoscopic suture technique is the cheapest but technically demanding. According to our experience endoscopic stapler may be useful in some cases, although it is the most expensive method.

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Management of Severe Septic Complication Following Revision of Gastric Pouch for Weight Regain After Gastric Bypass

Single-Incision Versus Standard Laparoscopic Appendectomy: Comparison of Surgical Outcomes of 180 Consecutive Cases

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

D. Saavedra-Perez, O. Vidal, M.. Valentini, C. Ginesta, M. Marti, J.J. Espert, G. Guerson, J.C. Garcia-Valdecasas

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

Hospital Clinic of Barcelona, Spain

Aims: to show a successful management of challenging case of sepsis and abdominal wall wound closure following revisional surgery for obesity. Method: A 41 years-old female patient who underwent laparoscopic gastric bypass for morbid obesity in 2011 and lost 5 stones (31.75 kilograms), she regained 3 stones (19.05 kilograms) during 2012–2013. Gastroscopy and gastrograffin study showed large gastric pouch of 100–150 mls capacity. We have proceeded with laparoscopic revision of gastric pouch and was relatively an easy operation. She was discharged on 4th postoperative day as per our protocol. She was re-presented tow days later with an acute abdomen. The white cell count was 19 9 109/L, C Reacting Protein of 420 mg/L, urea of 11 mmol/L and normal creatinine. The lactate was 3.7 and base excess was -9 and Ph of 7.2 on arterial blood gas analysis. An urgent computed tomography showed significant free fluid and gas in the abdominal cavity. An urgent laparoscopy showed severe peritonitis, upper abdominal abscess. Conversion to laparotomy was done and drainage of pus and peritoneal lavage was performed. The abdomen was left open and the wound was managed by sandwich technique. The patients nursed at intensive care unit. Next day re-exploration showed the leak from gastro-jejunostomy. Closure of the leak and peritoneal lavage was performed. 10 successive lavages over 2 weeks period were performed and abdomen was left open in all of these sessions. The patient showed improvement except her creatinine was creeping up to 144 mgs/dl. At this stage we had controlled the sepsis but got a challenge to close the laparotomy. We used combination of a biological mesh (Strattice, LifeCell, NJ, USA) as well as component separation. The patient’s renal function was getting worse and was referred to the renal unit. Results: she did well and recovered without residual renal or abdominal wound complications after 3 months of follow up. Conclusions: management of sepsis following bariatric surgery could be challenging and conversion to laparotomy was warranted when laparoscopy was not providing the access and feasibility to treat the cause of sepsis and its complications.

Aims: Laparoscopic appendectomy via the three trocar technique is widely used for appendectomy. Single incision Laparoscopic surgery (SILS) for appendectomy is a wellestablished procedure and represents the next step in developing the concept of ‘minimally invasive surgery’. Here, we described our 48 month experience with SILS appendectomy. Methods: Between December 2008 and December 2012, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of our institution who agreed to undergo SILS appendectomy were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS appendectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic appendectomy during the same study period. Results: The SILS and standard appendectomy groups included 180 patients each. SILS was successfully performed in all patients and none of them required conversion to an open procedure or a conventional laparoscopic appendectomy by adding more entry ports. The median operating time of 45 min in the SILS group was not significantly different than that in the standard laparoscopic appendectomy group. We sutured fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS patient [ 28 BMI (p = 0.026). Conclusions: SILS appendectomy offers better cosmetic appealing results than the standard umbilical access and, we can reduce the risk of incisional hernia in obese patients.



Single Port Laparoscopy for Critically Ill Patients Suspected of Acute Mesenteric Ischemia

For Beginners, Single Port Laparoscopic Appendectomy

A. Ronan, F. Narouz, H. Al Furajii, D.K. Hill

¨. U ¨ . Firat, I. Solak, S. Ersin, ¨ nalp, O T. Sezer, H. Yildirim, O C. Hoscoskun

Beaumont Hospital, Dublin, Ireland

Ege University School of Medicine, Izmir, Turkey

Background: Acute mesenteric ischemia may be a primary cause or secondary effect of critical illness. Radiological imaging early in the process may be non-specific. There is a benefit for selected patients in undergoing a minimally invasive procedure to examine the intestine and mesentery and permit clear diagnosis and therapeutic resection if the condition is proven and remediable. In those with global bowel infarction, avoidance of laparotomy allows prioritization of patient dignity and optimal palliation. Methods: With the patient under general anaesthesia and positioned in lithotomy, a three centimeter transumbilical incision is made. A Surgical Glove Port is placed onto a wound protector-retractor (ALEXIS S, Applied Medical) positioned in this wound. Laparoscopy is thereby permitted only full examination of the peritoneal cavity to establish the presence and extent of intestinal ischemia. If limited, resectable disease is present, the affect loop of intestine can be directly withdrawn via the single port access site or alternatively the procedure can be converted to either conventional multiport laparoscopy or indeed laparotomy. If the investigation reveals normal findings or unsurvivable widespread infarction, the procedure can be concluded with only a single small wound requiring closure. Patients: Over the past six months, we have used this technique in three patients suspected of acute mesenteric ischaemia and multiorgan failure. In each case, segmental gangrene was seen and the affected ileal portion resected via a small extension of the single port laparoscopic access site. Two patients had anastomosis performed while one had an end ileostomy constructed. Conclusion: Single port laparoscopy is often viewed as a rarefied technique with limited, elective indications. We present this video to demonstrate its usefulness as an option even in extremely sick patients with potentially life-threatening pathology. Further, it easily permits in-line laparotomy and, in such situations, aligns well with conversion straight to open access without recourse to multiport laparoscopy as an intermediate escalatory step.

Aims: While surgical operations performed through single port provides excellent cosmetic outcomes for patients, in terms of surgeons, they cause difficulties technically, longer operating time and need more experience. In the process of learning this new technique, it is the debate that which surgery needs to be done. Methods: From July 2012 to May 2013, 95 patients underwent single port laparoscopic surgery. Cholecystectomy in 50 patients, transabdominal preperitoneal hernia repair in 18 patients, appendectomy in 17 patients, umbilical hernia repair in 4 patients, splenectomy in 5 patients and adrenalectomy in 1 patient were performed. Results: 10 Female and 7 male patients underwent SILS appendectomy. The mean age was 25,6 (18–52). There was no conversion to conventional multiport laparoscopy. The mean duration of hospital stay was 20 hours. There was no complication. Appendix stump was oblitered with a stapler in 10 patients, silk suture ties in 7 patients. Histology was appendix vermiformis in 1 patient, perforated appendicitis in 1 patient and phlegmonous appendicitis in 15 patients. Conclusion: Single-port laparoscopic surgery is technically difficult and has long learning curve. However, for beginners to adapt to the technique, we recommend starting with laparoscopic appendectomy instead of laparoscopic cholecystectomy and obliteration of appendix stump with a stapler.

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Biliary Ileus - Laparoscopic Approach 1

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I. Diaconescu , I. Dogaru , G. Andrei , I. Vacaroiu , M.R. Bratu , C. Tudor1, R. Craciun1, M. Beuran1, B.V. Martian1 1

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Emergency Clinical Hospital, Bucharest, Romania; Regional Hospital Constanta, Constanta, Romania We present on video a patient aged 57 years who was admitted with symptoms of intestinal obstruction without any history of surgery. Abdominal radiography reveals air leakage fluid levels and dilated loops computed tomography reveals stasis, no highlight an obstacle course. We performed a laparoscopic approach and dilated intestinal loops were found with total obstruction at distal ileum. The loop exhibited by minilaparotomy, followed by extraction of the stones and enterography. Conclusion: Not all patients are candidates for laparoscopic surgery permanent cure but most are suitable for laparoscopic approach. Laparoscopic approach may be an effective and safe therapeutic solution for rare cases of intestinal occlusion as biliary ileus.

Minimal Invasive Management of Small Bowel Obstruction from a Gallstone M. Mersich, O. Ping, K. Dede, A. Bursics Uzsoki Teaching Hospital, Budapest, Hungary Case report: 63 years old woman was presented with symptoms of small bowel obstruction at our emergency department. Urgent examinations (US, X-ray, lab) verified a high level jejunal obstruction with the suspicion of gallstone-ileus. Diagnosis is based on history taking, physical exam, and X-Ray (pneumocholangiogram) and the output of nasogastric tube. Indication of urgent operation was judged in the case of the obese patient. During laparoscopy the site of the obstruction was clearly identified at the middle part of the jejunum. After a mini-lap we performed enterotomy in order to remo of gallstone, and the site of gallbladder was investigated by direct palpation. (Bouveret-syndrome). Postoperative course was uneventful, patient was discharged on the 5th postoperative day. After 9 months patients was planned to readmit to remove gallbladder and reconstruction of duodenum by laparoscopy. Preoperative examination (in the time of abstract submission) showed significant stenosis in both internal carotic artery, so preventive management of carotic stenosis is planned first. To our knowledge, laparoscopic management of small bowel obstruction is not a first treatment of choice, and quite a few case is reported in the European literature. Diagnosis is mainly based on traditional examinations. In the cases of small bowel obstructions gallstone is a relative rare cause, so gallstone-ileus can be often a ‘surprise’ in acute management of ileus. Laparoscopic management could be safe in cases of appropriate preoperative diagnosis and a relative high-level obstruction.



Laparoscopic Cholecystectomy with Halsted’s Drainage in Treatment of Complicated Acute Cholecystitis: 6-Year Experience

The Role of Laparoscopy in Emergency Surgery

N.S. Glagolev, G.B. Ivakhov, A.V. Ustimenko Sechenov First Moscow Medical University, Krasnogorsk, Russia Aims: to estimate the efficacy of laparoscopic cholecystectomy with Halsted’s drainage of common bile duct (CBD) as the emergency operation in cases of complicated acute calculous cholecystitis. Methods: 630 emergency laparoscopic cholecystectomies about acute calculus cholecystitis were done from 2008 till 2013. Destructive forms were confirmed out of 485 patients (77 %), urgent operation were perform immediately. Local peritonitis about acute destructive cholecystitis was registered in 81 cases (13 %). 56 patients (9 %) were finally operated with laparoscopic drainage of CBD by Halsted’s. Method: 14 cases were about local peritonitis and obstructive jaundice, 13 cases were about intraoperationally detected choledocholithiasis, 18 cases were about biliary pancreatitis. Other cases were about stenosis of terminal part of CBD detected intraoperative after cholangioscopy and impossibility of cystic duct’s stump clipping and also due to technical impossibility to execute intraoperational cholangioscopy. Drainage has to be fixed in the stump of cystic duct by suture with walls of cystic duct. Drainage was removed on 25–30 days after operation in planning examination after hospital discharge. Results: duration of operation in cases with insertion of Halsted’s drainage were about 75–80 minutes. In cases with uncomplicated acute cholecystitis were about 60–65 minutes. Patients with biliary pancreatitis, hyperamylasemia were recovered in 24-hours after insertion operation. Intraoperationally verified choledocholithiasis with gallstones less than 10 mm in 7 cases was not the indication for choledochotomy or conversion. Choledocholithiasis, obstructive jaundice were treated by second-stage procedure - ERCP. Conversion frequency is about 2 % (impossibility to identify anatomic structures due to the dense infiltration). No complications or procedure-related deaths occurred in patients with Halsted’s drainage. Conclusion: we assume that absolutely indication to insertion of Halsted’s drainage are obstructive jaundice, biliary pancreatitis and intraoperationally verified choledocholithiasis in cases of complicated acute calculus cholecystitis. In addition, Halsted’s drainage is a ‘key’ to biliary tree in postoperative period. It is important in patients with latent choledocholithiasis. In other hand, this technique require some difficult laparoscopic skills (suturing, bimanual technique etc.). In this way, advanced laparoscopic skills can expand the boundaries of the application of miniinvasive operation in cases of complicated acute calculus cholecystitis.

C. Neophytou, N. Hussain, W. Al-Khyatt, J. Ahmed Royal Derby Hospital, Derby, United Kingdom Aims: The role of laparoscopy in emergency surgery is increasing over the last 20 years. It allows both the evaluation and treatment of many common acute abdominal disorders. The aim of this study is to present the outcomes from emergency laparoscopic procedures performed in our unit and investigate the role of laparoscopic surgery in the management of the acute abdomen. Methods: A prospectively maintained database of 28 (15 male) patients underwent emergency laparoscopic procedures between August 2011 and April 2013 was analysed. Appendicectomy and cholecystectomy procedures were excluded. Demographic data and preoperative comorbidities, operative outcomes, conversion rates, early postoperative complications and length of hospital stay were reviewed. Results: Median age (range) was 72 (21–94) years. The majority of the patients presented with symptoms of bowel obstruction. 22 emergency and 6 urgent laparoscopic procedures were performed, including 11 small bowel resections for small bowel obstruction and four for tumours, two splenectomies and one perforated peptic ulcer repair. The average hospital stay was 7.4 days. We recorded four post-operative complications (chest and wound infection, anastomotic leak) and two deaths. The conversion rate was 11 % and this was mainly due to dense adhesions. Conclusion: Our results show that laparoscopy can be used safely and effectively in the management of acute abdominal pathologies. Our conversion rate was lower when compared to the international literature with comparable morbidity, mortality and length of hospital stay. Indications and management were in agreement with the 2011 European Association for Endoscopic Surgery guidelines. Presence of trauma, bowel ischaemia and perforation should not exclude laparoscopic approach although careful selection of patients is needed. Conversion to open procedure does not necessarily imply failure in management. Practice of laparoscopic surgery in such cases should be encouraged to increase cohorts and strengthen evidence.

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Emergency Laparoscopic Approach for Ruptured Ectopic Pregnancy

Laparoscopic Mesh Repair of a Morgagni Hernia L.F. Doran, K. Moorthy

A. Chiotoroiu, S. Paun, B. Gaspar, I. Negoi, M. Filip, B. Stoica, I. Tanase, M. Beuran

St Mary’s Hospital, London, United Kingdom

Bucharest Emergency Hospital, Bucharest, Romania

Laparoscopic repair of a large symptomatic Morgagni hernia in a 58 year old gentleman. The gentleman was discharged on post operative day 5 and made an excellent recovery from surgery.

Introduction: Ruptured ectopic pregnancy represents a life threatening condition with possible fertility consequences. Ectopic pregnancy remains an important cause of maternal death, accounting for a considerable amount of pregnancy-related deaths. Available evidence clearly demonstrates the superiority of laparoscopic approach in gynecological emergencies even in patients with previous surgeries. Material and Method: Retrospective study of patients admitted for gynecologic acute abdominal pain and approached by laparoscopy in Bucharest Emergency Hospital during a 48 month period. Results: 75 patients with gynecologic acute abdominal pain were admitted, from which 20 % were diagnosed with ruptured ectopic pregnancy. The mean age of hospitalised patients was 33,3 years. Ultrasound upon admission was the primary diagnostic method with a good admittance-discharge diagnostic consistency. The majority of the patients showing moderate or massive hemoperitoneum. Salpingectomy, salpingotomy and adnexectomy were performed on a case by case basis. The mean hemoglobin level upon admission was 11.1 g/dL. Assuming the same protocol of resuscitation, the median postoperative decrease in hemoglobin level was 1.20 g/dL. Minor parietal hematoma was encountered in one case. No deaths occured on the studied group. Conclusions: Laparoscopic approach provides diagnostic accuracy and therapeutic options in emergency in patients with ruptured ectopic pregnancies. Laparoscopy avoids extensive preoperative investigations. In our opinion for a ultrasound characterized gynecologic injury the hemodynamic instability is the only relative contraindication for laparoscopic approach Keywords: Ruptured ectopic pregnancy; Laparoscopy; Gynecologic emergency.


P225 - Endocrine Surgery

Laparoscopic Approach in Trauma and Emergency Surgery: A 5-Year Experience at a Single Center

Laparoscopic Partial Adrenalectomy

A.F.K. Gok1, Y Soytas2, M. Ucuncu2, C.B. Kulle2, M. Ilhan2, M. Tukenmez2, F. Yanar2, H. Yanar2, K. Gunay2, C. Ertekin2

O.M. Gulko1, V.V. Chornyi1, M.E. Nytchytaylo1, O.A. Lavryk1, I.S. Suprun2 1

National Institute of Surgery and Transplantology, Kyiv, Ukraine; State Institution, V.P. Komissarenko’s Institute of Endocrinology and Metabolism, Kyiv, Ukraine

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

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Aims: Minimally invasive surgical procedures are more often used ubiquitously in elective and emergency cases, either for diagnostic approach or treatment. The aim of this study is to present a 5-year experience at a single center. Material and Method: At Istanbul School of Medicine, Trauma and Emergency Surgery Unit, 1442 patients underwent laparoscopic surgery between January 2008 and June 2013. Patients were analyzed retrospectively. Results: In the study period, laparoscopic cholecystectomy or partial cholecystectomy was performed in 710 patients with acute cholecystitis. Laparoscopic appendectomy was performed in 546 patients with acute appendicitis. Second look laparoscopy was performed in 28 patients with a diagnosis of acute mesenteric ischemia. Nine patients with perforated gastroduodenal ulcer underwent laparoscopic omental patch. Nine patients with obstructive colorectal cancer underwent laparoscopic colostomy or right hemicolectomy. Five patients with small bowel obstruction underwent laparoscopic bridotomy. Three patients with iatrogenic colon perforation underwent laparoscopic repair. Laparoscopic gastrojejunostomy was performed for gastric outlet obstruction caused by peptic ulcer to two patients. Gynecological pathology was observed in 6 of 29 patients with acute abdominal pain. Diagnostic laparoscopy was performed in 101 patients with left thoracoabdominal stab wound and laparoscopic diaphragmatic repair was performed in 26 of them. Laparoscopy related morbidity was observed in 12 patients and mortality was seen in 17 patients. Conclusions: The mortality and morbidity of laparoscopic interventions are low, due to an experienced surgical team and carefully selected patients. Due to the increasing surgical experience, technological advances and the variation of laparoscopic surgical techniques, minimally invasive surgery will be used more widely in emergency situations.

Background and Aim: Most endoscopic surgeries on adrenal glands involve total removal of the whole gland. The criteria for performing a laparoscopic partial adrenalectomy have not been described. The aim of the work was to improve the results of surgical treatment of adrenal glands with introduction of a new kind of surgeries - laparoscopic partial adrenalectomy. Materials and Methods: 32 Partial adrenalectomies (adenomadrenalectomies) in 27 patients were performed: 9 right-sided; 13 left-sided: 5 bilateral. Patients with small benign solitary (for each side) adrenal tumors were selected. The adrenal tumors were evaluated by preoperative thin-slice contrast-enhanced computed tomography scan. Partial adrenalectomy was performed using a welding technology. Welding technology is adequate for most of the small vessels and for the resection itself - to divide the adrenal tissue, with only the right main vein requiring clip. Bipolar welding endoscopic instrument allows for precise dissection along a plane between normal tissue and tumor and provide good hemostasis. Results and Discussion: The operating time, blood loss and postoperative hospital stay in patients undergoing laparoscopic partial adrenalectomy was similar to that for patients undergoing laparoscopic complete adrenalectomy. There was no intra- or postoperative complication in any patient. Excessive hormonal levels and symptoms all disappeared in all patients. We have not encountered any case of adrenal insufficiency or reoccurrence of a disease. Conclusions: Laparoscopic partial adrenalectomy is a progressive kind of surgery, which can be performed safely using a welding technology. Keywords: Laparoscopic Partial Adrenalectomy; Laparoscopic Adenomadrenalectomy; Welding technology.

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A New Suction Tube Retractor for Gasless Endoscopic Thyroid Surgery

Adrenocortical Cancer. Current State of the Problem. Differentiated Approach to Diagnosis and Treatment. Application of Endovideosurgical Treatment

Y. Usui, I. Akiyama, S. Teruta, K. Okada, K. Nanba, M. Naito

A. Babich, N.A. Maystrenko, P.N. Romashchenko, V.S. Dovganyuk

Okayama Medical Center, Okayama, Japan Background and Methods: We have performed approximately 200 cases of gasless endoscopic thyroid surgery since 1999. We have modified and improved our surgical techniques by developing various surgical instruments. We made U-retractor (2000), U-trocar (2005) and U-Kelly forceps (2008). Ultrasonically activated scalpels produce a mist that impedes vision during surgery. Therefore, suction is necessary, when the ultrasonically activated scalpel is used in this surgery. An additional surgical tool such as a suction tube might be a hindrance in the small working space of the gasless endoscopic thyroid surgery. In 2013 a new surgical instrument with dual function, i.e. wound retraction and suction was invented. The instrument was called the ‘U-suction tube retractor’. This V-shaped suction device is a metallic tube with minute holes at the tip and with a tiny ring near the end. The ring is for a rubber band by which the U-suction tube retractor is pulled up and is connected to a holder. Results: The new U-suction tube retractor would facilitate a wider working port and eliminate the mist created by the ultrasonically activated scalpel effectively. Recent data showed no difference of operative time, hoarseness, blood loss and hospital stay between conventional thyroid lobectomy and gasless endoscopic lobectomy. Conclusion: Gasless endoscopic thyroid surgery has been improved in the last 13 years. This operation was cost effective, because almost all surgical instruments were reusable and was satisfactory experience to both the patients and surgeons.

Medical-Military Academy Saint - Petersburg, Saint-Petersburg, Russia Actuality: Adrenocortical carcinoma (ACC) is a rare and highly malignant endocrine tumour, with poor prognosis and bad outcomes after treatment. The overall survival is five years from detection; postoperative disease-free survival at 5 years is only around 30 % and recurrence rates are frequent Surgical removing of the tumor via open operative access is considered the therapy of choice in the 1-2-3 stages of ACC; Application of endovideosurgical access for adrenalectomy in patient with ACC is controversial at present. At present time there is no consensus on diagnostic approaches and treatment options; also there is no since recommendation about using adjuvant chemotherapy and mitotan. Unfortunately, treatment for this aggressive cancer is still ineffective. Aims: Improve outcomes in patients with ACC through the development of modern diagnostic algorithm and optimization of ACC treatment strategy including the use of endovidesurgical technology Materials and Methods: In Medical Military Academy accumulated an experience of checkup and surgical treatment of 98 patients with ACC. By estimation of patients condition pay attention to combination clinical signs of endocrinopathy with small signs symptoms of malignant tumor. By suspicion on ACC estimated in blood level of cortisol, interleikin - 6, dehydroepiandrosterone sulfas, carcinoembryonic antigen with standard methods. There are estimated diagnostical opportunities of instrumental research methods ultrasound, CTscan, magnetic resonance tomography, one-photon emission tomography with methaiodinebenzylguanidine, marked 123I (OPET with MIBG-123I), PET and spiral tomography with 18fluorodeoxyglucose (PET/SCT), lower cavography, tropane tumor biopsy, allow to verify malignant adrenal glands lesion on pre-operative stage. Removed adrenal tumors from all patients be subject to morphological and immunohistochemical research. Results: Study of modern opportunities clinical laboratory and instrumental diagnostics allow to determine aggregate signs of ACC, influencing on choosing open or endovideosurgical access for adrenalectomy. Using the diagnostic algorithm developed in our clinic allows to verify ACC on early stages of tumor growth - I and II stages. Executable operations using with endovideosurgical in such cases provide in patients good immediate and distant results 5-years survive lance after endovideosurgical adrenalectomy are 89 %.



Management of Adrenal Incidentaloma by Laparoscopic Transperitoneal Anterior and Submesocolic Approach

Comparison of the Hemodynamic Parameters Between Transperitoneal and Retroperitoneoscopic Adrenalectomy for Pheochromocytoma

A. Balla1, S. Quaresima2, M. Guerrieri3, R. Campagnacci3, G. Lezoche3, G. d’Ambrosio2, M. Antonica2, A. Paganini2 1

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Sapienza University of Rome, Italy, Rome, Italy; Department of General Surgery, Surgical Specialties and Organ Transplantation, Rome, Italy; 3Universita` Politecnica delle Marche Ospedali Riuniti, Ancona, Italy Aims: Adrenal incidentaloma (AI) is a clinically silent adrenal mass that is incidentally discovered during diagnostic workup for other clinical conditions not related to suspicion of an adrenal disease. Aims of this paper was to evaluate the safety and effectiveness of laparoscopic adrenalectomy (LA) with a transperitoneal anterior approach for lesions on the right side, and with a transperitoneal anterior submesocolic approach in case of left sided lesions. Methods: From January 1994 to December 2012, 117 patients underwent laparoscopic adrenalectomy for AI by an anterior transperitoneal approach in two centers (Rome, Ancona, Italy) which follow an identical treatment protocol. Sixty-seven (57.26 %) and 50 (42.73 %) patients underwent right and left adrenalectomy, respectively. An anterior transperitoneal approach was used for right-sided lesions (57.26 %) and in 13 (11.1 %) patients with left-sided lesions. A transperitoneal submesocolic approach was used in 37 (31.62 %) patients with left-sided lesions. Results: Mean operative time for right and left transperitoneal anterior LA was 119 (range: 35–255) and 150 minutes (range: 80–210), respectively. Mean operative time for transperitoneal submesocolic left LA was 86 minutes (range: 45–240). For left LA the difference in operative time was statistically significant (p = 0,0001). Conversion to open surgery occurred in 2 (1.7 %) cases. Nine patients (7.69 %) underwent associated procedures with no change in patient position: cholecystectomy (7), left ovariectomy (1), right renal cyst capitonnage (1). Morbidity included 1 major and 1 minor complications (1.7 %). Mortality was nil. Mean lesion size was 4,2 cm (range 1–10 cm). Hospitalization was 3,6 days (range 2–12 days). Definitive histology was as follows: adrenocortical adenoma (80), myelolipoma (17), nodular hyperplasia (10), adrenocortical carcinoma (4), cysts (2), pheochromocytoma (2), hemorrhagic pseudocyst (1), organized adrenal hemorrhage (1). Conclusions: LA was safe and effective in the treatment of AI, also in case of larger lesions. Early identification and ligation of the adrenal vein with no prior adrenal gland manipulation are the major advantages of the anterior transperitoneal approach.

E.J. Ban1, S.J. Jung2, C.R. Lee2, S.W. Kang2, J.J. Jeong2, K.H. Nam2, W.W. Chung2, C.S. Park2 1 Yonsei University College of Medicine, Seoul, Korea; 2Yonsei College of Medicine, Seoul, Korea

Background: Hemodynamic instability still underlies difficulties during adrenalectomy for pheochromocytoma. Little is known about hemodynamic instability during laparoscopic retroperitoneoscopic adrenalectomy. The aim of this study is to compare perioperative differences in hemodynamic parameters between transperitoneal adrenalectomy (TPA) and retroperitoneoscopic adrenalectomy (RPA) for pheochromocytoma. Method: Thirteen patients underwent the TPA, and another 13 patients underwent RPA. These patients were compared to investigate the differences in hemodynamic parameters between the two groups. Prospectively established data were retrospectively reviewed. Results: Demographic and clinical parameters at presentation were similar between the groups, except for less operative time, intraoperative blood loss, and shorter hospital stay in the RPA group. The RPA was similar to the TPA on the incidence of intraoperative blood pressure fluctuation. While compared to the TPA, the process of the RPA could effectively control the degree of fluctuations in intraoperative systolic blood pressure (P \ 0.05) Morbidity occurred in the RPA; one patient developed a pleural effusion. There was no perioperative mortality. Conclusion: Compared with TPA, the RPA is safer and more effective than TPA for pheochromocytoma. The good hemodynamic stability observed with this technique makes it very attractive for the treatment of pheochromocytoma.

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Comparison Between Endoscopic Thyroidectomy and Conventional Open Thyroidectomy

Comparison of Swallowing Disorder Following Gasless Transaxillary Endoscopic Thyroidectomy vs. Conventional Open Thyroidectomy

Y. Eom, J.S. Bae, S.H. Lee, H.Y. Kwak, J.B. Seo, Y.R. Hong, B.J. Chae, S.B.J. Song, S.S. Jung

E.Y. Kim, W.S. Byon, Y.L. Park, C.H. Park, J.S. Yun

Catholic University of Korea College of Medicine, Seoul St. Mary’s Hospital, Seoul, Korea

Sungkyunkwan University School of Medicine, Kangbuk Samsung Medical Center, Seoul, Korea

Recently, endoscopic thyroidectomy has been applied to thyroid surgery during the last 10 years. It has been used only to a limited patient due to some technical and anatomical limitation. The aim of this study was to compare the complication of endoscopy and conventional open thyroidectomy. 1007 patients underwent open lobectomy and isthmectomy (Open group), and 223 patients underwent endoscopic lobectomy and isthmectomy via the axilla (Endo group) between January 2011 and August 2013 in the Department of Surgery, Catholic University of Korea College of Medicine. These patients were analyzed for the clinicopathologic characteristics and postoperative complication using medical record and the final pathologic results, retrospectively. A total of 1230 patients underwent lobectomy and isthmectomy. Endoscopic lobectomy and isthmectomy via axilla approach (Endo group) was performed in 223 patients (18.1 %) (benign lesion: 6, malignant lesion: 217) and conventional open lobectomy and isthmectomy (Open group) was performed in 1007 patients (81.9 %) (benign lesion: 24, malignant lesion: 980). Compared with the Open group, the Endo group patients presented younger age (mean age 36.25 ± 7.56 vs. 46.15 ± 11.77, p = 0.000). The operative time in the Endo group was longer compared to the Open group (85.75 ± 26.05 vs. 82.61 ± 20.51, p = 0.000). There was no statistical difference between the Endo group and the Open group in relation to postoperative hospital stay (2.92 ± 0.41 vs. 2.70 ± 1.42, p = 0.089), whether central lymph node dissection (CND) (206 vs. 937, p = 0.628), tumor size (0.60 ± 0.47 vs. 0.83 ± 0.84, p = 0.250), histology (benign vs. malignancy, 6 vs. 217, 24 vs. 980, p = 0.856), and number of retrieved lymph node (4.95 ± 4.07 vs. 6.10 ± 4.90, p = 0.416). In the malignant lesion, the Open group had higher stage (p = 0.011). Postoperative complication rate was 2.88 % and 6.73 %, respectively (Open group vs. Endo group, p = 0.005). There was no complication such as hypercapnea, tracheal injury, and esophageal injury. Bleeding occurred in 0.20 % and 0.45 % of patients, respectively (p = 0.494). Transient hypocalcemia occurred in 0.30 % and 0.00 % of patients, respectively (p = 0.414). Permanent hypocalcemia occurred in 0.10 % and 0.00 % of patients, respectively (p = 0.638). Transient RLN injury occurred in 2.38 % and 6.28 % of patients, respectively (p = 0.002). There was no permanent RLN injury in both group. Compared to conventional open thyroidectomy, endoscopic thyroidectomy shows insignificant postoperative complication, as well as good cosmetic results. Endoscopic thyroidectomy can be safe, so it can be extended to more patients.

Aims: In conventional open thyroidectomy, it is necessary to create a sub-platysma muscle flap in front of the strap muscle to provide working space. Adhesion between the flap and the strap muscle can occur after the operation, disrupting strap muscle movement and causing a swallowing disorder. Gasless transaxillary endoscopic thyroidectomy approaches the thyroid through the posterior of the strap muscle and does not require a sub-platysmal muscle flap. The present study compared flap/muscle adhesion and occurrence of swallowing disorder following gasless transaxillary endoscopic thyroidectomy vs. conventional open thyroidectomy. Methods: Forty-seven patients receiving thyroidectomy at the Kangbuk Samsung Medical Center, Seoul, Korea, were divided into two groups: Group O (24 patients) underwent conventional open thyroidectomy, and Group E (23 patients) underwent gasless transaxillary endoscopic thyroidectomy. The subjective Swallowing Impairment Index 6 (SIS-6) was used to evaluate the degree of post-operative swallowing disorder. Video recordings of swallowing movement were used to determine the contraction/relaxation (CR) ratio and evaluate adhesion, pre-operation, 3 days postoperation, and 1 month post-operation. Barium video fluoroscopy was used to measure movement of the hyoid bone and strap muscle. Results: Group O had significantly higher post-operative SIS-6 scores than Group E (P \ 0.027), indicating greater swallowing disorder. The CR ratio increased in Group O after the operation and continued to increase during 1 month post-operation, but decreased in Group E (P \ 0.001). Videofluoroscopy showed that hyoid bone movement in Group O decreased by 55.46 and 56.75 % at 3 days and 1 month post-operation, respectively, while the corresponding decreases in Group E were 84.04 and 83.69 %. Conclusions: Conventional open thyroidectomy allowed adhesion of the strap muscle and subplatysma muscle flap, resulting in non-specific dysphagia. These complications did not occur following gasless transaxillary endoscopic thyroidectomy.



The Optimal Approach for Laparoscopic Adrenalectomy Through Mono Port(LAMP) Regarding Left of Right Sides: A Comparative Study

Vocal Outcomes Following Endoscopic Thyroid Lobectomy: Possible Association with Individual Physical Appearance

W.S. Byon, E.Y. Kim, J.S. Yun, Y.L. Park, C.H. Park

Seoul St. Mary’s Hospital, Seoul, Korea

Sungkyunkwan University School of Medicine, Kangbuk Samsung Medical Center, Seoul, Korea

Background: Voice following thyroidectomy are affected with many factors including injury of recurrent laryngeal nerve, superior laryngeal nerve, strape muscles and many other factors. Cernea et al. proposed anatomical classification of external branch of superior laryngeal nerve by three type and it was revealed that type 2b groups are more prevalent among individuals with short stature. We designed this study to figure out the relationship between individual stature, body weight, BMI with vocal outcome after endoscopic thyroid lobectomy Methods: one hundred sixty two patients underwent endoscopic thyroid lobectomy between 2010 and 2013. We reviewed preoperative and postoperative acoustic voice analysis, thyroidectomyrelated voice questionnaire, perceptual analysis and height, body weight, BMI, length of neck. Results: There was relationship between postoperative F0(fundamental frequency), SFF (speaking fundamental frequency) and individual BMI, length of neck in acoustic analysis. Conclusion: We found patients with short neck, high BMI score are more risky for postoperative vocal problems including long lasting low-pitched voice.

Aims: Several studies have shown the feasibility and safety of both transperitoneal and posterior retroperitoneal approaches for single incision laparoscopic adrenalectomy, but none have compared the outcomes according to the left or right-sided location of the adrenal glands. The aim of this study was to describe surgical techniques, to analyze the outcomes and to provide insight on the optimal choice of surgical approach for each individual patient undergoing laparoscopic adrenalectomy through mono port(LAMP). Methods: From March 2009 to May 2012, 33 patients who received LAMP were included in our study. 11 patients received surgery for right-sided adrenal tumors, and 22 patients for left-sided tumors. The surgical outcomes attained using the transperitoneal approach (TPA) and posterior retroperitoneal approach (PRA) according to the right and left sides were analyzed and compared. Results: In right-sided adrenalectomies, no significant differences were found between the LAMPTPA and LAMP-PRA groups in terms of patient characteristics and clinicopathologic data. However, the LAMP-PRA group had a shorter mean operative time, which was statistically significant (62.56 ± 39.461 vs 125.00 ± 43.589 min; P = 0.038). For adrenalectomies of the left side, no significant differences were found between patient groups for both approaches. The LAMP-TPA group had a shorter mean operative time than the LAMP-PRA group (71.50 ± 27.773 vs 95.00 ± 39.461 min; P = 0.256), but there was no significant difference. Conclusions: We report that LAMP-PRA is more appropriate for right-sided laparoscopic adrenalectomies due to anatomical characteristics and better surgical outcomes. For left-sided laparoscopic adrenalectomies, however, we propose LAMP-TPA as a more suitable method. Nonetheless, further studies are needed to evaluate the feasibility and safety of LAMP-PRA and LAMP-TPA.

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S.Y. Kim, J.S. Bae, J.O. Park, D.I. Sun

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New Approach in Single Incision Endoscopic Thyroidectomy Using Lifting Method: By Original Retractor Via Anterior Chest or Axillary Incision

Video Assisted Total Thyroidectomy for Graves’ Disease

K. Kayano, N. Nishie, A. Miura, J. Kohmoto, H. Mizutani, M. Kojo, S. Nishioka Ako Central Hospital, Ako, Japan We have developed single incision endoscopic thyroidectomy (SIET) via anterior chest (C-) or axillary incision (A-) using the lifting method since 2001. We created an original retractor and a new approach in recent cases. In this study, we presented our recent results with regard to surgical outcome and patients’ complaints. Method: Our procedure of C-SIET and A-SIET was performed in 82 patients (mean age 56, Male 15 Female 67). 16 patients of 82 (C-SIET :12, A-SIET :4) were operated in new approach. A-SIET was introduced for younger women than C-SIET. The patients are placed in a supine position with the neck extended. The arm on the tumor side is raised over the forehead to expose the axilla in A-SIET. A 30 mm (C-) or a 40 mm (A-) vertical incision is made in the anterior chest or the axilla. Flexible scope (Olympus Co. Japan) is used through 5 mm trocar detached the retractor. In new approach, the thyroid is exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle (SCM), both of the skin and sternal head are lifted up by an original retractor (Takasago Medical Co. Japan). Partial or hemi thyroidectomy is performed using an ultrasonic scalpel. Results: No scars in the neck were left in all cases. Benign and hemilateral tumors sized to less than 6 cm and micropapillary carcinoma sized to less than 1 cm were operated. Operation time is 182.5 ± 14 min. in new approach including many difficult cases, 167.6 ± 10 min. in previous method. Five complications (temporary hoarseness 2 cases, skin injury 2, and artery injury 1) were experienced in previous method, no complications were demonstrated in new approach method. Conclusion: It is required to be careful of recurrent nerve palsy in any approaches. New approach is useful to operate and make the working space wider without stress. An original retractor can be introduced easily in most hospital, because it is not so expensive. Most of women satisfied cosmetic results, young ladies especially prefer to our axillary method, because of completely hidden scars.

M. Hirata, H. Arima, A. Nakajo, Y. Kijima, K. Baba, S. Mori, T. Arigami, Y. Uenosono, M. Sakoda, H. Okumura, K. Maemura, H. Yoshinaka, S. Natsugoe Japan/Kagoshima University, Kagoshima, Japan Introduction: Surgery is a common treatment option in the management of Graves’ disease. We select Video-Assisted Neck Surgery (VANS) which is gasless precordial approach with anterior neck skin lifting method, and perform endoscopic total or near-total thyroidectomy to avoid postoperative recurrence of hyperthyroidism. Indication Criteria: The patients who cannot continue the anti-thyroid drugs due to side effects. The patients who had no remission by ATD over two years or more, and prefer surgical treatment to radioiodine therapy.(include pregnant woman) The patients who had Graves’ ophthalmopathy The patients who had thyroid tumors The patients with the weight of the thyroid less than 100 g We retrospectively investigated 26 patients of Graves’ disease who underwent VANS to evaluate its advantages or disadvantages. Material and Method: From 2007 to 2012, 26 patients with Graves’ disease received endoscopic total or near-total thyroidectomy in our hospital. We divided them into two groups; the former group contains 10 cases (2007–2009), and the latter 16 cases (2010–2012), and investigated the weight of the thyroid gland, the amount of bleeding, operative time and complication. Results: We can confirm and preserve bilateral upper parathyroid gland macroscopically with fine endoscopic view. In endoscopic thyroidectomy, a sense of postoperative incongruity around the neck tends to disappear earlier than conventional open surgery; and that is more conspicuous in young patients than in elder. With preoperative inorganic iodine preparation, we could perform endoscopic thyroidectomy with very little bleeding despite of blood flow rich organ. The median weight of removed thyroid gland was 57.7 g in the former, and 40 g in the latter. The median operative time was 319 minutes vs 201 minutes respectively. The median amount of bleeding was 115 ml of former, and was l20 ml of latter. In the former, one patient had post-operative bleeding and four patients had hypocarcemia. In the latter, postoperative bleeding and Horner syndrome and hypocarcemia was seen in one patient each other. There were no patients who had permanent recurrent nerve palsy. By the learning curve effect, the operative data of the latter group were improved. Conclusions: Endoscopic thyroidectomy has an excellent cosmetic advantage with small amount of bleeding.



Comparative Outcomes of Open and Laparoscopic Operations for Insulinoma

Influence of Laparoscopic Gastric Plication on Carbohydrate Metabolism in Patients with Type 1 Diabetes Mellitus. Our Observations

I. Boyko, D. Gerych, V. Khomyak, P. Revura, V. Kemin Danylo Halytsky Lviv National Medical University, Lviv, Ukraine Aims: In last decade laparoscopic approach is used widely for surgical treatment of neuroendocrine tumors of pancreatic gland. The goal of our study was to compare the results of conventional and laparoscopic operations for insulinoma. Methods: For 28 years (1984–2012) in our clinic, we operated 38 patients with insulinomas (26 women and 12 men, median age - 48,5 ± 12 years, 17–83 years). For tumor localization we have used ultrasound, computed tomography, endoscopic ultrasound, angiography. First laparoscopic operation for insulinoma in our center was performed in 2006. Main inclusion criteria for laparoscopic approach were sporadic lesions, absence of signs of malignant growth, localization of the tumor far then 3 mm from main pancreatic duct according to localization studies. Results: Solitary insulinoma was localized in 33 cases: in the head of the pancreas - in 4 patients, in the body - in 9, tail - in 20 cases. In 5 (13 %) cases insulinoma was localized during the intraoperative revision of pancreatic gland. We have performed open surgery in 28 (74 %) patients and laparoscopic - in 10 (26 %) cases. In patients with conventional approach enucleation of the tumor was performed in 19 (50 %) cases, distal pancreatectomy - in 7 (18 %), Whipple procedure - in 2 (5 %) patients, when the tumor was adjacent to main pancreatic duct in the head of the pancreas. Laparoscopically we have performed enucleation of the tumor in 7 (19 %) cases and distal pancreatectomy - in 3 (8 %). No laparoscopic procedures were converted to open operations. We compared results of open vs laparoscopic operations: duration of the tumor enucleation 2.1 ± 0.22 hours vs 2.0 ± 0.48 hours (p [ 0.05), distal pancreatectomy - 2.6 ± 0.45 hours vs 3.0 ± 1.02 hours (p [ 0.05), start of enteral feeding – 34:16.3 hours vs 16 ± 4.6 hours (p \ 0.05), postoperative complications rate - 10 (22 %) vs 2 (4 %) (p \ 0.05). Conclusions: Laparoscopic operations for insulinoma are effective with low mortality rate and quicker postoperative recovery compared to open surgery.

I. Havrysh, O. Lukavetskiy, M. Kondratuk, I. Kravchuk, R. Havrysh Lviv Regional Clinical Hospital, Lviv, Ukraine Aims: To study the impact and long-term effects of laparoscopic gastric plication (LGP) to the individual parameters of carbohydrate metabolism in patients with type 1 diabetes mellitus (DM1). Methods: From October 2011 to January 2014 we operated 13 patients with DM1, 7 man and 4 women. Age of patients was from 18 to 56 years. Duration of diabetes form 1 to 9 years. All patients were taking daily doses of insulin - from 12 to 90 IU. BMI have not exceed number of 35. In all patients autoantibody testing were performed - glutamic acid decarboxylase autoantibodies (GADA), islet cell autoantibodies (ICA), insulinoma-associated (IA-2) autoantibodies. Among the patients were 2 groups. 1st group: 3 patients with positive autoantibody testing. 2nd group: 10 patients with normal antibodies testing. In all patients gastric plication was performed. The average operation time was 95 min (70 -130 min). We have not observed any intra- or postoperative complications. No mortality. We measured blood glucose, glycated hemoglobin (A1c) and parameters of lipid and carbohydrate metabolism in all patients before surgery. After operation, we measured blood glucose daily, glycated hemoglobin (A1c) after 3, 6, 12, 24 months. Results: 3 months after surgery in 10 patients marked reduction of insulin dose by 30–75 %, 2 patients from 2nd group- insulin dose without change. 6 months after surgery: in 1st group all patients returned to preoperative insulin dose. 2nd group - 2 (20 %) patients completely refused from insulin, 4 (40 %) patients receiving 20 % of the preoperative dose, 2 (20 %) reduced daily insulin dose by 50 %, in 2 (20 %) patients - insulin dose without change. 12 months after surgery (4 patients from 2nd group) - 1 patient refused from insulin, 2 patients reduced daily dose by 50 % and 1 patient without any effect. 24 months after surgery - 1 patient from 2nd group completely refused of taking. Conclusions: 1) Laparoscopic gastric plication leads to changes in carbohydrate metabolism, normalize blood glucose level and reduce insulin daily dose in 70 % of patients with type 1 diabetes mellitus with normal antibodies level. 2) Effect of LGP on the course of type 1 diabetes needs further investigation and research.

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Two Decades of Laparoscopic Adrenalectomy: 343 Operations in a Single Centre Experience

Laparoscopic Adrenalectomy for Big Tumors

G. Lezoche UNIVPM, Ancona, Italy Aims: To report a single institution experience during two decades of Laparoscopic Adrenalectomy (LA). Methods: From April 1993 to December 2013, 343 patients were treated in the Department of General Surgery at the University of Ancona. The only exclusion criteria to LA were multi abdominal surgery or evidence of tumor invasion and/or lymph node involvement. All procedures followed a transperitoneal route and patient position was supine for anterior access and lateral for flank approach. From 2004 the sub-mesocolic approach was performed in selected cases. Results: There were 149 males and 194 females; mean age was 59,3 years. Adrenalectomies were 213 right, 130 left, of which 12 bilateral. Mortality occurred in 1 case (0,3 %) for sepsis. Conversion to open surgery occurred in 7 cases (2,1 %); i.o. bleeding (6); hypertensive paroxysm during pheochromocytoma treatment (1). Minor complications occurred in 15 cases (4,45 %). The mean operating time was 81 min (45–110) for right LA and 95,4 min for left LA (41–127). Mean hospital stay was 3 days (1–10). 30-days readmission rate was less than 0,5 %. Histology: Cushing 40, Conn 45, Pheochromocytoma 41, Non-secreting Adenoma 202, Carcinoma/Metastases 15. Mean lesion size was 5,6 cm (2–9). Conclusions: LA is safe and effective. It is the gold standard for benign lesions, with minimal dissection, short operating time, low surgical impact and rapid return to daily activities.

H. Markogiannakis, P. Kekis, N. Memos, I. Manouras, P. Kontogianni, Z. Vrakopoulou, M. Matiatou, G. Zografos, A. Manouras Hippokration Hospital, University of Athens, Athens Medical School, Athens, Greece Aims: To evaluate the perioperative results of laparoscopic adrenalectomy for big adrenal tumors. Methods: Prospective study of all cases undergoing laparoscopic adrenalectomy in our department between 2006 and 2013. Patients were divided into two groups: those with an adrenal mass = 7 cm (group A) and those \ 7 cm (group B). Results: During the 8-year study period, 103 unilateral laparoscopic adrenalectomies were performed (mean age: 53.3 ± 7.9 years, female: 60.2 %). Mean adrenal tumor diameter was 4.8 ± 0.8 cm (range: 1–12 cm). Group A was composed of 21 patients (20.4 %) and group B of 82 (79.6 %). Comparison between group A and group B revealed no statistically significant difference in regards to age, ASA score, BMI, previous abdominal surgery, left/ right adrenalectomy, postoperative feeding time, postoperative pain VAS score at rest and at movement, analgesia requirements, complications, hospital stay and the final outcome (p [ 0.1). In contrast, group A had more men (57 % vs. 35.4 %, p = 0.02), significantly longer operative (108.7 ± 9.1 min vs. 85.8 ± 6.7 min, p = 0.02) and anesthesia time (131.8 ± 9.6 min vs. 111.3 ± 7.8 min, p = 0.02) as well as higher conversion rate to an open adrenalectomy (14.2 % vs. 1.2 %, p = 0.01). Conclusion: Laparoscopic adrenalectomy for patients with large tumors is safe and effective when performed by surgeons highly experienced in laparoscopic endocrine surgery. Although the procedure for large masses is technically demanding, size criterion should not be considered a contraindication to laparoscopic adrenalectomy. Longer operative and anesthesia time and, in addition, a higher likelihood of conversion should, however, be expected in such cases.



Comparison Between Left and Right Laparoscopic Adrenalectomies in an 8-Years Period

Safety and Feasibility of Laparoscopic Adrenalectomy: What is the Role of Tumor Size? A Single Institution Experience

H. Markogiannakis1, P. Kekis1, N. Memos1, I. Manouras1, A. Papadima2, C. Zoubouli2, G. Kafiri2, G. Zografos1, A. Manouras1

N. Aksakal, O. Agcaoglu, U. Barbaros, M. Tukenmez, S. Dogan, B. Kilic, Y. Erbil, R. Seven, S. Ozarmagan, S. Mercan

1

Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

Hippokration Hospital, University of Athens, Athens Medical School, Athens, Greece; 2Hippokration Hospital, Athens, Greece Introduction: Our aim was the comparison of left and right laparoscopic adrenalectomies. Methods: Prospective study of all adrenalectomies between 1/1/2006 and 31/12/2013. Results: Among 103 unilateral laparoscopic adrenalectomies, 54 (52.4 %) were left (group A) and 49 (47.6 %) right (group B). No statistically significant differences between group A and B were identified regarding age, sex, ASA physical status, BMI, adrenal tumor diameter, conversion rate, intraoperative and postoperative complications, postoperative feeding time, postoperative pain VAS score, analgesia requirements, hospital stay and final outcome. On the contrary, group A cases had more often previous laparotomy history (42.6 % vs. 18.4 %, p = 0.01), were more frequently simultaneously submitted to additional laparoscopic procedures (i.e., cholecystectomy, 26 % vs. 14.3 %, p = 0.03) and required longer operative (96.4 ± 8.3 min vs. 84 ± 5.4 min, p = 0.02) and anesthesia time (121.2 ± 7.5 min vs. 109.2:16.2 min, p = 0.02). Additionally, group A included more pheochromocytomas (20.3 % vs. 4 %, p = 0.01) and solitary metastases (11.1 % vs. 8.1 %, p = 0.05) but less non-functioning adenomas (22.3 % vs. 38.8 %, p = 0.01) than group B. Conclusion: Compared to right cases, left laparoscopic adrenalectomy patients present more often with previous laparotomy and concurrent abdominal surgical pathologies and require longer operative and anesthesia time. They also more often have a pheochromocytoma or single adrenal metastasis but less frequently a non-functioning adenoma.

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Aims: Although, there are studies in the literature having shown the feasibility and safety of laparoscopic adrenalectomy, there are still debates for tumor size and the requirement of the minimal invasive approach. Our hypothesis was that the use of laparoscopy facilitates minimally invasive resection of large adrenal tumors regardless of tumor size. Methods: Within 7 years, 149 patients underwent laparoscopic adrenalectomy at one institution. The patients were divided into two study groups according to tumor size. Group 1 included patients with adrenal tumors smaller than 5 cm and group 2 included larger than 5 cm. Patient demographics and clinical parameters, operative time, complications, hospital stay and final pathology were analyzed. Statistical analyses of clinical and perioperative parameters were performed using Student t and Chi-square tests. Results: There were 88 patients in group 1 and 70 in group 2. There were no significant differences between study groups regarding patient demographics, operative time, hospital stay, and complications. Estimated blood loss was significantly higher in group 2 (p = 0.002). The conversion to open rate was similar between study groups with 5.6 % versus 4.2 %, respectively. Pathology was similar between groups. Conclusions: Our study shows that the use laparoscopy for adrenal tumors larger than 5 cm is a safe and feasible technique. Laparoscopic adrenalectomy is our preferred minimally invasive surgical approach for removing large adrenal tumors.

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P244 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Adrenalectomy in Patients with Previous Laparotomy

Local Excision of Early Rectal Cancer (T1) with Transanal Endoscopic Microsurgery

H. Markogiannakis, P. Kekis, N. Memos, P. Kontogianni, Z. Vrakopoulou, M. Matiatou, G. Doulami, G. Zografos, A. Manouras

S.D. Duek, W. Khoury, K. Kluger

Hippokration Hospital, University of Athens, Athens Medical School, Athens, Greece Aims: To evaluate the results of laparoscopic adrenalectomy for patients with previous laparotomy. Methods: Prospective study of all adrenalectomies between 2006 and 2013. Patients were divided into two groups: those with a previous laparotomy history (group A) and those without laparotomy (group B). Results: During the 8-year study period, 103 unilateral laparoscopic adrenalectomies were performed (mean age: 53.3 ± 7.9 years, female: 60.2 %). Group A comprised of 32 patients (31 %) and group B of 71 (69 %). Comparison between the two groups showed that group A had more women (75 % vs. 53.5 %, p = 0.002), more left adrenalectomies (71.8 % vs. 43.6 %, p = 0.001) and required longer operative (98.7 ± 7.9 vs. 86.8 ± 6.3 min, p = 0.04), anesthesia (127.8 ± 8.2 vs. 110 ± 5.1 min, p = 0.02) and hospitalization time (2.4 ± 0.2 vs. 1.8 ± 0.1 days, p = 0.02). On the contrary, no statistically significant differences in regards to age, ASA score, BMI, conversion rate, adrenal tumor diameter, postoperative feeding time, postoperative pain VAS score at rest and at movement, analgesia requirements, complications, and the final outcome were identified (p [ 0.1). Conclusion: Laparoscopic adrenalectomy for cases with previous laparotomy is safe and effective but requires longer operative and anesthesia time. A substantial portion of the patients submitted to adrenalectomy will have had prior abdominal surgery and they should not be denied the benefits of a laparoscopic procedure.

Rambam medical center, Haifa, Israel Background: Local excision for early rectal cancer is appealing for its low morbidity and good functional results. However, its use is limited by inability to assess regional lymph nodes and uncertainty of oncologic outcome. Objective: To review the authors’ experience with local excision of early rectal cancers by TEM (Transanal endoscopic microsurgery) and to assess patients’ outcome. Methods: A retrospective chart review of patients who underwent local excision of early rectal cancer by TEM during the years 1995–2011 in the colorectal unit. Factors analyzed included those related to the patient [age, gender], tumor [size, distance from the anal verge, differentiation], and additional treatment. Results: There were 34 patients with T1 rectal cancer that underwent transanal endoscopic microsurgery. In 31 patients (91 %) surgical margins were free of tumor, in one (3 %) margins were involved by the tumor and in 2 patients (6 %) margins could not be stated. Post-operative complications were recorded in 2 patients (6 %). There was no post-operative mortality. The mean hospital stay was 37 hours. 30 patients (88) were followed up for a mean period of 55 months. Two patients (6 %) had salvage low anterior resection, one due to suspected local recurrence and one due to lymphovascular invasion in final pathology evaluation. No tumor was found in the specimens. One patients (3 %) had local recurrence, 7 months post surgery. He received chemoradiotherapy and then an APR was done. He died 13 months later due to metastatic disease. Six patients died of unrelated reasons. Conclusions: Local excision of early rectal cancer is an acceptable and feasible alternative to formal resection. It has low complication rate, short postoperative stay and low recurrence rate.


P245 - Gastroduodenal Diseases

Laparoscopic Adrenalectomy: A Suitable Opportunity for Surgical Trainees?

The Causes of Insufficiency of Endoscopic Hemostasis in Peptic Ulcer Bleeding

C. Jukes, S. Dighe, N. Farkas, P. Jethwa

M.V. Baglaenko, S.V. Silouyanov, V.A. Bneyan

Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom

Moscow Municipal Hospital #15 n.a. O.M. Filatov, Moscow, Russia

Aims: The routine use of cross-sectional diagnostic imaging has led to an increase in the detection of adrenal lesions, with an estimated incidence of 7 % in patients 70 years of age or older. As laparoscopic adrenalectomy becomes increasingly used for the resection of these lesions, we sought to assess the safety and efficacy of this procedure in the hands of trainee laparoscopic surgeons. Methods: Retrospective analysis of a prospectively collected database for all laparoscopic adrenalectomies performed at a single institution. All lesions had been evaluated by CT and/or MRI, a 24 hour urine metanephrine assay, overnight dexamethasone suppression (1 mg) and plasma aldosterone-renin ratio. Results: Fourteen adrenalectomies were performed between October 2010 and December 2013, 5 right-sided and 9 left-sided. Seven procedures were performed by one consultant (PJ) and 7 by Specialist Registrars (ST3-6) under supervision. There were 4 male and 10 female patients. Mean age and BMI was 65 years and 28.4 respectively. Mean operative time was 99 minutes, length of stay 2 days, and reduction in Hb of 0.85 g/dL, with no transfusions required. One patient, with the consultant as primary surgeon, was re-admitted 3 days post-discharge with a lower respiratory tract infection, and also developed a port-site wound infection. Two patients with previous contralateral nephrectomy and adrenalectomy required medical management for adrenal insufficiency. When comparing the trainees’ procedures with those of the consultant there was no significant increase in operative time, length of stay, variations in Hb, or complications. Conclusions: Despite the technical considerations associated with laparoscopic adrenalectomy, we believe it can be considered as an appropriate procedure for surgical trainees to add to their repertoire without any increase in morbidity or effects on theatre efficiency.

Introduction: peptic ulcer bleeding remains a serious problem with a high mortality rate up to 6–25 %. The conservative treatment with proton pump inhibitors and endoscopic hemostasis is the standard tactic, but its effectiveness could be limited by several factors. Aims: to evaluate the risk factors and causes of inefficiency endoscopic hemostasis Materials and Methods: in a retrospective study for the period from 2012 to 2013, included 378 patients with peptic ulcer bleeding, including 241 men (63.7 %), women - 137 (36.3 %). Initially hospitalized with bleeding ulcer 296 (78.3 %) patients and in 82 (21.7 %) - the episode of ulcer bleeding developed during the hospital stay for other diseases. The Helicobacter Pylori infection was serologically confirmed in 73.2 % of patients. Results: Endoscopic hemostasis performed in ??242 (64 %) patients. The hemorrhagic shock detected in 95 (39.3 %) patients. The distribution of patients with endoscopic hemostasis by Forrest’s classification: FIa - 28 (11.6 %), FIb - 72 (29.7 %), FIIa - 85 (35.1 %), FIIb - 42 (17.4 %), FIIc - 15 (6.2 %). All the patients received therapy with intravenous administration of proton pump inhibitors. The distribution of patients depending on the type of endoscopic hemostasis: injection - 51 (21.1 %), thermal - 132 (54.5 %), mechanical (clipping) - 13 (5.4 %), combined - 46 (19 %). The rebleeding after endoscopic hemostasis totally observed in 29 (12 %) patients, including 6 (2.5 %) with more than 2 rebleedings. The overall mortality among patients with endoscopic hemostasis was 11.6 %, in case of recurrent bleeding - 11 (37.9 %). The surgery was performed in 20 (8.3 %) patients: due to rebleeding - 12(5 %), unstoppable bleeding - 6 (2.5 %), high risk of rebleeding - 2 (0.8 %). Among the operated patients: penetrated ulcer detected in 3 (15 %) patients, hemorrhagic shock at admission observed in 12 (60 %) and ulcer size [ 2 cm in 6 (30 %) patients. Conclusion: the insufficiency of endoscopic hemostasis with followed conservative treatment, which required surgical intervention was observed in 8.3 % patients. To the factors limiting the effectiveness of endoscopic hemostasis can be attributed: the size of the ulcer [ 2 cm, deep penetrating ulcers and hemorrhagic shock at admission.

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Endoscopic Changes Vater’s Papilla After Minimally Invasive Surgery in the Treatment of a Bile Stone Disease

Self Laparoscopy and Endoscopy Cooperative Surgery

A. Leontyev1, A. Korotkevich2, R. Repnikova3, A. Baranov2, A. Faev1, A. Alekseev4 Hospital Nr 29, Novokuznetsk, Russia; 2Advanced Medical School for doctors, Novokuznetsk, Russia; 3Kemerovo medical academy, Kemerovo, Russia; 4Municipal clinical hospital Nr 1, Novokuznetsk, Russia 1

Aims: Laparoscopic cholecystectomy (LCE) is the ‘gold standard’ surgical treatment of patients with GSD. The number of patients with a diagnosis of postcholecystectomy syndrome reaches 40 % and has no tendency to decrease. Methods: 1 year after laparoscopic cholecystectomy performed endoscopic examination with a tour of the zone of Vater’s papilla in 53 patients. Men 16 (30,2 %), women 37 (69.8 %) in the age of from 24 to 69 years. Examination was performed with the help of video endoscopic system Fujinon 4400, under local anesthesia oropharynx by 10 % lidocaine-spray. After review of the inspection of the upper gastrointestinal tract, performed aiming inspection zone of Vater’s papilla, evaluated the lining of the small intestine, the dimensions, the shape and the mouth of Vater’s papilla, the rhythm the expiration of bile. Results: After endoscopic examination sphincter of Oddi dysfunction was diagnosed in 18 (34,0 %) patients, papillitis in 11 (20,8 %) cases, the signs of chronic pancreatitis in 7 (13,1 %) cases. Analysis of the obtained data pointed to a possible combination of several features in one patient. Pathological changes in the area of Vater’s papilla at endoscopy not detected in 17 (32,1 %) patient. Defined combination of several features in one patient. Pathological changes in the area of Vater’s papilla at endoscopy not detected in 17 (32,1 %) patients. Conclusions: 1. Performing endoscopic examination is an effective method of diagnostics of changes in the area of Vater’s papilla after minimally invasive surgery in the treatment of a bile stone disease. 2. Definition of the sphincter of Oddi dysfunction and signs of papillitis defined at 34.0 % and 20.8 % of patients, respectively.

H. Ohara, M. Masuda Fujieda Hesei Memorial Hospital, Fujieda, Japan Background: The difficulty of laparoscopic wedge resection depends on the tumor location of stomach. In our institution, a gastrointestinal surgeon perform endoscopic submucosal dissection (ESD). Since 2004, we have performed 160 cases of ESD with good results with the application of the laparoscopic surgery technique. Recently we have performed Laparoscopy and Endoscopy Cooperative Surgery (LECS) by same doctor on three patients with submucosal tumor. This method, including the selection of three strategies, will be discussed. Method: Three patients underwent LECS for resection of gastrointestinal stromal tumor (GIST). In case 1 and case 3, tumors were located near the esophagogastric junction. In case 2, tumor was located on the upper posterior wall. We divided the purposes of LECS to three strategies, preventing postoperative transformation of stomach, sliding from the esophagogastric junction, and marking of posterior wall lesion. In case 1 and case 3, the purpose was sliding from the esophagogastric junction. In case 2, the purpose was marking of posterior wall lesion. Both mucosal and submucosal layers around the tumor were circumferentially dissected by using endoscopy. Subsequently, under the views of endoscopy and laparoscopy, the lesion was exactly grasped and dissected by using an laparoscopic staple devices. Results: The mean operation time was 183 min, and the estimated blood los was 20 ml. The postoperative course was uneventful in all cases. Conclusion: LECS procedure does not depend on the location such as the vicinity of esophagogastric junction or the posterior wall of stomach body. Furthermore, LECS procedure performed by same doctor is safe and reliable.



Laparoscopic Gastrectomy D2 Dissection for Elderly Patient with Post Perforated Gastric Cancer

Impact of Comobidities on Postoperative Complications and Overall Survival in Patients Undergoing LaparoscopyAssisted Gastrectomy for Gastric Cancer

S. Khunpugdee, T. Khuhaprema National Cancer Institute, Bangkok, Thailand Aims: To clarify the safety and efficacy of laparoscopic gastrectomy (LG) for advanced gastric cancer (AGC) even post laparotomy for perforated gastric cancer if provided by surgeon proficient in both management of gastric cancer and advanced minimally invasive techniques. Methods: Case report of male patient 79 year old, ASA2, with hypertension, BMI 19.14, was referring to NCI Thai after 2 weeks of laparotomy and simple suture and biopsy for perforated antral gastric cancer. After another 2 weeks used for investigation and improve nutrition, the patient underwent total laparoscopic distal gastrectomy. Results: Laparoscopic adhesionolysis and total laparoscopic distal gastrectomy with D2 node dissection, Roux En Y gastrojejunostomy were performed. No immediately perioperative complication occurred. The patient had bowel function as passing the first flatus and start oral liquid diet in 3rd postoperative day. After many days of step up oral fluid diet, ambulation and rehabilitation, the patient was discharged. Hospital stay was 9 days post operation. The patient came for the first follow up at 30 days post operation with satisfy results of physical and laboratory examination. Pathological report was anterior wall gastric cancer 5.7 9 3 9 3 cm, 5.8 and 5 cm far from proximal and distal margins, moderately differentiated adenocarcinoma, invading into perigastric fat, surgical margins were free of tumor, all 28 lymph nodes were negative for metastases. Conclusion: Many studies have shown laparoscopic gastrectomy to have better early postoperative outcomes including less pain, a shorter hospital stay, better preserved lung function and improved cosmesis compare to conventional open gastrectomy. The role of laparoscopic gastrectomy in locally advanced gastric cancer remains controversial, however in experience hands as surgeon proficient in both management of gastric cancer and advanced minimally invasive techniques, adequate lymphadenectomy is possible and oncologic outcome can comparable to open surgery. For complicated case such as postperforated locally advanced gastric cancer, role of laparoscopic surgery should not be considered as contraindication but should depend on the surgeon’s familiar techniques.

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M. Inokuchi, K. Kato, F. S. Otsuki, Y. Sato, Y. Yoshimitsu, K. Kojima Tokyo Medical and Dental University, Tokyo, Japan Background: Comorbidities are considered to predict postoperative complications (PCs), although few studies have specifically focused on the details of comorbidities or the relation between survival and comorbidities. Methods: We retrospectively studied 529 patients with gastric cancer (GC) who underwent laparoscopy-assisted gastrectomy (LAG). PCs were defined as grade 2 or higher events according to the Clavien-Dindo classification. We evaluated various comorbidities as risk factors for PCs and examined the relation between risky comorbidities and survival. Result: A total of 87 (16.4 %) patients had PCs. There was no PC-related death. On univariate analysis, heart disease, central nervous system (CNS) disease, liver disease, renal dysfunction, and restrictive pulmonary dysfunction were significantly associated with PCs. Both liver disease and heart disease were independent risk factors significantly related to PCs on multivariate analysis (odds ratio [OR] = 3.25, p = 0.022; OR = 2.36, p = 0.017, respectively). The following factors showed trends toward being risk factors on multivariate analysis: CNS disease (OR = 2.24, p = 0.050), renal dysfunction (OR = 2.01, p = 0.058), male gender (OR = 1.75, p = 0.082), higher age (= 75 years, OR = 1.70, p = 0.075), combined resection (excluding resection of gallbladder; OR = 2.85, p = 0.081), and extended operating time (= 300 minutes, OR = 1.61, p = 0.079). The number of risky comorbidities was an independent predictor of postoperative survival (one comorbidity, HR = 2.78, p = 0.001; multiple comorbidities, HR = 3.34, p = 0.002). Both higher age (HR = 2.18, p = 0.006) and advanced pathological stage (stage 3, HR = 7.53, p \ 0.001) were also significant predictors of overall survival, although insufficient lymphadenectomy was not significant (HR = 1.51, p = 0.17). Conclusion: The number of risky comorbidities associated with PCs was an independent predictor of postoperative survival. In the strategy for GC patients with multiple risky comorbidities, less invasive treatment, such as a reduced extent of lymphadenectomy, should be considered.

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Short- and Long-Term Outcomes of Laparoscopy-Assisted Distal Gastrectomy with D2 Lymph Node Dissection

The Results of a New Liver Retractor for Protecting the Liver Function in Laparoscopic Gastrectomy

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

A. Iida, D. Fujimoto, K. Sawai, M. Morikawa, K. Koneri, M. Murakami, Y. Hirono, T. Goi, K. Katayama, A. Yamaguchi

Kitasato University, Sagamihara, Japan; 2Saitama Medical University International Medical Center, Hidaka, Japan

University of Fukui, Yoshida-gun, Fukui, Japan

1

Aims: The aim of this study was to evaluate short- and long-term outcomes of laparoscopyassisted distal gastrectomy (LADG) with D2 lymph node dissection for cT2N0 or cT2N1 gastric cancer. Methods: We examined short- and long-term outcomes of 49 patients who underwent LADG with D2 dissection performed between September 2008 and December 2012 compared with 44 patients who underwent open distal gastrectomy (ODG) with D2 dissection performed between January 2006 and December 2010, for cT2N0 or cT2N1 gastric cancer. No significant difference of patients’ background was found between LADG and ODG. Results: Mean operation time was significantly longer in LADG than in ODG (306 ± 68 vs 237 ± 68 min, P \ 0.001). Mean blood loss was significantly less in LADG than in ODG (100 ± 69 vs 376 ± 222 ml, P \ 0.001). Mean duration of postoperative hospital stay was significantly shorter in LADG than in ODG (9 ± 3 vs 11 ± 3 days, P \ 0.018). Mean number of harvested lymph nodes was larger in LADG than in ODG (44 ± 15 vs 38 ± 14, P = 0.059). One anastomotic leakage, 1 R-Y stasis, and 1 abdominal abscess were found in LADG, whereas 1 pancreatic fistula and 1 pneumonia were found in ODG. Mortality was found in neither group. Three patients recurred in each group. First sites of recurrence were bone in 1, peritoneum in 1, and hepatoduodenal ligament lymph nodes in 1 in LADG, whereas liver in 1, paraaortic lymph nodes in 1, and lymph nodes on the posterior surface of the pancreatic head in 1 in ODG. Five-year overall survival rate was similar in the two groups (87.7 % in LADG and 94.7 % in ODG, P = 0.56). CRP levels in postoperative day 1 and 3 were significantly less in LADG than in ODG (3.73 ± 0.39 vs 7.37 ± 0.50 mg/dl, P \ 0.001; 8.56 ± 0.75 vs 12.88 ± 1.10 mg/dl, P = 0.001). Conclusions: LADG for cT2N0 or cT2N1 gastric cancer had better short-term outcomes and similar long-term outcomes. It could be one of the standard treatments in the near future.

We often experienced abnormal liver function test after laparoscopic gastrectomy. The reason is the compression to the liver by retractor that is necessary to make a surgical field. Aims: We evaluate the two liver retractors by investigating the liver function test (AST) through the surgery, retrospectively. Method: The results of liver function test were measured before surgery, and after surgery at Day 1, 7 and 30. For liver retraction, we used Nathan son’s liver retractor (NL) in 58 cases, or EndoLift (EL) in recent 6 cases. Results: 83 % of the cases in NL showed abnormal liver function at day 1. But 79 % of the abnormal cases recovered to normal function at day 7. However, EL showed normal liver function through the surgery in all cases. (p \ 0.01 at day 1) [Discussion] NL is convenient retractor with easy handling, but it shut the partial liver circulation easily by vertical compression. EL enables a protective retraction for the liver by its shape and the direction for the retraction. Past reports also revealed the liver dis-function by NL in spite of its usefulness. Conclusion: EndoLift was a useful liver retractor for protecting liver function during the surgery, not only for a reduced-port surgery tool.



Feasibility of Delta-Shaped Anastomosis Without Additional Suture in Laparoscopic Distal Gastrectomy

Purely Laparoscopic Reconstructions After Laparoscopic Gastrectomy

Y. Nagahisa, Y. Kawamoto, Y. Tsukumo, T. Itou

K. Kojima, M. Inokuchi, K. Kato, H. Sugita, S. Otuki

Kurashiki Central Hospital, Kurashiki, Japan

Tokyo Medical and Dental University, Tokyo, Japan

Aims: Intra-abdominal delta-shaped (DS) gastroduodenostomy by endoscopic linear staplers, developed by Kanaya et al. in 2002, is a reconstructive procedure for totally laparoscopic distal gastrectomy (TLDG). However, there may be pitfalls for small incision closure using endoscopic linear staplers. According to Noshiro et al., unsuccessful common channel closure on the greater curvature side may result in abscess, pancreatitis or anastomosis leakage, and additional suturing with PDSII is necessary. In order to clarify the feasibility, we evaluated the short-term outcomes of DS anastomosis without additional suture. Methods: Intra-abdominal DS anastomosis was undertaken according to the method described by Kanaya et al. Following detailed monitoring of the greater curvature side on common channel closure with endoscopic linear staplers, additional suture was not undertaken, and a resected specimen was analyzed to confirm all gastric and duodenal layers. The surgical complications were assessed by the Clavien-Dindo classification. Results: From December 2008 and December 2013, inclusive, 135 patients underwent TLDG and DS anastomosis for gastric cancer at Himeji Medical Center and Kurashiki Central Hospital. The mean age was 68.4 (32–90) years. Specimen analysis confirmed all gastric and duodenal layers in all cases. The mean time for anastomosis was 12 min. Grade 2 or higher postoperative complications occurred in 9 patients (6.7 %). Pancreas-related complication was the most frequent morbidity (3.0 %), followed by anastomotic hemorrhage (1.5 %). There was no anastomotic leakage or stricture. Conclusions: DS anastomosis without additional suture was feasible, and might be feasible as another standard reconstructive procedure for TLDG.

We will show purely laparoscopic reconstructions after laparoscopic gastrectomy. At first, intracorporeal ante-colic R-Y reconstruction after distal gastrectomy nest, R-Y reconstruction after total gastrectomy using assembled purse-string suture device 1. R-Y Reconstruction after Distal Gastrectomy A similar incision was made on the greater curvature of the remnant stomach. The antimesenteric surface of the jejunum 25 cm distal to the ligament of Treitz was marked with a purple dye, at which point a small incision was made. The cartridge fork of the endoscopic linear stapler was inserted through the small incision of the jejunum, and the jejunal loop was brought up the ante-colic route. An isoperistaltic gastrojejunostomy was performed, creating a side-to-side anastomosis using the Echelon Flex 60 with a 60/3.5-mm blue cartridge. A small hole was made on the jejunal mesentery to insert the stapler. The first assistant surgeon carefully held the anterior and posterior sides of the staple line of the gastrojejunostomy, ensuring that there was no overlap. The common entry hole for the gastrojejunostomy and jejunal loop were closed together with a single Echelon Flex 60 stapler with a 60/3.5-mm blue cartridge. The closure of the entry hole and dissection of the jejunal loop were performed simultaneously by the stapler, resulting in a functional end-toend anastomosis between the stomach and jejunum, which was completed intracorporeally. 2. R-Y Reconstruction after Total Gastrectomy The anvil of the circular stapler (ECS25) and the tip of the detachable ENDO-PSI were inserted into the abdominal cavity from the umbilical wound. The lid was attached to the retractor and re-pneumoperitoneum was done. The gripper of the detachable ENDO-PSI was inserted form the left lower port and was attached to the tip of the device. The detachable ENDO-PSI was hung on the esophageal stump, and a nylon 2–0 straight needle was let through the esophagus wall. Stump of the esophagus was cut. The detachable ENDO-PSI was removed from the esophagus. The tip, which was detached from the gripper, was left in the position that does not become the obstacle. The anvil was inserted and fixed to the esophagus using knot pusher.

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Mucinous Cystadenoma Carcinoma Associated Pancreatic Well Differentiated Neuroendocrine

Feasibility of Laparoscopic Gastrectomy for Patients with Risk Factors for Postoperative Cardiac Complications

P.M. Ripa Galvan1, J.A. Ruiz Yonser2, V.H. Avalos Gomez1, M.D. Reyes Salas1

N. Nishi1, M. Inokuchi2, K. Kojima2

TEC de Monterrey, Monterrey, Mexico; 2UMAE 25 IMSS, Monterrey, Mexico

1

Introduction: Pancreatic cystic neoplasms encompass various entities with different malignant potential. 90 % is constituted by: serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasm pseudo papillary solid tumor. The remaining 10 % is made up of non-neoplastic cystic lesions. Mucinous cystic tumors have a high premalignant potential, so they should be resected. OBJECTIVE Female patient, 49 years of age who has the following Background: DM2, History of Acute Pancreatitis in October 2004 with 20 days internment receiving medical and symptomatic management. Surgical history: 2005 Cistoyeyunoanastomosis ‘Y’ Roux later recurrence requiring reoperation new in 2006. Material and Methods: Starts in October 2004 with box Acute Pancreatitis expressed with significant epigastric pain and irradiated to URQ, significant vomiting and elevated amylase level, So she was hospitalized for 20 days receiving medical treatment and symptomatic what the picture is resolved. Subsequently requires cistoyeyunoanastomosis performed twice (2005 and 2006) for recurrence. And now comes because of abdominal pain and weight loss. abdominal pain on superficial and deep palpation upper right quadrant and epigastric, Murphy denied normal peristalsis present tumor was palpable in the left upper quadrant. Laboratory: AFP 1.06, 11.8 Ca -125, Ca 19–9 0.8; ACE 1.94. Abdominal US requests which reports cystic image 167 9 142 9 135 mm approximately 1680 cc volume, body and tail of the pancreas. Subsequently abdominal CT where multilobulated tumor dependent pancreatic body and tail of approximately 15 by 20 cm is evidence requested. Results: They decide to go to surgery the patient and perform distal pancreatectomy and pathology report: Pancreatic mucinous cystadenoma associated with well -differentiated neuroendocrine carcinoma, carcinoid tumor Classic. Conclusions: The treatment choice for these tumors is surgical resection with curative intent, but because of their malignancy and the presence of metastases at diagnosis mainly liver metastases, it is sometimes not possible. Usually have typical or atypical carcinoid syndrome in less than 50 % in addition to the triad: abdominal pain, diarrhea and weight loss. Their survival at 5 years is low, around 30 %. Pancreatic carcinoid tumors are malignant secrete serotonin and a high percentage of about 70 %.

Tojun Hospital, Tokyo, Japan; 2Tokyo Medical and Dental University, Tokyo, Japan

1

Background: The cardiac risk index (CRI) was useful to predict postoperative cardiac complications after various surgeries. A validation study of CRI showed that 6 independent factors, including ischemic disease, congestive heart failure, history of cerebrovascular disease, insulin therapy, serum creatinine [ 2.0 mg/dl, and high-risk type of surgery, correlate with major cardiac complications. Patients with 0, 1, 2, or 3 or more factors were assigned to classes I, II, III, or IV. To assess the feasibility of laparoscopic gastrectomy (LG) for patients with cardiac risks, we preformed this study. Method: This study included 1026 patients underwent radical gastrectomy for gastric cancer in authors’ institutions between 1999 and 2011. We investigated the relation between CRI and grade II or more postoperative complication defined as the Clavien-Dindo classification. We compared clinical outcomes of LG with them of OG in the patients with the class III or IV of CRI. Results: The class II, III, and IV of CRI were 893 (87.0 %), 110 (10.7 %), and 23 (2.2 %). Postoperative cardiac complications were found in 4 (0.4 %), 8 (7.3 %), and 2 (8.7 %) patients with the class II, III, and IV (p = 0.035). Pulmonary and abdominal complications were not associated with CRI. In patients with the class III or IV of CRI, postoperative cardiac complications were found in 3 (4.4 %) of 68 patients underwent LG, and in 7 (10.8 %) of 65 patients did OG (p = 0.20). Conclusion: LG is tolerated in patients with several risks of cardiac complications, and similar to OG.



Resection of Acinar Cells Pancreatic Cancer by Laparoscopy

Laparoscopic D2 Gastrectomy for Gastric CA

P.M. Ripa Galvan1, D. Aguierre Mar1, J.A. Ruiz Yonser2, V.H. Avalos Gomez1, M.D. Reyes Salas1

M.K. Hussein

TEC de Monterrey, Monterrey, Mexico; 2UMAE 25 IMSS, Monterrey, Mexico 1

Introduction: Acinar cell carcinoma of the pancreas (CCA) is a neoplasm of unknown etiology, rare in our area, which accounts for 1–2 % of exocrine pancreatic tumors. It commonly occurs in males, and an average age of 65. Aims: We report a case of a patient with acinar cell carcinoma of the pancreas as a rare clinico-pathological entity. Material and Methods: We report a 59 years old male presenting with a history of a month with hematuria. An abdominal CT scan showed a tumor located in the retroperitoneum then An abdominal MR showed a 40 mm diameter tumor located in pancreatic tail. The patient was operated, and during the laparotomy an encapsulated tumor of the pancreas measuring 4 x 4 x 4 cm was found. The tail of the pancreas and splen were excised on block. In the postoperative period the patient received chemotherapy. Results: The pathological study of the surgical piece disclosed an acinar cell carcinoma. After three months of follow up he is a good condition and with out evidence of tumor relapse. Conclusion: Acinar cell carcinomas are aggressive tumors and most patients die from their cancer within a mean of 18 months after diagnosis and a 5 year survival of 5.9 %; however, the overall survival is better than pancreatic ductal adenocarcinoma (Klimstra DS et al.). Younger patients (less than 60 years old) and patients with tumors less than 10 cm tend to have longer survival than patients over 60 years or with larger tumors. Patients who present with symptoms of elevated lipase do much worse (mean survival 8.8 months). Resection is the treatment of choice, with or without chemoradiation therapy, and metastases may be present at the time of diagnosis. Keywords: Acinar cell tumor of the pancreas; Distal pancreatectomy; Laparoscopy.

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American University of Beirut Medical Center, Beirut 1107 2020, Lebanon Aims: Presented are results of 15 Laparoscopic D2 Gastric resection that were all completed Laparoscopically at the American University of Beirut Medical Center and affiliated Hospitals. Methods: All patients had adeno CA of the stomach; two of the patients are stage I, while the rest were stage II or III. The average LN retrieved is 38. No mortality and no complications were encountered except for 1 leak at the esophagojejunal anastomosis treated by drainage and 1 duodenal leak treated successfully. Results: Patients were discharged between 7 to 9 days post-operative with minimal to mild post-operative discomfort. The technical details of Laparoscopic D2 Gastrectomy will be illustrated in this video presentation. Conclusion: Unfortunately, Laparoscopic Gastrectomy cannot be considered yet a new surgical gold standard as of today. However, one may certainly state that Laparoscopic Gastrectomy for Gastric Cancer is a safe, reproducible technique oncological surgical principles applied when carried out by Laparoscopic experienced surgeons in appropriately selected patients.

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Surgical Outcomes and Oncologic Efficiency of Laparoscopic Gastrectomy for Advanced Gastric Cancer Patients in NCI Thailand

Laparoscopic Complete Mesocolic Excision for Transverse Colon Cancer

S. Khunpugdee, T. Khuhaprema National Cancer Institute, Bangkok, Thailand Aims: We evaluated the short-term surgical outcomes and oncologic efficiency of laparoscopic gastrectomy with D2 lymphadenectomy (LG with D2) for gastric cancer patients in National Cancer Institute as first series study in Thailand. Methods: The records of 15 patients who underwent laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer between 2010 and 2013 in NCI Thailand were retrospective reviewed. Surgical outcomes such as perioperative complication, postoperative courses, morbidities, mortality, and oncological results were investigated. Results: The clinicopathological characteristics of the 15 LG patients were Sex, male/ female = 8/7; Age, year- + SD = 56.7- + 16 yrs; BMI, kg/m2 - + SD = 19.7- + 2.6; Abdominal operation history = 1; Tumor size, mm- + SD = 67- + 73 mm; Tumor invasion, T1 = 2, T2 = 0, T3 = 4, T4 = 9; mean total number of harvested lymph nodes was 27- + 11; Nodal metastasis, N0 = 4, N1 = 1, N2 = 2, N3 = 8, Differentiations, Differentiated = 4, Undifferentiated = 11, StageGrouping, StageIA = 1, StageIIB = 4, StageIIIA = 1, StageIIIB = 3, StageIIIC = 4, StageIV = 2; type of LG, LDG/LTG = 7/ 8. No patient underwent open conversion. The postoperative complication found in one patient was delayed gastric emptying function. We had no mortality in 30 days POD period. Follow up to December 2013, 8 patients survived with 7 patients still free from disease, 4 patients were cancer deaths, 2 patients were non cancer deaths and 1 patient loosed follow up. Conclusion: Radical gastrectomy with regional lymph node dissection has long been the mainstay curative treatment for gastric cancer, but recently, minimal invasive therapies, such as endoscopic resection and laparoscopic gastrectomy, have gained wide acceptance as treatment modality for early gastric cancer (EGC). Laparoscopic gastrectomy (LG) for advance gastric cancer (AGC) remains a challenging procedure because of it technical difficulties and possible complications. However, unfortunately, almost gastric cancers diagnosed in Thai patients were advanced gastric cancer and only a few surgeons with much experience of laparoscopic surgery currently perform laparoscopic gastrectomy with D2 lymphadenectomy for treatment of gastric cancer. This study had shown the safety and technical feasibility of LG with D2 for advanced gastric cancer treatment. All the LG with D2 in this series operated by the surgeon, who experienced in more three hundreds cases of laparoscopic colorectal cancer surgery, lead to familiar with minimally invasive techniques enough to handle this more complicated procedure.

M. Fukunaga Juntendo University Urayasu Hospital, Urayasu, Japan Background: Laparoscopic surgery for colon cancer (LAC) is gaining wider acceptance for the standard treatment. But laparoscopic complete mesocolic excision (CME) with central vascular ligation for transverse colon cancer is technically difficult. We indicated CME for advanced cancer since 1994. The aim of this study was assess the safety and feasibility of our pincer operation to perform laparoscopic CME. Operative Procedure: Pre-operative 3D-CT angiography gives us a precise information of variable branching patterns and tumor supplying vessel. 5 ports are placed in each abdominal quadrants. 1st step: Omental sac is opened, and superior mesenteric vessels (IMA, IMV) are exposed under the inferior edge of the pancreas. Gastrocolic trunk and the surface of the pancreas head is identified and separated along the transverse mesocolon and the accessory colic vein is transected. 2nd step. From posterior to anterior leaf of transverse mesocolon, lymph node dissection is carried out along IMV and IMA and the origin of MCA is identified and transected and CME is performed. 3rd step: Mobilization is performed if the need arises. 4th step: Specimen extraction and extra-corporeal anastomosis trough the small incision. Result: Between 1993 and December 2013, 159 patients for transverse colon cancer were operated; 82 patients were performed CME with central vascular ligation 24 patients of transverse colectomy, 33 of extended rt. hemi-colectomy, 14 of rt. hemi-colectomy, 2 of extended lt. hemi-colectomy and 9 of lt. hemi-colectomy. 39 in Stage II and 32 in Stage III and 11 in StageIV. The mean operative time was 210 min. The mean estimated blood loss was 103 ml. 1(1.3 %) patients were converted to open surgery. Anastomotic leakage was observed in 2 patients (2.5 %). The 5-year overall and disease-free survival rates were 93.3 % for stage II and 80.2 % for stage III disease. Conclusion: Laparoscopic CME is feasible and acceptable both short and long term outcomes for the treatment of transverse colon cancer.



Total Laparoscopic Distal Gastrectomy with Billroth Ii Reconstruction

Surgical Outcome of Laparoscopy-Assisted Gastrectomy for Elderly Patients with Gastric Cancer

K.H. Jun, J.H. Kim, H.M. Chin

T. Enoki, N. Kugimiya, K. Oka, E. Harada, K. Hamano

St. Vincent’s Hospital, The Catholic University of Korea, Suwon, Korea

Yamaguchi University, Ube, Japan

Purpose: The aim of this study was to introduce our technique and evaluated the technical efficacy of Billroth II (B-II) reconstruction after total laparoscopic distal gastrectomy (TLDG). Methods: We performed TLDG using B-II type anastomosis in a total of 67 consecutive patients with gastric adenocarcinomas and evaluated the techniques and postoperative outcomes. Results: The mean operative time was 177.3 ± 40.1 minutes, including reconstruction time, which was 26.2 ± 3.5 minutes. Most patients were of pathologic stage IA (88.1 %) or IB (4.5 %), 1 patient was of stage IIA, and 4 were of stage IIB. The length of postoperative hospital stay was 9.4 ± 5.0 (7–43). There was no mortality. Two cases required reoperation because of anastomosis leakage and duodenal stump leakage. Postoperative endoscopy revealed that the anastomosis area was extremely soft, and no abnormalities were observed. Conclusions: TLDG with B-II reconstruction is technically feasible in gastric cancer patients.

Background: Old age is generally recognized as a risk factor for major abdominal surgery, because of the lack of functional reserve and the presence of comorbidities. Laparoscopyassisted gastrectomy (LAG) has been demonstrated to have some advantages compared to conventional open gastrectomy, such as reduced blood loss, decreased postoperative pain and early recovery. The aim of this study is to clarify the early surgical outcome of LAG for elderly patients with gastric cancer. Patients and Method: One hundred one patients, ages of 65 or more, were enrolled in this study, who underwent LAG (distal or proximal, n = 62; total, n = 39) for histrogically proven adenocarcinoma of the stomach in our department during last 5 years. The patients were divided into 2 groups according to age, Group A (65 * 74 years: n = 40) and Group B (]75 years: n = 61). Patients’ clinicopathological features (Onodera’s prognostic nutritional index (PNI), ASA score, number of comorbid diseases, T categories, N categories) as well as postoperative complication assessed by the Clavien-Dindo Classification (CD grade) were evaluated retrospectively. Results: Although ASA score and number of comorbid diseases were not different between groups, PNI was low in group B (46.3 ± 6.3 vs 48.9 ± 6.8, p = 0.052). Pathological examination revealed patients in group B had more advanced tumors (T2, T3 or T4) (50.8 % vs 32.5 %, p = 0.069). Overall postoperative complications occurred in 39 patients (40 %), and the rates were similar in the two groups. Severe complication (more than CD grade IIIb) were heart failure and cerebral infarction in group A (2/40), pancreatic fistula and myocardial infarction in group B (2/61), whose rates were not different. Although the mortality was not found in group B, 1 patient in group A died of cerebral infarction. Conclusion: Although elderly patients with gastric cancer had lower PNI, they tolerated well LAG.

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Short-Term Outcomes of the Reduced Port Laparoscopic Distal Gastrectomy

Laparoscopic Pancreas-Sparing Duodenectomy

C. Tanaka Nagoya University, Nagoya, Japan Aims: In recent reduced port surgery (RPS), in which fewer ports are used than in conventional procedures, has become increasingly popular in cholecystectomy and appendectomy. However, the use of RPS in laparoscopic distal gastrectomy (RP-LAG) for early gastric cancer, a procedure that requires high level of technique, has not been reported. The aim of this report is to describe the feasibility of RP-LAG. Methods: We retrospectively collected data from patients who underwent the laparoscopic distal gastrectomy performed at Nagoya University Hospital between 2011 and 2013. Of these patients, 30 underwent RP-LAG and 40 underwent conventional laparoscopic distal gastrectomy (C-LAG). In RP-LAG, a Free Access (Top Corporation, Tokyo, Japan) was inserted into an umbilical incision. Two 12 mm trocars were inserted through the Free Access. Two 3- and one 12-mm trocars were placed in the left side and the right side of the abdomen. The short-term outcomes of RP-LAG were compared with the results of the C-LAG that were performed between 2011 and 2013. Results: Body mass index were 22.3 ± 2.2 in RP-DAG patients vs. 23.8 ± 3.1 kg/m2 in C-LAG patients (p = 0.01). There was no significant difference in the other patient background (age, gender, comorbidity, final stage) between the RP-LAG group and the C-LAG group. There was no need for additional ports, and there were no conversions to open surgery. There were no significant differences in the average operation time (RP-LAG, 199 ± 56 min; C-LAG 202 ± 46 min; p = 0.616), estimated blood loss (90 ± 160 ml, 106 ± 99 ml, p = 0.054), number of lymph node dissected (31 ± 15, 31 ± 14, p = 0.950) and postoperative complications (Clavien-Dindo classification ?IIIa; 6.6 %, 2.5 %, p = 0.085). There were no mortalities in both groups. Conclusion: Reduced port laparoscopic distal gastrectomy is a safe and feasible method in selected patients.

H. Yanagibashi Chiba Cancer Center, Chiba, Japan Aims: Pancreatoduodenectomy, originally performed for malignancy of the duodenum, is also commonly used for potentially malignant lesions. Recent advances in diagnostic imaging and the surgical anatomy of the pancreatoduodenal region permit pancreas-sparing duodenectomy (PSD). Although PSD is an attractive surgical procedure for patients with disease of the duodenum without pancreatic involvement, the surgical technique is challenging due to the close anatomical relationship between the pancreas and the duodenum. Methods: Three patients with duodenal tumor without pancreatic or nodal involvement underwent pure laparoscopic PSD. Surgical technique: In two patients, pure laparoscopic pancreas-sparing subtotal duodenectomy was performed. End-to-side anastomosis between the common duct of the bile and pancreatic ducts and the jejunal limb was performed intracorporeally following the duodenal resection. In the remaining patient, laparoscopic pancreas-sparing infra-ampullary duodenectomy was performed. Side-to-side anastomosis between the duodenal second portion and the jejunal limb was performed intracorporeally. Results: In all patients, laparoscopic PSD could be successfully performed, as planned. In all three patients, the surgical margin was free of neoplastic change. Conclusions: Laparoscopic PSD is minimally invasive, safe and feasible in selected patients with disease of the duodenum without pancreatic or nodal involvement. However, the benefit of this procedure is yet to be proven. Obviously, not only adequate experience in pancreatic surgery but also expertise in laparoscopy is mandatory and careful selection of patients is essential for successful application of this procedure.



Long-Term Quality of Life After Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer : Compared With Open Distal Gastrectomy

Laparoscopic vs. Open Gastric Wedge Resection for Primary Gastrointestinal Tumors: Clinical Outcomes and Health Care Costs Analysis

T. Yumiba, Y. Yamasaki, Y. Akamaru, M. Fujii, Y. Morimoto, K. Yasumasa, E. Kono

N. de’Angelis, F. Brunetti, E. Felli, V. Zuddas, D. Azoulay

Osaka Kosei-Nenkin Hospital, Osaka, Japan Aims: Laparoscopy-assisted distal gastrectomy (LADG) has been thought to be less invasive than open distal gastrectomy (ODG). The quality of life (QOL) after LADG as compared with ODG is still controversial. The aim of this study was to clarify whether LADG gives gastric cancer patients better QOL than ODG in long term follow up. Methods: We studied 104 patients with distal gastrectomy for stage I gastric cancer, divided into 2 groups: Group A (n = 50); LADG, Group B (n = 54); ODG. We compared LADG with ODG as to QOL (food intake, body weight change, dumping syndrome, esophageal reflux) in more than 1 year after surgery. The incidence of bowel obstruction was evaluated. Results: 1) % food intake in Group A (84 ± 13 %, mean ± SD) was not significantly different from Group B (77 ± 16 %). 2) % body weight change in Group A (91.6 ± 5.9 %) was not significantly different from Group B (92.0 ± 6.7 %). 3) The incidence of dumping syndrome in Group A (20/50, 40.0 %) was not significantly different from Group B (22/54, 40.7 %). 4) The incidence of esophageal reflux in Group A (9/50, 18.0 %) was not significantly different from Group B (13/54, 24.1 %). 5) The incidence of bowel obstruction in Group A (1/50, 2.0 %) was significantly less than Group B (9/54, 16.7 %). Conclusion: Long-term QOL in LADG patients was not significantly different from ODG patients. The incidence of bowel obstruction in LADG patients was significantly less than ODG patients.

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Hospital Henri-Mondor, UPEC, Cre´teil, France Aims: Gastrointestinal stromal tumors (GISTs) of the stomach are rare neoplasms that usually require surgical treatment. The study aims to compare laparoscopic (LWR) vs. open wedge resections (OWR) for primary gastric GISTs in a size and location matched analysis. Methods: Twenty-five patients who underwent LWR were matched by tumor size and location with 25 patients who underwent OWR. GISTs close to the pylorus or the esophagogastric junction, incidental and metastatic GISTs were excluded. Results: Demographic, clinical and histological variables did not differ between groups. Estimated blood loss (OWR: 98.7 ml vs. LWR: 54.4 ml, p = 0.001), time to flatus (OWR: 5.3 days vs. LWR: 3.2 days, p = 0.008), and duration of hospitalization stay (OWR: 8.1 days vs. LWR: 5.8 days, p = 0.008) were significantly lower in the LWR group. Overall, 6 (12 %) patients developed minor postoperative complications medically treated. Mortality was nil. All resections had R0-margins without tumor rupture. No group difference was observed for the incidence of diseases during the follow-up (average 46.8 months). The OWR procedure had significantly higher costs (+34 %) than the LWR. Conclusion: LWR and OWR for gastric GISTs are safe and oncologically feasible. However, laparoscopy is associated with faster recovery and shorter hospital stay, which reflect advantage in terms of contracted costs for the healthcare system.

Surg Endosc



Direct Esophagogastrostomy Using a Circular Stapler in Totally Laparoscopic Proximal Gastrectomy for Early Gastric Cancer

Postoperative Complications After Open And LaparoscopyAssisted Gastrectomy For Elderly Patients with Gastric Cancer

S. Kadoya, N. Ishikawa, G. Watanabe

T. Kaetsu1, S. Tamaki1, Y. Masuda1, A. Ohta1, K. Arai2, M. Murakami3

Kanazawa University, Kanazawa, Japan

Kikuna Memorial Hospital, Yokohama, Japan; 2Showa University Northern Yokohama Hospital, Yokohama, Japan; 3Showa University Hospital, Tokyo, Japan 1

Aims: Proximal gastrectomy for early gastric cancer in the proximal third is performed to preserve physiological function of the remnant stomach. But, for proximal gastrectomy, laparoscopic approach has not gained wide acceptance because of the difficulty of reconstructive procedure. Direct esophagogastrostomy in proximal gastrectomy is simple procedure and favorable to laparoscopic surgery, because it requires only one anastomosis. In this study, we report our new surgical techniques and initial experiences of direct esophagogastrostomy using a circular stapler in totally laparoscopic proximal gastrectomy (TLPG) for early gastric cancer. Methods: Between April 2011 and May 2013, 15 patients (11 males, 4 females) with early gastric cancer located in the proximal third underwent TLPG with the direct esophagogastrostomy. Surgical techniques: The patient was placed in the supine position with legs apart and five trocars were inserted in the upper abdomen. Mobilization of the stomach and perigastric lymphadenectomy (#1,2,3,4 s,7,8a,9,11p) were initially performed. The esophagus was transected using an linear stapler. The umbilical incision was extended vertically to 4 cm, the proximal stomach was exteriorized through the small umbilicus incision. An anvil head was placed into the esophagus by the trans-oral method (OrvilTM; Covidien, Norwalk, CT). A circular stapler was inserted through an opening in the anterior side of the antrum, and the center rod was pierced through the anterior wall, 2 cm from the lesser curvature and 3 cm from the top of the remnant stomach. The anastomosis was performed end-to-side by a double stapling technique. Finally, seromuscular anchoring suture was made between the top of the remnant stomach and the lower esophagus on the left side. This anastomosis techniques allowed the top of the remnant stomach to wrap the lower esophagus in a semicircular fashion and established an acute angle at the esophagogastrostomy to prevent regurgitation. Results: The median operation time was 285 min and the median blood loss was 25 ml. This reconstructive procedure was successfully performed without intraoperative complications. There were no anastomosis-related postoperative complications, such as anastomotic leakage and stenosis. Conclusions: Our surgical techniques for TLPG is easy, safe, and effective. This reconstructive procedure deserves further clinical evaluation to assess patients’ quality of life.

P267 - Gastroduodenal Diseases Laparoscopic and Endoscopic Cooperative Surgery (LECS) for Gastrointestinal Stromal Tumor (GIST) of the Stomach: An Experience of 10 Patients Y. Takahashi, T. Watanabe, M. Tochimoto, Y. Horiguchi, M. Kawaguchi, H. Kato, O. Hosokawa Yokohama Sakae Kyosai Hospital, Yokohama, Japan Aims: Laparoscopic wedge resection has been increasingly applied for GIST of the stomach. However, laparoscopic wedge resection should not be adapted for GISTs located near ECJ or the pyloric ring. When tumor is resected by use of the conventional laparoscopic liner stapler technique, it may cause gastric obstruction and also a resection of relative large section of healthy stomach may be required. What is worse, when the tumor is intraluminal growth type, it is difficult to recognize from the location and the accurate line to be cut off. We have therefore adopted LECS in order to solve these problems. Method: The first port is placed through the umbilicus using an open method. The laparoscopy is inserted via the umbilical port, and four operating ports are inserted through bilateral upper and lower abdominal areas. In some cases, the operating ports are decreased or we adopt single incision LECS. The location of the tumor is confirmed by intra luminal endoscopy. Blood vessels in the excision area around the tumor are cut by using an ultrasonically activated devise (LCS). This can make it easy to provide a better working space. Accordingly, about a third of stomach wall around the tumor are dissected by using needle knife via intraluminal endoscopy. Subsequently, the remaining line of incision around the tumor is laparoscopilally dissected by using LCS. The resected tumor is collected into surgical bag and taken out. The incision line is then properly closed with EndoGIA. An air leakage test is performed by use of endoscopic insufflations. Result: There are 10 patient mean age of 61.4 (range: 45–79). The mean operative time is 127.6 minutes. The mean postoperative hospital stay is 10.6 days (range: 7–13). All procedures were completed successfully without converting to open surgery and any perioperative complications. Conclusion: LECS is an excellent procedure to be adopted for the dissection of GIST of the stomach because it is not attributed to the location of the tumor and safety.

Aims: The aim of this study is to assess the postoperative complications of laparoscopy-assisted gastrectomy (LAG) compared with open gastrectomy (OG) in elderly patients after curative resection. Methods: We retrospectively analyzed the data from 141 patients who underwent gastrectomy for gastric cancer from July 2006 to June 2013. Of these 141 patients, 55 were underwent curative resection and older than 75 years of age. Postoperative complications were assessed for 19 patients after LAG and 26 patients after OG according to the Clavien-Dindo classification. The study groups were compared with respect to clinicopathological findings, preoperative status, and surgical outcomes. Results: Regarding clinicopathological characteristics, degree of stage grouping was significantly lower in the LAG group than in the OG group (P \ 0.05). The findings for the following parameters were similar in the two groups: operation time, American Society of Anesthesiologistsphysical status (ASA-PS) and duration of postoperative hospital stay. Major postoperative complications (Clavien-Dindo classification = IIIa) tend to be fewer in the LAG group compared with the OG group (5.2 % vs. 23.1 %, P = 0.085). However, no significant difference was observed between two groups. When compared with an incidence of intra-thoracial complications between two groups, 23.1 % in OG group is slightly high (5.2 % in LAG group). Conclusions: There was no significant difference in severe postoperative complication rates between the LAG and the OG groups. Laparoscopic gastrectomy for elderly patients with gastric cancer is therefore feasible in terms of the incidence and severity of postoperative complications.

P269 - Gastroduodenal Diseases Total Laparoscopic Gastrectomy for Gastric Diseases at Our Hospital N. Tomizawa1, T. Ando1, K. Arakawa1, K. Muroya1, K. Kobayashi1, R. Kurosaki1, H. Sato1, Y. Suto1, R. Kato1, T. Shiraishi1, N. Ozawa1, Y. Sunose2, I. Takeyoshi2, Y. Enokida1 1 Red Cross Maebashi Hospital, Maebashi-shi, Japan; 2Gunma University Graduate School of Medicine, Maebashi-shi, Japan

Introduction: Laparoscopic surgery against gastric diseases is an increasingly performed procedure. However, laparotomy is necessary in order to extract the resected organs. In our institution, resected organs are extracted via the vagina, and all intestinal anastomoses are performed under total laparoscopy. Therefore, incisions of the abdominal wall are limited to the port insertion sites. We report here the technique and results at our institution. Methods: Transvaginal specimen extraction was performed in cases where the resected stomach and surrounding structure could be safely extracted via the vagina, and when the intestinal anastomoses and sutures could be performed under total laparoscopy. Malignant tumor diseases with serous membrane invasion were excluded due to increased risk of cancer cell implantation. Obese patients were also excluded due to technical issues. Most adequate diseases were early stage gastric cancer and gastric submucosal tumor. Technique: Lymph node dissection is performed in the same way as in usual laparoscopic surgery. The stomach is dissected prior to construction of the transvaginal pathway. Transvaginal specimen extraction (TSVE): appropriate operative field is obtained by using a cusco vaginal speculum, which is used in gynecological operations. While the anterior wall of the vaginal is lifted anteriorly, posterior colpotomy is performed laparoscopically. The resected specimen is grasped by forceps inserted through the vaginal incision, and then extracted transvaginally. The incision is sutured under direct visual guidance or laparoscopic guidance. All anastomoses are performed by use of automatic suture devices, and all sutures are done laparoscopically because intraperitoneal access routes are limited to laparoscopic ports. To date (December 2013), this technique was successfully performed in 11 gastric cancer cases (8 hemigastrectomies and 3 total gastrectomies) and 4 gastrointestinal stromal tumor cases (partial gastrectomy). Reconstruction after hemigastrectomy was done by Roux-en-Y method in 4 cases and delta anastomosis in 4 cases. For total gastrectomy, reconstruction were all done by Roux-en-Y method and in 2 cases, automatic suture devices for Y limb anastomosis were inserted transvaginally. Conclusions: Although umbilical incision is frequently performed for specimen extraction in total laparoscopic gastric surgeries, we believe that transvaginal specimen extraction is a less invasive method.

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Laparoscopic and Endoscopic Cooperative Surgery (LECS) for Gastric Duplication Located Near EGJ

Evaluation of the Delta-Shaped Anastomosis in Laparoscopic Distal Gastrectomy

T. Watanabe, Y. Takahashi, M. Tochimoto, Y. Horiguchi, H. Kato, M. Kawaguchi, O. Hosokawa

H. Kitagami, K. Nakamura, Y. Aoyama, T. Kato, H. Ushigome, T. Watanabe, A. Yasuda, M. Yamamoto, Y. Shimizu, T. Hayakawa, M. Tanaka

Yokohama Sakae Kyousai Hospital, Yokohama, Japan Aims: Gastrointestinal duplication is a congenital rare disease entity. Gastric duplication seem appear even more rarely. LECS is a very effective surgical procedure to resect the lesion near esophagogastric junction (EGJ). Case: A-35 year-old woman referred our hospital complained of vomiting and epigastralgia for more ten years. Abdominal ultrasonography (US) and computed tomography (CT) showed a cystic lesion 4 cm in diameter which was contiguous with a lumen and adjusted to EGJ. It was possible to observe inside of cystic lesion by Endoscopy. Endoscopy revealed the normal gastric mucosa in the inner of cystic lesion. Endoscopic ultrasonography showed that cyst wall had a five-layer structure similar to the stomach wall. A barium esophagogastric study showed an image of a protruding pouch in the upper gastric region. These examinations revealed gastric duplication located near EGJ. Operative Procedure: A 20-mm incision was made in the umbilicus. A SILSPort (Covidien,) was placed through an open approach, and a 5-mm laparoscope and two 5-mm ports were inserted through the SILS port. A 2-mm mini-loop retractor was inserted at epigastral region to retract the wall of the stomach. After the location of the lesion was confirmed by intraluminal endoscopy and laparoscopy, blood vessels in the smaller curvature area around the lesion were cut by using an ultrasonically activated device (LCS). Under endoscopic control, the duplication was resected at the neck with EndoGIA and then successfully retrieved with a laparoscopic pouch. Then, the staple lines were carefully examined and tested by submerging insufflated stomach under sterile to observe bubbles and there was no evidence of a leak. Result: The procedures were uneventful. She was placed on a regular diet on postoperative day 3 and discharged 7d later. She did not show any complications after surgery. On her first 6-month follow up visit, patient did no complaint of any symptoms, while normal radiographic and endoscopic examinations. Conclusions: Taking it into consideration that LECS for dissection of duplication of the stomach can be performed in safety, we came to the conclusion that LECS is an excellent procedure to be adopted for the dissection of duplication of the stomach.

Kariya Toyota General Hospital, Kariya, Japan Background: Although we formerly used either delta-shaped anastomosis (Delta) or Roux-en-Y anastomosis (RY) for reconstruction in laparoscopic distal gastrectomy (LDG), we currently adopt Delta, under a total laparoscopic approach as first-line reconstruction. In this study, we evaluated our Delta results and usefulness. Methods: The subjects were the patients who were diagnosed with Stage I gastric cancer and had undergone LDG. They were divided into two groups: Group D including 110 patients who underwent Delta, and Group RY including 60 patients who underwent RY. We compared the groups regarding operation results, postoperative clinical symptoms, gastrointestinal fiberscopy (GIF) findings, and changes in bodyweight. Results: The operative time and anastomotic time were 238 and 15 minutes in Group D, and 258 and 38 minutes in Group RY, respectively. There were significant differences. Complications in Group D were anastomotic leakage (n = 1) and obstruction (n = 2) that could be improved conservatively. Complications in Group RY were obstruction (n = 2) and mesenteric hemorrhage (n = 1). Postoperative clinical symptoms manifested in 25.5 % of Group D patients; this rate decreased to 5.5 % one year later. Similar results were recognized in Group RY. Patients underwent GIF one year later, followed by an intergroup comparison. There were no differences in gastritis and residual food incidences. Bile reflux incidence was significantly higher in Group D. There was no intergroup difference in postoperative changes in bodyweight. Conclusion: Whether we adopted Delta or RY reconstruction in LDG, no postoperative differences manifested between the procedures. Delta can be conducted quickly using totally laparoscopic approach, and is considered an excellent anastomosis.



Short-Term Outcomes of Esophagojejunostomy Using a Double Stapling Method with EeaTM OrvilTM During Laparoscopic Total Gastrectomy and Proximal Gastrectomy

Intracorporeal Esophagojejunostomy Using Linear Staplers After Laparoscopic Total Gastrectomy

K. Tanaka, T. Kojima, E. Hiraguchi, H. Hashida, J. Mitsui, M. Wada, T. Kushibiki Hakodate Central General Hospital, Hakodate, Japan Aims: Several methods for achieving esophagojejunal anastomosis during laparoscopic gastrectomy have been reported. However, reconstruction of the esophagojejunal anastomosis was required for the complexity of the surgical skills. Therefore, laparoscopic esophagojejunal anastomosis still had high rate of anastomosis-related complications. Esophagojejunostomy using a double stapling method with EEATM OrVilTM during laparoscopic total gastrectomy and proximal gastrectomy has been performed since 2008 in our department, and after 2011, reinforcing sutures are placed after double stapling to avoid postoperative anastomotic leakage. This study aimed to determine whether there were differences in the short-term outcomes of this technique with (after 2011) and without (before 2011) reinforcement. Methods and Procedures: We investigated the short-term outcomes of 25 patients who underwent total laparoscopic esophagojejunal anastomosis using EEATM OrVilTM from September 2008. Patients without reinforcement were classified into a control group (n = 12) while those with reinforcement were classified into an intervention group (n = 13). Clinical and operative features, and postoperative complications were compared between these two groups. The reinforcing suture was placed at the point of double stapling with a horizontal mattress suture using laparoscopic technique. Double tract reconstruction during proximal gastrectomy was performed using a deltashaped gastrojejunostomy. Roux-en-Y reconstruction was performed during total gastrectomy. All patients underwent retrocolic reconstruction. Results: No significant difference was observed in clinical and operative features (age, sex, operative procedure, dissected lymph nodes, operation time, and blood loss) between the 2 groups. Five patients in the control group developed anastomotic leakage (41.7 %), which was not observed in any patient in the intervention group (P = 0.015). Reoperation was required for 2 patients with anastomotic leakage and poor drainage. Anastomotic stenosis was observed in 3 patients with anastomotic leakage. Other complications included postoperative bleeding in 1 patient in the control group and pneumonia in 1 patient in the intervention group. Conclusion: The rate of anastomotic leakage can be significantly decreased by placing reinforcing sutures after double stapling of the esophagojejunal anastomosis with EEATM OrVilTM.

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T. Yamaura Osaka Red Cross Hospital, Osaka, Japan Aims: Laparoscopic total gastrectomy (LTG) for gastric cancer has not been widespread because of the difficulty in reconstruction. To date, esphagojejunostomy in LTG is performed with linear staplers or with circular stapler, but there is no standard procedure. We routinely use linear staplers, with the advantage of better view in laparoscopic caudal-cranial direction. Herein, we have introduced our procedures and evaluate the surgical outcomes. Procedures: We have two procedures of esophagojejunostomy, functional end-to-end anastomosis (FEEA) and the overlap procedure. In both procedures, stapler jaws are inserted into the left side of the esophageal stump and the jejunal limb. FEEA is a procedure of antiperistaltic anastomosis in which entry-hole closure is also done with linear stapler, whereas overlap procedure is isoperistaltic anastomosis with hand-sewn entryhole closure. FEEA is selected in cases when abdominal esophagus is preserved, and Overlap procedure is selected in cases anastomosis is made in the lower mediastinum, in such cases with esophageal invasion. We usually perform FEEA because FEEA is simpler than the overlap procedure. Methods: From April 2011 to March 2013, 51 patients underwent LTG in our hospital. In 39 cases, FEEA was done (FEEA group), the overlap procedure in 12 cases (Overlap group). We evaluate anastomosis time, intra/post-operative anastomotic complications. Results: The average time for anastomosis was 13.4 min in FEEA, 31.0 min in Overlap. There was 1 intra-operative complication. Naso-gastric tube was caught between stapler jaws in FEEA group. And, there was 1 post-operative complication, minor leakage in FEEA group. In this case, conservative treatment was successful. Conclusions: Intracorporeal esophagojejunostomy using linear staplers was safe and feasible with good surgical view. It provided good surgical outcome and was reproducible. With the acquirement of the surgical skills of FEEA and Overlap, esophagojejunostomy with linear stapler can be the standard procedure of choice in LTG.

Surg Endosc



Technique and Clinical Outcomes of Laparoscopy Assisted Proximal Gastrectomy

Two Cases of Laparoscopic Gastrectomy After Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery

H. Takeshita, S. Sakuramoto, K. Takase, M. Washio, Y. Fujimori, S. Oka, H. Sato, S. Yamaguchi, I. Koyama

H. Kawamura, S. Shibasaki, N. Minagawa, S. Homma, N. Takahashi, A. Taketomi

Saitama Medical University International Medical Center, Saitama, Japan

Hokkaido University Graduate School of Medicine, Sapporo, Japan

Aims: We present the technique and outcomes of laparoscopy assisted proximal gastrectomy (LAPG) using the pretilted anvil head (OrVil) by the transoral approach in 12 patients performed in 2013. Methods: Our surgical technique is as follows: A camera port is inserted into the upper umbilicus region and two operating ports are placed in the right and left lateral abdomen in each. D1 + lymph node dissection are performed. The esophagus is dissected using a linear stapler following complete detachment of the paraesophageal region; this is followed by proximal gastrectomy with extraction of the stomach via the 4–5 cm mini-incision. Under laparoscopic view, an anastomosis of the esophagus and the anterior wall of remnant stomach is performed using the transoral OrVil and a circular stapler passed through a small opening of the anterior wall of remnant stomach. Finally, partial fundoplication is performed by looping the remnant stomach around the esophagus. Results: The mean operative time was 311 minutes, mean blood loss 56 g. The mean number of dissected lymph nodes was 27.8. The mean time to start of oral intake and postoperative hospital stay were 4.0 days and 13.6 days, respectively. The postoperative complication was a Grade 2 anastomotic leakage and Grade 2 Cholecystitis in each one patient. All patients have been recurrence free survival during the short postoperative follow-up. Conclusion: Our LAPG technique requires a relatively long operative period, but is a safe and feasible surgical procedure with curability.

Aims: We successfully executed laparoscopic distal gastrectomies (LDG) on two patients who had undergone prior coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). Cases: An LDG preserving the RGEA graft with Roux en-Y reconstruction was performed on a 73- and 69-year-old man. The RGEA was previously utilized during CABG for the posterior descending branch in both cases. The laparoscopic approach helped avoid injury to the RGEA associated with laparotomy and retractor placement. In addition, the locations of ports necessary for laparoscopy were situated away from the RGEA graft as well as adhesions after bypass. Using typical laparoscopic settings, we were able to easily identify the grafted RGEA. Conclusions: We consider that LDG is not only less invasive but is also associated with a lower risk of injury to the RGEA graft than open gastrectomy procedures.



Technique of Esophagojejunostomy Using Transoral Placement of the Pretilted Anvil Head after Laparoscopic Total Gastrectomy for Gastric Cancer

Laparoscopic Gastrectomy Following Preoperative Chemotherapy for Locally Advanced Gastric Cancer

S. Sakuramoto1, H. Takeshita1, K. Takase1, M. Washio1, Y. Fujimori1, S. Oka1, H. Sato1, N. Katada2, S. Yamaguchi1, I. Koyama1 1

International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan; 2Kitasato University School of Medicine, Sagamihara Kanagawa, Japan Background: During esophagojejunostomy using a circular stapler after laparoscopy-assisted total gastrectomy (LATG), placement of the anvil head via the transabdominal approach proved difficult. The authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head via the transoral approach. Methods: Between November 2007 and December 2013, esophagojejunostomy was performed using the transoral, pretilted anvil head in 135 patients after LATG. The anesthesiologist introduced the anvil while observing its passage through the pharynx. During the anastomosis, we kept the jejunum fixed in position with a silicone band Lig-ALoops, thereby preventing the intestine from slipping off the shaft of the stapler. Results: Esophagojejunal anastomosis using the transoral anvil head was achieved successfully in 134 patients; for 1 patient, passage of the anvil head was difficult owing to esophageal stenosis. No other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. The only major postoperative complication was an anastomotic leakage in two patients and the minor complication was an anastomotic stenosis in 12 patients, in whom mild relief was achieved using a bougie. Conclusion: Esophagojejunostomy using the transoral pretilted anvil head is a simple and safe technique.

N. Musha, Y. Sato, T. Tanabe, A. Kuwabara, T. Tsubono, Y. Sakai Saiseikai Niigata Daini Hospital, Niigata, Japan Background: Peri-operative chemotherapy has been widely accepted for locally advanced gastric cancer. Considering the patient compliance with intensive chemotherapy, presurgical chemotherapy is an attractive and promising approach. The surgical approach for gastric cancer have shifted to laparoscopic surgery. We report on the short-term consequences of laparoscopic gastrectomy following preoperative chemotherapy. Methods: From March 2011 to December 2013, 12 patients underwent preoperative chemotherapy followed by laparoscopic gastrectomy with lymph node dissection, and 24 patients without preoperative chemotherapy had laparoscopic gastrectomy for clinical T3– T4 advanced gastric cancer. We evaluated the short-term results between two groups. Results: Patients with younger age, clinical stage 3B and 4 cancer, or clinical N2 were more likely to receive preoperative chemotherapy. The mean number of chemotherapy cycles was 4 (2–6). Nine (75 %) of 12 patients had the DCS (Docetaxel + Cisplatin + S1) regimen, 2 (16.7 %) had the XP (Capecitabine + Cisplatin) with Trastuzumab regimen, 1 (8.3 %) had the XP, and 1 (8.3 %) had the SP (S1 + Cisplatin) regimen, respectively. In the preoperative chemotherapy group, down-staging was obtained in 10 cases (83.3 %). Two (16.7 %) of the 12 patients with preoperative chemotherapy experienced a pCR. The preoperative chemotherapy group in comparison with the clinical T3-T4 group showed a higher indication rate of total gastrectomy (83.3 % vs. 20.8 %, p = 0.002), longer operation time (418 min vs. 333 min, p \ 0.01). There were no significant differences in duration of pneumoperitoneum (257 min vs. 225 min, P = 0.111), number of lymph nodes retrieved (43 vs. 40, p = 0.481), overall postoperative complication rate (33.3 % vs. 37.5 %, p = 0.902), mortality rate (0 % vs. 0 %, NS) and median postoperative length of stay (11 days vs. 9 days, p = 0.436), respectively. Conclusion: Preoperative chemotherapy for patients with locally advanced gastric cancer results in significant clinical down staging. Laparoscopic gastrectomy for down staged patients following preoperative chemotherapy is acceptable strategy.

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Laparoscopic Local Gastric Excision with Gastroscopic Cooperation for Treatment of Gist

Five Cases of Gastrointestinal Stromal Tumor (GIST) Operated by Sils: How do We Use 2 Operating Technique Separately?

Y. Watanabe1, K. Sato2, M. Yoshida1, M. Morimoto1, Y. Yamamoto1, Y. Kojima1, O. Yusuke1, J. Kuwabara1, T. Kondo1, T. Yamada1

T. Aoki, N. Tsujimura, E. Nakao, T. Otsuru, R. Watanabe, T. Matsumoto, H. Takemoto, K. Takachi, N. Nishioka, S. Iijima, Y. Uemura, K. Kobayashi

Ehime University, Toon-shi, Japan; 2Ehime University Hospital, Toon-shi, Japan 1

Backgrounds and Purposes: In a histologically proven gastrointestinal stromal tumor (GIST), the standard treatment is excision unless major morbidity is expected. However, according to the low rate of infiltration and lymph node metastasis, minimally invasive surgical procedures are now applied to preserve gastric function as much as possible. For local gastric excision, several procedures have been developed such as lesion-lifting technique and laparoscopic and endoscopic cooperative surgery (LECS) for early gastric cancer and GIST. However, LECS can be performed only in well-equipped facilities and by skilled endoscopists who can achieve endoscopic submucosal dissection (ESD) which is not yet popular in many countries. Here, we present a simple technique which may provide the versatility for gastric local resection. Procedures: Firstly, marking of the tumor is applied to the serous region planned to be excised by intraoperative endoscopy and omental bursa exposure is added. The vessels around the tumor along the lesser curvature are dissected to avoid injuring the anterior trunk of the vagal nerve. Subsequently, a full-thickness incision is partially made in the front most marked region. The tissue pad of the ultrasonic shear is inserted into the stomach lumen while using a gastroscope, the mucosal/submucosal and seromuscular layers are individually incised by ultrasonic shear while confirming the margin of the tumor. Although approach of LECS is directed outward, i.e. from mucosal to seromuscular layer and finally directed inward, our procedure is directed simply inward. By a fairly ‘ stretch’ of the mucosal/submucosal layer, seromuscular layer can be incised separately from the mucosal/submucosal layer with a minimum requirement of the margin of tumor and excessive resection leading to the deformation and narrowing can be prevented. The defect of the stomach is simply closed using a linear stapler or a hand-sewing technique without difficulties. Finally, the passage through the remnant stomach and the hemostasis from the closed region are re-confirmed by gastroscopy. Conclusion: This procedure can be used no matter where the tumor locates, even near the esophagogastric junction or the pyloric ring. This procedure which does not require the IT knife during LECS seems to provide us a simplicity, versatility and economical benefits.

Assessment of Copper Metabolism After Laparoscopic Gastrectomy with Roux-en-Y Reconstruction for Gastric Cancer 2

3

3

3

K. Higuchi , K. Kojima , M. Inokuchi , K. Kato , H. Sugita , S. Otsuki3, A. Kamiya3, Y. Sato3, M. Nakagawa3, H. Yanaka3, K. Kobayashi3, K. Sugihara4 1 Tokyo Medical and Dental University, Tokyo, Japan; 2Center for Minimally Invasive Surgery/Tokyo Medical and Dental University, Tokyo, Japan; 3Department of Gastric Surgery/Tokyo Medical and Dental University, Tokyo, Japan; 4Department of Surgical Oncology/ Tokyo Medical and Dental University, Tokyo, Japan

Background: Copper plays an important role as a cofactor for various enzymes in the human body, and copper deficiency leads to functional disorders of hematopoiesis such as anemia and neutropenia, as well as neurological disorders such as myelopathy. Some recent reports have noted that copper deficiency can occur to the patients who underwent laparoscopic bariatric surgery or who were fed with enteral nutrition through a jejunostomy. There have been no reports which assess the serum copper state of the patients who undergo laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer. Method: A cross-sectional study was conducted from June to December in 2013. The serum copper levels of 208 out clinic patients who underwent curative total or distal gastrectomy followed by Roux-en-Y reconstruction were obtained and analyzed. Results: The mean serum copper level was 105.8 ± 21.2 lg/dl (normal range: 68–128 lg/ dl). The incidence of copper deficiency was 1.4 %, and there were no patients with symptoms caused by copper deficiency. The mean follow-up period was 1029 ± 720 days. Any specific risk factor was not identified, but the mean serum copper levels of male patients, younger patients, and those whose follow-up periods were less than 3 years were significantly lower Conclusion: Roux-en-Y method is a feasible reconstruction of laparoscopic gastrectomy for gastric cancer in terms of copper metabolism.

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Nowadays single incision laparoscopic surgery (SILS) is being performed for a variety of diseases. We report here 5 cases of gastrointestinal stromal tumor (GIST) which is operated by SILS. We targeted 5 cases of GIST that we had operated from January 2010 to January 2013. Three cases were extraluminal type, and 2 cases were intraluminal type. The median age was 69 years old and the ratio of men and women was 2 to 3. Operating technique for extraluminal type, a laparoscopic port was made by open method (3-cm) via an umbilicus, and pneumoperitoneum was established by using laparoscopic protector and gloves. We observed into the peritoneum, and identified about 2–3 cm pedunculated polyp like tumor on gastric wall. Because of pedunculated polyp like, we inserted a mini-loop retractor (Covidien) via left subcostal plane, holding pedunculated part to retract the tumor, and performed gastric partial gastrectomy (including tumor) by using Endo-GIA (Covidien). For intraluminal type, a laparoscopic port was made by open method (3-cm) via an umbilicus. We derived anterior wall of gastric antrum from the port and opened (3-cm). Pneumostomach was established by using laparoscopic protector and gloves. We observed into the stomach, and identified about 1.5–3 cm pedunculated polyp like tumor on gastric wall. We inserted fine grasper, holding pedunculated part to retract the tumor, and performed gastric partial gastrectomy (including tumor) by using Endo-GIA (Covidien). The median operating time was 84 (60–117), and the blood loss were a little in all cases. No accident and complication were occurred in all cases. All patients were alive with disease free. They are satisfied with a wound not to be outstanding. We do not need a complicated maneuver for laparoscopic surgery for extraluminal or intraluminal type of GIST. To use 2 operating technique separately will be useful. We consider that SILS is extremely beneficial operative method for extraluminal or intraluminal of GIST such as our cases.



1

Kinki Central Hospital, Itami, Japan

Reduced Port Distal Gastrectomy for Early Gastric Cancer H. Kashiwagi, K. Kumagai, E. Monma, M. Nozue Shonai Amarume Hospital, Yamagata, Japan Background: Although recent trend in laparoscopic procedures have been towards minimizing the number of incisions, four or five ports are normally required to complete laparoscopic gastrectomy because of the complexity of this procedure. Multi-channel ports such as the SILS-port (Covidien Japan) are now available and are crucial for performing Single Incision Laparoscopic Surgery (SILS) or reduced port surgery (RPS). We carried out Reduced Port Distal Gastrectomy (RPDG) using a dual ports method with a SILS port. Methods: Fourteen patients who were diagnosed as early stage gastric cancer were offered the RPDG. Mean age and Body Mass Index (BMI) were 65.6 and 21.0, respectively. Distant metastasis or regional lymph node swelling was not seen in any case. A 5 mm flexible scope (Olympus, JAPAN) and SILS-port were used and a nylon ligature with a straight needle, instead of a surgical instrument, was available to raise the gastric wall, instead of surgical instrument. The cases of extra indication of endoscopic submucosal dissection (ESD) or additional treatment cases after ESD, according to the guideline published by the Japanese Gastric Cancer Association, were nominated for laparoscopic distal gastrectomy. Results: The average operative time was 268 ± 37.4 minutes and blood loss was 43.4 ± 50.7 ml. Patients recovered well and experienced no complications after surgery. All patients could tolerate soft meals on the first day after surgery and the average hospital stay was 8.4 days. Past conventional laparoscopic distal gastrectomy (LAG) cases were evaluated to the short-term outcome and no difference was seen in mean operative time or operative blood loss. The length of hospital stay after surgery was shorter for the RPDG group than the conventional operation group (p \ 0.0001). Interestingly, the trend of serum CRP elevation after surgery in RPDG group was lower in the RPDG group than the conventional LAG group (p = 0.07). Conclusions: Although the benefits of RPS have not been established, this type of surgery may be expected to have some advantages. Cosmetic benefit and shorter hospital stay are definitive advantages. Less invasiveness can be expected according to the trend of serum CRP elevation after RPDG, although statistical difference was not seen.

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Novel Full-Thickness Resection Technique for Gastric Cancer: Non-exposed Endoscopic Wall-Inversion Surgery (NEWS)

The Influence of Obesity in Laparoscopic Distal Gastrectomy with D2 Lymph Node Dissection

T. Mitsui1, M. Bando1, K. Niimi2, M. Fujishiro2, K. Sato1, T. Mouri1, N. Tamura1, Y. Murata1, Y. Seto2, Y. Sato1

S. Okumura1, S. Knaya2, T. Yamaura2, A. Arimoto2

Kawakita General Hospital, Tokyo, Japan; 2The University of Tokyo Hospital, Tokyo, Japan

Japan, Osaka, Japan; 2Osaka Red Cross Hospital, Osaka, Japan

1

1

Aims: Local resection is an option for early gastric cancer, which carries a negligible risk of lymph node metastasis but is difficult to be applied endoscopic submucosal dissection (ESD) because of a strong ulcer scar. Non-exposed endoscopic wall-inversion surgery (NEWS) has been devised as a novel full-thickness resection technique to prevent intraabdominal contamination or possible tumor seeding and to be effective to resect minimum area as possible. Here, we describe the first case of intramucosal gastric cancer with an ulcer scar which was successfully treated by NEWS. Methods: A 75-year-old male was referred to the department of surgery for the treatment of EGC with an ulcer scar. The proposed treatment was laparoscopic local resection using NEWS because of the risk of perforation. The NEWS procedure was performed as described below. First, markings on both the mucosal and serosal surfaces were made around a model lesion, and 0.9 % normal saline with indigo carmine was injected into the submucosa around the markings. Next, a circumferential sero-muscular incision was laparoscopically made from the outside. Then, the sero-muscular layer was sutured in a linear fashion with the lesion inverted into the inside. Finally, a circumferential mucosubmucosal incision was endoscopically made and the lesion was completely removed perorally. Results: Neither intraoperative nor postoperative complication was observed. Conclusion: Since NEWS enables minimum area as possible whole-layer excision without transmural communication, it is good indication for early gastric cancer which fits the criteria but is difficult to be treated by ESD.

Aims: Obesity is thought to influence operation time and postoperative complications in laparoscopic surgery for gastric cancer. We have applied laparoscopic distal gastrectomy (LDG) to gastric cancer regardless of degree of obesity. We investigate the influence of obesity in LDG with D2 lymph node dissection for advanced gastric cancer. Methods: 52 patients with advanced gastric cancer who underwent LDG with D2 lymph node dissection in our hospital from April 2011 to March 2013 were divided into two groups by body mass index (BMI): 17 patients into the obesity group (BMI?25) and 35 patients into the normal weight group (BMI \ 25). Operation time, postoperative complications, the number of resected lymph nodes, and postoperative length of stay were compared in the two groups. Results: The average of operation time in the obesity group was equivalent to the normal weight group (320 vs 330 minutes). The average number of resected lymph nodes in the obesity group was also equivalent to the normal weight group (43.4 vs 41.2 lymph nodes). The postoperative complications regarded as grade ? or more in Clavien-Dindo Classification occurred more frequently in the obesity group than in the normal weight group (29 % vs 17 %). But most of the postoperative complications in the obesity group were abdominal abscesses (18 %), and the rate of pancreatic fistula was equivalent (6 % vs 6 %). There was no anastomotic leakage in both groups. The median postoperative length of stay was longer in the obesity group than in the normal weight group (14 days vs 11 days). Conclusion: LDG with D2 lymph node dissection for an obese patient is safe and the quality is almost the same as that for a normal weight patient.



The Short-Term Outcomes of Laparoscopy-Assisted Proximal Gastrectomy with Jejunal Interposition for Early Gastric Cancer in the Upper Third of the Stomach

Surgical Outcomes of the Delta-Shaped Anastomosis in Laparoscopic Billroth I Distal Gastrectomy

K. Yajima Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan Aims: The aim of this study is to clarify the short-term outcomes including safety and feasibility of laparoscopy-assisted proximal gastrectomy (LAPG) with jejunal interposition (JI). Patients and Methods: Since 2007, 63 patients with early gastric cancer were intent to LAPG with JI. The indication for LAPG was cT1N0M0 tumor located upper third of the stomach. The 1/2 proximal gastric resection with D1 or D1 plus lymphadenectomy, and reconstruction of JI with 10 cm single loop were performed. Clinicopathological characteristics, surgical outcomes were evaluated in 60 patients with laparoscopic surgery thorough out. Results: Three patients were converted to open proximal gastrectomy because of the anastomotic difficulties in two patients and the intraabdominal adhesion in one; therefore, the laparoscopic complete rate was 95.2 %. Median operation time was 260 (range; 183–462) minutes and median blood loss was 50 (0–710) ml. The median postoperative hospital stay was 13 (range; 8–129) days. The median number of dissected node was 26 (range; 12–72). Postoperative complications were occurred 13 events in 10 patients according to the Clavien-Dindo classification Grade II and more. The anastomotic leakage of esophagojejunostomy was seen in six patients. Although, there were three patients with positive for pathological lymph node metastasis, all 60 patients were achieved with no residual tumor pathologically. Conclusions: The LAPG with JI was accomplished surgical procedure in high rate and relatively ease in experienced surgeons. On the other hand, postoperative complications especially anastomotic leakage of esophagojejunostomy is high. More safely standard surgical procedure especially anastomotic method is problem with now confronts us.

K. Yuu Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan Aims: The aim of this study is to evaluate the feasibility of the delta-shaped anastomosis for the patients with gastric cancer in laparoscopic distal gastrectomy (LDG). Patients and Methods: From April 2012, 59 consecutive patients with gastric cancer who reconstructed delta-shaped anastomosis in LDG were enrolled. Our indication of LDG was clinical T1N0M0 tumor, and usual lymphadenectomy was D1 plus. The time of deltashaped anastomosis was defined as between first incision of the stomach for entry hole and final closure of the entry hole by liner stapler. The clinicopathological characteristics, surgical procedures, short-term outcomes were evaluated retrospectively. Postoperative complication was defined as Grade II and over according to the Clavien-Dindo classification. Results: The main tumor location was middle third of the stomach in 24 patients and lower third in 35. Median total operation time was 276 min. (range; 123- 337 min.) and median estimation of blood loss was 13 ml (range; 0–350 ml). The median time of delta-shaped anastomosis was 24 minutes (range; 10–48 minutes). Intraoperative complications concerning anastomosis occurred in six patients (10.2 %); there was duodenal injury by head of liner stapler in one patient and dissection of the duodenal in five. There was no patient with conversion to other anastomotic method. The anastomotic leakage occurred in two patients (3.4 %); one patient was carried out remnant total gastrectomy for anastomotic stenosis following leakage. Median postoperative hospital stay was 10 days (range; 8–188 days). Conclusion: The time of delta-shaped anastomosis was acceptable and the minor technical failure of anastomosis was recoverable. Postoperative complication rate was minimum, on the other hand, one patient were needed for reoperation. The delta-shaped anastomosis is relatively safe and feasible anastomotic technique for LDG.

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Laparoscopic Distal Gastrectomy (D2) for Gastric Cancer Patients

Comparison of Different Surgical Techniques in the Treatment of Gastric Stromal Tumors

T. Suwa, S. Inose, K. Kitamura, T. Matsumura, K. Karikomi, E. Totsuka, N. Nakamura, K. Okada

´ braha´m, Gy. La´za´r P. Paszt, Zs. Simonka, Sz. A

Kashiwa Kousei General Hospital, Kashiwa, Chiba, Japan Introduction: Laparoscopic distal gastrectomy (LDG) with dissection of the regional lymph nodes has become a common procedure among endoscopic surgeons. But it has still some technical difficulties in dissecting lymph nodes at the supra-pancreatic area. To reduce this difficulty, we have stuck to coaxial scope setting. Our procedure is shown as follows: Surgical Procedure: 1. A 12-mm trochar was inserted below the navel for a laparoscope. Four 5-mm trochars were inserted in the upper right, median left, left abdomen and middle right abdomen. One 12-mm trochar was inserted in the middle left abdomen. In total, six trochars were used. 2. The operator was located between patient legs and the monitor was located over the patient head. The left gastroepiploic vessels were clipped and cut by LCS and the dissection for lymph nodes was made. The right gastroepiploic vessels were clipped and cut by LCS and the lymph nodes were dissected. The duodenum was cut with an endoscopic linear stapler. 3. The lesser omentum was cut and the right crus of the diaphragm was exposed. The lymph nodes along the proper hepatic artery was dissected and the right gastroepiploic vessels were clipped and cut by LCS. The common hepatic artery and the splenic artery were exposed, and the lymph nodes were dissected. The left gastric vein was clipped and cut by LCS. This procedure was performed under excellent surgical view by pulling up the gastropancreatic folds to the anterior abdominal wall and pushing the pancreas gently. The lymph nodes around the left gastric artery and the celiac artery were dissected. The left gastric artery was divided after double-clipping. Then the stomach was cut by the endoscopic linear stapler. 4. The duodeno gastrostomy was made with a method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis. Results: We have performed LDG with dissection of the regional lymph nodes (D2) for gastric cancer patients. Dissecting lymph nodes at the supra-pancreatic area was safely performed with coaxial scope setting, because the operator could see the lesion in the coaxially set monitor over the patient head. This setting was also helpful to the procedure in the intracorporeal gastroduodenostomy.

University of Szeged, Hungary Background: The clinical appearance of gastric GIST ranges from accidentally diagnosed little lesions through complicated cases (bleeding etc.) to incurable disseminated diseases. Operative treatment remains the standard procedure for non-metastatic gastrointestinal stromal tumors (GISTs). We retrospectively analyzed the single institution results of surgery on gastric GISTs. Methods: A total of 33 surgical interventions for gastric GIST were performed between 1998 and 2013, male/female ratio: 14/19, mean age: 66.32 (40–86 years). The diagnostic procedures included endoscopy with biopsy, CT and endosonography. The operations involved open atypical gastric wall resections (12 cases), major gastric resections (7 cases), laparoscopic wedge resections/ enucleations (13 cases) and surgical biopsy (1 case). For the assessment of the risk of GIST, the Fletcher classification was used. The mean follow-up period was more than 3 years (range: 5 to 112 months). Results: One perioperative death occurred, due to a cardiac dysfunction. The histology revealed R0 resection in all resectable cases. There were 1 c-kit-negative, non-classified, 1 very low risk, 16 low-risk, 9 intermediate and 6 high-risk cases. The overall disease-free survival was 88 %. Adjuvant therapy was applied for one patient with metastatic disease. Conclusions: Gastric GISTs have a high rate of resectability. The organ preserving surgery like laparoscopic resection of GISTs is considered safe and effective as compared with open techniques.



Laparoscopic Total Gastrectomy (D1 +) for Gastric Cancer Patients Using Coaxial Scope Setting

Reduced Port Distal Gastrectomy Versus Conventional Laparoscopic Distal Gastrectomy: A Matched-Pair Comparative Study

T. Suwa, S. Inose, K. Kitamura, T. Matsumura, K. Karikomi, E. Totsuka, N. Nakamura, K. Okada Kashiwa Kousei General Hospital, Kashiwa, Chiba, Japan Introduction: Laparoscopic total gastrectomy (LTG) with dissection of the regional lymph nodes has some technical difficulties in dissecting lymph nodes at the supra-pancreatic area. To reduce this difficulty, we have used coaxial scope setting. Our procedure is shown as follows: Surgical Procedure: 1. Five trochars were used in this procedure. 2. The operator was located between patient legs and the monitor was located over the patient head. Under laparoscopic view, the left gastroepiploic vessels were clipped and cut and the dissection for lymph nodes along the left gastroepiploic vessels was made. The right gastroepiploic vessels were clipped and cut and the inflapyloric lymph nodes were dissected. The duodenum was cut using linear stapler. 3. The lymph nodes along the proper hepatic artery was dissected and the right gastroepiploic vessels were clipped and cut. The inflapyloric lymph nodes were dissected. The common hepatic artery and the splenic artery were exposed, and the lymph nodes along these vessels were dissected. The left gastric vein was clipped and cut. This procedure was performed under a very nice surgical view by pulling up the gastropancreatic folds to the anterior abdominal wall. The lymph nodes around the left gastric artery and the celiac artery were dissected. The left gastric artery was divided after double-clipping. 4. The abdominal esophagus was exposed and clamped. The esophagus was cut and sutured as a preparation for 25-mm anvil. Then 25-mm anvil was placed in the esophagus. The stomach was put into the plastic bag not to contaminate the peritoneal cavity. 5. The small 45-mm incision was made below the navel and the stomach was taken out from the body. The jejuno-jejunostomy of Roux-en Y anastomosis was made first and the small incision was sealed using the glove. Under a very nice laparoscopic view the esophago-jejunostomy was made by 25-mm circular stapler inserted through the glove. Results: We have performed LTG with dissection of the regional lymph nodes (D1 +) for gastric cancer patients. Dissecting lymph nodes at the supra-pancreatic area was easier in our procedure with coaxial scope setting.

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K. Shibao, N. Sato, H. Higure, K. Yamacuchi University of Occupational & Environmental Health, Kitakyushu, Japan Background: Reduced port surgery (RPS), which reduces the number of ports, as well as the size of the devices, to minimize the invasiveness of laparoscopic surgery, has been applied to various abdominal surgical procedures. This report describes the results of a matched-pair comparative study between reduced port distal gastrectomy (RPDG) using an EZ AccessTM oval type device and conventional laparoscopic distal gastrectomy (CLDG), and evaluates the feasibility of RPDG for gastric cancer. Methods: We performed laparoscopic distal gastrectomy through the EZ AccessTM oval type device with three trocars in the umbilical incision, plus the use of another 5 mm and 2 mm ports, the same as when performing RPDG. A total of 25 patients undergoing RPDG were compared with patients undergoing CLDG (using five ports) during the same period. Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiologists (ASA) score and the type of reconstruction. The short-term outcomes, including postoperative pain, were compared between the two groups. Results: All routine procedures performed during CLDG were achieved in RPDG. The length of the operation, blood loss, hospital stay, complication rate and number of dissected lymph nodes were similar in both groups. In contrast, the numerical rating scale (NRS) score decreased in the RPDG group in comparison to that in the CLDG group (2 vs. 2.9 at 24 hours after the surgery, p = 0.036). However, the number of analgesic doses required during the 96 hours after surgery was similar between the two groups. Conclusion: Reduced port surgery using the EZ AccessTM oval type device was successfully applied for gastric cancer without prolonging the operation. This method is technically feasible, reduces postoperative pain and produces superior cosmetic results. Prospective trials are required to confirm these results.

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Laparoscopy and Endoscopy Cooperative Surgery (LECS) for Gastrointestinal Stromal Tumor in the Stomach

Extracorporeal Hand-Sewn Anastomosis Through a Minilaparotomy in Laparoscopic Distal Gastrectomy

S. Ohki, T. Hikichi, T. Monnma, M. Sato, T. Yazawa, S. Takenoshita

Y. Takayama, Y. Kaneoka, A. Maeda, S. Onoe, M. Isogai

Fukushima Medical University, Fukusima, Japan

Ogaki Municipal Hospital, Ogaki, Japan

Introduction: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasms of gastrointestinal tract, approximately 70 % of GIST originate in the stomach. Laparoscopic wedge resection are minimary invasive surgery for GIST. We applied a laparoscopy and endoscopy cooperative surgery (LECS) for gastric wedge resection with the minimum surgical margins of gastric wall. Patients and Methods: Since 2004 till 2013, 23 patients diagnosed GIST were treated. All patients were underwent EUS-FNA. 16 patients underwent conventional laparoscopic wedge resection, 7 patients underwent LECS. The Mucosal and submucosal layer were dissected circumferently using ESD procedure, and perforated gastric wall by endoscopy at one place. Subsequently the seromuscular layer were laparoscopically dissected along the line of ESD. Results: In all cases, LECS was successful. The mean of tumor sizes were 24 mm in diameter. The mean operation time and blood loss were 193 min and 6.6 ml. The post operative course was uneventful in all cases. Histology and Immunohistochemistry confirmed GIST in all patients. According to Immunohistochemistry, 4 cases in very low risk, 2 cases in low risk, one case in high risk using modified Fletcher classification. There has been no recurrence up to present. Conclusion: LECS could be applicable for GIST, and it is effective for tumor located near esopagogastric junction or pyloric ring.

Background: In open gastrectomy, gastroduodenostomy or gastroenterostomy is carried out with the hand-sewn technique. So in the same manner as open surgery, hand-sewn anastomosis is performed through a small incision in laparoscopic distal gastrectomy. The objective of the present study is to introduce our surgical technique and assess short-term outcomes of our procedure. Surgical Procedures: Intracorporeally, we mobilize the stomach and dissecting lymph nodes. Duodenal resection below the pyloric ring is performed using a linear stapler. A 57 cm midline incision in the upper abdomen is made. The stomach is extracted through this minilaparotomy incision. Then two clamps are applied to the greater curvature of the stomach at a distance of 4 cm. After the gastric wall is incised between the two clamps, a linear stapler is used to divide the distal stomach and close the lesser curvature. We grasp the stump of the oral side and anal side by angle clamps. Good and stable operative field around the stumps of intestinal tracts is provided with fixation of these angle clamps by OctopusR. Gambee fashion using 3-0 vicryl is done in the same manner as open surgery. A drain is inserted around the anastomosis and each wound is closed. Results: Between June 2009 and December 2013, this procedure was performed in 156 patients (107 men and 49 women). The mean age was 64.1(range, 40–81). The Billroth I reconstruction was used in 66 cases. The Billroth II and Roux-en-Y methods were used in the remaining 88 and 2 patients, The mean operative time was 157.3 minutes (range, 103–368) and estimated blood loss was 34 ml (range, 3–580). No anastomotic stenosis was observed, but only one patient (0.6 %) had postoperative anastomotic leakage. The mean duration of postoperative hospital stay was 14.5 days (range, 10–51 days). The absorbable threads used in anastomosis are cheaper than linear stapler and circular stapler, which are often used in intracorporeally anastomosis. Conclusion: This procedure is the similar method as conventional open surgery, and feasible, safe and cost-effective.



Laparoscopic Gastrectomy in the Elderly: Is it Better?

Single Incision Laparoscopic Surgery for Gastric Submucosal Tumor

T. Tan1, R. Rao2 Khoo Teck Puat Hospital, Singapore; 2Tan Tock Seng Hospital, Singapore

W.C. Fan, F.M. Chen, C.H. Chen

Aims: Review outcomes after laparoscopic gastrectomy for gastric tumor in the geriatric population group. Background: Overall peri-operative mortality rates for gastrectomy are about 1–6 %. Some studies have shown that there is higher morbidity and mortality in the elderly age group but others have demonstrated comparable outcomes regardless of age. The laparoscopic approach have been suggested to have a significant reduction of intraoperative blood loss, a reduced risk of postoperative complications and shorter hospital stay. These benefits were at the cost of longer operative time. Methods: A retrospective review of patients 75 years old and above that underwent gastrectomy for gastric tumor in our centre from January 2012 to December 2013 was performed. Amongst these, 9 patients had a laparoscopic gastrectomy (LG) and 14 were done open (OG). Results: Median American Society of Anesthesiologists (ASA) score is 3 for both groups. Ratio of subtotal and total gastrectomy patients in both groups is comparable. Total lymph nodes obtained from lymphadenectomy in the LG arm was higher (57.6 [40–79] versus 24.4 [7–43], p \ 0.05). Length of stay was 8.2 (5–14) for the LG group compared to 16.8 (7–28) in the OG group (p \ 0.05). There was no morbidity or 30-day mortality in the LG group compared to 28.6 % (4 patients had nosocomial pneumonia) and 7.1 % (1 death) in the OG group (p = 0.127 and p = 1.0 respectively). Operative time was comparable with average of 227 (125–380) minutes in the LG group compared to 207 (160–255) in the OG group (p = 0.456). Conclusion: Laparoscopic gastrectomy is safe and may be preferred in the elderly population with earlier discharge from the hospital and higher lymph node yield. There is a suggestion of less respiratory compromise from the laparoscopic approach. We present a short video of laparoscopic gastrectomy for advanced gastric cancer: tips and tricks.

Purpose: Single incision laparoscopic surgery (SILS) is a new developed minimally invasive technique for local excision of gastric tumors. The aim of this study is to determine whether SILS is a feasible treatment for gastric submucosal tumors. Materials and Methods: During April 2009 to December 2013, seventeen patients with gastric submucosal tumor received SILS in our community hospital were reviewed. Preand post-operative variables were analyzed and collected. Results: Most gastric submucosal tumor was gastrointestinal stromal tumor (GIST). The 14 GIST were located at esophageal-cardiac junction (n = 4), fundus (n = 5), antrum (n = 4), and pylorus (n = 1). An antrum glomus tumor, leiomyoma, and ectopic pancreas were also treated. All the tumors were successfully excised by SILS. 13 trans-gastric resection, and 4 laparoscopic wedge resection were done. Intraoperative hemorrhage is minimal. The hospitalization period (mean 5.47 days) was short. During a follow-up length of 24.5 months, no patient developed a recurrence. Conclusion: SILS is a safe procedure and can achieve good results in terms of local tumor resection, with lower recurrences rates, lower complication rates for gastric submucosal tumor.

1

Kaohsiung Municipal Ta-Tung hospital, Kaohsiung, Taiwan

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Gist and Benign Tumors Laparoscopic Surgery Management Classification

Laparoscopic Operations with Natural Orifice Specimen Extraction in Abdominal Oncology

S. Morales-Conde, D. Aparicio Sańchez, I. Alarcoń del Agua, M. Socas Macıás, J. Can˜ete Go´mez, A. Navas Cue´llar, M. Rubio-Manzanares Dorado, J.M. Cadet Dussort, F.J. Padillo Ruiz, A. Barranco Moreno

S.V. Baydo, A.B. Vinnytska, A.V. Zhygulin, D.A. Golub, S.I. Pryndyuk

HU Virgen del Rocio, Sevilla, Spain Introduction: The classic surgical treatment for GIST and benign tumors ([2 cm without distant spread) consisted of laparotomic gastrectomy (typical or atypical). In recent years, with new advancements in minimally invasive surgery, have emerged conventional laparoscopic and single port (PU) techniques which provide us new opportunities while respecting oncologic criteria for resection of these tumors. Material and Methods: We conducted a literature search for the different classifications that exist for the management of these tumors including both pathways: laparoscopic and laparotomy approach. We believe these classifications are not suitable for the following reasons: They had not contemplated laparoscopy in tumors more than 5 cm, tumors of the gastroduodenal junction (GDJ) and gastroesophageal junction (GEJ) are treated differently, there are less invasive approach techniques than gastrotomies, different groups in which indicate similar approach paths, etc. Then we combined the advantages of these classifications with our experience in treatment of GIST and benign gastric tumors. Results: Given the data provided by the literature and our surgical experience, we offer a surgical strategy based on tumor location and size. Group A (exophytic tumors) is subdivided into IIA, GDJ and GEJ tumors, and AI for the rest. The group B consists of intragastric intramural tumors. We distinguish BI which comprise GDJ, GEJ and posterior wall, BII comprising lesser curvature and BIII for the rest. In tumors from BI group, we have developed I-EASI (Intragastric Endoscopic Assisted Single Incision Surgery) which represents an approach to a new cavity (intragastric) of benign tumors and GIST. Conclusions: A new classification in surgical treatment managing of benign gastric tumors and GIST is presented on through our experience and previous classifications found in the literature is intended as a guide for consensus in these tumors management. The I-EASI (single port surgery assisted by intragastric endoscopy) offers the advantages of single port laparoscopic surgery with those made of intraoperative endoscopy showing an improvement postoperatively. It should be used in benign tumors and GIST localized in gastric backside, EGJ or GDJ. The classification presented is flexible and is subject to changes according to new future experience.

Zina Memorial Lissod Cancer Hospital, Kiev, Ukraine Aims: Current techniques of laparoscopic colorectal procedures and gastrectomy require an abdominal incision for specimen extraction, which may reduce the advantages of laparoscopic surgery. This report is intended to represent our experience in performing totally laparoscopic anterior resection (TLAR) and totally laparoscopic subtotal gastrectomy (TLSGE) with transvaginal extraction of the specimen. Methods: In this study 115 consecutive patients operated in our clinic were included (67 TLAR for rectal cancer and 48 laparoscopic gastrectomy for gastric cancer). For specimen extraction in 18 female patients the natural orifice (NOSE) transvaginal route was used. TLSGE with D2 lymph node dissection was performed using five trocars and a conventional procedure. Reconstruction was performed using the intracorporeal Roux-an-Y method and an endo-GIA 60. Standard four ports technique was used for TLAR. Posterior colpotomy was done with 11-mm trocar. The specimen was extracted through vagina. Then anastomosis was done using circular stapler. The colpotomy was sutured through vagina or using intracorporeally technique. Results: The number of lymph nodes harvested was 17.8 after rectal resection and 17.3 - after gastric surgery. The average operative time was 142 minutes for TLAR and 330 - for TLSGE. No death or complications occurred. The median hospital stay was 4.2 days after rectal surgery, 6.7 after gastrectomy and was shorter then after conventional procedures. The level of postoperative pain was assessed by visual-analog pain scale. According to preliminary results it was detected the tendency of decreasing pain level after transvaginal extraction vs ‘traditional’. Conclusions: The NOSE approach is feasible and safe in abdominal oncology. This minimally invasive technique may provide an effective way to reduce postoperative pain and abdominal wall morbidity, with low complication rate.



Surgical Outcomes of Laparoscopy-Assisted Total Gastrectomy in Stage I Gastric Cancer Patients

A Feasibility Study of Minilaparoscopy and Single Incision Intragastric Surgery for Resection of Experimental Pre-pyloric Pseudotumors in Pigs

D. Ichikawa1, S. Komatsu1, T. Kubota1, K. Okamoto2, H. Konishi2, A. Shiozaki2, H. Fujiwara2, R. Morimura2, Y. Murayama2, Y. Kuriu1, H. Ikoma2, M. Nakanishi1, C. Sakakura1, E. Otsuji2 Kyoto Prefectural University of Medicine, Kyoto, Japan; 2Kyoto, Kyoto, Japan 1

Aims: Laparoscopic gastrectomy has recently been more widely performed as a less invasive surgical technique that offers many advantages in comparison with open gastrectomy. Many surgeons, however, still hesitate to apply the laparoscopic approach to proximal gastrectomy due to technical complexities and difficulties, especially during reconstruction. This retrospective study was designed to assess the feasibility and surgical outcomes of the laparoscopy-assisted total gastrectomy (LATG) in clinical stage I gastric cancer patients. Methods: Eighty-five patients with clinical stage I gastric cancer underwent LATG with D1 plus lymph node dissection between 2007 and 2013 in our hospital. Esophago-jejunostomy was performed intracorporeally using a circular stapler with an incision in left upper abdomen. We investigated their clinicopathologic factors, intraoperative and postoperative complications, and also long-term outcomes. Results: Median surgical duration and blood loss was 390 min and 70 ml, respectively during the LATG. This approach using a circular stapler from the left side facilitated a good laparoscopic visual field for the plane of the esophago-jejunostomy, compared to that using an approach from midline incision. Therefore, no reconstruction-related intraoperative complication was encountered, although two patients (2.4 %) were converted to open surgery due to unanticipated hemorrhage during introduction period. Four patients developed postoperative complications, of which three were surgical site infection and one blind-loop syndrome. Other three patients developed surgery-related complications during follow-up period; two internal hernias which required reoperations, and one delayed anastomotic stenosis which were resolved by endoscopic dilation. The 5-year survival rate was 94 %. Conclusions: LATG with a small incision in a left upper quadrant could be a simple, easy and safe technique, and demonstrate similar oncologic outcome for clinical stage I gastric cancer patients when performed by surgeons with sufficient experience in open gastrectomy.

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F.M. Sanchez Margallo, A. Tapia Araya Minimally Invasive Surgery Centre, Caćeres, Spain Objective: This study attempts to evaluate the feasibility and effectiveness of the combination of flexible endoscopy and laparoscopy during intragastric treatment of experimental submucosal pseudotumors placed at the pre-pyloric area in a swine model. Material and Methods: Six healthy female pigs underwent a transparietal injection of sterile alginate creating a model of submucosal pseudotumor in the gastric antrum near the pyloric sphincter. The surgical procedures combined minilaparoscopy intragastric surgery with endoscopic vision (n = 3) and single-incision intragastric surgery with endoscopic vision (n = 3). The pseudotumors were resected and the gastric mucosal layer was closed using intragastric sutures. Finally, the gastrostomy and minilaparotomy after single-incision surgery and gastric incisions after minilaparoscopy were closed. A one-month clinical follow-up was completed and a histological examination of the pyloric area was accomplished in all animals. Results: The pseudotumors ranged from 3 to 5 cm in diameter. The transgastric approaches were performed without any complication in all animals. More technical limitations were encountered during the single-incision surgery regarding the minilaparoscopic surgery. The perforation of gastric wall was the main complication encountered. The intragastric suture was feasible in both approaches and no alterations of the gastric emptying or digestive symptoms were observed after surgery. Total operative time ranged from 70 to 130 min. No complications were encountered during the postoperative follow-up. Exploratory laparotomy not showed alterations in the abdominal cavity. Conclusion: This study confirms the utility of the described experimental model of intragastric pseudotumors for research and training in minimally invasive intragastric surgery. The combinations of minilaparoscopy or single-incision approach with endoscopic vision were determined technically feasible, safe and useful to remove this type of lesions. More studies are necessary in order to establish the role of transgastric surgery in the treatment of intragastric tumors.

Surg Endosc



Needle Forcepses Enables Minimally Invasive Surgery in Laparoscopy and Endoscopy Cooperative Surgery for Gastric Submucosal Tumors

Combined Laparoscopic Resection for Synchronous Early Gastric Cancer and Intraabdominal Malignancies

H. Shimizu1, T. Kudo1, S. Nakazawa1, Y. Miyamae1, Y. Motegi1, H. Toya1, I. Sakamoto1, M. Aiba1, T. Tanaka1, T. Ogawa1, I. Takeyoshi2 1

Takasaki General Medical Center, Takasaki, Japan; 2Gunma University Graduate School of Medicine, Maebashi, Japan

Purpose: Laparoscopic partial gastrectomy has been the first choice of surgical procedure for gastric submucosal tumors (SMTs). However, some patients who have SMTs growing intraluminally or located near the esophagocardiac junction (ECJ) or the pyloric ring (PR) must undergo excessive gastric resection that results in postoperative deformation or stenosis of the remnant stomach. We have recently introduced minimally invasive surgery using novel needle forcepses such as Endo-ReliefTM (ER, Hirata Precisions Co., Ltd., Japan) and SLIM line (KARL STORZ GmbH & Co. KG) in laparoscopy and endoscopy cooperative surgery (LECS) for gastric submucosal tumors (GSMTs). The aim of this study was to evaluate the safety and benefit of minimally invasive surgery using the needle forcepses in LECS for GSMTs. Methods: Between April 2012 and December 2013, six patients underwent LECS using needle forcepses for GSMTs that were located near the ECJ or PR, with a maximum diameter ranging from 20 to 50 mm, with no ulceration. Ports were placed below the umbilicus and into the right middle abdomen. The needle forcepses were directly inserted into the right upper, left upper, and left middle abdomen under laparoscopic guidance. Results: Patients characteristics were: Male/Female 3/3; median age 60 (range 27–79); tumor location (ECJ/PR) 3/3. The mean distance from tumors to the ECJ or PR, operation time, and intraoperative blood loss were 31.7 ± 6.8 mm, 221 ± 50.6 min, and 12.7 ± 9.1 ml, respectively. Cases near the ECJ underwent suturing of the defect in the gastric wall with ECHELON FLEXTM 60 ENDOPATHÒ Staplers (Gold), and cases near the PR underwent closing of the defect by laparoscopic hand-suturing technique. No drainage tube was used postoperatively. The pathological maximum tumor size ranged from 21 to 48 mm (mean 28.7 mm). In all cases, postoperative course was uneventful, and postoperative oral intake and hospital stay were 1.0 and 4.0 days, respectively. Conclusion: LECS using needle forcepses is safe and beneficial for patients who undergo gastric partial resection for GSMTs.

C. Hagiwara Tokyo Metropolitan Cancer and Infectious disease center Komagome Hospital, Tokyo, Japan Aims: The aim of this study is to clarify the usefulness of combined laparoscopic resection for the patients with synchronous early gastric cancer and intraabdominal malignancies. Methods: From 2007, 439 patients with early gastric underwent laparoscopic gastrectomy with curative intent. Eight (1.8 %) patients with synchronous intraabdominal malignancies were enrolled. Clinicopathological characteristics, surgical procedures, and short-term outcomes were evaluated. Results: The synchronous intraabdominal malignancies were including colorectal cancer in five patients, hepatocellular carcinoma in two, and intraductal papillary mucinous carcinoma in one. All eight patients were finished for combined resection in laparoscopic approach. The types of gastrectomy were distal in five patients, total in two, and proximal in one. Only two patients with low anterior resection were needed two more ports in addition to gastric surgery. Median operation time was 406 min. (range: 253–668 min.) and blood loss was 245 ml (20–800 ml), respectively. Postoperative morbidity according to the Clavien-Dindo classification Grade II and more was observed in three patients (38 %). The median duration of postoperative hospital stay was 18.5 days (range: 13–36 days). Conclusion: The gastrectomy combined with upper abdominal lesion is not necessary to the additional ports. The laparoscopic combined laparoscopic resection for the patients with synchronous early gastric cancer and intraabdominal malignancies is relatively safety and highly complete rate. To add the cases, suitable number of ports, ports site, and minilaparotomy site may be clear.

P301 - Gastroduodenal Diseases P299 - Gastroduodenal Diseases Laparoscopic Graham Patch for Perforated Peptic Ulcer at Dr George Mukhari Academic Mukhari Hospital M.N. Latakgomo, M.Z. Koto Dr George Mukhari Hospital, Pretoria, South Africa Introduction: Perforated peptic ulcer is a relatively common acute surgical condition. It remains a challenge for a treating surgeon especially in patients with high Boey score and those with giant ulcers. Minimally invasive surgery has become integral part of management of this condition. Aims: To update on our initial experience with laparoscopic Graham patch for perforated peptic ulcer. Methods: This is a retrospective review of prospectively collected data on patients who presented with perforated peptic ulcer between 01 November 2011 to December 2013. Exclusion criteria include those who were offered open surgery. The patients demographics, clinical condition, operative procedure and outcome were all collected. All patients were resuscitated fully and offered laparoscopic Graham patch. A three port technique was used for most cases and additional port was inserted when necessary. Results: During this period 53 patients were seen, (47 males and 6 females) their mean age 44 years (19–71). Average Boey score 2. The average operative time was 90 min, the mean hospital stay was 4 days. One patient spent 2 days in ICU because she had associated comorbidity preoperatively and one patient had superficial wound sepsis. Conclusion: Laparoscopic Graham patch is safe and feasible in our setting. Patient with a high Boey score did better than expected.

A Case of Totally Laparoscopic Gastrectomy for Early Gastric Cancer Accompanied with Huge Hiatal Hernia T. Shima1, K. Yajima2 1 Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan; 2Metropolitan Komagome Hospital, Tokyo, Japan

We here present a case of totally laparoscopic approach for early gastric cancer accompanied with huge hiatal hernia. An 80-year-old woman was referred to chief complain as dysphagea. Upper gastrointestinal fiber revealed the type 0–IIc shaped tumor with ulcer scar, 2.0 cm in size, located in middle body of the stomach. Biopsy specimen showed welldifferentiated adenocarcinoma. Upper gastrointestinal series and abdomino-pelvic CT scan showed a half of proximal stomach and transverse colon was prolapsed into the lower mediastinal; these findings were compatible with the Type III mixed hiatal hernia. Clinical diagnosis of early gastric cancer, T1b(SM)N0M0, Stage IA, accompanied with hiatal hernia was made. Distal gastrectomy with D1 plus lymphadenectomy was carried out using five ports, pneumoperitoneum method in our usual laparoscopic technique. After the gastrectomy, the stomach was successfully reduced back into the peritoneal cavity. The hernia sac ` was excised and the hernia orifice was closed by interrupted suture using 2-0 PROLENEO polypropylene suture (ETHICON, Tokyo, Japan). The dissection was performed through a laparoscopic approach. Reconstruction using Roux-en-Y method was selected because of avoiding the postoperative gastroesophageal reflex disease. Total operative time was 337 min. and blood loss was 15 ml. Postoperative courses were uneventful and she discharged 10th post operative day.

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Laparoscopic Removal of a Foreign Body Penetrating the Gastric Wall

Laparoscopic Extended Total Gastrectomy for a GastroOesophageal Junctional Tumour

C. Markakis1, N. Paschalidis2, P. Dikeakos1, E. Spartalis1, M. Voultsos2, S. Rizos2

P.A. Ireland, A. Menon, K. Akhtar

University of Athens, Athens, Greece; 2Tzaneio General Hospital, Piraeus, Greece

Salford Royal Foundation Trust, Salford, United Kingdom

1

Aims: Foreign body ingestion usually occurs at the extremes of age and in specific subsets of the population. Diagnosis can be cumbersome when the patient has no recall of the actual ingestion itself. A multimodality approach is required to identify those with ambiguous symptomatology that do require treatment. Such cases can be treated either endoscopically or via an open or laparoscopic approach, although a certain level of technical expertise is required. Our aim is to present a case of foreign body ingestion, in which laparoscopic removal was safe and effective following a failed endoscopic approach. Methods: We describe the case of an 81 year old Caucasian male admitted to our emergency department complaining of intermittent epigastric pain and nausea. The patient’s history was unremarkable except for the possible ingestion of a foreign body during a meal 2 weeks earlier. Abdominal radiologic studies (X-rays, ultrasonography) did not reveal any pathology pertaining to a foreign body. A subsequent computed tomography scan depicted a foreign body lodged in the stomach wall, which was thickened due to marked edema. Following upper gastrointestinal endoscopy, the foreign body was identified and found to be extending in an antero-posterior axis but attempts of endoscopic removal were unsuccessful. The patient was taken to the operating room and laparoscopic surgery was performed. Results: The foreign body measured approximately 4.5 cm at its greater axis and was identified as a bone which was penetrating both the anterior and posterior stomach wall. The foreign body was removed and the perforation was carefully repaired. The patient was discharged uneventfully 10 days postoperatively. Conclusions: Even though foreign body ingestion occurs often, most cases ([80 %) are resolved without intervention and with minimal morbidity and mortality. The role of modern radiological modalities alongside endoscopic techniques remains pivotal in those cases that do require intervention. If endoscopic removal fails, the patient must be taken to the operating room for removal of the foreign body. This is feasible through a laparoscopic approach and can be performed safely by an experienced laparoscopic surgeon.

Aims: Recent meta-analyses have suggested that Laparoscopic Total Gastrectomy (LTG) is associated with fewer postoperative complications and equivalent lymph node yields when compared with the open procedure. We present a video of a laparoscopic extended total gastrectomy (LETG) for an adenocarcinoma at the gastro-oesophageal junction (GOJ). Methods: An 82 year old gentleman with severe cardiac co-morbidities presented with a T2N0 adenocarcinoma extending 2 cm distally from the GOJ. The patient was positioned with the operating surgeon positioned between the legs. Peritoneal access was gained with 5 ports over the upper abdomen. A 30 degree laparoscope and an Endoflex liver retractor were used. Dissection using an Harmonic ScalpelTM was commenced with excision of the omental bursa over the transverse mesocolon and pancreatic fascia. The gastroepiploic vessels were identified and ligated close to their origin with titanium clips. The right and left gastric arteries were also identified and ligated with titanium and HemolockTM clips respectively. En bloc D2 lymphadenectomy was performed over the hepatic, splenic and left gastric arteries. Complete mobilisation of the entire greater curve and lesser curves was performed with Harmonic ScalpelTM to the left and right crura respectively. The oesophagus was mobilised at the hiatus with a crural cuff, with dissection continued into the mediastinum. The oesophagus and duodenum were both divided using a laparoscopic linear stapler. The oesophago-jejunal anastomosis was constructed using an OrvilTM inserted perorally by the anaesthestist and an EEATM circular stapler inserted by the surgeon. A Rouxen-Y reconstruction was performed by fashioning a jejunojejunostomy with a linear stapler, with the enterotomy closed with locking suture. Anastomotic integrity checked with Methylene blue dye and the specimen extracted using a bag. Results: The patient made a satisfactory recovery and was discharged after 11 days in hospital. Our unit has performed 24 LTG between 2007 and 2012 with 0 % 30-day mortality. Conclusions: LETG appears to be a safe and feasible technique for the management of junctional tumours. Further data is required to see if oncological efficacy and survival is comparable to the open approach.



Three Ports Technique for Laparoscopy Assisted Distal Gastrectomy for Gastric Cancer

Laparoscopic Approach in GISTs Treatment

T. Amin

M. Aral1, A. Gouveia2, J. Preto2, S. Carneiro2, J. Barbosa2, J. Costa Maia2 Centro Hospital Saõ Joaõ, Maia, Portugal; 2CHSJ, Porto, Portugal

Assiut University, South Egypt Cancer Institute, Assiut, Egypt

1

Background: Laparoscopy assisted distal gastrectomy (LADG) was first reported be S. Kitano in 1991. Since then it gradually gained maturity. This study is evaluating the safety and feasibility of LADG using 3-port technique. Study Design: Fourteen patients have been enrolled for 3-ports laparoscopy assisted distal gastrectomy. The patient’s demographics and perioperative data were collected prospectively. The surgeon stood on the left of the patient (left handed surgeon), and the video laparoscope operator stood on the right of the patient. Three ports were used; one transumbilical 10-mm port for the laparoscope and another tow 5-mm ports were used, one in the left pre-axillary line 2–3 cm below the costal margin and the second in the left midclavicular line 2–4 cm above the level of the umbilicus. The D1a lymphadenectomy was performed according to the lymph node classification of the Japanese Gastric Cancer Association. After complete dissection, the umbilical port is extended to be 5 cm for gastric extraction. The stomach proximal transection site was selected according to the location of the tumor. Distal gastrectomy with Billroth I or Billroth II anastomosis were extra-corporeally performed using the hand-sewn method. Results: The mean operative time was 170 minutes. Estimated blood loss was 65 ml. No use for additional ports or conversion to open surgery. No intra-operative major complications. The mean time for hospital stay was 9 days. One case of pneumonia and one death were the post-operative complications. The mean number of retrieved lymph nodes was 21 and all the cases have free surgical margin. Conclusions: Three-ports LADG could be a safe and oncologically feasible procedure; however, further studies are required.

Background: Gastrointestinal stromal tumors (GISTs) represent 1–3 % of all gastrointestinal (GI) tumors, but are the most common mesenchymal tumors of the GI tract. Currently the laparoscopic approach is increasingly adopted. However, there has been some controversy about the impact of tumor size on the technical feasibility, risk of tumor rupture and the long- term oncologic safety. Methods: We studied retrospectively all surgically treated GIST patients at our hospital between 1992 and 2012. Data on clinical and hystopathological variables, management and survival outcomes were analyzed. Results: Overall, we treated 167 patients; 141 had macroscopic complete (R0 or R1) tumor resection, 24 (17 %) by a laparoscopic approach (LAP). In this group (LAP), 10 patients (41.7 %) were male and median age was 61.5 years. Tumor site was: stomach (18; 75 %), duodenum (4; 16.7 %) and small bowel (2; 8.3 %). Laparoscopic resection was segmental in 17 cases (70.8 %), local excision in 6 (25 %), and a total organ resection (gastrectomy) in 1 case. Mean size of laparoscopic resected tumors was 4 cm (1–13 cm), and 17 cases (70.8 %) had low-grade risk lesions. R0 resections were obtained in 18 interventions (75 %) and R1 in 6 (25 %). Only 2 patients received imatinib in the adjuvant setting. In the follow-up of these patients, we registered only 1 death from hepatic recurrence (22 months), and no loco-regional recurrence was found. Mean survival in laparoscopic group was 212.52 (±10.93) months. Conclusions: Laparoscopic resection is safe and applicable to most localized GISTs. Tumor size shouldn’t be a contraindication to laparoscopic approach.

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Laparoscopic Subtotal Gastrectomy and D2 Lymphadenectomy for Gastric Adenocarcinoma

Comparison of Proximal Gastrectomy and Total Gastrectomy in Early Gastric Cancer

L.F. Doran, K. Moorthy

H.M.Y. Yoon, Y.W. Kim, K.W. Ryu, B.W. Eom


National Cancer Center, Goyang-si, Korea

84 year old lady who was found on staging investigations to have a T1 gastric adenocarcinoma within the gastric body. Laparoscopic subtotal gastrectomy and D2 lymphadenectomy performed. Patient made and unremarkable post operative course and was discharge on post operative day 10. Subsequent histology revealed that the tumour was a Signet ring cell adenocarcinoma of the body of the stomach (pT1 N0 R0 (0/46 lymph nodes involved))

Purpose: Proximal gastrectomy for early gastric cancer in upper third of stomach can preserve the function of stomach and improve the nutrition and quality of life. However, reflux esophagitis and stenosis have been frequent in proximal gastrectomy. The aim of the study was to compare proximal gastrectomy (PG) and total gastrectomy (TG) in short term outcome Methods: We conducted single center-based case-control study. The study included 20 patients who underwent laparoscopy assisted TG, 9 patients robot assisted TG, 13 patients laparoscopy assisted PG, and 4 patients robot assisted PG between July 2012 and October 2013. All patients were followed up for more than 3 months. Clinicopathologic data, operation related data, postoperative morbidity and pathologic data were analyzed by Student t-test and Chi-Square test. Results: Operating time (minutes) was 235.3 + 44.0 in PG and 206.9 + 51.6 in TG (p = 0.064). Estimated blood loss (ml) was 105.6 + 142.3 in PG and 115.9 + 152.4 in TG (p = 0.819). Regarding the postoperative complications, there were 4 patients (23.5 %) in PG and 4 patients (13.8 %) in TG (p = 0.400). Weight change during 3 months was 6.8 + 3.2 in PG and 7.3 + 3.6 in TG (p = 0.603). The change of hemoglobin level was 1.7 + 1.2 in PG and 1.2 + 1.1 in TG (p = 0.162) Conclusion: PG was comparable to TG in short term outcome. The comparison regarding the results of long term follow-up will be needed.



Laparoscopic Distal Gastrectomy for Gastric Cancer Using Outermost Layer Lymph Node Dissection Technique

Clinical Application of Totally Laparoscopic Esophagojejunostomy by Delta-Shaped Anastomosis in Radical Total Gastrectomy

S. Takiguchi1, K. Murakami1, Y. Miyazaki2, T. Takahashi2, Y. Kurokawa2, M. Ymasaki1, H. Miyata1, K. Nakajima2, M. Mori2, Y. Doki2 1

2

OsakaUniversity, Osaka, Japan; Osaka Univ. Medical school, Osaka, Japan Introduction: The number of laparoscopic distal gastrectomy (LDG) has increased worldwide because of instrumental, however this procedure is technical demand. Magnified view is a weapon for fine lymph node (LN) dissection. The choice for divided layer in the suprapancreatic LN dissection is very important to complete safety dissection. The concept of the outer most dissection technique is to keep in mind the outer layer of vessel plexus while LN dissection. The connection between the vascular plexus and LNs is loose, and it could be dissected with minimum traction. Because vessel plexus is aggregate of the fiber, dissector or the tip of energy device was easy to enter inside. Once the fiber was attached to the LN, the space became small and force of traction became stronger. This might be a cause to make pancreatic complication. In this paper, to evaluate the impact of this technique, the series with keeping the outermost layer of the vessels was compared retrospectively. Material and Method: 69 cases of LDG were analyzed, 33 cases (P) between 2008 and 2009 were using a previous technique and 36 cases (O) were using this technique. There was no significant difference in the back ground of patients. Although there were no significant differences in the blood loss and operation time, CRP at POD 1 was: 3.9 ± 0.36 vs. 5.0 ± 0.32 (O vs. P p = 0.03). Amylase level of drainage fluid at POD1 was 875 ± 584 vs. 2635 vs. 610 (O vs. P p = 0.04). Pancreatic fistula (Grade B) complication was 3 vs. 0 cases (O vs. P). Conclusion: Outer most lymph node dissection technique was useful to suprapancreatic LN dissection in LDG.

L. Zang1, M.H. Zheng2, P. Xue2, W.G. Hu2, J.J. Ma2, B. Feng2 1

Shanghai Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China; 2Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China Objective: To explore the safety and feasibility of totally laparoscopic esophagojejunostomy by delta-shapedanastomosis in radical total gastrectomy. Methods: Clinical date of 7 patients who received totally laparoscopic esophagojejunostomy by delta-shaped anastomosis in our center from July 2013 to October 2013 was retrospectively analyzed. Do some research about the surgical technique, safety, postoperative conditions and follow-up results. Results: The operation was successfully carried out in all the 7 patients, without any severe intraoperative complications. The mean operation time for this procedure was (233.6 ± 22.5)min, of which the time for anastomosis was (33.8 ± 6.7)min. Mean estimated blood loss was (33.8 ± 6.7)min, mean number of lymph node harvest was (35.6 ± 3.8). The gastric tube was removed at the first postoperative day. Time for first flatus, liquid food and semi-liquid diet was 2.4 ± 0.5 d, 4.0 ± 0.6 d and 5.3 ± 0.5 d respectively. Postoperative hospital stay was 9.7 ± 1.4 d. No postoperative fistula, stenosis, hemorrhage or intracorporeal infection occurred. The result of short-term follow-up was satisfied. Conclusion: Totally laparoscopic esophagojejunostomy by delta-shaped anastomosis is safe and feasible in total gastrectomy, especially performed by surgeons familiar with laparoscopic gastric cancer surgery. The size of anastomoses is not restricted to diameters of esophagus and jejunum. The short-term outcome of this procedure is satisfied and the long-term outcome remains further research.

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P312 - Gynaecology

Intramural Duodenal Hematoma After Endoscopic Therapy for a Bleeding Duodenal Ulcer

Laparoscopic and Transanal Excision of Large Lower and Mid Rectal Deep Endometriotic Nodules: The Rouen Technique

A. Dibra, Ej. Çeliku, Et. Çeliku

V. Bridoux, H. Roman, E. Huet, L. Marpeau, F. Michot, J.J. Tuech

Mother Teresa University Hospital Center, Tirana, Albania

Rouen University Hospital, Rouen, France

We describe a case of IDH (Intramural Duodenal Hematoma) occurring following endoscopic therapy for bleeding duodenal ulcer in an adult patient with no evidence of other pathologies. A 18-year-old man was admitted to our hospital with gastrointestinal bleeding manifested by melena. Five months previously he had undergone endoscopic sclerotherapy for bleeding duodenal ulcera. Endoscopy revealed a Forrest 2a ulcer in the duodenal bulb, and sclerotherapy was performed by injecting 10 ml of 0.2 % epinephrine and 20 ml of NaCl 0.9 % solution. The hematoma appeared on the second day of endoscopic intervention, reveled by endoscopy than confirmed by MRI and CT scan of the abdomen, causing transient duodenal obstruction. Conservative management in the form of nasogastric tube and total parenteral nutrition resulted in reduction of obstructive symptoms within 4 weeks.

Aims: The surgical management of deep endometriotic nodules infiltrating the lower and mid-rectum is challenging. There is increasing evidence suggesting that the radical surgery based on colorectal resection may be responsible for postoperative digestive functional complaints related to rectal removal, such as distal constipation, increase in frequency of bowel movements or anal incontinence. We report a new technique using the ContourÒ Transtar TM-STR5G (Ethicon EndoSurgery Inc., Cincinnati, OH, USA) in combined laparoscopic and transanal full thickness disc excision of endometriotic nodules infiltrating the low- and mid-rectum. The contour stapler is a device which was basically developed to perform stapled transanal rectal resection (STARR). Methods: The procedure was performed by combined laparoscopic and transanal route, and required a multidisciplinary team involving a gynecologist and a general surgeon. The laparoscopic step was performed by deep shaving of the rectal area infiltrated by the nodule, aiming to render it soft and thin. Then, the general surgeon seized the shaved area into the stapler jaws and carried out a large disc excision. The quality of the rectal suture was checked by both laparoscopic and transanal route. Conclusion: This new technique of transanal rectal disc excision using the contour stapler may be applied in patients with infiltrating endometrial nodules of the rectum up to 10 cm from the anal margin and up to 5 cm in diameter, thus it specifically avoids low colorectal resections

P311 - Gynaecology

P313 - Gynaecology

Iatrogenic Laparoscopic Bowel, Ureteric and Vascular Injuries in Gynecological Procedures

The Perforated Intrauterin Device: Laparoscopic Retrieval

A. Bouhelal, A. Benjamin, B. Patel Queen Mary University of London, London, United Kingdom The available literature lacks comprehensive studies that investigate the link between iatrogenic laparoscopic injuries and treatment modalities to diagnostic time are rare. We conducted a systematic review focusing on the prevalence and management of iatrogenic injuries in gynaecologic laparoscopic surgery; from January 2000 to January 2013. Methodology: Keywords: ‘Injur*’, ‘Laparoscop*’, ‘Gynaecol*’, ‘Laparoscopy[Mesh]’, ‘Gynaecological surgical procedure[Mesh]’, ‘Bowel’, ‘Ureter’ and ‘Vascular’ in several combinations. Data extractions with quantitative and qualitative analysis conducted independently by two independent reviewers. Results: 87 studies met the inclusion criteria. In Bowel related literature, 38 studies were identified with sample sizes of 39,751 patients and 104 injuries reported, 35 publications discussing ureteric injury were identified with sample size of 61,523 patients and 60 reported injuries. The search for Iatrogenic vascular injuries resulted in 14 publications reporting vascular damage with sample size of, 6,114 patients and 30 reported injury. Injury rates were 0.28 % bowel, 0.09 % ureter and 0.49 % vascular. Uterine fibroids associated with 28.07 % of bowel injuries and 27.45 % of ureteric injuries; majority of vascular injuries linked to ovarian cysts. Laparoscopic assisted vaginal hysterectomy, diathermy and trocar (10 mm) associated with highest levels of injuries. Large bowel, mid to lower third of ureter and abdominal aorta were anatomic sites most injured. Bowel injuries diagnosed in 2–6 days, ureteric injuries in 7–16 days with vascular being intra-operatively and within 24 hours of surgery. Conclusions: A steady decline in iatrogenic laparoscopic injuries is evident however less dramatic improvement was observed in the time from injury to diagnosis.

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E. Colak, N. Ozlem, G.O. Kucuk, R. Aktimur Samsun Education and Research Hospital, Samsun, Turkey The intrauterin device (IUD) is the one of the most effective and economic contraceptive methods in the whole world. Uterin perforation is a major but infrequent complication of an UID. We offer a 41 years-old woman with a history of IUD placement 2 years earlier presented with complaints of pelvic pain. Physical examination was tenderness to palpation over right lower quadrant. Abdominal sonography showed the UID in the abdominal cavity. She then underwent a laparoscopic removal of the translocated IUD. There was no perforation in the intestine. The patient was discharged home on the first postoperative day without complication. The symptoms of IUD migration into the abdominal cavity can be nonspecific. Confirmation of a missing IUD is mandatory. Laparoscopic surgery for the elective removal of migrated IUD is a safe and effective method.

Surg Endosc

P314 - Gynaecology

P316 - Gynaecology

Laparoscopic Management of Left Ovarian Cavernous Haemangioma - Case Report

Laparoscopic Hysterectomy for Benign Uterine Pathologies

B.A.P. Popescu, F. Iordache, S. Paun, C. Turculet, I. Grintescu, M. Vartic, M. Beuran Emergency Clinical Hospital Bucharest, Bucharest, Romania Aims: A cavernous haemangioma is a tumor that does not contain tissue of the organ in which is situated in and the ovarian site is an extremely rare location. Methods: We present the case of a patient, P.M. of 61 years old, that was referred to our clinic in March of 2013, after a gynecological consult and a transvaginal ultrasound, with the suspicion of a sigmoid tumor. The patient had a personal history of high blood pressure, varicose veins, chronic venous insufficiency and an open appendectomy and had obesity grade I (BMI 31.2). Results: We began our paraclinical exams with an abdominal ultrasound which described a hipoecogenic image of 4 cm in diameter, with nonhomogeneous content, at the level of left adnexa. Following the initial suspicion we performed a colonoscopy, that was completely normal, with the exception of noncomplicated internal hemorrhoids. The gynecological consult did not bring any new information of the left adnexal tumor. All the tumoral markers performed were normal (CA125, HE4, CEA, CA19-9). The CT examination found a tumor at the level of the left adnexa that looked like an aneurysm of the left adnexal venous plexous. We decided to perform a laparoscopic adnexectomy and we encountered a tumoral mass of 5/4 cm with the lomboovarian pedicle enlarged and tortuous veins at this level. We had a small hemoragic incident after clipping with Hemolocks and cutting the lomboovarian pedicle with LigaSure, that needed additional clipping (titanium clips). The histopathology report showed the left ovary with many corpus albicans and a nodular formation well delimitated formed by dilated thin walled spaces filled with red blood cells and lined with endothelial cells, well suggestive of a cavernous haemangioma. Conclusions: The ovarian haemangioma should be included in the differential diagnosis of the ovarian tumors and they raise a challenge for the physician due to their rare occurence.

S. Sedlar, B. Sviracevic, S. Arbanas General Hospital, Sremska Mitrovica, Serbia Summary: In this paper we present our experience in laparoscopic hysterectomy (LH). All the hysterectomies have been performed in our general hospital. We report 94 LHs with or without adnexectomy, performed in the last three years. Introduction: Hysterectomy is the oldest and the most frequent gynecologic operation and also the elective one in almost 90 % of the cases. It is the only permanent solution for benign uterine pathologies and its symptoms. Laparoscopic hysterectomy enables faster return to everyday activities, shorter duration of hospital stay and lower blood loss. Material and Methods: A retrospective observational study of all LH performed in our department. Medical records were reviewed for following patient characteristics: age, operating time, uterine weight and volume, post-operative haemoglobin variation, length of hospital stay, intra and postoperative complications and therapy usage of antibiotics. Results: Average age was 48,91 years (range 32 to 67 years). Mean operating time was 96,87 minutes (range 45 do 140 min). Average uterine weight was 281 gr (120–560 gr) and volume was 281,0373 ccm3 (maximum 725,29 ccm3. Average hospital stay was 3,33 days (2–7). Post-operative level of hemoglobin, in average, was lower than pre - operative for 1.23 g/dl. Two complications occured: ureteral injury and post-operative bleeding. Fifteen operated patients (15,96 %) were receiving antibiotic therapy. Discussion: Laparoscopic hysterectomy is a good option for accurately selected patients. It is characterized by decreased intensity of postoperative pain, reduced need for therapeutic use of antibiotics, shorter period of hospitalization, less complicated postoperative care and faster return of patients to everyday life and activities: all factors leading to a more satisfied patient.

P315 - Gynaecology

P317 - Gynaecology

Solving of the Total Uterine Prolapse by Laparoscopic Ventrofixation

Laparoscopy in Pregnancy: An Evidenced-Based Review

S. Sviracevic, S. Sedlar, M. Malobabic General Hospital, Sremaska Mitrovica, Serbia Summary: Laparoscopic uterine ventrofixation with ligamentopexy represents a modified method of Gilliam-Dolores operations. Operation is performed by laparoscopy and applied in women with subtotal or total prolapse with and without stress incontinence. Due to its simplicity and short duration it is indicated in women of late age, and those who have some other diseases where a longer duration of the operation could have negative consequences. We have not had a recurrence. Materials and Methods: During the last 5 years we have done 32 surgeries in women with total prolapse of which 23 with stress incontinence. All patients were between 70 and 78 years old, with an average age of 73.28, mainly in a slightly worse health condition, with associated diseases in terms of regulated arterial hypertension, chronic cardiomyopathy, etc. We perform the operations by creating a low-pressure pneumoperitoneum, up to 10 mmHg. The 5 mm trocar is introduced two finger breadths above the pubic symphysis and about 3 cm lateral to the midline, round ties are caught and pulled out of the abdominal wall. Through mesometrium a threadlike stitch length of about 15 cm is made but not tied. Using the clamps one end of the thread is slipped under the skin to the opposite hole, and the same is done on the other side. The ends of the threads are tied and they pull round ties towards the middle of the abdomen, subcutaneous, and in front of the abdominal fascia. Through two new holes of 5 mm fundus of the uterus is fixed to the anterior abdominal wall, with two stitches. Results: We have done 32 operations with total prolapse of which 23 had stress incontinence. Duration of surgery was approximately 15 minutes and the patients were discharged the next day. Discussion: This is our laparoscopic modification of classical ventrofixation with ligamentopexy by Gilliam-Dolores. Because of its shortness of duration and minimal invasion is applicable in elderly people who are in poor physical condition and have some associated diseases that correspond to their age. These operations passed without complications and have given excellent results.

M. Ghellai National Cancer Institute, Misurata, Libia 0.2 % of pregnant women require intra-abdominal general surgical procedure during their pregnancies, appendicitis and cholecystitis being the most common. During its infancy, some argued that laparoscopy was contraindicated during pregnancy. Concerns was technical difficulty due to gravid uterus, Interfere with visualization risk of injury to mother by the altered physiology by pneumoperitoneum or decreased in venous return and risk to the fetus by trocar insertion or CO2 insufflation. Several recent studies have shown that laparoscopy is safe during any trimester with no increase risk to mother or fetus. 26–28 wks is the limit for successful completion of laparoscopic surgery during pregnancy. Rizzo et al. studied the long-term effects of laparoscopy on 11 children for a period of 1–8 years and found no growth or developmental delay. In fact, delaying surgical intervention in symptomatic patients may lead to further complications such as increase abortion and preterm labor rates. Delay in diagnosis and treatment may increase the perforation rate to 10 % and it has been reported that perforated appendicitis is associated with 40 % preterm labor. On the other hand, the fetal mortality rate in uncomplicated appendicitis is 5 % while in perforated appendicitis 30 %. Laparoscopic cholecystectomy is considered the treatment of choice for symptomatic gall bladder diseases regardless of trimester. During pregnancy, symptoms recurrence rates are 92 %, 64 % and 44 % in I, II and III trimesters subsequently. Recent studies have shown that delay in surgery is associated with significant morbidity. Compared with cholecystectomy, non-operative therapy leads to an increased abortion and preterm labor rates. Gall stones pancreatitis and acute cholecystitis leads to an increased maternal mortality, 15 %, and increased fetal demise, 10–60 %. Additionally we will review the physiological changes associated with use of laparoscopy during pregnancy and we will provide an evidenced-based guidelines for the use of laparoscopy during pregnancy.

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Laparoscopic Colon Surgery Outcomes from a Community Hospital; Local Care on Par with Academic Centers

Anatomical Correction is Achieved by Laparoscopic Ventral Rectopexy for Internal Rectal Prolapse

A. Dobradin1, M. Brown1, J. Muravsky2

A. Tsunoda, T. Ohta, Y. Kiyasu, H. Kusanagi

1

Kameda Medical Center, Chiba, Japan

Florida Hospital, Winter park, United States of America; St Mathhew’s University, Orlando, United States of America

2

Background: Minimally invasive techniques are becoming the standard of care for the majority of procedures performed. The goal being to shorten the length of stay, decrease the postoperative pain as much as possible and maintain a high standard for the outcomes of the procedures for patients Objective: The aim of our study is to show that the current trend of positive results for a minimally invasive approach to segmental colectomy in larger hospital centers and research oriented hospitals can be reproduced in a community hospital setting. Design: Patient demographics, surgical data and outcomes were collected over a 4 year and 5 month time period (Jan 2009 - May 2013) was gathered through electronic medical records and indicators for the quality of the outcome were reviewed. A total of 163 patients were included with ages that ranged from ages 20–96 years old. The major outcomes which were measured included the patient demographics, procedure type, operative approach, length of stay post operatively, number of days of intravenous narcotic use, blood loss, indication for surgery, operative time, lymph nodes retrieved, conversion rate, complications, readmissions and reoperations. Results: The mean operative time was 131 min, mean blood loss was 38 mL. The mean length of stay for was 3.82 days. The overall readmission rate was 6.79 % and the reoperation rate was calculated as 6.8 %. The mean number of days that IV pain medication was used was 1.1 days. The overall conversion rate from laparoscopic to open was 0.6 %. Conclusion: The use of laparoscopic technique for segmental colectomy in a community based hospital setting can reproduce the results seen in large volume hospital centres and research based hospital settings.

Introduction: The laparoscopic ventral rectopexy (LVR) for internal rectal prolapse (IRP) has been reported to offer satisfactory functional results. However, whether the anatomical correction for IRP is achieved by LVR has been scarcely addressed. The aim of the study was to evaluate the image of IRP after LVR. Methods: Consecutive patients with IRP undergoing LVR were prospectively assessed. Bowel function was evaluated after surgery using constipation scoring system (CSS) and fecal incontinence severity index (FISI). Depth of infolding and size of associated rectocele were measured by defecography examined before and 6 months after LVR. Results: Twenty-five patients with IRP, all females, mean age 75 years (range 62–89) underwent LVR between Feb 2012 and Oct 2013. 48 % (12) had undergone previous pelvic surgery. The mean operative time was 204 min (range 147–335). Mean blood loss was 11 ml (1–30) and mean postoperative length of stay 2 days (1–6). There was no mortality. One each had port-site hernia and wound infection. Seventeen patients were examined defecography at 6 months. Preoperative CSS scores improved significantly at 6 months (mean 10 vs. 7; P = 0.006). Preoperative FISI scores improved significantly at 6 months (mean 26 vs. 11; P \ 0.0001). Defecography showed that preoperative depth of infolding has shortened significantly at 6 months (mean 25 mm vs. 6 mm; P \ 0.0001). Size of associated rectocele (n = 6) has also decreased significantly at 6 months (mean 27 mm vs. 10 mm; P = 0.001). Conclusion: LVR provided improved anatomical correction for IRP, and good results for associated symptoms of constipation and incontinence.



Short Term Results in Elderly Patients Treated with Laparoscopic Segmental Transverse Colectomy

Laparoscopically Restorative Proctocolectomy with TME and Ileal Pouch-Anal Anastomosis for Malignant Familial Adenomatous Polyposis

A. Dobradin1, P. Lenferna de la Motte2, M. Romilowych2 1

Florida Hospital, Winter park, United States of America; St Mathhew’s University, Orlando, United States of America

2

Purpose: As the population ages, surgeons will encounter elderly patients (70 + years) requiring surgical resection for colon cancer more frequently. This population carries an increased surgical risk and, when treated for colon cancer, frequently have inadequate lymph node retrieval. Utilizing laparoscopic surgery for colon resection becomes a valuable approach by reducing recovery time, length of stay, post-operative pain, and rates of infection. Laparoscopic transverse colectomy presents a significant surgical challenge in the aspects of technical approach; high rate of conversion, adequate lymph node retrieval and the necessity of extended mobilization of the right or left colon. Methods: A retrospective review of a group of 11 patients, from a single surgeon’s practice, treated with laparoscopic segmental transverse colectomy since 2006 was reviewed surgical and early post-operative outcomes. Results: Patient population includes 9 patients with transverse colon cancer (including one with synchronous sigmoid colon malignancy) and 2 with adenoma. The mean age was 80.4 years. Laparoscopic segmental procedure was completed in 100 % of cases, with splenic flexure mobilization performed in 6. The mean number of lymph nodes harvested among patients with malignant disease was 14.8. Post-operatively, patients remained in hospital for an average of 5.1 days and 4 patients required no opioid pain medications; with the majority pain free by the second post-operative day. Conclusion: The surgical treatment of transverse colon neoplasms among elderly (age [ 70) can be successfully accomplished with laparoscopic segmental resection technique with excellent outcomes measured by rate of complication, adequate lymph node harvesting, length of stay, and patient satisfaction.

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F. Zaharie, G. Ciorogar, V. Hodor, L. Mocan, C. Iancu Iuliu Hatieganu, University of Medicine and Pharmacy, Cluj-napoca, Romania Introduction: Familial adenomatous polyposis (FAP) is an inherited disorder characterized by large intestine and rectal cancer. The average age at which an individual develops colon cancer in the classical form of FAP is 39 years. In severe forms of familial adenomatous polyposis the malignant can appear in early age with aggressive behavior. Case Presentation: We present the case of a 21 year old patient with rectal bleeding, diarrhea, weight loss, anorexia and flatulence. The patient is known with familial adenomatous polyposis, gastric polyps and a significant family history (mother, 2 uncles and 1 aunt with colon cancer). Colonoscopy reveals hundreds of polyps with variate sizes and shapes located on the entire colorectal length. After preoperative preparation, the treatment of choice is laparoscopic restorative proctocolectomy with TME and ileal pouch completed with endoanal excision of inferior rectal polyps. The histopathologic diagnosis is well differentiated rectal adenocarcinoma T1N1aMx developed on a tubulo-villous adenoma located on the rectosigmoid junction, the rest of the polyps with benign characters. The postoperative evolution is favorable, the patient is discharged on day 20 after surgical treatment.

Surg Endosc



Single-Incision Laparoscopic Surgery for Performing Transanal Endoscopic Microsurgery in Three Forms of Platform

Laparoscopic Colorectal Surgery

S. Hayashi1, T. Takayama1, M. Matsuda1, M. Ikarashi1, K. Hagiwara1, H. Tamegai1, T. Suzuki2 Nihon University School of Medicine, Tokyo, Japan; 2Toridekitasouma Medical Association Hospital, Toride, Japan

B. Mayir, T.M. Oruc, T. Bilecik, C.O. Ensari, U. Dogan, U. Koc, R. Eryilmaz Antalya Training and Research Hospital, Antalya, Turkey

1

Aims: Transanal endoscopic microsurgery using a platform for single-incision laparoscopic surgery (SILSTEM) is safe and efficacy for excising rectal lesions. Although the laparoscopic surgeons commonly have used the SILSTM port for this technique, we examined three forms of platform. Methods: The SILSTM port (SP), EZTM access (EA), and GelPOINTTM Path (GP) were measured for their dimensions, length, and trocar channels, and the each platforms were employed. Over a 3-year period, ten patients underwent SILSTEM by one surgeon. After the patient was placed in the adequate position. A SP, EA or GP was introduced into the anal canal, and the bowel was extended by carbon dioxide insufflation. A 5-mm 30° or flexible laparoscope was set in the port. The tumors were completely excised from the rectal wall with the use of ultrasonic surgical scissors or monopolar cautery. The defect created by resection was irrigated with saline solution to prevent local recurrence and were closed with running sutures using a laparoscopic suturing device and an absorbable suture clips. Clinicopathology, intraoperative parameters, and postoperative outcomes were recorded. Results: Seven men and three women (median age 66 years) underwent SILSTEM using platform SP in three patients, EA in five, GP in two. Tumors located 7 cm (range 5–9.5) from the anal verge. Median operation time was 134 min (range 71–313). Median blood loss was 4 ml (range 1–71). Pathology confirmed adenocarcinoma in six patients, adenoma in three, carcinoid in one. No patient died. Patients were discharged within 7 days (range 2–13) postoperatively. There was no postoperative fecal incontinence or soiling. One patient had rectal stenosis due to a circumferential lesion: Good defecation was achieved after balloon dilation. One patient had retroperitoneal emphysema that gradually disappeared. Deep Submucosal adenocarcinoma was diagnosed in one patient, with positive lymphatic and venous invasion: Laparoscopic intersphincteric resection was performed 3 months after SILSTEM. Overall median follow-up was 20.1 months (range 1.7–36.2). There were no recurrences. Conclusion: SILSTEM can effectively resect rectal tumors using any of three platforms. Large prospective trials are needed to define the advantages, disadvantages, and indications for each platform.

Introduction: Recent inventions in endoscopic techniques brought out advancements in treatment of colorectal disease. We analyzed our laparoscopic colorectal resection procedures that we performed in our clinic. Method: Patients who operated laparoscopically for colorectal cancer were included in the study. Reports of patients were collected from patient files retrospectively. Localizations of tumor, complications, length of stay in hospital, operation time, reason for conversion to open surgery rate, pathologic findings were recorded. Results: 31 patients were included in study. 12 of them (39 %) were female, 19 of them (61 %) were male. Ages range from 37 to 81 (average age is 60,7). Tumors were located cecum in 4 patients, right colon in 4 patients, transverse colon in 1 patients, splenic flexura in 1 patients, rectosigmoid colon in 14 patients, and rectum in 5 patients. Resection of liver metastasis was performed in one patients. Lymph node count range from 0 to 30 (average: 10,9). Length os stay in hospital was 10,7 (4–26) days. Conversion to laparotomy was necessary in 6 patients. Reasons for conversion to laparotomy were invasion of adjacent organ in 4 patients, bleeding in one patients and technic problem with stapler in ne patients. In one patient ureter injury and in another patient anastomotic leakage was seen. In any patients mortality wasn’t observed. Conclusion: Our results correspond with the recent literature and we observed that Laparoscopic colorectal surgery procedure is being held out safely in our clinic.



A Case of Jejunal Fibromatosis Treatment with Using Laparoscopic Surgery

Comparison of Laparoscopic Versus Conventional Surgery for Rectal Cancer After Neoadjuvant Chemoradiation A Matched Case-Controlled Study

T. Bilecik1, R. Eryilmaz2, B. Mayir1, C. Ensari1 1

Antalya Education and Research Hospital, Antalya, Turkey; Akdeniz University School of Medicine, Antalya, Turkey

Y.L. Lai, C.C. Chu, I.P. Huang, C.C. Chen, T.S. Cheng, C.M. Chen

2

Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan

Fibromatosis is the most common primary tumor of mesentery. Mesenteric fibromatosis is a very rare lesion which does not metastasise but can be locally aggressive. Desmoid tumors may be classified as extra-abdominal, abdominal wall, or intra-abdominal. The etiology of fibromatosis has not been determined. Most of the patients with mesenteric fibromatosis are asymptomatic. Here, we have presented a case who was 45 years old, complained of left lower quadrant pain. Preoperative evaluation included abdominal ultrasound, computed tomography. According to the CT report, the patient was diagnosed with gastrointestinal stromal tumor. A mobile mass was seen on the jejunal meso during laparoscopic exploration. The tumor was removed by wide excision with safe margins. Patients was discharged after a 5-day operation. The histological diagnosis was of jejunal aggressive fibromatosis. Immunohistochemical analysis indicated tumor cells were positive for b -catenin with nuclear accumulation. (Figure) Even though there are different types of treatment protocols, surgery with negative surgical margin is preferred to prevent local recurrence. We report a case of jejunal desmoid tumor which was resected by laparoscopic surgery. In these type of cases safe margins can be done with wide laparoscopic excision.

Purpose: To access the safety and short-term follow up of laparoscopic surgery compared with that of open surgery in patients with mid- or low rectal cancer receiving neoadjuvant chemoradiation (nCRT). Materials and Methods: Between 2007 Dec. to 2011 Dec. there were 108 consecutive patients with locally advanced rectal cancer receiving nCRT and underwent curative laparoscopic surgery subsequently. All patients with rectal adenocarcinoma were clinically diagnosed with cT1-3N0-2 lesions by pelvic CT or MRI. The recruitment of patients underwent open surgery was performed by propensity score analysis in 1:2 ratio. Clinical demographic data, peri-operative profiles and pathologic results were recorded and analysed. Post-op morbidity, anastomotic leakage rate, and short term follow up were discussed. After surgery, tumor stage was stratified according to AJCC 7th edition. Results: There were total 324 patients enrolled with 108 patients in laparoscopic group and 216 patients in conventional open group. The average age was 58.7 ± 11.2 years-old (range: 31–82) and 58 ± 11 years-old (range: 23 * 83) in laparoscopic and in open group respectively. The conversion rate was 6.5 %. Surgical time was longer and there was more blood loss in open group (p \ 0.0001 both). Hospital stay length was shorter in laparoscopic group than in open group (p \ 0.0001). The mean follow up time was 27.8 ± 13.9 months (range: 6.9 to 59 months) in laparoscopic group and 53.8 ± 31.7 (range: 9 to 140 months) in open group. There is no difference in overall, local, distant or both local and distal metastasis rate. (p = 0.773, 0.365, 0.595, 0.593 respectively). Conclusion: In this present study, laparoscopic surgery for patients with rectal cancer after nCRT is feasible and is associated with better surgical outcomes. The complication and anastmosis leakage rate are comparable in both group as well as short-term recurrence rate and three-year disease free survival

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Tips and Tricks to Prevent the Anastomotic Leakage in Laparoscopic Surgery for Rectal Cancer

Reduced-Port Laparoscopic Colectomy in Right-Hemi Colon Cancer

Y. Sumi, K. Yamashita, K. Kanemitsu, S. Kanaji, M. Yamamoto, T. Imanishi, T. Nakamura, S. Suzuki, K. Tanaka, Y. Kakeji

K. Baba, S. Mori, M. Yanagi, H. Okumura, M. Sakoda, K. Maemura, A. Nakajyo, A. Nakajyo, S. Ishigami, S. Natsugoe


Kagoshima University, Kagoshima, Japan

Introduction: Laparoscopic surgery for rectal cancer is still a challenging procedure. There is a wide variation among hospitals or surgeons in the rate of anastomotic leakage. We present our ingenious method and postoperative data. Materials and Methods: We place special emphasis on the following four points. (1) Apply effective traction of the rectum: apply tension effectively by looping the cotton tape around the rectum. We can loop the cotton tape very easily by getting a little creative technique. (2) Cut the rectum vertically to the axis of the rectum: dissect to the level of the levator ani and cut systematically by using two cartridges of the linear stapler. (3) Reinforce and reduce the pressure at the site of the anastomosis: suture the site of double stapling, and check for the presence or absence of active bleeding at the anastomosis by fiberscope. Place a transanal drainage tube. (4) Make a covering stoma: We make it in cases in which the distance from the anastomosis to be the dentate line is within 2 cm. We compared the rate of anastomotic leakage before and after introduction of the above ingenuity. Result: Before the introduction of our ingenious method, the rate of anastomotic leakage was 10.0 % (60 cases; Jan. 2005–Sep. 2010). After the introduction, it was 4.3 % (69 cases; Oct. 2010–Dec. 2013). Conclusion: We could reduce the rate of anastomotic leakage by a creative and simple method.

Objective: We aimed to describe a novel surgical technique and our early experience with 7 patients who underwent reduced-port laparoscopic colectomy (RPLC) for right-hemi colon cancer. Methods: This study was designed as a retrospective case series of prospectively gathered data. Between February 2009 and September 2013, 7 consecutive patients who received RPLC for right-hemi colon cancer were included (5 male and 2 female, median age: 67 years old). Patients were excluded if they had high BMI ([25 kg/m2 for men and [30 kg/m2 for women), T4 cancer or bulky tumors, small bowel obstruction or perforation due to the original tumor, dense adhesions, American Society Anesthesiologist scores (ASA) of 4 or 5, or stage IV colon cancer. The procedures were performed with medial to lateral access via RPLC using a GelPOINT through an umbilical zigzag skin incision. After setting the GelPOINT, a 3-mm trocar for the left hand and 5-mm trocars for the right hand of operator were positioned under laparoscopic guidance. Operator uses two independent trocars in the same way as conventional laparoscopic colectomy. The outcomes were evaluated in terms of operation time, intraoperative blood loss, number of harvested lymph nodes, length of hospital stay after operation, and surgical complications. Results: Five patients who had ascending colon cancer, one patient who had cecum colon cancer and one patient who had transverse colon cancer were performed RPLC. Median surgery time was 251 minutes, and median intraoperative blood loss was 25 mL. The median number of harvested lymph nodes was 20. Median length of post operative hospitalization was 11 days. There were no complications and mortality in relation to the operation. Conclusion: Our experience indicates that reduced-port laparoscopic colectomy for the patient with right-hemi colon cancer is a safe and feasible procedure.



Ideal Procedure to Approach Right Colic Vein for Safe Lymphadenectomy in a Laparoscopic Right Hemicolectomy

Hand-Assisted Laparoscopic Restorative Total Proctocolectomy (Ileoanal Pouch) Dividing the Ano-Rectum with the Novel Radial Cartridge for Endo-GIA

T. Ohnishi, Y. Fujie, K. Nishida, T. Yanagawa, K. Hashimoto, S. Fujita, J. Fujita, T. Yoshida, T. Tono, S. Imaoka, T. Monden

E. Balen, J. Suarez, B. Oronoz, F. Oteiza, M.A. Ciga

NTT West Osaka hospital, Osaka, Japan

Complejo Hospitalario de Navarra, Pamplona, Spain

Aims: Various branching pattern of superior mesenteric vessels might make laparoscopic right hemicolectomy difficult and establishment of ideal procedure of lymphadenectomy according to each type of variation is desirable. We have payed special attention to the right colic vein (RCV), which might be the candidate of unexpected gloss bleeding, and here we show our procedure of dissecting RCV. Method: Medially approached lymphadenectomy is started from caudal side of transverse mesocolon, and roots of ileocolic vessels, right and middle colic arteries are disclosed during this period. In cases whose root of RCV becomes apparent easily during this procedure, it is cut then. In other cases with latent RCV, it would be searched and cut later during the separation between transverse mesocolon and pancreatic head viewing from cranial side of transverse mesocolon. Results: We performed laparoscopic right hemicolectomy for 23 consecutive patients with advanced right-sided colon cancer. RCVs were cut approaching from caudal side in 12 cases. Among these cases, RCV branched directly from superior mesenteric vein in 4 cases and from gastrocolic trunk in 8 cases. RCVs were searched and cut approaching from cranial side in 9 cases, all of which branched from gastrocolic trunk. The remaining 2 cases lacked RCV. Median operation time, amount of bleeding and number of harvested lymph nodes were 248 min, 25 gr and 28, respectively. All RCVs were cut safely. Conclusion: The authors consider the described method to be one of the important point for safe lymphadenectomy during a laparoscopic right hemicolectomy.

A 36-year old male, suffering from medically-resistant ulcerative colitis, had an elective laparoscopic restorative total proctocolectomy (CO2 pneumoperitoneum 12-mm-Hg) in the Lloyd-Davies position (15° tilt, and 30°-reverse- or Trendelenburg position). Ports: an open approach for a 10-mm supraumbilical (optics), two 5-mm at the right and left abdomen, and 12-mm port near the anterior and superior right iliac spine. A 5-mm Ligasure device and an aspiration-irrigation hook were used to divide peritoneal fascias, dissect cleavage planes and achieve vascular haemosthasis without clips. A standard laparoscopic mobilization of the left and right colon was performed, dividing all segmentary branches of the inferior mesenteric artery and the ileocolic pedicle, while identifying both ureters and hypogastric nerves. Afterwards, a hand-assisted device (GelPort) was positioned in a suprapubic 8-cm midline laparotomy, and the surgeon’s left hand assisted mobilization of the transverse colon and both colonic flexures, separating them from the stomach, duodenum, pancreas, spleen and Gerota’s fascia bilaterally, and sealing the right, transverse, left colic arteries and the inferior mesenteric vein below the pancreas. Once the superior rectal artery branches had been divided at the level of the upper rectum, the rectum was dissected close to the muscular coat until the pelvic floor was reached circumferentially: the assistance of the surgeon’s left hand was extremely useful for a safe pelvic dissection. Under control of the assistant’s finger anal palpation, a novel Radial cartridge of the EndoGIA (Covidien) was applied to the anorectal junction in an anterior-toposterior direction, secured and fired: the 55-mm wide Radial cartridge cannot fit from right-to-left (as would be done in open surgery with a 30-mm TA) in narrow pelvis. A remaining 1 cm of rectum had to be divided with another firing of a reticulated purple cartridge. The surgical specimen was now excised through the Gel port, after dividing the terminal ileum with a linear stapler. A 20-cm-long ileal J-pouch was constructed with 3 firings of a 75-mm straight GIA. Hand-assisted orientation of the pouch and ileoanal anastomosis was performed transanally with a 29-mm circular stapler. A Turnbull ileostomy was raised in the right lower quadrant and the wounds closed.

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Comparison of Laparoscopic Versus Open Surgery After Insertion of Self-Expandable Metallic Stents in Acute Malignant Colorectal Obstruction: A Case-Matched Study

Artery Preserving Laparoscopic Lymph Node Dissection Using 3D-CT Angiography for Rectal or Left-Sided Colon Cancer

Ch. Angkurawaranon, T. Akaraviputh, V. Chinswangwattanakul, A. Methasate, A. Trakarnsgna, J. Swangsri Siriraj Hospital, Bangkok, Thailand Aims: Self-expanding metallic stents (SEMS) have been widely used to relieve acute malignant colorectal obstruction as a bridge to surgery. The surgical approach after SEMS insertion varies from open approach to laparoscopic-assisted approach. The primary objective of this study is to compare the outcomes of laparoscopic approach and open approach after SEMS insertion. Patients and Methods: From January 2007 to December 2010, cross-sectional medical records reviewed a total of 76 patients who underwent colorectal stenting with SEMS. Patients and tumor characteristics, complications, morbidity and mortality were obtained. Results: The mean age of the patients was 68 years (range 15–108 years). The intent of the placement for palliation was 31.6 % and for bridge-to-surgery was 68.4 %. The technical success of SEMS was found in 71 patients (93.4 %), and the clinical stent success was 100 %. Forty-three patients underwent surgery; open surgery was performed in 19 patients (44.2 %: Group A), and laparoscopic-assisted surgery was performed in 24 patients (55.8 %: Group B). All clinicopathological parameters were matched. Group B had a higher chance of primary anastomosis than group A (P = 0.012, Odd ratio 2.717, 95 %CI: 1.79–4.012). The post-operative complications, mortality rate, recurrence rate, disease free status, overall survival rates between the two groups were non-significant. Conclusion: Colonic stent is an effective treatment of acute malignant colonic obstruction. Our study suggests the advantage of laparoscopic approach resection after colonic stenting results in a higher primary anastomosis rate than open surgery.

Y. Maeda, T. Shinohara, A. Nagatsu, N. Futakawa, T. Hamada Hokkaido Cancer Center, Sapporo, Japan Aims: To investigate the branching pattern and length of the IMA (inferior mesenteric artery) using 3D-CT angiography before laparoscopic surgery for rectal and left-sided colon cancer and evaluate oncologic outcomes after artery-preserving lymph node dissection. Methods: We reviewed the records of 83 patients who underwent laparoscopic surgery with D2 or D3 lymph node dissection using preoperative 3D-CT angiography. The branching patterns of the IMA, LCA (left colic artery), SA (sigmoid artery) and SRA (superior rectal artery) were analyzed, and the length of the IMA from its origin to the root of the LCA was measured. The adequacy of artery-preserving (LCA or/and SRA) lymph node dissection was evaluated according to the number of lymph nodes harvested and the incidence of local recurrence. Results: The branching type of IMA was visualized on preoperative 3D-CT angiography in all 83 patients. The branching types were classified into the following three patterns: the SA branching off from the LCA (47 %); the SA branching off from the SRA (28 %); and all three arteries branching off from the same point (25 %). The mean distance from the root of the IMA to the root of the LCA was 39.7 mm (20–80 mm). There were no significant differences in the length of the IMA between the arterial branching types. In 13 % of the patients, the LCA ran along the margin of the sigmoid colon (not directly to the splenic flexure); the mean length of the IMA in this atypical pattern was significantly longer (47.0 mm) than that observed in the typical running pattern of the LCA. The LCA was preserved in 46 patients, the SRA was preserved in 13 patients and both the LCA and SRA were preserved in 16 patients. The mean number of lymph nodes identified in the specimens was 19.8 in the D3 group and 13.2 in the D2 group. Positive nodes were detected in 26 patients (31 %). No patients developed local or LN recurrence after a median follow-up of 29 months. Conclusions: These results indicate that artery-preserving laparoscopic lymph node dissection using 3D-CT angiography is an acceptable treatment strategy in patients with leftsided colorectal cancer.



Technical Aspect and Clinical Results: Of Laparoscopic Transverse Colon Cancer Resection

Laparoscopic Partial Excision of the Cecum for Mucocele of the Appendix

S. Yamaguchi, T. Ishii, J. Tashiro, H. Kondo, A. Suzuki, K. Hara

K. Ietsugu, K. Yoshida, H. Sugawara, K. Kiyohara

Saitama Medical University International Medical Center, Hidaka, Japan

Tonami Municipal General Hospital, Tonami City, Toyama Pref., Japan

Background: Transverse colon cancer was excluded for most of randomized trials of laparoscopic surgery because of technical difficulty. Purpose of this presentation is to demonstrate theoretical technique and to assess clinical results for laparoscopic transverse colon cancer resection. Technique: Basically transverse colon cancer is divided into two groups of right and left sides. Right sided cancer is associated with hepatic flexure mobilization and right hemicolectomy. Left sided cancer is associated with splenic flexure mobilization and adequate partial colon resection. Medial to lateral approach and lymphadenectomy of origin of regional vessels is performed. Clues of anatomy are accessory right colic vein from Henle’s gastrocolic trunk for right sided cancer and accessory middle colic vessels for left sided cancer. Recognition of each vessels and division of safe and adequate part are important. Results: 97 patients underwent transverse colon cancer resection since 2007 to of 2013 during 1 conversion to open surgery. Mean age was 68.1, 50 males and 47 females, mean lymph node harvests were 27.3, mean operative time and blood loss was 193 minutes, and 28 g. Procedures were right hemicolectomy: 48, transverse colectomy: 31, splenic flexure colectomy: 17, and total colectomy: 1. Stage distribution was I: 27, II: 39, III: 31. There were 4 recurrence, all patients were Stage III and recurrent sites were liver: I, lung: II, lymph node, and abdominal wall. Conclusion: Medial to lateral approach and lymphadenectomy of the origin of regional vessels were safe and feasible for transverse colon cancer.

Background: Mucocele of the appendix is rare and about 0.08–4.1 % of appendectomy. Pathological diagnosis is simple mucocele 25 %, mucinous cystadenoma 63 % and mucinous cystadenocarcinoma 12 %. We have to operate carefully not to perforate the mucocele. It may lead to pseudomyxoma peritonei in case of mucinous cystadenocarcinoma. Methods: From January 2004 to June 2013, we estimated the cases of the laparoscopic resection for mucocele of the appendix in our hospital. Results: Four laparoscopic partial resections of the cecum were performed in our department. We have decided to perform the appendectomy including the orifice of the appendix, so partial excision of the cecum is reasonable. Two cases were mucinous cystadenoma, two were simple mucocele in histopathological examination. There were no cancer cases. Laparoscopic partial excision of the cecum was performed for two cases and the average operative time was 109 minutes. Single-incision laparoscopic surgery was performed for two cases and the average operative time was 132 minutes. Amount of bleeding was a little. All patients had a good postoperative course. Conclusions: Laparoscopic partial excision of the cecum is feasible and safe for the patients of mucocele of the appendix.

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Laparoscopic Pelvic Excenteration for Locally Advanced and Recurrent Rectal Cancer

Laparoscopic Appendectomy with Hand-Made Loop

M. Sekimoto, M. Ikeda, M. Miyake, N. Haraguchi, S. Nakamori, M. Miyazaki, M. Hirao, A. Miyamoto, K. Nishikawa, T. Asaoka, K. Yamamoto Osaka National Hospital, Osaka, Japan Aims: Rectal cancer adherent to or invading into surrounding organs could have a chance of cure by combined resection of affected organs. However, such operation is invasive to the patients and has seldom been performed laparoscopically due to the technical difficulty. In order to lessen the invasiveness of the operation, we have employed laparoscopic technique since April 2013. In this paper, we show the early results of the five cases of pelvic excenteration for locally advanced and recurrent rectal cancer. Methods: We are performing about 200 laparoscopic colorectal surgeries for colorectal cancer annually; however, cases necessary for posterior/total pelvic excenteration have been operated on with open technique. In April 2013, we had urologists expertized to laparoscopic prostatectomy. Since then, cooperative team started laparoscopic pelvic excenteration. The technique consisted of the laparoscopic excision of the lesion and the reconstruction of the urinary tract via the small abdominal incision. Results: Four cases of total pelvic excenteration and one case of posterior pelvic excenteration were performed laparoscopically. The mean of age was 57.6 yr. There were three men and two women, and four cases of primary rectal cancer and one case of locally recurrent rectal cancer. All cases underwent preoperative chemotherapy or chemoradiotherapy. Bilateral lymph node dissection along the pelvic wall was performed in three cases. The mean of operative time was 753(579–1047) min, and blood loss was 662(100–1870) g. There was no mortality. No intraoperative morbidity occurred. As for the postoperative morbidity, a surgical site infection and a urinary infection occurred, which improved conservatively. The patients were allowed to be discharged when they were able to take care of their stomas by themselves. Postoperative hospital stay was 35.8(32–40) days. R0 resection was achieved in all cases. Conclusion: Comparing with open surgery, the laparoscopic approach gave a good view of the operative field even in the deep pelvis. There were less blood loss and morbidities. The laparoscopic pelvic excenteration by the hands of expertized surgeons was feasible and safe, as for the short term results.

T. Bilecik1, B. Mayir1, R. Eryilmaz2, C. Ensari1, T. Oruç1 1

Antalya Education and Research Hospital, Antalya, Turkey; Akdeniz University School of Medicine, Antalya, Turkey

2

Introduction: Acute appendicitis is the most common abdominal pathology requiring emergent surgical procedure. For treatment, laparoscopic surgery is commonly performed. For closure of stump of appendix, different procedures are used. Aims of this study is to evaluation of the results of patients in whom stump of appendix was closed with hand made loop during laparoscopic appendectomy (LA). Material and Methods: Patients in whom stump of appendix was closed with hand made loop during LA were included in the study. Reports of patients were collected from patient files retrospectively. Laparoscopic appendectomy was applied through 3 ports. Two loops were placed to stump of appendix. Root was a modification of Tayside loop that has been described in literature and has shown to be safe. Results: 70 patients were included in study. 28 of them (40 %) were female, 42 of them (60 %) were male. Ages range from 13 to 60 (average age is 30). During postoperative period, one surgical wound infection and two intraabdominal abscess were detected. There was no leakage from stump of appendix in any patients. Discussion: One of the most important component of cost of LA is technique of closure of stump. Stapler, endoloop, various clips or hand-made loop could be used for closure. We recommend hand made loop usage for closure as an easy, safe and cheap method.



Safety and Feasibility of Hand-Assisted Laparoscopic Surgery for Ulcerative Colitis

Short-Term Outcomes of 4 Port Laparoscopic Surgery for Colorectal Cancer Performed by Resident Physicians; A Single Center Retrospective Study

T. Yamamoto, S. Umegae, K. Matsumoto Yokkaichi Social Insurance Hospital, Yokkaichi, Japan Aims: Since 2005, we have introduced hand-assisted laparoscopic surgery (HALS) for patients with ulcerative colitis (UC) and extensive Crohn’s colitis. This study was to assess safety and feasibility of HALS for UC. Methods: Seventy UC patients were treated with HALS (HALS group). The outcomes of HALS were compared with those of open surgery conducted for 70 age-, sex- and disease severity-matched patients (OPEN group). Results: In both groups, 37 elective patients were treated with a total proctocolectomy and ileal pouch-anal (canal) anastomosis with a loop ileostomy, and 33 emergency patients with a total colectomy (rectal closure) with an end-ileostomy. In the HALS group, intra-operative complications were experienced in two patients (duodenal injury 1, colonic perforation 1). None of the patients required conversion to open procedure, and laparoscopic procedure was successfully completed in all patients. In the HALS group, the mean operative time was 293 minutes, which was significantly longer than 258 minutes in the OPEN group. The mean intra-operative blood loss was not significantly different between the groups. Eighteen patients (26 %) in the HALS group and 20 patients (29 %) in the OPEN group experienced postoperative complications (not significant). Six patients in the HALS group and 7 patients in the OPEN group required laparotomy for postoperative complications (not significant). Conclusions: Although HALS takes longer time as compared with open surgery, it can be safely conducted without conversion to open procedure. HALS is a feasible option in the surgical management of UC.

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Y. Kawamoto, Y. Nagahisa, Y. Uchida, Y. Tsukumo, T. Ito Kurashiki Central Hospital, Kurashiki, Japan Aims: Five port surgery with an umbilical scope port is the most common method of laparoscopic colorectal resection in Japan and other countries. However, this method is technically limited because operation directly under the scope port, 2 forceps control by an assistant and mirror imaging are difficult. In order to eliminate these difficulties, we altered the scope port site according to the cancer site and performed 4 port surgery, enabling resident physicians to participate. We evaluated the short-term outcomes of 4 port laparoscopic colorectal resection for colorectal cancer with participation by at least one 1st to 3rd-year surgical resident physician under supervision. Methods: We performed a retrospective chart review of all patients who had undergone 4 port laparoscopic colorectal resection for a cancerous lesion between April 2013 and December 2013 in a single institution. Primary surgeon, operating time, lymphadenectomy number, postoperative period until hospital discharge, and postoperative complications were reviewed. Results: Eighty-three patients were identified among which 38 (45.8 %) were female. The mean age was 69.1 ± 9.5 years. Thirty (36.2 %) patients had right-sided tumor, 23 (27.7 %) patients had left-sided tumor, 29 (34.9 %) patients had rectal tumor, and 1 (1.2 %) patient had both right and left-sided tumor. A Resident physician was the primary surgeon in 58 (69.9 %) patients and first assistant in 25 (30.1 %) patients. Hemorrhage necessitated open surgery in one patient. The mean operating time was 250 ± 78 min and mean lymphadenectomy number was 19.7 ± 11.4. Postoperative complications greater than ClavienDindo classification grade II occurred in 20 (24.1 %) patients: surgical site infection (n = 1), intraabdominal abscess (n = 5), postoperative hemorrhage (n = 1), pancreatitis (n = 2), anastomotic leakage (n = 2), anastomotic hemorrhage (n = 2), urinary tract infection (n = 2), deep venous thrombosis (n = 1), chylorrhea (n = 2), femoral-popliteal bypass reocclusion (n = 1), and ileus (n = 1). One patient with anastomotic hemorrhage required endoscopic intervention and one patient with femoral-popliteal bypass reocclusion required surgical intervention. Pharmacological therapy was successful for all other complications. Conclusions: Four port laparoscopic surgery for colorectal cancer is safe and the short-term results are satisfactory even with resident physicians participation. This method might be an effective option for both resident physicians and laparoscopic surgeons.

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Short- and Long-Term Results: Of Laparoscopic Sigmoidectomy with Preservation of the Superior Rectal Artery

Conservative Treatment of Anastomotic Leakage After Rectal Resection

T. Wakahara, A. Toyokawa, D. Lee, Y. Harada, Y. Ueda, S. Shirakawa, M. Awadu, H. Ashitani, S. Tsuchida, Y. Hasegawa

L. Sakra, J. Flasar, M. Sacha, J. Siller

Yodogawa Christian Hospital, Osaka, Japan Background: During the resection of sigmoid colon cancers, the root of the inferior mesenteric artery (IMA) is usually divided in order to remove the lymph nodes present along its length. However, this sometimes results in an insufficient blood supply to the anastomosis, leading to anastomotic leakage. We conducted a retrospective analysis to determine the feasibility and potential benefits of preserving the superior rectal artery (SRA) during the resection of sigmoid colon cancers by comparing SRA-preserving and non-SRA-preserving cases. Methods: Fifty-seven patients underwent SRA-preserving sigmoidectomy with D2 or D3 lymph node dissection (group A) between June 2008 and May 2012 and were compared with 35 patients who underwent sigmoidectomy without preservation of the SRA (group B) during the same period. Clinicopathological data were analyzed retrospectively. Results: The amount of blood loss, the number of harvested lymph nodes, and the postoperative morbidity rate did not differ significantly between the two groups. There were no cases of anastomotic leakage in group A (0 %) and 1 case of anastomotic leakage in group B (2.9 %), although this difference was not significant (p = 0.380). The median follow-up period was 36.6 months. The 3-year relapse-free survival (RFS) rates also did not differ significantly between the two groups, irrespective of lymph node status. The 3-year RFS rates of group A and B were 88.1 % and 95.5 %, respectively, in lymph node negative cases (p = 0.4375), and 66.7 % and 64.8 %, respectively, in lymph node positive cases (p = 0.8843). Conclusion: Sigmoidectomy with SRA preservation can be performed without compromising the quality of lymph node dissection and relapse-free survival. No advantage of preserving the SRA could be demonstrated in this retrospective study; however, it is noteworthy that no anastomotic leakage was noted among the 57 patients who underwent SRA-preserving sigmoidectomy.

Pardubice Hospital, Pardubice, Czech Republic Introduction: Resection of the lower and middle rectum is one of the most difficult procedures in the field of colorectal surgery. Anastomotic leakage represents a very serious and life threatening complication. The incidence of this complication is influenced by many well-known risk factors. Occurrence is present in 4–21 % cases. A specific part of these complications can by treated in a conservative way. Material and Method: The study uses data about anastomotic leakages after rectal resection which were provided by the Surgical Dept. Pardubice from January 1, 2010 until June 30, 2013. 199 patients underwent rectal resection for rectal carcinoma. 19 (9.5 %) leaks were noticed during this period. 12 (6.0 %) leaks were treated conservatively (A diverting ileostomy was made in every case.). Complex conservative therapy consisted of nutrition support, antibiotics and, predominantly, colonoscopic lavage (3–4 times per week). The average length of this treatment was 82 days. 8 (67 %) anastomotic leaks were successfully healed by this approach. Results: The study presents the possible application of the conservative approach to anastomotic leakage after rectal resection. Treatment comprises a complex of specific approaches where the main role is played by colonoscopic periodic lavage. Conclusion: This conservative approach can lead to the successful healing of this serious complication.



Totally Laparoscopic Sigmoid Colectomy with Transanal Specimen Extraction Using the Reduced-Port Surgery Technique

The Experience of 116 Laparoscopic Rectal Resection

Y. Tajima

E. Poskus, V. Jotautas, P. Zeromskas, S. Mikalauskas, G. Simutis, K. Strupas

Nagaoka Chuo General Hospital, Nagaoka, Japan

Vilnius University Hospital, Vilnius, Lithuania

Aims: Transanal specimen extraction (TASE) in laparoscopic colorectal surgery has been developed to prevent wound complications. We previously reported that the attachment of the AlexisÒ wound retractor (Applied Medical, rancho Santa Margarita, CA, USA) to the rectum is helpful to achieve smooth extraction and reduced intracorporeal contamination. In addition, we began performing TASE combined with reduced-port surgery (RPS) since December 2011. The aim of this study was to identify the short-term outcomes of our technique. Methods: We prospectively collected data on 17 patients who underwent totally laparoscopic sigmoid colectomy with TASE and RPS from December 2011 to April 2013. We inserted a multiport access device (GelPOINTÒ advanced access platform; Applied Medical, USA) through a 15–20 mm length mini-laparotomy in the navel. A 12-mm port for a laparoscope or a linear stapler was placed in the GelPOINT. The second port was a 5-mm port for surgeon’s right hand or a laparoscope in the right lower quadrant, which was used as a drain site. The third port was a 3-mm port for the surgeon’s left hand in the right flank. Lymph node dissection and transection of proximal and distal colon were performed. The transected rectal stump was opened transversely, and a long Babcock grasper was inserted transanally through the opened rectal stump. One of a pair of Alexis rings was held and pulled out of the anus. The other ring was placed in the opened rectal stump. The specimen was then extracted transanally through the Alexis. After the Alexis had been removed, the rectal opening was reclosed with a linear stapler. End-to-end colorectal anastomosis was performed using the double-stapling technique. Results: Transanal extraction was achieved in 15 cases. We switched to transabdominal extraction in two cases involving a bulky specimen. In 15 cases, mean operation time was 227 min. There were five postoperative complications including two anastomotic leakages. The median hospital stay was 7.5 days. All patients remained disease free. The mean Wexner score was 1.1 at 6 months after the operation. Conclusion: Totally laparoscopic sigmoid colectomy with TASE using RPS technique appears to be feasible, safe, and oncologically acceptable for selected cases.

Aims: Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. There are doubts about laparoscopic rectal cancer treatment effectiveness. The aim of this study is to assess early results of laparoscopic rectal surgery for rectal cancer. Methods: This survey deals with retrospective analysis of short - term results of the 116 laparoscopic rectal resections. 116 patients operated on from 2006 to 2012 due to rectal tumors were analyzed retrospectively. Factors like patients’ demographics, duration of operation, conversion rate, hospital stay, physical activity, first bowel movement, postoperative complication rate, operation radicality, and number of removed lymph nodes were evaluated. Results: Mean age of patients was 65.3 years. 96 operations were performed due to cancer, and 20 due to large adenomas. Where were 10 conversions (8.6 %). The latter were excluded from the analysis. Mean duration of operation: 211.7 minutes (min. 110, max. 390). The first 36 operation had lasted 225 min., second 36–211 min. third 36 -180 min. Complication rate: overall 15 (14.1 %), suture leakage 4 (3.8 %). First bowel movement after 2.2 days, physical activity: after 1.4 days. All resections were type R0, but 4 patient’s circumferential margins were\2 cm. Patient’s lymph node number: 12.8 (min. 2, max. 31). Mean postoperative hospital stay: 7.8 days. Lethal outcome - 2 (1.1 %). Conclusions: laparoscopic rectal resection is safe but requires experience in the operation technique. Long-term results of this operation have yet to be investigated.

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A Simple Hand-Assisted Laparoscopic Extraperitoneal Sigmoid Colostomy Technique Performed Via a Perineal Incision

Technical Tips for Preventing Anastomotic Leakage in Laparoscopic Low Anterior Resection

K. Yamashita, R. Sugimoto, S. Miyauchi, Y. Takahashi, R. Yoshida, N. Waki, S. Hirayama, H. Kawai, H. Nishi, M. Ishizaki

T. Yatsuoka

Okayama Rosai Hospital, Okayama, Japan Background: Although an extraperitoneal colostomy is often performed to prevent postoperative parastomal hernia formation after an open abdominoperineal resection for rectal neoplasms, it is not typically conducted via a laparoscopic approach because of the difficulty associated with the extraperitoneal route. Purpose: We describe a simple hand-assisted laparoscopic extraperitoneal sigmoid colostomy technique performed via a perineal incision. Methods: For this study, we enrolled 4 consecutive patients (3 men and 1 woman) who underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. After the laparoscopic abdominoperineal resection, the surgeon inserted his left hand into the pelvis via a perineal incision. Then, under laparoscopic guidance, gently separated the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel using the fingers, just as in open methods. Results: The technique was successful in all 4 patients. We performed the peritoneal separation from the previously dissected paracolic gutter toward the proposed stoma site in the left flank. The pneumoperitoneal pressure was maintained within the normal range during the entire procedure. Conclusions: This surgical technique is easy, and helps to prevent the development of parastomal hernias.

Saitama Cancer Center, Saitama, Japan Aims: End-to-end low rectal anastomosis with the double-stapling technique (DST) was reported by Knight and Griffen in 1980. Despite of the recent advance of stapling devices, low anterior resection (LAR) of the rectum has a greater risk of anastomotic complication compared with other rectal surgeries. The development of a leak is known to be associated with local recurrence and worse prognosis after a curative resection for rectal cancer. The purpose of this study is to address technical tips for preventing anastomotic leakage after laparoscopic low anterior resection (Lap LAR) and review the clinical outcome of our experiences. Methods: We completely mobilize the rectum to the pelvic bottom due to perform a safe transection of the lower rectum. The lower rectal segment is transected and closed horizontally using a single-fire cartridge with a flexible linear stapler as possible. Performing the DST, the center rod of circular stapler is pierced through one third of the left end of the rectum stapler line to eliminate the dog-ear on the left side (eliminating the left lateral intersection). We make the mattress sutures to eliminate right-sided dog-ear in DST anastomosis. After performing the anastomotic air leak testing to identify anastomotic leakage, we use the routine intra-operative colonoscopy (IOC) to allow direct visualization for anastomotic bleeding and unintended bowel wall injury. A transanal drainage tube is inserted through the anastomosis. Results: Between January 2007 and December 2013, 1446 patients undergoing anterior resection for rectal cancer was done. Conventional open low anterior resection (Open LAR) was performed in 250 patients and Lap LAR was done in 28 patients. In Open LAR group anastomotic leakage occurred in 18 patients (6.9 %) and in Lap LAR group anastomotic leakage occurred in one patients (3.5 %). Conclusion: Our techniques may be safe and effective means of reducing the occurrence of anastomotic leakage in laparoscopic low anterior resection. Making further risk reduction in colorectal anastomosis, a larger-scale prospective randomized study is necessary for further clarification of this issue in laparoscopic surgery.



The First Trans Anal Endoscopic Operation ‘TEO’ Performed in Egypt: Reporting a Combined TEO and Total Gastrectomy in a Familial Adenomatous Polyposis Patient

Comparison of Short-Term Surgical Outcomes After Three Laparoscopic Procedures for Low Rectal Cancer

M. Shoukry Hafez

M. Oya, S. Sameshima, S. Shinichi, N. Nobumi, E. Takeshita, K. Shinichiro, O. Takashi, S. Yoshitake

Al Salam Oncology Center, Cairo, Egypt

Koshigaya Hospital, Dokkyo Medical University, Saitama, Japan

Introduction: Familial adenomatous polyposis patients are liable to multiple operative interventions throughout their life time. In the era of endoscopic surgery, the minimally invasive approach should be the primary mode of surgical intervention to minimize the long term complications and optimize the cosmetic outcome. Patient and Method: A 28 years old male patient was referred to our center having a villous adenoma of the rectum. He had a total colectomy some years before for colonic polyposis, and ileo rectal anastomosis. During his admission we performed an upper gi endoscopy for him and found that he also has polyposis involving the stomach and the first part of he duodenum. We decided to perform a trans anal operation ‘teo’ for the rectal lesion together with laparoscopic total gastrectomy and esophagojujenal anastomosis. Results: both procedures we completed successfully endoscopically. The patient was discharged on post operative day 10. The pathology showed multiple villous and tubulovillous adenomata with varying degrees of dysplasia amounting to high grade. Margins were clear in both specimen. The patient did not receive a blood transfusion. Conclusion: combined endoscopic procedures for patients suffering from polyposis is safe and yields excellent results with minimal morbidity and a superior functional and cosmetic outcome.

Laparoscopic resection for low rectal cancer is thought to be technically difficult mainly because it includes procedures within the narrow pelvis. In the current study, we retrospectively compared short-term surgical outcomes of three procedures performed for low rectal cancer: very low anterior resection with stapled anastomosis (VLAR), intersphincteric resection with hand-sewn transanal anastomosis (ISR) and abdominoperineal resection (APR). Laparoscopic procedure for low rectal cancer at our institution consists of the high ligation of the inferior mesenteric artery and total mesorectal excision with the preservation of the pelvic autonomic nerves. Suspected lateral lymph node metastasis was removed under small lower midline laparotomy. Neo-adjuvant chemoradiotherapy or systemic chemotherapy is usually performed for T3 or deeper tumors. Temporary fecal diversion was used for some patients undergoing VLAR and all the patients undergoing ISR. A total of 44 patients underwent potentially curative resection for low rectal cancer between June, 2010 and August 2013. The median age at operation was 67.0 years ranging 37- 87. 29 patients were male and 15 patients were female. VLAR, ISR and APR were performed in 22, 6 and 16 patients, respectively. Procedures mainly depended on the site and the size of the lesions. Conversion to conventional laparotomy was needed in three patients. Operation time did not differ by the procedure (median: range, VLAR 310: 225–574 min., ISR. 384: 286–758 min, APR 380: 215–637 min) SSI was marginally more frequent after APR VLAR 1/22. ISR 1/6, APR 5/16). SSI after APR was mainly infection at the perineum. Postoperative hospital stay was significantly longer after APR (median: range, VLAR 15.5: 8–73 days, ISR 17: 13–72 days, APR 21.5: 15–48 days), Laparoscopic VLAR, ISR and APR are almost evenly difficult with regard to operation time. Unscheduled conversion was uncommon in all of the three procedures. Short-term outcomes of the three procedures were also similar except for perineal wound infection after APR.

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Transanal Endoluminal Total Mesorectal Resection by Transanal Endoscopic Microsurgery for Management of Low Rectal Cancer: Oncological Results at 3 Years Medium Follow-Up

Significance of Total Colectomy and Ileal-Puch Anal Anastomosis with Mucosectomy for the Familiar Adenomatous Polyposis Patients by Laparoscopic Procedure

S. Quaresima, A. Balla, A. Paganini, G. d’Ambrosio, E. Lezoche

N. Matsubara, K. Tsukamoto, M. Hamanaka, Y. Kobayashi, D. Yamagishi, N. Beppu, T. Yamano, M. Noda, N. Tomita

Policlinico Umberto I, Rome, Italy Aims: Transanal Endoluminal Total Mesorectal Resection (TATMR) by Transanal Endoscopic Microsurgery (TEM) is a radical surgical approach for management of ultralow rectal cancer and extra rectal disease limited to the pelvic floor as an alternative to Abdominal Perineal Resection. Aims is to evaluate the preliminary oncological results at 3 years’ mean follow-up. Methods: By TEM, the dissection starts 1 cm below the lower tumor margin. The incision line reaches the pelvic floor and the dissection follows the same plane as described by Heald. Complete mesorectum excision with preservation of presacral fascia and parasympathetic pelvic plexus is posteriorly. Anteriorly the plane of incision follows the recto-vaginal septum in females and the prostatic capsule and seminal vesicles in males, removing Denonvilliers’ fascia. Transanal dissection reaches the peritoneal reflection. Splenic flexure mobilization and vascular control are performed by laparoscopy, followed by colo-anal anastomosis and ileostomy. Results: From October 2008, TATMR by TEM was performed in ten patients with rectal cancer (6 males, 4 females, median age 67 years). Preoperative staging was: T4 N + (5), T3 N + (3), T3N0 (1), T2 N + (1). All patients underwent neoadjuvant radiochemotherapy (n-RCT). Eight patients were no-responders to n-RCT, 1 showed both dowstaging and downsizing, 1 only downsizing. Mean tumor diameter was 4,7 cm (range 3–7 cm). Mean operative time was 440 min (range 360–600 min). No conversion was observed. Mean tumor distance from the anal verge was 2.9 cm (range 2–4 cm). Final staging was pT3N0 (1), pT3N2 (1), pT2N0 (3), pT0N0 (4), pT1N0 (1). Postoperative complications included anastomotic leakage (3) and temporary urinary incontinence (1). Mean hospital stay was 16.6 days (range 9–22 days). Late complications included anastomotic stricture (2) and recto-vaginal fistula (1) treated by stent. pT3 and pN+ patients underwent adjuvant chemotherapy. At mean follow-up of 36 months (range 7–60) one patient died from unrelated causes and one patient developed liver metastases at 25 months. Conclusions: TATMR is a safe and effective approach for treatment of ultralow rectal cancer. Larger patient series and at least five years’ follow up are required to better evaluate the oncologic results.

Hyogo College of Medicine, Nihinomiya, Japan Background: Familial adenomatous polyposis (FAP) is a dominantly inherited syndrome. Risk of cancer begins to increase after late teenager if not treated. Recent years laparoscopic prophylactic surgery was chosen for FAP in many hospitals. Standard operation is the total proctocolectomy/ileal pouch-anal anastomosis with mucosectomy and hand-sawn anastomosis. From the oncological point of view hand-sawn anastomosis is desirable, however, stapled anastomosis is sometimes chosen because of easy and simple in many occasions. The purpose of this study is to evaluate the feasibility and short- and long-term outcomes after laparoscopic total proctocolectomy/ileal pouch-anal anastomosis with mucosectomy and hand-sawn anastomosis. Method and Procedures: From the year of 2000 to 2012, 95 patients underwent prophylactic surgery for FAP. Among them 12 patients underwent laparoscopic total proctocolectomy with hand sawn-anastomosis except 2 cases of ileo-rectal stapled anastomosis. Among the 83 open cases of total proctocolectomy, 3 cases were ileo-rectal stapled anastomosis. Diverting ileostomy was created in 3 (25 %) cases of lap group and 13 (16 %) of open group. Main outcomes were: 30 anastomotic leak and pouch failure; longterm desmoids and malignant recurrence. Results: Anastomotic leakage was observed in none of the cases of either group, and no pouch failure was observed in either group. Long-term small-bowel obstruction occurred in 6 patients of open group and required surgery in 2 patients. Desmoids occurred in 3 patients in open group. Liver and lung metastasis was observed in 4 patients in open group and one patient deceased 4 years post operatively. No pelvic recurrence including anastomosis site occurred in both procedures with hand-sawn anastomosis. Conclusions: Total proctocolectomy with hand sawn-anastomosis for FAP patients is oncologically desirable procedure and only distant metastasis was observed. Laparoscopic total proctocolectomy with hand sawn-anastomosis may minimize the small bowel obstruction and development of desmoids. Lap procedure is feasible and may be an appealing alternative to open surgery with possible advantages.



Efficacy and Safety of Single-Incision Laparoscopic Interval Appendectomy: A Single Center Experience

Laparoscopy Assisted Anterior Resection with Total Mesorectal Excision for Rectal Cancer-Feasibility of 3-Ports Technique After Previous 5 Pelvic Surgeries

T. Miura, H. Yamada, Y. Miyasaka, T. Mizota, N. Takemoto, K. Konishi Nippon Telegraph and Telephone East Corporation Sapporo Hospital, Sapporo, Hokkaido, Japan Aims: We have performed laparoscopic interval appendectomy after a course of antibiotics for acute appendicitis, and we have adapted single-incision laparoscopic surgery to interval appendectomy. The aim of this study was to assess the efficacy and safety of single-incision laparoscopic interval appendectomy (SILIA). Methods: Between January 2010 and December 2013, a total of 57 consecutive patients underwent laparoscopic interval appendectomy in our institution after conservative management comprising antibiotic treatment for acute appendicitis. Since 2013, we have applied SILIA, using a 2-cm incision made within the umbilical folds and carried down to the fascia, to insert a LAP PROTECTOR and EZ access (Hakko, Japan). Two 5-mm ports and a 3-mm port were inserted through the EZ access. The laparoscope used was a 5-mm flexible scope. Seven of the 57 patients underwent SILIA, and conventional laparoscopic interval appendectomy (CLIA) with three ports was performed in the remaining 50. SILIA and CLIA were retrospectively compared by statistical evaluation of age, sex, body mass index (BMI), operative time, complications, use of analgesics and postoperative hospital stay. Result: No patients treated using SILIA were converted to conventional laparoscopic or open procedures. No significant differences were found between SILIA and CLIA, including operative time (p = 0.080), complications (p = 0.590), use of analgesics (p = 0.511) and postoperative hospital stay (p = 0.258). Conclusion: These findings suggest SILIA is comparable to CLIA in terms of both feasibility and safety. SILIA is also not difficult to perform as an operative method. Outcomes, including postoperative quality of life and cosmesis, need to be evaluated with further cases.

T. Amin Assiut University, South Egypt Cancer Institute, Assiut, Egypt History: Female patient of 46 years old, presented with constipation alternating with diarrhea of one month duration. PR examination revealed ulcerating lesion 8–10 cm from the anal verge. Colonoscopy and biopsy revealed moderately differentiated adenocarcinoma. CT revealed localized non metastasizing lesion at the med rectum. The patient has a history of previous 4 c. sections and a laparotomy for ovarian cystectomy. Procedure: Laparoscopic anterior resection was decided. The patient was put in the modified lithotomy position with head was down. Three ports were used for the procedure; one 10 mm supra-umbilical port for the camera and another two working ports; one just below the level of the umbilicus at the right med clavicular line and the other in the right lower abdominal quadrant. The procedure started with adhesolysis then exposing the rectosigmoid and its mesentery. Sigmoid vessels and IMA were secured and divided then dissection was continued till full mobilization of the rectum, sigmoid and lt. colon. Finally, 4 to 5 cm supra-umbilical incision was made through which mobilized colon was extracted, specimen divided and hand sewn tension free anastomosis was done. Results: There is no intra-operative complications. Post-operative period has passed without events and no intra-operative or post-operative blood transfusion. Final pathology revealed moderately differentiated adenocarcinoma and 14 LNs was yielded (T3N0 M0). Conclusion: In this case, we could successfully do laparoscopy assisted anterior resection on top of previous 5 pelvic surgeries without complications.

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Single-Incision Laparoscopic Colectomy for Colon Cancer: Single Institutional Experiences with 229 Cases

Laparoscopic Total Colectomy for Familial Adenomatous Polyposis Based on Genetic Testing

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

T. Yazawa, S. Ohoki, I. Nakamura, T. Monnma, T. Nakajima, M. Takawa, S. Suzuki, K. Kumamoto, S. Takenoshita

Fukui Prefectural Hospital, Fukui, Japan

Fukushima Medical University, Fukushima City, Japan

Introduction: Single-incision laparoscopic surgery (SILS) has recently been developed with the aim to further reduce the invasiveness of conventional laparoscopy. In the present study, our initial experiences with SILS for colon cancer are reviewed, and its outcomes are evaluated. Methods: Our initial experience of SILS for colon cancer is presented. 229 patients (123 women) were treated with the SILS procedure between August 2010 and November 2013. The abdomen was approached through a 2.5 cm transumbilical incision. Almost all the procedures were performed with standard laparoscopic instruments, and the operative procedures were similar to those employed in the standard laparoscopic colectomy. Results: Fourteen patients were converted to laparotomy including the extension of the incision over 3 cm, and three patients required an additional port insertion. The other 212 patients (93 %) underwent a curative resection of the colon cancer. The mean skin incision was 2.76 cm. The mean operative time and blood loss were 166.7 min and 50.1 ml, respectively. The mean number of harvested lymph nodes was 25.2. Intra- or postoperative complications occurred in nine patients (2; surgical site infection, 1; incisional hernia, 1; anastomotic leakage, 2; small bowel obstruction, 2; anastomotic bleeding, 1; intra-peritoneal bleeding). The patients were discharged after a mean period of 11.5 postoperative days. Conclusions: Our initial experiences suggested that SILC is feasible and safe for colorectal cancer patients. However, further studies need to be undertaken to prove that it has noncosmetic advantages over conventional laparoscopic colectomy.

Background: Familial adenomatous polyposis (FAP) results from germline adenomatous polyposis coli (APC) gene mutations. FAP is associated with an almost 100 % chance of colorectal cancer by the age of 50 years. Surgery is the only prophylaxis. Ileoanal anastomosis (IAA) or Ileoanal canal anastomosis (IACA) is often performed in FAP. However, these operations are still not standard for deteriorating QOL due to a postoperative complication and an analdys function. Recently, the correlation between location of mutation on the APC gene (genotype) and clinical manifestations (phenotype) has been reported. We usually perform IAA or IACA to classic FAP, but based on an analysis of genotype, we select ileorectal anastomosis (IRA) to attenuated FAP (AFAP) or to a sparse type of FAP without carcinoma in lower rectum. Methods: We present the informations about 3 patients who had been underwent the laparoscopic total colectomy with IRA based on genetic testing. All patients were classical FAP and we performed polypectomy of all rectal polyps before surgery. Results: 3 patients were treated. 2 were women, median age was 40 years. All patients were classical FAP and the area of mutation site did not existed in genetic hotspot of profuse type and caner development. No patients were converted to open surgery. The mean of incision length was 5 cm, anastomotic leakage was not revealed. Pathology revealed cancer of the ascending colon in one patient. The post operative course was uneventful in all cases. No cases of adenocarcinoma at the residual rectal mucosa developed and no cases of desmoid tumor and metastasis of other organs occurred. Conclusion: IAA and IACA are recommended for FAP surgery. However, when no cancer is detected in rectum at the time of diagnosis, the application of preventive surgery should be decided carefully, and the disadvantages of surgery should not exceed the risk of cancer development. Laparoscopic total colectomy and IRA is safe and feasible for FAP.



Single-Incision Plus One Port Laparoscopic Anterior Resection for Rectal Cancer: Single Institutional 109 Initial Experiences

Laparoscopic Super-Low Anterior Resection with TME for UltraLow Rectal Carcinoma

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

M. Naito

Fukui Prefectural Hospital, Fukui, Japan Introduction: Only limited data in the literature about single-incision laparoscopic rectal surgery, because the laparoscopic stapler does not allow low rectal transection without sufficient distal margins from the umbilicus port. We have developed single-incision plus one port laparoscopic anterior resection of the rectum (SILS + 1-AR) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. Methods: A Lap protector (LP) mini was inserted through a 2.5 cm transumbilical incision, and an EZ-access was mounted to LP and three 5-mm ports were placed in EZ-access. A 12 mm port was inserted in right lower quadrant. Almost all the procedures were performed with usual laparoscopic instruments, and the operative procedures were much the same as in usual laparoscopic anterior resection of the rectum using a flexible scope. The rectum was transected using endoscopic linear stapler inserted from the right lower quadrant port. Results: We underwent modified SILS + 1-AR in 109 patients with advanced rectal cancer. Eight patients were converted to laparotomy and one patient required an additional port insertion. The other 100 patients (91.7 %) underwent a curative anterior resection of the rectum. We transected the lower rectum with laparoscopic stapler inserted from the port of the right lower quadrant. Postoperative complications occurred in seven patients (4 anastomotic leakages, 2 small bowel obstructions and one intra-peritoneal abscess). Conclusions: The safety and feasibility of SILS + 1-AR for advanced rectal cancer was established in this study. However, further studies are needed to prove the advantages of this procedure to conventional laparoscopic law anterior resection.

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Okayama Medical Center, Okayama City, Japan Introduction: In recent years, sphincter preservation and improvement of quality of life have become the primary goals in the management of low-lying rectal carcinoma. We started laparoscopic super-low anterior resection with TME for ultra-low rectal carcinoma from January 2011. So we report a short-term results of laparoscopic super-low anterior resection with TME. Methods: Super-low anterior resection with TME was performed in the patients with a anastomosis-line within 2 cm from the dentate line. We investigated 6 cases of laparoscopic super-low anterior resection with TME for ultra-low rectal carcinoma. Results: Between January 2011 and December 2013, 42 cases of anterior resection with TME for rectal carcinoma was performed. In 42 cases, 12 cases (29 %) were performed super-low anterior resection with TME, 6 cases (14 %) with laparoscopic surgery and 6 cases with open surgery. In 6 laparoscopic surgery cases, 3 male and 3 female were observed. The mean age was 66.6 years old (range, 56–86). Tumor type were 1:3 cases, 2:3 cases. The average distance from tumor to anal verge was 4.0 cm. Anastomosis was performed with DST: 4 cases, with direct coloanal anastomosis: 2 cases. Average anastomotic distance from the dentate line was 1.3 cm. Covering stoma was created in 4 cases. Lateral lymph node dissection was performed in 2 cases laparoscopically. The pathological type was all moderately differentiated adenocarcinoma. Tumor depths were m:1, sm:4, mp:1. No lymph node metastasis was found. All postoperative pathological stage was Dukes stage A. The all pTMN staging was phase I. No conversion to open surgery was observed with no mortarity. Only one anastomotic dehiscence was observed without covering stoma case. Covering stoma was closed after average 3.1 months. No recurrence was observed during this following period. Conclusion: All curative operation was performed safely using laparoscopic techniques. But covering stoma is necessary to avoid anastomotic dehiscence.

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Safety and Clinical Outcomes of Laparoscopic Resection of Transverse Colon Cancer: A Single-Center Experience

Laparoscopic Total Colectomy for Patients with Severe Ulcerative Colitis. Can the Results be Improved?

K. Danno, C. Matsuda, S. Miyazaki, M. Nishimura, M. Nomura, Y. Okumura, J. Kawada, M. Kubota, M. Nomura, H. Yoshida, T. Aono, K. Fujitani, K. Iwase, Y. Tanaka

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

Osaka General Medical Center, Osaka, Japan Purposes: The role of laparoscopic resection in management of transverse colon cancer remains controversial. The aim of this study is to assess the safety and outcome of laparoscopic resection of transverse colon cancer. Methods: This retrospective study analyzed 162 patients who underwent resection of transverse colon cancer, including 41 laparoscopic colectomies (LAC) and 121 conventional open colectomies (OC) in our hospital from January 1994 to December 2012. Operative details, short- and long-term outcomes were analyzed. Results: In the patient background, serum CEA level, CA19-9 level, BMI, age, were not significantly different. According to the TNM classification, the proportion of patients with early stage was higher in the LAC group than in the OC group. The operative time was longer in the LAC group than in the OC group (P \ 0.001). However, intraoperative blood loss was significantly lower (P \ 0.001) and postoperative recovery time was significantly shorter (P \ 0.001) in the LAC group than in the OC group. Long-term outcomes were investigated in patients with stage II and III disease (131 patients). No significant difference was observed between groups in terms of the 5-year disease-free and overall survival rates, which were 73.6 % and 83.3 % in the OC group, and 93.8 % and 91.7 % in the LAC group. Conclusion: Laparoscopic resection of transverse colon cancer may be associated with lower blood loss and shorter length of hospital stay, compared with open resection. These results suggest that laparoscopic resection of transverse colon cancer is safe and feasible.

Hospital Aleman, Buenos Aires, Argentina Aims: Many authors report that laparoscopic approach in severe ulcerative colitis has longer surgical time and morbidity during the learning curve. The aim of this study is to assess if the acquisition of experience by the surgical team can improve the outcomes of laparoscopic total colectomy in severe ulcerative colitis. Methods: A retrospective study was performed using a prospective collected database. All patients with severe ulcerative colitis who underwent laparoscopic total colectomy between August 2003 and July 2011 were included. The series was divided into two groups: the first 20 surgeries (G1); and the last 15 surgeries (G2). Perioperative outcomes were compared between groups. Results: Preoperative data was homogeneous between the two groups. G2 had shorter surgical time (G1: 199 +/- 39 vs. G2: 170 +/- 29 minutes; p \ 0.05). There were no differences in intraoperative complications and in the conversion rate, but the only patient who was converted to laparotomy belonged to G1. There were no differences in the postoperative complication rate and postoperative length of stay. Conclusions: The acquisition of experience by the surgical team in laparoscopic total colectomy for patients with severe ulcerative colitis decreases the surgical time and shows a tendency to decrease the conversion rate.



Multiple Appendiceal Diverticula

Experience of the Reduced Port Surgery for Colorectal Laparoscopic Surgery

N. Ozlem Samsun Education and Research Hospital, Samsun, Turkey Congenital anomaly of the appendix is very rare. It may seen incidentally in any abdominal operation except appendectomy. A congenital true diverticulum of the appendix is very uncommon. Case: a female patient in age 20 was operated for acute appendicitis. the appendix had multiple diverticula in laparoscopy. Appendectomy procedure and postoperative course was uneventful. The appendix vermiformis had also multiple diverticula macroscopically. Diverticulum of the appendix was on antimesenteric side, did not has infection. The appendiceal diverticula are very rare anomalies; there were only about 50 cases with congenital appendiceal diverticula in the literature. The diverticula of an appendix may be congenital or acquired. Congenital one is an true diverticula that has a mucosa, submucosa, serosa and also a muscular layer. Acquired diverticula is a false diverticula and does not have a muscular layer. Congenital appendiceal diverticula was thought that it is a developmental anomaly; caused by appendiceal duplication, cause by noting to recanalize appendiceal lumen at the end of development, noting to close the vitelline canal. There are diverticula in 0.3–2.2 % of the population. Most of them are acquired. Congenital diverticula are very rare in frequency of 0.014 %. Acquired diverticula are multiple mostly and in mesoappendix. But congenital ones are single and in antimesenteric border. Our case had diverticula that are in antimesenteric side and multiple and also true ones. Our case is original, cause has true and congenital diverticula and multiple diverticula in antimesenteric border. Best of our knowledge is an very rare occurence of a diverticula. A similar case was presented by Yucel et al. in j gastrointestinal surg. Their case had diverticula on antimesenteric border. They concluded it was a incidental finding.

S. Kitashiro, S. Okushiba, T. Okubo, Y. Kawarada, M. Kawada, Y. Suzuki, K. Yamamoto, H. Katoh Tonan Hospital, Sapporo, Japan Introduction: We introduce our technique of the three trocars method for colorectal cancer. This method means to perform surgery without assistant. It may operative offer many unique advantages, e.g., operator can control the operative view directory, it may diminish human error, enable the operation to progress speedily, and provide significant economic benefits (human assistant in not necessary. And it’s very useful when Single port surgery was introduced, because many points (operative procedure, the way to obtain adequate operative field) are similar to the three trocar method. Method: A total of 688 cases (included 70 Single port surgery) diagnosed with colorectal cancer between 2004 and 2013. Operative, and post operative characteristics including overall survival and surgical complication were analyzed. Result: The 5-years survival rate is 89 % in stage II and 70 % in stage III. The average surgical time was about 120 minutes for the colon, 150 minutes for the rectum and 112 minutes for single port surgery. In almost all operations, we successfully managed to get an adequate operative field. Only 14 patients were converted to conventional technique, but there were no additional trocar in single port surgery cases. Conclusion: We hereby report on the characteristics and outcomes of the three trocars method in our institute. And feasibility of this method was indicated. We believe that this method will prevail in terms of bringing benefits for single port colorectal cancer surgery.

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Outcomes of Laparoscopic Resection for Colorectal Cancer in Patients with Previous Abdominal Operations

Division of the Rectum with Intentional 2 Times in the Low Anterior Resection for Rectal Cancer: A Challenge Against Anastomotic Leakage

Y. Shingu, H. Hasegawa, E. Sakamoto, S. Komatsu, S. Norimizu, K. Akahane, K. Inaba, Y. Taguchi, T. Isagi, A. Makino, M. Watanabe, Y. Miura, M. Santo, N. Ohara, Y. Hara Nagoya Daini Red Cross Hospital, Nagoya, Japan

N. Ueno Takatsuki General Hospital, Takatsuki, Japan

Background: Previous abdominal surgery appears no longer a contraindication for laparoscopic surgery. However, there is little evidence concerning the safety of laparoscopic surgery for colorectal cancer with the increased difficulty. The aim of this study was to evaluate the impact of previous abdominal operations on laparoscopic resection for colorectal cancer in terms of short and long-term outcomes. Methods: Between January 2001 and March 2013, 1269 patients of colorectal cancer, without distant metastasis or invasion to adjacent organs, underwent laparoscopic colorectal resection. They were divided into two groups: 332 patients with previous abdominal operations (PAO group) and 937 without previous abdominal operation (NPAO group). Their clinical records in our prospectively maintained database were compared between two groups. Results: The two groups were homogeneous for clinical feature, including tumor location and stages. Conversion rate of PAO (9.6 %) was significantly higher than that of NPAO (3.4 %). There was no significant difference in mean operating time, mean estimated blood loss, and mean number of retrieved lymph nodes between the two groups. Time to recovery of bowel function and length of postoperative hospital stay were similar in both groups. Morbidity rates were also comparable (PAO 27.7 % vs. NPAO 28.0 %, p = 0.930). One surgical-related death (due to sepsis) occurred in NPAO group. Five-year overall survival rates in PAO and NPAO group were 85.8 % and 85.3 %, respectively, with no statistical significance. Conclusion: Although laparoscopic surgery in PAO group was associated with an increased conversion rate, the short-time and long-time outcomes were not affected. These results suggest that laparoscopic surgery for colorectal cancer following prior abdominal surgery is a safe and feasible procedure with sufficient tumor clearance.

Background: Laparoscopic low anterior resection with double-stapling technique for lower rectal cancer is considered technically demanding and challenging because of its difficult rectal transection and anastomosis which influence incidence of anastomotic leakage. It has been described that division of the rectum with only once is the best way against the leakage in spite of its difficult manipulation with 60 mm long stapler in the narrow pelvic space. To overcome its difficulty in handling 60 mm long stapler in the narrow pelvic space, we perform division of the rectum with 2 times intentionally using 30 or 45 mm long stapler. We will describe and exhibit our technique of the low anterior resection, especially with focus on division of the rectum. Method: After mobilization of the rectum to the pelvic floor, perirectal tissue on the transection line is excised. A detachable intestinal clip is applied on the line in order to perform intestinal irrigation and flatten the rectum. Rectum is divided along with the clip by halves with two times using 30 or 45 mm long stapler intentionally. Trans-anal anastomosis between rectum and upper colon is made with a circular stapler, when the crossing of staple line is pierced. Result: Ninety three cases of rectal cancer underwent anterior resection from April 2009 to December 2013, in 73 cases of which double stapling technique was performed. Among these 73 cases overall anastomotic leakage rate was 11.0 % (8/73). Leakage rate after rectal division with only once was 10.3 % (4/39) and one with 2 times was 9.1 % (2/ 22). The difference was not observed between two groups in average operation time (230.1 min. vs. 252.3 min.) and the amount of bleeding (38.0 ml vs. 41.3 ml). Conclusion: Division of the rectum with intentional 2 times is considered to be maneuver which can be enforced without making the stress and raising the risk of anastomotic leakage under the laparoscope low anterior resection which needs transection in lower order more.



A Prospective Study Addressing the Safety and Feasibility of TriStapletm in Double Stapling Technique for Laparoscopic Surgery for Colorectal Cancer

Laparoscopic Abdominoperineal Resection for Rectal Cancer

H. Hasegawa, K. Okabayashi, Y. Ishii, M. Tsuruta, M. Matsuda, Y. Kitagawa Keio University, Tokyo, Japan Aims: The progress of surgical stapling devices has brought about great change in anastomotic techniques for colorectal resection of left-sided colorectal cancer, and the ‘doublestapling technique’ has been the standard procedure in current clinical practice. Although several stapling instruments have been adopted, the safety and feasibility of these staplers have not yet been validated. The aim of this study is to assess the clinical application of novel stapling devices, Endo GIATM Reloads with Tri-StapleTM Technology, and clarify its feasibility and clinical safety. Methods: Patients with left-sided colorectal cancer requiring double stapling technique were consecutively enrolled in this study between 2012 and 2013. The utilized stapling system was Endo GIATM Reloads with Tri-StapleTM as a linear stapler and DST SeriesTM EEATM Staplers as a circular stapler. This study was approved by the institutional ethical committee and written informed consent was obtained from every patient. All data were prospectively collected. Results: A total of 51 patients were enrolled in this study, where 27 (53 %) had sigmoid colon cancer and 24 (47 %) rectal cancer. No diverting stoma was created. The number of firing staplers required at distal rectal division was within the range of one to two (one 32 cases and two 19 cases). After the division of rectum, inappropriate staple formation on the suture line and oozing from the suture line was observed in 8 (16 %) and 4 (8 %), respectively. At colonoscopy after completion of anastomosis, oozing from the suture line was observed in 4 (8 %). Postoperative complications developed in 6 patients, which included anastomotic leakage in two. Conclusion: Application of the novel surgical stapling instruments, Endo GIATM Reloads with Tri-StapleTM, was thought to be safe and feasible in double stapling technique in laparoscopic colorectal surgery.

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K. Sakamoto, H. Ro, K. Kure, H. Honjo, J. Aoki, Y. Okazawa, R. Takahashi, S. Ishiyama, K. Sugimoto, Y. Yaginuma, M. Takahashi, Y. Kojima, M. Goto, A. Okuzawa, Y. Tomiki Juntendo University, Tokyo, Japan Aims: Laparoscopic colon cancer surgery has been widely employed in recent years. However, the efficacy of laparoscopic surgery for rectal cancer (RC) remains controversial. We aimed to clarify the feasibility and oncologic outcomes of laparoscopic abdominoperineal resection (Lap APR) for rectal cancer performed at our institution. Method: This study was retrospective, employing results obtained between January 2005 and December 2013, and included 29 patients who underwent Lap APR for RC. We administered chemoradiation therapy (CRT) to 12 patients and neoadjuvant chemotherapy (NAC) to 4 patients with locally advanced lower RC (cT3/cT4 or N+), who agreed to receive preoperative treatment. Results: The 29 study group patients were 17 males and 12 females with a median age of 70 years. A partial vaginal resection was required in 3 patients, and lateral pelvic lymph node dissection in 16. In the more recent cases, dissection of the external anal sphincter was performed via the laparoscopic trans-abdominal approach and the perianal direct (open) approach at the same time. Operative complications occurred in 7 (24.1 %) patients, but did not necessitate conversion to open surgery. Postoperative complications occurred in 7 (24.1 %) patients; perianal infection in 5, and peritonitis and bowel obstruction in one each. There were no mortalities during the perioperative period. However, one patient underwent reoperation for bowel obstruction and another for delayed peritonitis. The radial margin (RM) was positive in 2 patients, and the median number of harvested lymph nodes was 21 (range; 0 to 54). Postoperative hospital stay was 15 (range; 7 to 67) days. The median follow-up was 23 (range; 1 to 83) months. Local recurrence was documented in 2 (6.9 %) patients, one of whom had a positive RM. Distant metastasis occurred in 3 patients, other than the 6 who underwent resection for Stage 4 primary RC. Conclusion: Lap APR is regarded as an excision of the external anal sphincter, and its feasibility depends on individual tumor extension features, because surgeons rely on a clear magnified pelvic visualization. Lap APR for RC is both safe and feasible, having no adverse impact on oncological outcomes.

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Intraoperative Colonoscopy for Anastomosis Assessment in Laparoscopic Assisted Left-Sided Colorectal Surgery

Feasibility and Safety of Laparoscopic Resection Following Stent Insertion for Obstructing Colon Cancer

C. Matsuda, K. Danno, S. Miyazaki, K. Fujitani, M. Kubota, J. Kawata, Y. Okumura, M. Nomura, M. Nishimura, Y. Matsui, Y. Tanaka

H. Tominaga, Y. Shimizu, S. Yamashita, K. Odagiri, T. Kurokawa, N. Honmyo, J. Moon, M. Inoue, T. Irei, M. Tanemura, N. Hatanaka, W. Kamiike

Osaka General Medical Center, Osaka, Japan

Kure Medical Center, Kure, Japan

Introduction: The aim of our study was to evaluate the use of intraoperative colonoscopy in laparoscopic assisted left-sided colorectal resection for the assessment of anastomosis. Methods: and Procedures: All consecutive laparoscopic assisted left-sided colorectal resections performed at our department between October 2008 and December 2013 were included in this study. After colorectal resection and reanastomosis with double stapling technique, an intraoperative colonoscopy was performed to detect anastomosis risk. Results: A total of 258 patients were enrolled in this study, and the anastomosis was checked via colonoscopy. Of the 258 patients, 102 (39.5 %) underwent a laparoscopic assisted sigmoid resection, 73 (28.3 %) a laparoscopic assisted high anterior resection, 83 (32.2 %) a laparoscopic assisted low anterior resection. In this study, 3 (1.2 %) anastomostic bleeding were detected and endoscopic clipping was performed during surgery. A total of 3 (1.2 %) postoperative anastomostic bleeding occurred, but did not required hemostasis. 7(2.7 %) anastomostic leakages were detected and oversewn during surgery. A total of 10 (3.9 %) anastomostic leakage occurred in the early postoperative period. Conclusions: Intraoperative air leak test using colonoscopy might not predict the possible postoperative anastomotic leakage; however, it is useful for the detection of the unexpectable failure around anastomotic site. The complication rate of anastomosis in laparoscopic-assisted colon resection can be reduced by intraoperative colonoscopy.

Introduction: Colorectal carcinoma can present with acute intestinal obstruction in 7–30 % of cases. In these cases, emergency surgical decompression becomes mandatory as traditional treatment option. Although effective, this is associated with high mortality due to old age, anesthetic risk and emergency surgery risks. Self-expanding metallic stent (SEMS) have been employed both as a palliative treatment for patients with obstructing colorectal cancer or as a bridge to surgery for potentially resectable colorectal cancer. Accordingly, SEMS as bridge to surgery increases the possibility of laparoscopic resection. Aims: The aim of the present study was to assess the feasibility and safety of laparoscopic resection. Methods: Between January 2012 and June 2013, laparoscopic resection was performed in 72 patients with colon cancer. 8 patients out of 72 underwent preoperative SEMS placement (i.e.; bridge to surgery). A retrospective analysis was conducted by the comparison between with stent (S group) or without stent insertion (NS group). Background factors include as following after was age, sex, ASA, tumor location, tumor size, T factor, N factor, number of metastatic lymphnodes and stage. Perioperative details included operative time, blood loss, length of hospital stay and perioperative complications. Results: Although primary factors of S groups were significantly advanced than those of NS group in (tumor size (S group:NS group; 5.4 ± 0.9:3.6 ± 2.2 cm) and depth (?T2/T3?; 0/8:26/38)), no significant differs were observed in remaining factors. Moreover, no significant differs were detected in perioperative details (operative time (234.6 ± 50.3:197.8 ± 56.5 minutes), blood loss (140 ± 163:97.9 ± 134 ml), hospital stay (14.5 ± 5.3:14.9 ± 6.9 days) and perioperative complication (Yes/No; 1/7:13/51)). Conclusion: The present study demonstrates that the presence of a SEMS does not compromise the laparoscopic approach. Laparoscopic resection following stent insertion for obstructing colon cancer could be performed with a favorable safety profile and short-term outcome. Large-scale comparative studies with long-term follow-up are further needed to demonstrate a significant benefit of this approach.



Oncologic Outcomes of Laparoscopic Versus Open Surgery After Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer

Laparoscopic Surgery for the Splenic-Flexure Colon Cancer

K.H. Lee, J.S. Kim, J.Y. Kim Chungnam National University Hospital, Daejeon, Korea Aims: Oncologic outcomes of laparoscopic surgery after neoadjuvant chemoradiotherapy in rectal cancer have not been demonstrated. We compared oncologic outcomes of laparoscopic and open surgery after neoadjuvant chemoradiotherapy in rectal cancer retrospectively, with the aim to evaluate oncologic safety and efficacy of laparoscopic surgery. Methods: Between 1994 and 2013, patients diagnosed to locally advanced rectal cancer and treated by neoadjuvant chemoradiotherapy following radical surgery were included in the retrospective comparative study. Patients who had distant metastasis or treated by local excision were excluded. Survival were estimated by Kaplan Meier method and compared with the Cox-proportional hazard model. Results: 214 patients were diagnosed to locally advanced rectal cancer and treated by neoadjuvant chemoradiotherapy. Three patients diagnosed of distant metastasis after neoadjuvant chemoradiotherapy and 5 patients treated with local excision were excluded. One hundred seventeen patients and 99 patients were included in laparoscopic group and open surgery group. Surgical and pathologic result including retrieved lymph nodes and circumferential resection margin were similar in the two groups. There was no significant difference of 5 year local recurrence. (4.3 % vs. 6.1 %, p = 0.133) By contrast, 5 year disease free survival was significantly higher in the laparoscopic group. (82.1 % vs. 64.6 %, p = 0.010). Conclusion: Oncologic outcomes of laparoscopic surgery after neoadjuvant chemoradiotherapy in locally advanced rectal cancer are suggested to be similar with those of open surgery.

A. Suzuki Japan, Hidaka, Japan Purpose: The main feeding artery of the splenic-flexure colon cancer is middle colic artery (MCA) or left colic artery (LCA). About lymph nodes dissection, it is important which artery is main feeding artery. Usually, we remove both intermediate lymph nodes of the MCA and the LCA, additionally the origin of main feeding artery is removed. This study was assessed about difference of short term results between two feeding arteries of MCA and LCA. Methods: The laparoscopic surgery for splenic flexure cancer was performed in 51 patients during April 2007 to November 2013. Assessed factors were gender, age, operation time, blood loss count, pathological stage, level of lymph node dissection, lymph node harvests, and complication. Result: The MCA was the main feeding artery in 28 patients (MCA group), and the LCA was the main feeding artery in 23 patients (LCA group). Significant differences between MCA group and LCA group were observed as follows; blood loss count (\ 30 g): 82.1 % (MCA), 47.8 % (LCA) (p = 0.01), pathological stage (pStage II–IV): 50 % (MCA), 73.9 % (LCA) (p = 0.014). About level of lymph node dissection, 46 % of MCA were D2 and 56.5 % of LCA were D3. This distribution was related to pathological stage. Stage II or more was 50 % in MCA group and 73.9 % in the LCA group. Gender, age, operation time, number of dissection lymph nodes, and complication were no significant difference. Conclusion: In laparoscopic surgery for the splenic-flexure colon cancer, blood loss count of MCA group was less than that of LCA group. This has potential impact on level of lymph node dissection, because LCA group was more advanced stage in this study.

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Laparoscopic Surgery in Colon Cancer. Review of 487 Cases

A Novel Technique for Intracorporeal End-to-End Anastomosis in Totally Laparoscopic Colectomy

C. Pe´rez San Jose´1, M. Aguinagalde2, F. Ellacuria2, S. Leturio2, E. Martin2, G. Maitane2, E. Eider2 1

2

Hospital de Basurto - Bilbao, Bilbao, Spain; Hospital de Basurto, Bilbao, Spain Introduction: A retrospective study has been made of a series of consecutive laparoscopic colectomies in patients with colon cancer during the last 15 years. Material and Methods: A total of 487 patients with colon cancer were operated on by laparoscopy for colon cancer between May 1998 and December 2013. The procedure was initiated by two surgeons with experience in advanced laparoscopic surgery. Tumours located in the rectum are not included in this series, nor are the tumours in which there was preoperative evidence of infiltration of neighbouring organs. The presence of distant metastasis, prior abdominal surgery or tumours with intraoperative finding of infiltration of neighbouring organs were not motives for exclusion. Results: The mean age of the patients is 70 years (range 31–95) with a male/female ratio of 2/1.4. The location of the tumours was: right colon 38 %, transverse 6 %, descending 10 %, sigmoid 43 % and synchronous carcinomas in 3 %. The surgical techniques used were: Right hemicolectomy 207 (43 %), left hemicolectomy 57 (12 %), subtotal colectomy 5 (1.5 %), sigmoidectomy 175 (36 %), LAR 22 (4 %), segmental resection 13 (2.5 %) and Hartmann operation 2 (0.5 %). In 76 cases (16 %) complementary surgical techniques were also practiced for associated pathology or for oncological needs. The surgery was performed with the oncological intention in 437 cases (90 %). It was converted to open surgery in 2 cases (0.4 %). The operative time was 165 ± 25 minutes. The mean hospital stay was 7.6 ± 6.2 days. The rate of complications was 10 % and of reoperation in 22 cases (4.5 %). The operative mortality was 1 % (5 cases). TNM classification: Stage I 25 %, II 40 %, III 24 %, IV 11 %. The number of lymph nodes was 13 ± 6. During the follow-up, 4 port-site metastases (0.8 %) were detected. Conclusions: Laparoscopic colectomy is a reliable and safe procedure. In surgical teams with experience in advanced laparoscopic surgery it is a technique with low morbi-mortality and minimum rate of conversion to open surgery and of reoperation, which allows shortening the hospital stay. As for the oncological results, the number of nodes obtained is correct with a low incidence of port-site metastasis.

E. Harada, N. Kugimiya, K. Oka, T. Enoki, K. Hamano Yamaguchi University, Ube, Japan Aims: To evaluate the safety and feasibility of intracorporeal end-to-end anastomosis using a novel procedure, which we have termed the modified book-binding technique (mBBT), in totally laparoscopic colectomy. Methods: The mBBT was conducted as follows: (1) a small hole was created for insertion of the laparoscopic stapler at the mesenteric side of the stapled ends of the intestine; (2) the stapler was inserted into each hole and held in a parallel manner; (3) before stapling, the stapled ends of the intestine were repositioned to resemble double doors that opened from the center with the small holes remaining as pivot points, and the stapler was inserted deeply; (4) after stapling, the stapled anterior walls of the intestines were resected owing to ischemia; (5) finally, the anterior wall was restapled with anchoring sutures and/or a handsewn closure was made with barbed sutures. Results: The first case occured postoperative ileus. Other cases showed no complications, including anastomotic leakage, intraabdominal abscess, and others. Conclusion: mBBT enables expansion of the anastomotic area and further applications such as colonic and ileocolic anastomosis. This technique is safe and feasible for end-to-end anastomosis.



Minilaparoscopic Approach for Single Port Laparoscopic Colectomy Using Multi-channel Access Device

Single Incision Laparoscopic Hartmann’s Procedure for Recurrent Peri-sigmoid Abscess and Sigmoid Stenosis from Crohn’s Disease

Y. Kawakami, R. Ganeko, H. Fujii, Y. Hirose Japanese Red Cross Fukui Hospital, Fukui, Japan Aims: Recently, reduced port laparoscopic surgery using minilaparoscopic instruments has been widely adopted as innovative features in minimally invasive surgery. We previously reported that the application of newly developed 2–3 mm minilaparoscopic instruments with supra-pubic approach in combining conventional 5 mm trocar in single port access laparoscopic appendectomy could be feasible with excellent cosmetic results. Thus we attempted to apply modified technique using minilaparoscopic instruments combined with novel multichannel access device at umbilicus for single port laparoscopic colectomy. Methods: From January to August of 2013, 5 consecutive patients with colon cancer (cT1–2, N0, M0, cStage I) were assigned to undergo single port laparoscopic colectomy at our hospital. We conducted to study our modified technique using multichannel access device (EZ accessTM, X-GATETM) with reusable metallic trocar (ENDOTIPTM, 3.3, 6 mm in diameter, KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) as a working port, and VERSAPORTTM, 5 mm in diameter, COVIDIEN, INC., Mansfield, MA, USA, XCELTM, 5 mm in diameter, ETHICON ENDO-SURGERY, INC., Pittsburgh, PA, USA) as a camera port. Straight-type grasping forceps and dissecting forceps (3.3 mm in diameter) were used through the lower abdominal quadrant port in the triangular co-axial setup. Results: Clinical records of 17 cases of conventional laparoscopic colectomy (From May of 2012 to April of 2013) were analyzed retrospectively in background factors, operative time, number of dissected lymph node and length of hospital stay. Of them, we had 5 cases with modified single access colectomy (male 2, female 3, average age of 63.6, range 52–76) as was 71.2(m 9, f 8), 53–83 in the control group. The average operative time in the modified group was 198 min (81–270), significantly shorter than that of 232 (113–396) in the control group. The average number of dissected lymph nodes in the modified group was 17.4 as was 13.6 in the control group. The mean hospital stay in the modified group was 13.2 days, same as that in the control group. Conclusions: We conclude that modified technique for single access laparoscopic colectomy for colon cancer could be a promising option with safety and an attractive advantage of better cosmetic result in managing this condition.

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F. Trelles, E. Chouillard Hoˆpital de Poissy/Saint Germain-en-Laye, Poissy, France Introduction: Multiple expert centers in colorectal surgery worldwide have been recently experiencing and expanding the use of more refined minimally invasive modalities to reduce parietal trauma and improve cosmesis, including naturally orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) with encouraging short-term outcomes. From different systematic reviews and meta-analysis, there appears to be compelling evidence that SILS colectomy results in faster recovery from reduced postoperative pain over conventional laparoscopy. SILS reversal of Hartmann’s procedure has already been performed successfully. To the best of our knowledge, we aim to present the first case of Hartmann’s procedure through SILS. Materials and Methods: A 53-year-old female patient with a past medical history of Crohn’s disease with severe perianal and colonic involvement now presents with a recurrent peri-sigmoid abscess close to the rectal sigmoid junction within a single site of structuring. She was first treated by percutaneous CT-guided drainage of the abscess and ulteriorly with sigmoid colon resection and end-stoma (Hartmann’s procedure). Patient is placed in the split-leg position (French position). The multichannel platform (Gelpoint) is placed through a single skin incision at the proposed stoma site. Sigmoid resection is performed with the lateral-to-medial technique. Rectal division is performed after getting a through and through defect to the mesocolon at the rectal sigmoid junction. Sigmoid mesocolon is divided cephalad initially with energy source device then with endostapler. A Jackson Pratt drain was place in the pouch of Douglas through the pigtail site. After taking down the splenic angle of the colon, the diseased sigmoid segment is pulled through the stoma site without tension. Proximal colon is divided extracorporeally and colostomy is finally performed. Results: The patient tolerated the procedure well without intraoperative complications neither significant blood loss. Operative time was 210 min. The patient made an entirely uncomplicated recovery, resumed diet on day 1 and was discharged on day 3. Final pathology was consistent with Crohn’s disease without malignancy. Conclusion: Hartmann’s procedure through SILS is feasible and safe. Although technically challenging, physiologic benefits may be obtained including fast recovery and less pain.

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The Efficacy of Umbilical Closure Without Epidermal-Suturing on Surgical Site Infections After Laparoscopic Colorectal Surgery

Efficacy and Safety of Laparoscopic Surgery in Elderly Patients with Colorectal Cancer

S. Shibasaki, S. Homma, N. Minagawa, H. Kawamura, N. Takahashi, A. Taketomi

Y. Inoue, A. Kawamoto, Y. Okugawa, J. Hiro, S. Saigusa, Y. Toiyama, T. Araki, K. Tanaka, Y. Mohri, M. Kusunoki

Hokkaido University, Sapporo, Japan

Mie University Graduate School of Medicine, Tsu, Japan

Background: Despite recent advancements in surgical technique including laparoscopic surgery, surgical site infections (SSIs) remain the common complication after colorectal resection. Once the SSI occurs, patients are forced to be poor cosmetic outcomes, prolong hospital stays, and increase hospital costs. As a result, their qualities of life were markedly impaired. In our institute, the non-suturing closure method of umbilical epidermis is applied in laparoscopic colorectal resection for prophylaxis of the SSI, especially wound infection. Here, we aimed to evaluate retrospectively the efficacy of this technique on SSIs in patients with colorectal cancer. Patients: From January 2010 to November 2013, 140 patients diagnosed with colorectal cancer underwent elective laparoscopic colorectal resection. The patient group was comprised of 87 males and 53 females, with a mean age of 65.8 ± 12.0 years. A mean body mass index was 23.2 ± 4.0 kg/m2. The location of the tumor was the colon in 86 patients and rectum in 54 patients. Methods: The umbilicus was used for camera port placement. Following intracorporeal maneuver, the umbilical incision was extended about 5 cm for extraction of the specimen and reconstruction. The umbilical fascia was closed with interrupted 0-vicryl sutures, and then pressed by a swab and sealed using a water-vapor-permeable film without epidermal suturing. The umbilical infection was defined as either the presence of purulent discharge, fat lysis, or detection of bacteria in cultures. Results: Conversion from laparoscopic to open surgery was required in 4 patients (2.8 %). The median operation time was 193 (range: 83–624) minutes, intraoperative blood loss was 10 (range: 0–1590) ml, and postoperative hospital stay was 14 (range: 8–48) days. Total SSIs occurred in 5 patients (3.6 %); umbilical superficial infection in three (2.1 %), superficial infection of peristomal site in one (0.7 %), and anastomotic leakage in one (0.7 %). Deep wound infection did not occur. Other postoperative complications (ClavienDindo classification = grade 2) occurred in 19 patients (13.6 %). Grade 3 in three (2.1 %, one with urinary disturbance, and two with acute cholecystitis) and Grade 4 in one (0.7 %) with acute heart failure. Conclusion: This umbilical closure technique has a great beneficial efficacy on the SSI in laparoscopic colorectal surgery.

Purpose: Colorectal cancer (CRC) is predominantly a disease of elderly. Elderly patients also have the potential for poorer outcomes due to an increased burden of comorbidities, functional dependency, and limited life expectancy. We aimed to evaluate the short-term outcome of laparoscopic surgery in elderly patients with CRC. Methods: One hundred forty eight patients who underwent laparoscopic surgery at our institution between June 2000 and December 2011 were enrolled. We compared differences between elderly patients (age = 75 years, n = 48) and non-elderly patients (age \ 75 years, n = 100), and evaluated the demographics, disease-related, operative and short-term data. Results: There were no significant differences in gender, body mass index, tumor characteristics and type of surgical procedures between the elderly and non-elderly groups. Although we found significant correlations between age and American Society of Anesthesiology score (ASA) (p = 0.0329) and cardiovascular disease (p = 0.0127), there were no significant differences between the two groups in surgical outcomes including operating time, bleeding, lymph-node harvest, complications and hospital stay period. Postoperative major and minor complications occurred in 24(16.2 %) of 148 patients. ASA and comorbidities were significantly correlated the complications, and multivariate analysis showed that not age but pulmonary disease was an independent factor affecting the postoperative complications [Odds Ratio (OR) 3.21, 95 %confidence interval (CI) 1.02–10.14, p = 0.0470]. Conclusion: Chronological age alone should not contraindicate laparoscopic surgery for CRC in elderly patients. Appropriate selection criteria for laparoscopic CRC surgery in both elderly and non-elderly patients may include pulmonary comorbidity.



Laparoscopic Left Hemicolectomy for Left Colon Carcinoma: A Retrospective Comparison Study with Open Surgery

Single Port Laparoscopic Surgery in Acute Appendicitis: Single Center Experience of Initial 374 Cases

J. Ma, A.G. Lu, B. Feng, Y.P. Zong, M.L. Wang, J.W. Li, J. Sun, M.H. Zheng

B.M. Kang, J.W. Hwang, B.Y. Ryu

Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai Min, Shanghai, China Objective To investigate the technique, short and long-term outcomes of laparoscopicassisted left hemicolectomy for the left colon carcinoma. Methods: Retrospective review of 122 consecutive patients with left colon cancer, who underwent laparoscopic (LAP) or open (OPEN) left hemicolectomy between January 2003 and December 2012. The technique of operation, status of recovery, complications, oncological clearance and results of long-term follow-up were compared between the LAP and the OPEN for left colon cancer. Results: Three of the LAP cases (4.2 %) were converted to open surgery. The mean operative time of the LAP and the OPEN was 153.5 ± 40.4 minutes and 157.6 ± 43.5 minutes, respectively (P [ 0.05). The estimated blood loss for the LAP was 109.4 ± 83.1 mL, which was less than the OPEN (168.6 ± 184.3 mL, P = 0.036). The LAP group had shorter hospital stay (11.1 ± 4.1 d vs. 13.6 ± 7.4 d, P = 0.019). The number of lymph nodes harvested was 14.3 ± 7.0 for the LAP and 13.0 ± 5.7 for the OPEN (P [ 0.05). Complications were observed in 9 patients (11.3 %) for the LAP and 10 (15.7 %) for the OPEN (P = 0.298). The median follow-up time was 45 (5–92) months for the LAP and 44 (7–93) months for the OPEN. Overall survival and disease free survival of the LAP was 76.6 % and 82.8 %, respectively, which were comparable with the OPEN (74.5 % and 81.2 %, P [ 0.05). Conclusion: Laparoscopic surgery is feasible and safe for patients with left colon cancer and can provide favorable short-term and long-term outcome.

Chuncheon Sacred Heart Hospital, Hallym University College of medicine, Chuncheon, Korea Aims: Single port laparoscopic surgery (SPLS) is recently at the center of attention of new operative technique in various field of surgery. It’s minimal incision is expected to decrease the pain and to improve the postoperative course of recovery and cosmetic results. We performed retrospective analysis of initially experienced cases with SPLS to evaluate the safety and efficacy in acute appendicitis. Methods: Between December 2008 and November 2013, SPLS was performed in total 383 patients with radiologically-diagnosed acute appendicitis. After exclusion of 9 patients with combined bowel resection for neoplastic lesion, total 374 patients were included in analysis. Data was collected by review of hospital chart and analyzed retrospectively. Results: Total 374 patients were composed of 185 men and 189 women with mean age of 31.3 years (range 7–85). Mean body mass index was 22.7 kg/m2. At admission, mean WBC count was 11,590/lL and mean hemoglobin was 13.9 g/dL. In 25 (6.7 %) patients, appendix was perforated with inflammation. Operation time was 36.7 minutes in average. In 66 (17.6 %) patients. draining tube was inserted through the umbilical incision site. In 22 (5.9 %) patients, initially planning SPLS was converted to open (n = 21) or reduced port laparoscopic surgery (n = 1) and no intraoperative complication occurred. The average postoperative hospital stay was 3.5 days (range 2–12). Postoperative complication developed in 7 (1.9 %) patients: grade 1 in 3 patients, grade 2 in 3 patients and grade 3b in 5 patients according to the Clavien-Dindo classification. Conclusion: SPLS was able to performed safely and efficiently in acute appendicitis. However our study has some limitation of retrospective single arm analysis, therefore large scaled prospective comparative trial was warranted.

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Evaluation of the Clinical Factors Included with Anal Function After Laparoscopic Intersphincteric Resection for Lower Rectal Cancer

Technique for Laparoscopic Segmental Resection of the Splenic Flexure with Preservation of Inferior Mesenteric Artery

N. Matsuhashi, T. Takahashi, K. Ichikawa, T. Tanahashi, K. Yawata, H. Imai, Y. Sasaki, Y. Tanaka, N. Okumura, K. Yamaguchi, S. Osada, Y. Kazuhiro Gifu University, Gifu, Japan Background: Intersphincteric resection (ISR) has been reported as a promising sphincter-preserving operation in selected patients with very low rectal cancer. The aim of the present study was to evaluate the clinical factors included with anal function after laparoscopic ISR for lower rectal tumor Study Design: Between July 2008 and December 2013, 777 patients with primary colorectal cancer underwent surger, 419 patients with colorectal cancer underwent laparoscopic surgery at our single institution. In addition, 128 patients with low rectal cancer underwent laparoscopic surgery. 25 patients with lower rectal cancer underwent laparoscopic ISR, Technical feasibility and safety of ISR, short- and long- term outcomes after laparoscopic ISR were evaluated. Additional data related to fecal incontinence conditions of the postoperative patients were evaluated with the Modified Fecal Incontinence Quality of Life scale (mFIQL). Sphincter function was also evaluated by manometric study and anorectal sensation testing after 12 months. Results: There was no perioperative mortality, 3 complications occurred in 3 patients, and the morbidity rate was 12.0 % (3/25). Postoperative complications detected included bleeding in 1 patient and ileus in 2 patients of the laparoscopic ISR group. The rate of severe complications of grade? 3a was 12.0 % and that of grade? 3b was 4.0 % (Clavien-Dindo classification). In the matched case-control study, blood loss was significantly lower (p \ 0.05) in the laparoscopic ISR group. Median postoperative hospital stay was 13.2 days in the laparoscopic ISR group and was significantly shorter than that in the open ISR group. Cancer recurrence was detected in 1 (8 %) patient in 1 inguinal lymph node. mFIQL total score was 34.9 points from 12 months to 24 months after stoma closure and 37.6 points from 24 months to 54 months after stoma closure. No significant difference between groups was observed in mFIQL total score. No significant difference between the ISR and ULAR groups was observed in maximum resting and maximum squeeze pressures. Conclusions: Laparoscopic ISR for lower rectal cancer provides benefits in the early postoperative period without increasing morbidity or mortality. The outcome for continence is not worse after ISR than ULAR.

G. David1, E. Cassinotti2, E.M. Colombo1, G. Borroni1, A. Marzorati1, S. Spampatti1, L. Giavarini1, V. Quintodei1, L. Boni1 Universita` degli studi dell’Insubria, Varese, Italy; 2Ospedale di Circolo-fond. Macchi - University of Insubria, Varese, Italy 1

Aims: This video shows the technique for laparoscopic segmental resection of the splenic flexure for cancer with selective preservation of the inferior mesenteric artery (IMA) and ligation of the left colic vessels and left branch of the middle colic. Material and Methods: The patient is placed in lithotomic position with the bed tilted towards the right. The surgeon and the camera assistant stand on the right side while the assistant surgeon is positioned on the left. The pneumoperitoneum is induced using a Verres needle in left ipocondrium and 10 mm trocar inserted in right flank just above the umbilicus for the camera. Further 2 trocars (12 and 5 mm) were inserted in the right lower and right upper quadrants respectively, another 5 mm trocar for the assistant in the left ipocondrium. Results: The procedure starts with the mobilization of the small bowel toward the right abdomen and the identification of the ligament of Treitz. The IMA is partially dissected till the origin of the left colic artery and vein; at this point the left colic vessels are divided between clips. The procedure carries on with an extended dissection of the Toldt’s fascia and the identification at the level of Treitz’ ligament of the inferior mesenteric vein, that is isolated and divided between clips. The procedure carries on with the dissection of the mesentery of the left side of the transverse colon that will include the left branches of the middle colic vessels, the transverse colon is resected 10 cm from the tumor with an endoscopic linear stapler. The procedure continues with the mobilization of the descending colon that is then resected with an endoscopic linear stapler. After mobilization of the remaining transverse and sigmoid colon, the two segments are approximated to facilitate a side to side anastomosis that is performed extra corporally through a 4 cm para-rectal mini laparotomy used for specimen extraction. Conclusions: Laparoscopic segmental resection is feasible and can be performed respecting the oncological principles by ligation of the vessels at their origins.



Intra-operative Stapler-Related Complications of Laparoscopic Low Anterior Resection for Rectal Cancer

The Use of Percutaneous and Intra Abdominal Retractors for Reduced Port Colonic Surgery

Y.S. Lee, J.H. Kim, J.G. Kim

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

The Catholic university of Korea, Incheon, Korea Purpose: Laparoscopic low anterior resection for rectal cancer is technically demanding procedure and intra-operative stapler-related complications make it more complicated. The aim of this study is to analyze impact of intra-operative stapler-related complications on short-term surgical outcomes and clinical outcomes including anastomosis leakage and risk factors for stapler-related complications. Methods: Consecutive 363 cases of laparoscopic low anterior resection from August 2004 to November 2012 were enrolled in this study. We compared the surgical and clinical outcomes between two groups; groups with and without intra-operative stapler-related complications. And we also analyzed risk factors for stapler-related complications; we defined stapler-related complications like follows; 1) linear stapler failure; visible stapler-line disruption after linear stapler firing, 2) circular stapler failure; visible anastomosis line disruption after circular stapler firing, 3) air-leak test positive only; presence of air without visible stapler-line disruption after anastomosis. We defined persistent leakage like follows; 1) persistent contrast leakage was identified by gastrografin enema at 1 year after surgery, 2) anastomosis leakage was developed after ileostomy reversal. Results: There were 20 intra-operative stapler-related complications (5.5 %). There were more male, longer operation time and more diversion ileostomy in group with stapler-related complications. And group with intra-operative stapler-related complications needed more staplers to cut distal rectum and more splenic flexure mobilization. There were no differences in terms of morbidity, conversion rate, leak rate, diet start and hospital stays. Although there was no difference in terms of anastomosis leakage, there was significant more persistent anastomosis leak rate in the group with stapler-related complications. (15 % vs. 0.9 %, p = 0.000) In univariated analysis, risk factors for stapler-related complications were male sex, T4 stage and 3 or more the 3 staplers to cut distal rectum. Conclusion: The intra-operative stapler-related complications in laparoscopic low anterior resection increases operation time, number of stapler needed for distal rectal resection, rate of diversion ileostomy and rate of splenic flexure mobilization but do not adversely affect surgical morbidity and clinical outcomes. However intra-operative stapler-related complications increased persistent anastomosis leakage rate.

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University of Insubria, Varese, Italy Background: Laparoscopic colectomies are usually performed using 4 or 5 ports in different quadrants. In order to further reduce surgical trauma and to improve cosmetic, ‘reduced port surgery’ is becoming increasingly popular but it poses some limits mainly related to ergonomics and traction and contra-tractions. The use of percutaneous as well as endo-retractors may help to overcome some of these problems. This video shows our experience with new retractors during different reduced port, right, left and transverse colectomy. Materials and Methods: Two different retractors have been used: Percutaneous (T-PEA LIFTER, Surgical Perspective, Strasbourg, France), that thanks to the use of a straight needle attached a surgical suture that end with ‘plastic’ button can be introduced through a 10 mm port and used to lift solid organ in particular the fundus of the uterus during anterior rectal resection. Intra-abdominal adjustable retractors (VERSA LIFTER, Surgical Perspective, Strasburg, France) that allow dynamic organ suspension during laparoscopic procedures. The device is inserted in the abdominal cavity through an existing 10-mm port using a dedicated introducer and it is completely repositionable and adjustable intraoperatively. The system consists of two clips connected together by a 0.35 mm diameter Teflon-coated polyester thread. One clip is attached to the organ to be suspended, the other one is attached to the peritoneum in the desired suspension angle, while the thread between the two anchors adjusts the distance after their application (60 mm–115 mm). Clips can be easily manipulated in the abdominal cavity during surgery with a simple grasper and anchors can be re-placed numerous times; the grasper or a hook are also used to pull the thread loop, while holding the peritoneum clip in place, to determine the working length of the VERSA LIFTERÒ. Results: We used these devices during right, left and transverse colectomy for cancer and their use was always extremely intuitive requiring a minimal learning curve. No intra or post-operative complications related to those devices were reported. Conclusions: In our experience percutaneous and endo-retractors are helpful device that allow the reduction of the assisting port, usually required only for traction and contra-traction. during laparoscopic colectomies.

Surg Endosc



Quality of Life in Local Advanced Rectal Cancer Treated by TEM or Laparoscopic Total Mesorectal Excision After Neoadjuvant Radio-Chemoterapy

Laparoscopic Colorectal Cancer Surgery: Early Result in Initial Experiences

G. d’Ambrosio, A. Balla, F. Mattei, S. Quaresima, A. Paganini, E.L. Lezoche Sapienza University, Rome, Italy Aims: In selected patients with N0 rectal cancer Endoluminal Loco-Regional Resection (ELRR) by Transanal Endoscopic Microsurgery (TEM) may be an alternative treatment option to Laparoscopic Total Mesorectal Excision (LTME). Aims of this study is retrospectively compare the short and medium term Quality of Life (QoL) in patients with iT2iT3 N0-N + rectal cancer, who underwent ELRR or LTME after neoadjuvant Radio-Chemoterapy (n-RCT). Methods: Thirty patients with iT2 or iT3 rectal cancer who underwent TEM (n = 15) or LTME (n = 15) were enrolled in this study. QoL was evaluated by EORTC QLQ-C30 and QLQ-C38 questionnaires at admission, after n-RCT and 1, 6, and 12 months after surgery. Results: No statistically significant differences, before and after n-RCT, were observed between two groups. At 1 month, QLQ-C30 showed statistically significant differences with better results in the TEM group in the following items: Nausea/Vomiting (p = 0,05), Appetite Loss (p = 0,003) and Costipation (p = 0,05). In QLQ-CR38 significant differences were observed for better scores in TEM group in the following items: Body Image (p = 0,05), Sexual Functioning (p = 0,03), Future Perspective (p = 0,05) and Weight Loss (p = 0,036). At 6 months in QLQ-C30, LTME showed worst statistically impact on Global Health Status (p = 0,05), Emotional Functioning (p = 0,021), Dyspnoea (p = 0,008), Insomnia (p = 0,012), Appetite Loss (p = 0,014) and in QLQ-CR38 in Body Image (p = 0,05) and Defecation Problems (p = 0,001). At one year, the two groups were homogenous in QLQ-C30 questionnaire. In QLQ-CR38, TEM results were better than LTME results in Body Image (p = 0,006), Defecation Problems (p = 0,01) and Weight Loss (p = 0,005). Conclusions: No statistically significant difference between the two group was observed after n-RCT. Patients in the TEM Group had better QoL than LTME Group at 1 and 6 months after surgery in both questionnaires. At 12 months after surgery, only QLQ-CR38 questionnaire showed better results in the TEM Group.

M. Ilhan, H. Yanar, M. Ilhan, K. Gok, I. Azamat, S. Egin, S. Meriç, K. Gu¨nay, C. Ertekin Istanbul University, Istanbul medical faculty, Istanbul, Turkey Introduction: The aim of the this study is to present early results of laparoscopic resection of colorectal cancer patients. Material and Methods: hundred and thirty patients hospitalized and laparoscopic resection is done between January 2009 and September 2012 with the diagnosis of colorectal cancer were evaluated and the early results have been reported. Conclusion: 67 of 130 cases were male and 63 were female, median age was 58(24–96), median length of hospital stay 8.3 (4–2) days. In 54 patients left colon, 51 cases rectum, 25 cases right colon tumors were present. In 5 cases (%3.8) operation is completed with open surgery. The most common complication was wound infection. 4 patients underwent reoperation because of anastomotic leakage. Median follow up time was 17.5 (3–57) months, local recurrence was observed in one patient during this time (T4a). Recurrences were not detected at the port site, incision and the pelvis. Postoperative mortality was not observed in any patients in the early stages. Discussion: Laparoscopic colorectal surgery can be performed safely and efficiently in centers that have experience about laparoscopic and open colorectal surgery. In any of the cases a negative effect of laparoscopy is not detected



Our First Experience of Right Hemicolectomy by SILS (Single Incision Laparoscopic Surgery)

Laparoscopic Right Hemicolectomy Strategy in Colonic Obstruction

M. Ilhan, H. Yanar, B. Ozcinar, M. Ilhan, K. Gok, Z. Akyol, Z. Ozdemir, K. Gu¨nay

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

Istanbul University, Istanbul medical faculty, Istanbul, Turkey

Prince Charles Hospital, Cheltenham, United Kingdom

Introduction: In recent years, single incision laparoscopic colectomy surgery has been used in order to reduce scars and give better cosmetic results. The aim of this study is to present our initial three cases of SILS single incision right hemicolectomy. Material and Methods: SILS right hemicolectomy was undergone to three patients with cancer at Istanbul Faculty of Medicine between January 2011 and December 2012. The data of these 3 cases were analyzed retrospectively. Conclusion: All of the cases were women and the mean age was 42. Two patients were taken to surgery due to right colon cancer and the third was operated due to appendiceal neuroendocrine tumor. All resections were made with a single incision inside of abdominal and hand port was put in there. Anastomoses were made with linear stapler after colon segments had been removed out of abdomen. Then the for the segments which were made anastomoses were put in. Mean of the operations time was 64 (58–71). All of the patients had gas discharge on second day; they were all discharged on fifth day from hospital. Discussion: Colectomy by SILS can be done safely in the hands of those who experience standard laparoscopic colon surgery without increasing the rate of complication after surgery, the less scarring and better cosmetic result.

Introduction: Laparoscopic surgery for bowel obstruction is a challenging operation with limited working space, increased risk of iatrogenic injury and a high conversion rate. We present a surgical strategy in a patient with a small bowel obstruction who underwent a laparoscopic right hemicolectomy. Method: Naso-gastric tube is inserted to deflate the stomach and aspirate the small bowel contents the night before surgery. The pneumo-peritoneum is performed by open technique. The camera in the suprapubic port provides a good panroramic view of the abdomen and a maximum right side up tilt provides adequate exposure of the right side of the abdomen. If there is still difficulty, the air in the bowel can be aspirated by a laparoscopic needle. Instead of traction on the caecum, the ileo-colic pedicle is tented with two graspers and a mesenteric window is created. The third part of the duodenum is identified followed by the division of the ileo-colic pedicle. The dissection is carried on medially. The terminal ileum is freed from the pelvic brim followed by lateral and posterior colonic mobilisation of the hepatic flexure. After checking the mobility of the right colon, the specimen is delivered through a 6 cm midline supra-umbilical incision. In cases of bulky tumours, to minimise the incision size for the specimen delivery, the terminal ileum is delivered first and divided followed by the transverse colon. The specimen is delivered by traction on both colonic and ileal ends. Side to side stapled ileo-colic anastomoses is performed. The small bowel content is then milked towards the stomach to facilitate the closure of the wound. Result: Patient had an uneventful recovery Conclusion: The above strategy is helpful in laparoscopic right hemicolectomy for the colonic obstruction.

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Characteristics of the Minimal Invasive Treatment of an Apendiceal Mass

Possibilities of Application of the Laparoscopic Operations in the Treatment of Colorectal Cancer

B.A.P. Popescu, S. Paun, F. Iordache, C. Turculet, I. Grintescu, M. Vartic, M. Beuran

V.Y.u. Shapovalov1, A.A. Shudrak2, M.A. Kashtalyan3

Emergency Clinical Hospital Bucharest, Bucharest, Romania Aims: An appendiceal mass represents a form of an acute appendicitis with a late presentation to the physician and it is formed by the inflamed appendix covered by small intestine and/or greater omentum adherent to it. There are lots of controversies regarding the treatment of such a mass: early surgical treatment, conservative treatment followed by surgical treatment, classical or laparoscopic approach. We would like to show our initial laparoscopic experience approach to this problem. Methods: We evaluated all the laparoscopic procedures for acute appendicitis or complications of acute appendicitis in the last year performed by a single surgeon. From these we selected only two cases that were diagnosed clinically and paraclinically as an appendiceal mass. Laboratory tests, abdominal ultrasound and CT were performed for these patients. Both patients were males, one of 65 years old and the other of 40 years old and both of them had high counts of leucocytosis which persisted after a few days of treatment with Cefuroxime and Metronidazole. At that time the decision to perform an exploratory laparoscopy was taken. The approach was the same: patient supine, 3 trocars, 2 of 10 mm (supraombilical for camera and left flank) and one in the suprapubic area of 5 mm. In both patients the dissection of the appendix could not be performed safely and in both of them an abcess was drained and 2 drains were left in (Douglas pouch, right paracolic space). Results: The operative times were: 60 and 45 minutes without any blood loss. Patients continued intravenous treatment with the chosen antibiotics postoperatively. Time to first flatus was 24 hours in both patients. The older patient was released in the 6th postoperative day and the other in the 4th, without any complications. Conclusions: The lack of randomized trials of such a pathology, leads to a lot of different approaches. We think that a conservative approach with a minimal drainage of the surrounding abscess is the preferred one. This will lead to no further symptoms. Due to this fact many times the patient will refuse the further surgical approach or will not come for the check-up.

1 Odessa National Medical University, 411 Military Hospital, Odessa, Ukraine; 2Main Military Clinical Hospital, Kiev, Ukraine; 3Odessa National Medical University, Odessa, Ukraine

Aims: Estimate the role and possibilities of the laparoscopic operations in treatment of colorectal cancer. Methods: 182 laparoscopic operations for colorectal cancer were performed in proctologic departments of the Main Military Medical Clinical Centre (Kiev) and the Military Medical Clinical Centre of the South Region (Odessa) in the last 3 years. The average patient’s age was 61,4 + 3,4 years. There were 104 male and 78 female. Adenocarcinoma of the miscellaneous degree was diagnosed by all patients. Right hemicolectomy (26) was performed for cancer of cecum and right colon. Left hemicolectomy (39) was performed for left and sigmoid colon. Anterior rectum resection (38) was performed with tumor localization in rectosigmoid and upper ampullar part of the rectum. Low anterior resection of the rectum (29) was performed with tumor localization in the middle ampullar part of the rectum. Intersphincteric resection (32) was performed with tumor localization in the lower ampullar part of the rectum. Abdominoperineal resection of the rectum (18) was performed with the tumor localization in the external sphincter muscle of the anus. ?2-3N0-2M0-1 degree of tumor distribution took place by all patients. Radiotherapy 20–25 Gr was carried out by the patients with the upper, middle, and low ampullar parts of the rectum in the preoperative period. Radical laparoscopic operation covered well known oncological principles: adequate species resection borders, high ligation of the blood vessels, conventional lymphadenectomy, technical simplicity and reliability of the anastomosis formation, operative access. Results: The duration of a surgical intervention was in average 230 + 20,2 min, intraoperational blood loss was 110 + 10 ml. The peristalsis recovery occurred on the 2nd day after the laparoscopic operation, the stool occurred on the 3–4th day of postoperative period. The average duration of the treatment was 8,1 + 1,4 days. Conclusions: 1. The application of the complex of modern diagnostic technologies allows to identify the stage, localization and size of the tumor in the preoperative period for the definition of the prescription for the open or laparoscopic operation. 2. The performing of the laparoscopic operation essentially shortens the patient’s staying in a hospital and fastens his rehabilitation.



Single Incision Laparoscopic Appendectomy Versus Traditional Three-Port Laparoscopic Appendectomy: Our Early Experience

Comparison of Reduced-Port and Conventional Laparoscopic Total Proctocolectomy with Ileal J Pouch-Anal Anastomosis

S. Vellei, A. Borri, L.M. Pernice

J. Hiro, Y. Inoue, A. Kawamoto, Y. Okugawa, S. Saigusa, Y. Toiyama, T. Araki, K. Tanaka, Y. Mohri, M. Kusunoki

University of Florence, Florence, Italy Aims: The aim of this study was the comparison between single incision laparoscopic appendectomy (SILA) and three port appendectomy (TPA) with the same features. Methods: All procedures were performed by two surgeons from June 2012 to December 2013. In total 20 SILA and 20 TPA were included. There were 25 women and 15 men, from 16 to 62 years old, SILA average 26, TPA average 29.2. We excluded patients undergoing combined surgery and with BMI [ 30. Bipolar forceps were used to treat mesoappendix. The appendix was severed with endo-loop in 5 SILA and 7 TPA, and a stapler in the others. Post-operative pain was evaluated with the ‘visual analog scale’ (VAS). Patients received systemic analgesic therapy with e.v. paracetamol (1 g /8 hours), supplemented with 30 mg Ketolorac if VAS [ 5. After surgery we examined patients at 1, 3 and 6 months. Results: The operative time was on average of 49.6 min in SILA and on average of 52.2 min in TPA. No case required conversion to traditional laparoscopy or laparotomy. On the first day VAS average was 3.9 for SILA and 4.6 for TPA. Patients undergoing SILA required, in total, 150 mg of Ketolorac, and undergoing TPA 270 mg. The hospital stay was on average of 2.3 for SILA and on average of 2.75 for TPA. No early or late complications were observed (infection, abscess, incisional hernia, reoperation). Follow-up showed no umbilical hernias and patients reported satisfactory levels of aesthetic results on a scale from unsatisfactory to excellent. After one month we obtained 85 % excellent satisfaction, after three months 94 %, after six months the same, for SILA; for TPA the first check-up gave 95 % good satisfaction, the second 100 % good satisfaction, the third 34 % excellent and 66 % good. Conclusions: The results, although preliminary, demonstrate that the tested method is feasible and safe, it does not prolong the operative period. Hospital stays were shorter and overall caused less postoperative pain with less use of analgesics than the three-port method. The clear advantage is its cosmetic benefit.

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Mie University Graduate School of Medicine, Tsu, Japan Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). While minimal invasive techniques have been applied increasingly, clear evidence of superiority for laparoscopic procedures is not yet available. The aim of this study is to compare reduced-port laparoscopic IPAA (RPL-IPAA) with conventional laparoscopic IPAA (CL-IPAA) regarding short-term outcomes to assess safety. Methods: We reviewed 33 patients with UC or FAP who underwent laparoscopic surgery at our institution between January 2000 and December 2013. All patients underwent total proctocolectomy with IPAA. Although 6 ports were placed in CL-IPAA, RPL-IPAA included the use of instrument placed through the drain site, stoma site and umbilical. Data from consecutive patients undergoing RPL-IPAA were analyzed and compared with those from CL-IPAA. Results: During the study period, 9 patients underwent RPL-IPAA, and CL-IPAA was performed in 24 patients. Two cases with CL-IPAA converted open laparotomy, however, RPL-IPAA were completed successfully. As a results of devised procedure in RPL-IAA for maintenance of good visualization, splenic flexure mobilization, and the reconstruction of ileal J pouch, the mean operative time (367 vs. 363 minutes) and mean blood loss (127 vs. 157 g) did not differ between the 2 groups. Short-term outcomes including postoperative complications, length of hospital stay (19 vs. 21 days) were also similar between the 2 groups. Conclusions: RPL-IPAA can be safely performed with short-term outcomes comparable to conventional laparoscopy.

Surg Endosc



Laparoscopic Management of Initially and Recurrent Crohn’s Disease

Laparoscopic Radical Lymph Node Dissection Along Middle Colic Artery Based on Embryology of Mesocolon for Right-Hemi Colon Cancer

A. Kawamoto, Y. Inoue, H Fujikawa, Y. Okugawa, Y. Okita, J. Hiro, S. Saigusa, Y. Toiyama, T. Araki, K. Tanaka, Y. Mohri, M. Kusunoki Mie University School of Medicine, Tsu, Japan Purpose: Patients who underwent abdominal surgery for Crohn’s disease are predisposed to recurrence requiring reoperation, and minimally invasive surgery reducing the abdominal trauma is ideal for improving the outcomes. We report our experience of performing laparoscopic surgery for initially and recurrent Crohn’s disease through a retrospective review of 19 consecutive patients who underwent laparoscopic surgery at our institution between January 2011 and November 2013. Methods: To optimize surgical planning after diagnosis of stenosis, abscess, and fistula, we used small bowel imaging such as magnetic resonance enterography and/or multi-detector CT (MDCT). Single-port laparoscopic surgery was also introduced for selected patients when preoperative imaging identifies localized target lesion. Results: Two of 19 patients had previous open surgery for Crohn’s disease. As one patient had also repeated laparoscopic surgery for recurrent Crohn’s disease, twenty surgical procedures included laparoscopic ileocolectomy (n = 13), and small bowel resection with or without stricturoplasty (n = 7). These laparoscopic procedures were completed successfully without conversion to laparotomy. Intraoperative evaluation using intestinal scope was introduced in 7 patients, and mean operative time was 273 ± 24 minutes. There were no deaths, and no severe complications except for 2 surgical site infections. Six patients had single-port laparoscopic surgery. Single-port and conventional laparoscopic surgery groups had statistically similar operative times, estimated blood loss, and hospital stay periods, although one patient undergoing single-port laparoscopic surgery needed additional intraoperative ports. Two patients with previous open surgery had significantly higher estimated blood loss than that of patients with initial laparoscopic surgery (p = 0.0097), while the patients with repeated laparoscopic surgery for recurrent Crohn’s disease had no surgical difficulties in secondary surgery. Conclusion: Laparoscopic surgery including single-port laparoscopic management is a technically feasible approach for selected patients with initially and recurrent Crohn’s disease. However it must be carried out by a well-trained laparoscopic surgeon and further studies on large numbers of patients are need to confirm its role and effectiveness.

S. Mori, K. Baba, M. Yanagi, K. Tanoue, Y. Kita, S. Yanagita, Y. Uchikado, Y. Uenosono, H. Okumura, K. Maemura, S Ishigami, K. Aridome, S. Natsugoe Graduate School of Medicine, Kagoshima University, Kagosima, Japan Objective: To evaluate the safety and feasibility of laparoscopic radical lymph node dissection along the surgical trunk and middle colic artery based on embryology of transverse mesocolon in right- hemi colon cancer. Patients and Methods: We retrospectively analyzed 27 patients with right-hemi colon cancer who underwent laparoscopic radical lymph node dissection between January 2010 and June 2013. Video recordings of the procedure were utilized to assess the quality of the surgery. Operative data, pathological findings, complications and length of hospital stay were also assessed. Surgical Procedure: The dissection starts behind the pedicle of ileocolic vessels and proceed along the superior mesenteric vein (SMV). The ileocolic vessels are then cut at their roots. After embryological tissue planes comprising Told’s and pre-renal fascia were exposed, the wide separation between the pancreatic head and the transverse colon is performed. The dissection proceeds along the SMV, exposing the gastrocolic trunk of Henle. The middle colic artery can be identified from superior mesenteric artery and are cut at the roots of the right branch with lymph node dissection. After exposing the gastrocolic trunk of Henle and SMV, the exposure of fusion fascia between the omentum and the transvers mesocolon are performed, and the accessory middle colic veins are cut. Results: All patients underwent en bloc resection of the enveloped parietal planes with radical lymph node dissection along the surgical trunk without any serious intraoperative complications. Six, three, seven, and eleven patients had T1, T2, T3, and T3 tumors, respectively. The median number of lymph nodes retrieved was 24, with lymph node metastasis identified in 11 patients. According to the UICC cancer staging, the number of patients with stage I, II, II, IV was five, nine, nine and four, respectively. The median operative time and intraoperative blood loss were 290 min and 41 g, respectively. No postoperative complications occurred in any patient. The median hospital stay after surgery was 11 days. Conclusion: We propose that laparoscopic radical lymph node dissection along the surgical trunk and middle colic artery based on embryology of mesocolon is a safe and feasible procedure for right-hemi colon cancer.

P389 - Intestinal, Colorectal and Anal Disorders Recurrent Abscess Due to Retained Appendicolith After Laparoscopic Appendectomy


A. Reyhani Calvo, E. Martin Martin, I. Cendoya Ansola, E. Arteche Daubagna, A. Go´mez Portilla, E. Lo´pez de Heredia Armentia, L.A. Magrach Barcenilla, E.E. Palacios Bazan, B. Ezurmendia Sinisterra, M. Larranãga Zabaleta, A. Etxart Lopetegui

Laparscopic Colorectal Surgery in Octogenerians

Hospital Universitario de Alava (Sede Santiago), Vitoria, Spain

Purpose: The aim of this study was to compare the outcomes between patients under 60 years of age and older patients over 80 years of age who underwent laparoscopic colorectal surgery with colorectal cancer. Methods: A retrospective analysis of 519 colorectal patients who underwent laparoscopic colorectal surgery for colorectal adenocarcinoma between January 2005 and December 2010 was collected and categorized into two groups of patients, those under 60 years of age (n = 404) and those over 80 years of age (n = 115). Results: The group of patients over 80 years age had a significantly higher American Society of Anesthesiology (ASA) score (p = 0.000), more preoperative comorbidities (p = 0.000), and had a tendency towards more tumors in a colonic location compared to the rectum (p = 0.034) and more advanced AJCC TNM stage (p = 0.001). There were no significant differences in operative time, conversion rate, resection margins, and numbers of harvested lymph nodes, hospital stay, and morbidity between the two groups. In multivariate analysis, rectal cancer and transfusion were independent variables of postoperative surgical morbidity. Male sex, previous abdominal surgery, T4 lesion and distant metastases were independent factors of postoperative medical morbidity. Conclusions: Laparoscopic colorectal surgery was effective and safe for elderly patients over 80 years of age and resulted in postoperative outcomes similar to those in younger patients.

Introduction: Retained or dropped appendicolith is an uncommon complication that can occur as a consequence of stone expulsion from the appendix before or during appendectomy. This phenomenon is frequently associated with intra-abdominal abscess of variable locations; therefore, recognition of its presence is of great clinical significance in the care of patients with post appendectomy abscesses. Case Report: A 45-year-old woman underwent a laparoscopic appendectomy for perforated appendicitis. She was discharged asymptomatic on the 3rd postoperative day. She developed fever and epigastric abdominal pain 5 days later and she also had a white blood cell count of 13,000. Computed tomography (CT) showed a collection in epigastric region containing a small calcified stone; she was placed on IV antibiotics and underwent a CTguided percutaneous drainage. Despite this, 3 weeks after she was discharged asymptomatic the epigastric collection recurred. A new CT showed the persistence of the retained appendicolith and the abscess in the epigastric region. A small open laparotomy was performed, during which the abscess was drained and the appendicolith was removed. Conclusions: Laparoscopic appendectomy is complicated by postoperative abscess five times more frequently than open surgery. Retained appendicolith can cause abscess formation after surgery and can be a source of persistent infection. The abscess can appear within weeks or months after the initial appendectomy. A systematic division of the appendix performed between double ligature helps to avoid this postoperative complication. Removal of retained appendicolith is necessary because it may act as an infected foreign body, which cannot be sterilized by antibiotics or with simple drainage alone. Treatment options include open, percutaneous, or laparoscopic drainage of the abscess and retrieval of the appendicolith; Percutaneous drainage is commonly used to treat intra-abdominal abscess, but it is in some cases ineffective for retained appendicolith removal, requiring laparoscopic access or, using an open access as it was required in our case.

J.K. Ju, K.T. Kim, G.H. Yeo Chonnam National University Hospital, Gwangju, Korea

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Laparoscopic Modified Double Stapling Technique Using V-LOCTM

Single-Incision Laparoscopic Colectomy with Complete Mesocolic Excision for Right-Sided Colon Cancer

J.K. Ju, K.T. Kim, G.H. Yeo

M. Miyo, I. Takemasa, A. Hamabe, M. Uemura, J. Nishimura, T. Hata, T. Mizushima, H. Yamamoto, Y. Doki, M. Mori

Chonnam National University Hospital, Gwangju, Korea Objectives: Inclusion of the transverse staple line closure of the distal rectal stump in the circular stapled anastomosis may minimize the risk of anastomotic complications including leakage. We evaluated the laparoscopic intracorporeal modified double stapling technique for formation of such an anastomosis using V-LocTM wound closure devices. Methods: Medical records of patients who underwent laparoscopic Modified double-stapling anastomosis using V-LocTM wound closure devices between January 2013 and August 2013 were analyzed to identify postoperative anastomotic complications. The primary goal was to identify postoperative anastomotic complications. Results: A total of 27 patients who underwent laparoscopic anterior resection and low anterior resection for rectosigmoid cancer and upper rectal cancer were included in the present study. The mean operation time was 156.7 min (95–210 min). One anastomotic stenosis was noted that anastomotic complication rate was 3.7 %. No anastomotic leakage was noted. Conclusion: Using V-Loc TM wound closure device, modified double stapling technique could be a simple, and good alternative for safe anastomosis in laparoscopic low anterior resection for left sided colon and rectal cancer patients.

P393 - Intestinal, Colorectal and Anal Disorders Influence of Endoscopic Stent Insertion on Detection of Circulating Tumor Cells from Obstructing Colon Cancer S. Yamashita1, M. Tanemura1, Y. Shimizu1, H. Tominaga1, K. Odagiri1, T. Kurokawa1, N. Honmyo1, J. Moon1, M. Inoue1, T. Irei1, T. Yamaguchi2, T. Kuwai2, H. Kono2, N. Hatanaka1, W. Kamiike1 1

National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan; 2Department of Gastroenterology, National Hospital Organization Kure Medical Cent, Kure, Japan Introduction: Small populations of cancer cells in the circulatory system that have detached from the primary tumor are designated as circulating tumor cells (CTCs). Many groups have reported that CTC detection was associated with colorectal cancer (CRC) poor prognosis. CRC can present with acute intestinal obstructions. Self-expanding metallic stents (SEMS) have been employed to release colonic obstruction as bridge to surgery, especially laparoscopic resection for potentially resectable CRC. Recently, SEMS has become the treatment of choice in many centers with facilities available. However, concerns have been raised to whether shear forces that act on the tumour during expanding stent may result in release of cancer cells into the circulation (i.e., CTCs). Aims: The present study was conducted to determine whether insertion of colonic stents results in increased levels of CTCs. Methods: Between October 2013 and November 2013, three patients who underwent colonic stent insertion for obstructing colorectal cancer were studied. To detect viable CTCs of CRC, we employed TelomeScan F35 detection system, which was constructed a GFP-expressing attenuated adenovirus, in which the telomerase promoter regulates viral replication. 7.5 ml of peripheral blood samples were obtained at before/after stent insertion. Results: The data were summarized in the table as described below. GFP + cells CD45-cells Cytokeratin + cells Vimentin + cells Case 1 Before stent 0 0 0 0 After stent 4 0 0 0 Case 2 Before stent 2 0 0 0 After stent 4 2 1 2 Case 3 Before stent 1 0 0 0 After stent 2 0 0 0 We excluded the blood cells with positive CD45+. Conclusion: This study has demonstrated that endoscopic stent insertion results in dissemination of cancer cells into the peripheral circulation.

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Osaka University Graduate School of Medicine, Suita, Japan Background: Complete mesocolic excision (CME) is a novel concept for colon cancer surgery that attempts to remove the entire mesocolon and all potential routes of metastatic tumor spread by dissection of embryologic tissue planes and ligation of the supplying vessels at their origin. CME not only provides improved oncologic outcomes, but also reduces the occurrence of complications, such as bleeding or damage of the retroperitoneal tissue. However there are few reports of single-incision laparoscopic colectomy (SLC) with CME. We will report our technical device of SLC with CME for right-sided colon cancer. Operation: The localization of tissues, vessels and tumors are confirmed preoperatively with multi-image 3D fusion virtual reality (FDG-PET, MDCTA and virtual colonography). A multichannel access device is fitted into a 2.5 cm incision in the umbilicus. Firstly the small bowel is fully removed to the head side in the Trendelenburg position. The dissection between the mesoileum and the retroperitoneum is initiated via the retroperitoneal approach and the pancreas is previously preserved while the right-sided colon is mobilized. We establish this manner as an essential procedure in SLC with CME. Secondly the small bowel is removed to the pelvic cavity by making position horizontal. The mesenteric window is opened. The ileocolic vessels are dissected at their origin. Laparoscopic CME is completed by dissecting the lymph nodes and lymphatic tissues at the origin of the ileocolic, right colic, and middle colic vessels. Finally in the head-up tilt position, the greater omentum is dissected and the hepatic flexure is mobilized. The specimen is extracted through the umbilical incision, after which extracorporeal functional end-to-end anastomosis is performed. Results: A total of 127 patients underwent SLC with CME for right-sided colon cancer from June 2009. Median operative time was 167 minutes, median blood loss was 30 ml, and median number of lymph nodes harvested was 23. One bleeding and two ileuses were observed postoperatively. All of them recovered with conservative treatment. Conclusions: The appropriate preoperative diagnosis and the stylized retroperitoneal approach maximally using change position make SLC with CME for right-sided colon cancer safe and feasible.

P395 - Intestinal, Colorectal and Anal Disorders Early Results: Of Single Incision Laparoscopic Colorectal Cancer Surgery K.Y. Hahn1, S.H. Kim2 Seongnam Central Hospital, Seongnam, Korea; 2Anam Hospital, Korea University, Seoul, Korea 1

Purpose: The safety and efficacy of laparoscopic colon cancer surgery were already proved by multi-center prospective randomized studies compared to conventional open surgery in colon cancer. In the advent of single incision laparoscopic surgery, this is another method of minimally invasive colo-rectal surgery. The purpose of study is to evaluate oncologic safety and operability of single incision laparoscopic colo-rectal cancer surgery. Method: From the April 2011 to July 2013, 14 cases of colo-rectal cancer operations were performed by single incision laparoscopic surgery. The 7 male and 7 female patients were enrolled. Mean age was 75.6. The 10 patients were hypertension. The two patients were diabetes mellitus. All procedures were performed by straight laparoscopic tools without any curved instruments. Results: The mean operation time was 240 minutes and mean blood loss was 150 cc. The procedures were 7 right hemi-colectomies, 5 anterior resections, one total colectomy with ileo-rectal anastomosis and one extended left hemi-colectomy. The mean number of harvested lymph nodes were 36. The two patients were stage 1. The stage 2 were seven and stage 3 were five respectively. Mean proximal and distal margins were 9.5 cm and 8.6 cm individually in fixed specimen. The mean tumor size was 4.25*3.86 cm. The mean followup period was 23 months without recurrence. There were no operation related complication and death. Discussion: The single incision laparoscopic surgery is safe and feasible procedure for colo-rectal cancer in my early experience. The curved or any devices for single incision laparoscopic surgery were not needed during procedures. The large scale prospective randomized study is warranted to confirm the oncologic and operative safety of this procedure compared to conventional laparoscopic surgery.

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Laparoscopic Rectopexy for the Treatment of Patients with Rectal Prolapse

Critical Appraisal of 903 Rectal Cancers: Laparoscopic Conversion Affects Long Term Outcomes

H. Idani1, Y. Kurose2, K. Nakano2, T. Ishii2, S. Asami2, H. Okawa2, Y. Yoshimoto2, A. Itoh2, K. Monden2, K. Hioki2, K. Hitoshi2, N. Takakura2

M.H. Chew, R. Dharmawan, M. Singh, C.L. Tang

1

Hiroshima City Hospital, Hiroshima, Japan; 2Fukuyama City Hospital, Fukuyama, Japan

Background: Laparoscopic mesh rectopexy has been introduced in these past ten years offering lower recurrence rate with less invasion. However it might be associated with mesh related complications such as infection, stricture or constipation. We have introduced direct suture rectopexy and compared its outcome with that of mesh rectopexy. Surgical procedures: The sigmoid colon and the rectum were fully mobilized. In the mesh rectopexy, 10 9 5 cm polypropylene mesh or Parietex mesh was fixed to the presacral fascia with absorbable tacks. The rectum was wrapped 2/3 around with the mesh and fixed with 4-0 absorbable suture materials. In the suture rectopexy, the anterior wall of the rectum was fixed onto the presacral fascia by two sutures with nonabsorbable suture materials. Retroperitoneum was repaired with 3-0 absorbable suture materials. Patients and Methods: From January 2004 to December 2013, 16 patients with full thickness rectal prolapse underwent laparoscopic rectopexy in our hospital. Mesh rectopexy (MR group) was performed on 12 and suture rectopexy (SR group) was performed on 4 patients. Operative time, blood loss, length of hospital stay, morbidity, recurrence rate and anal function were evaluated and compared in both groups. Results: A mean age of patients of MR group and SR group was 72 and 77 years, respectively. Concomitant right hemicolectomy was performed on one patient in SR group. Operative time for both groups was 139 and 153 min, respectively. The amount of blood loss was negligible in both groups. Mean length of hospital stay was 6.6 days for MR and 7.8 days for SR group. Constipation occurred in 4 patients in MR and 3 in SR group. Wexner score was markedly improved in both groups (MR: 6–1, SR: 17–1). During the median follow up period of 57 months in MR and 7 months in SR group, there has been no sign of recurrence in both groups. Conclusion: Laparoscopic rectopexy is safe and effective procedure for the treatment of rectal prolapse. Although further examination will be necessary, suture rectopexy has a comparable outcome to mesh rectopexy without the cost for mesh and might have lower incidence of infection.

Singapore General Hospital, Singapore, Singapore Background: Laparoscopic colorectal surgery has gained wide acceptance. Conversion rates range from 14–20 %; for reasons including adhesions, intraoperative complications and inability to properly visualize critical structures to allow safe colonic mobilization. Although short-term outcomes of laparoscopic-converted surgeries have been well studied, there are limited information about the long term effects of conversion. Our present study aims to analyze the long term outcomes of conversion of laparoscopic surgery for colorectal cancer. Methodology: 903 consecutive patients who underwent surgery for rectal cancer in Singapore General Hospital from January 2005 to December 2009 were analyzed. Treatment was classified as laparoscopic (LS), laparoscopy-assisted (LAS) and laparoscopy-converted (LC) surgery. Comparison was performed against Open surgery performed in the same duration of study in an approximately 1:2 ratio (lap n = 343, open n = 560). Statistical analysis was performed using the Statistical Package for Social Science (SPSS) and a p-value of \0.05 is considered statistically significant. Results: There were no clincodemographic differences between the laparoscopic vs open group. In the laparoscopic group, LAS group was 30.3 % and conversion rate was 10.7 %. Median follow-up period was 46 months (range: 1–98 months). There was significant difference in median operating time (148 vs 170 vs 155 vs 115 mins, p = 0.0001) and length of hospital stay (6.0 vs 7.0 vs 7.0 vs 8.0 days, p = 0.0001) between LS, LAS, LC and Open surgery. Open surgery had overall higher complication rate but were mainly minor complications. There was no difference in anastomotic leak or mortality. The overall cancer-free survival was 64.8 % (95 % CI: 60.9 %–68.7 %). When controlled for AJCC staging, LS provides the most favourable survival compared to LAS, LC & Open cases (78.9 % vs 61.1 % vs 59.5 % vs 60.9 %), with poorest outcome seen in LC surgeries. There was no significant difference in incidence of adhesive intestinal obstruction and incisional hernias between the 4 groups. Conclusion: LS for rectal cancer has superior length of stay with acceptable operating time. LS cases have significantly better cancer free survival while LC cases have the poorest survival. There is however no difference in risk of incisional hernias or adhesion formation in laparoscopic compared with open surgery.



Comparison of Laparoscopic Side-to-End and End-to-End Colorectal Anastomosis

Single-Port Laparoscopic Colorectal Resection for the Cases with Severe Intra-Abdominal Adhesion

F. Stipa, A. Burza, E. Soricelli

A. Hamabe, I. Takemasa, M. Uemura, J. Nishimura, T. Hata, T. Mizushima, H. Yamamoto, Y. Doki, M. Mori

San Giovanni Addolorata Hospital, Rome, Italy Introduction: The aim of this study was to assess the short-term outcomes of side-to-end and endto-end laparoscopic colorectal anastomosis. End-to-end anastomosis requires extensive colon mobilization and an extra-abdominal step to insert the anvil. For side-to-end anastomosis all steps are performed intra-abdominally. Methods: From July 2009 to April 2012, 30 patients with upper and mid rectal cancer, underwent laparoscopic resection and were divided into two groups, based on the anastomotic technique, sideto end (Group A, n = 15) and end-to-end (Group B, n = 15). Operative time, length of the surgical specimen, number of lymph nodes found in the resected specimen, radial clearance of resection margins, postoperative morbidity, return to bowel function, postoperative pain, hospital stay and functional results were analysed. Results: Median follow-up was 23 months (range, 7–52). Median operative time was shorter in Group I (180 min) when compared to Group II (225 min), p \ 0.001. Median length of surgical specimen was 19 cm (range, 12–28) in group I and 20 cm (range 13–27) in group II, p = 0.87. Median number of lymph nodes found in the resected specimen was 12 (range, 5–22) in group I and 13 (range, 7–22) in group II (p = 0.72). In all cases all resection margins were negative (R0). No intra-operative complications occurred. One patient in each group developed an anastomotic stricture, successfully treated with endoscopic dilation. In both groups, no significant differences in return to bowel function, resumption of food intake, postoperative pain and hospital stay were registered. Conclusion: Laparoscopic colorectal resection with side-to-end anastomosis is safe and, when compared to the standard end-to-end technique, can shorten significantly the operative time.

Osaka University, Suita, Japan Background: Single-port laparoscopic surgery (SPLS) is expected as the low-invasive treatment beyond conventional laparoscopic surgery (CLS). The initial port for laparoscope was commonly introduced without small laparotomy in CLS; in contrast, in SPLS, we usually place small laparotomy first and set the access device at umbilical incision, which contributes to the establishment of safe and easy access route into the peritoneal cavity. For the cases with severe intra-abdominal adhesion, open abdominal surgery is commonly standard approach. Recently, CLS has been increasingly used for these cases, while it is often unsuccessfully performed, resulting in the conversion to the open surgery. We considered that the placement of small laparotomy for the initial incision might be efficacious method especially for the adhesion cases; therefore we have performed SPLS for these cases. In this study, we retrospectively analyzed the efficiency of SPLS for the colorectal cancer resection with severe intra-abdominal adhesion. Method: A total of 10 cases with severe intra-abdominal adhesion were included from our 234 SLPS cases operated on from 2009 to 2012. The initial laparotomy was placed on the umbilicus, and the adhesion just beneath the umbilicus was dissected directly via the small laparotomy. After the placement of the access device, dissection was continued laparoscopically. Subsequently, colorectal cancer resection and lymph node dissection were performed. Results: In 10 patients (7 male and 3 female), there was no conversion to CLS or open surgery. In relation to tumor location, A/T/D/S/R were 2/3/2/2/1, respectively. In 3 cases, an additional port was inserted. The mean operative duration was 217 min and blood loss was 40 ml. In one case, intestine was damaged intraoperatively. One case of ileus was observed postoperatively. Oncologically appropriate resection was successfully performed in all the cases. The median length of the abdominal incision was 3.5 cm. The number of analgesics usage administered intravenously was 3. The first flatus was observed on postoperative day 3 and oral intake was resumed on day 5. Conclusion: SPLS might be useful option even for the cases with severe intra-abdominal adhesion, by accessing into peritoneal cavity with small laparotomy. SPLS has potential to provide lowinvasiveness for these cases.

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Single Incision Laparoscopic Colon Surgery was Feasible at a New-Opened Community Hospital: A Prospective Analysis of 286 Consecutive Patients

Colonic Marking with Light-Emitting Diode-Activated Indocyanine Green for Laparoscopic Colorectal Surgery

1

W.C. Su , W.C. Fan

2

1

Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; 2Kaohsiung Municipal Ta-Tung hospital, Kaohsiung, Taiwan

J. Nagata1, Y. Fukunaga2, T. Akiyoshi2, T. Konishi2, F. Yoshiya2, N. Satoshi2, M. Ueno2, Y. Chiriko2, T. Yamaguchi2, T. Nagasaki2, R. Ohno2, A. Ikeda2, T. Mukai2, K. Tomori2 1

Japanese Foundation for Cancer Research, Koto-ku, Japan; 2JFCR, Tokyo, Japan

Purpose: The feasible procedure of single incision laparoscopic colon surgery has been presented in literature. There is limited data from a community hospital. The purpose of this study was to evaluate whether the single incision laparoscopic colon surgery could be safely performed in a new-opened community hospital Materials and Methods: During April 2009 to December 2013, we reported 286 consecutive case of laparoscopic colectomy, 146 of these were single incision laparoscopic surgery (SILS). All operation were performed by two surgeon. Data were collected prospectively including patient demographic feature, co morbidity, peri-operative event, post-operative complications. The clinical data were compared. Results: The laparoscopic colectomy (LC) group included 140, and the SILS group included 146 patients. No differences were found between the two groups with regard to mean age, comorbidities, body mass index and ASA score. The operative time was shorter in the SILS (122 vs. 187 min, p \ 0.001) and estimated blood loss was fewer in the SILS (67.3 vs. 139.6 ml, p \ 0.001). Besides, the post-operative hospital stay was non-statically shorter in SILS (5.37 vs. 6.48 days, p = 0.066). Conclusion: Single incision laparoscopic colon surgery is safe procedure for benign and malignant colon disease by assistance of LagiPort of in a new-opened community hospital.

Background and Aims: Knowledge of the accurate location of colorectal lesions is necessary during laparoscopic surgery. Although tattooing with India ink has been generally used by preoperative endoscopy for tumor marking, several scientists report undetectable cases and some complications including focal peritonitis, small amount of leakage (socalled ‘tattooing dissemination’), inflammatory pseudotumor, abscess, and postoperative adhesion ileus. As we introduced the fluorescence imaging technique using light-emitting diode (LED)-activated indocyanine green (ICG) fluorescence for the colorectal laparoscopic surgery, feasibility and safety of this technique was investigated. Patients and Methods: This study enrolled 24 patients who underwent laparoscopic colorectal surgery. Indocyanine green was injected just near to the lesion under preoperative colonoscopy for colon cancer patients Tattooing with India ink near to the ICG was also performed at the same time. At surgery, the marking was firstly observed with white light and then ICG was activated with LED at a wavelength of 760 nm as the light source before colorectal resection. Once the specimen was removed, it was observed from the mucosal side on the side table whether the ICG marking and the India ink tattooing was put on. H&E-stained slides of the marked injection sites were also assessed histologically. Results: LED-induced fluorescence indicated tumor localization clearly and accurately in 24 patients (100 %) whereas the India ink tattooing was not confirmed in 10 patients. Whereas no perioperative complications to the dye were observed so-called tattooing dissemination due to India ink was observed in 6 patients. No inflammatory signs were noted on the H&E-stained slides of the identified injection sites in the resected specimens. Conclusions: The new technique for colonic marking with this fluorescence imaging of LED-activated ICG was feasible and safety. This technique may substitute for the conventional marking method with the India ink tattooing despite of requiring equipment of the light-emitting diode (LED) system.



Current Status of Laparoscopic Lateral Pelvic Lymph Node Dissection Following Total Mesorectal Excision for Advanced Low Rectal Cancer

Laparoscopic Sphincter Preserving Surgery for the Rectal Neuroendocrine Tumors

M. Ouchi, M. Fukunaga, K. Nagakari, M. Sugano, Y. Lee, Y. Iida, S. Yoshikawa, Y. Ito, G. Katsuno, Y. Hirasaki, D. Azuma, S. Kohama, J. Nomoto

Japanese Foundation for Cancer Research, Cancer Institute Hospital, Tokyo, Japan

Juntendo University Urayasu Hospital, Chiba, Japan Aims: In an effort to decrease postoperative local recurrence of advanced low rectal cancer, Lateral Pelvic Lymph Node Dissection (LPLD) following total mesorectal excision (TME) has been standard operative procedure in Japan. However, laparoscopic LPLD is not common due to technical aspects. Here, technical feasibility, safety and oncological outcome of laparoscopic LPLD are considered. Method: LPLD has been performed for T3/T4 rectal cancer, located at or below the peritoneal reflection, because the incidence of lateral lymph node metastasis in patients with low rectal cancer is high (20.1 %). There are three regions for LPLD- 1) From the common iliac to the external iliac 2) obturator nerve 3) internal iliac. LPLD is performed en-block as much as possible after the rectum separation for low anterior resection (LAR), and after the wound closure of the perineum for abdomino-perineal resection of the rectum. Results: 27 cases have been performed since 2001. Gender ratio was 20/7(male/female), mean age 60 years, 15 cases were abdomino-perineal resection of the rectum, 9 cases of (ultra-)low anterior resection, 1 case of ISR, and 2 cases of total pelvic exenteration. Average length from the anal verge was 4.08 cm, 9/18 cases of preventive/curative dissection, mean surgery time was 393.6 min, average amount of bleeding was 277.1 ml., average number of LPLD was 14.04, four cases of intraoperative complications, including 1 case of blood vessel damage (internal pudendal vein), six cases of postoperative complications, and 2 cases each of anastomosis leakage and urinary dysfunction were observed. The median months of postoperative observation was 40 months in which 10 cases of recurrence and 3 cases of local recurrence were observed. Conclusion: Recently, preoperative chemoradiotherapy has also been introduced, and indications for LPLD still require consideration. Evaluation of long-term follow-up is insufficient, but short-term postoperative outcome is generally favorable and laparoscopic LPLD is considered to be a useful operation method. From now, prospective controlled study comparing laparoscopy and conventional open surgery with long-term follow-up is considered necessary in the future.

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R. Ohno

Background: The rectal NETs suspected lymph node metastasis need TME according to rectal cancer. Recently, some studies reported that laparoscopic surgery for rectal cancer is safe and has short-term benefits compared with open surgery. And we have performed laparoscopic surgery for the rectal NETs at our institution. Methods: Between 2004 and 2013, 53 patients with rectal NETs underwent laparoscopic surgery. We performed TME for those which fill either among tumor size 10 mm or more, associated with central depression, suspected invasion to the muscularis propria, lymph node metastasis by preoperative images, or the presence of lymphovascular invasion or positive resection margin in prior local resection specimen. We retrospectively investigated short-term and long-term outcomes of this operation. Results: Of 53 (36 male and 17 female) patients, the median age was 55 years (30–84). The median distance from the anal verge was 5 cm (3–13), and the median tumor size was 8 mm (3–20). 36 patients underwent additional TME following to local resection and 17 initially underwent TME. Of those, four patients with lateral lymph node metastasis in preoperative images underwent lateral lymph node dissection. The surgical procedures were low anterior resection in 46 and intersphincteric resection in seven. The rate of sphincter preservation was 100 %. The median operating time was 254 min (124–505) and the median blood loss was 10 ml (0–70). There were no conversions to open surgery. In terms of postoperative complications, the anastomotic leakage and surgical site infection occurred in four and one patient, respectively. The tumor depth was 49 confined to the submucosal layer and three involving the muscularis propria. The pathological lymph node metastasis was confirmed in 21 patients (40 %), All four lateral lymph node dissection patients had the metastasis of this region. The 3-year disease free survival rate was 98.1 % in the median 34 months (4–98) follow-up period. The type of recurrence of the only one case was peritoneal dissemination in 27 months from the operation. Conclusion: For the rectal NETs, laparoscopic surgery appears to be technically and oncologically acceptable. Anal sphincter preservation is likely to be achieved in most cases.

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Prevention of Anastomotic Complications in Laparoscopic Surgery for Lower Rectal Cancer in Patients After Preoperative Chemoradiation Therapy

Single Port Laparoscopy-Assisted Abdomino-Perineal Resection Using the Planned Site of Stoma

Y. Hashiguchi1, S. Fujii1, M. Tsukamoto1, Y. Fukushima1, T. Akahane1, K. Nakamura1, T. Hayama1, T. Tsuchiya1, H. Yamada1, K. Nozawa1, K. Matsuda1, S. Soichiro2, T. Watanabe2 1

Teikyo University, Tokyo, Japan; 2University of Tokyo, Tokyo, Japan

Background: Anastomotic leakage is still a significant complication in surgery for rectal cancer. Purpose: The aim of this study is to present our clinical experience and suggest our practical methods for prevention of anastomotic leakage after laparoscopic rectal cancer surgery with preoperative chemoradiotherapy (CRT). Patients and Methods: We experienced 55 patients with cT3–cT4 rectal cancer who underwent laparoscopic surgery after CRT. The total dose of preoperative radiotherapy was 50.4 Gy, which was given in 28 fractions over 6 weeks. No hand-assisted techniques were used. A double stapling technique was generally used for the anastomosis. Diverting stoma was optional (40 %). Critical points of our procedure were as follows: 1) No excessive removal of fatty tissue around the oral colon for anastomosis 2) Careful confirmation of successful anastomosis A. The two intact concentric rings of the bowel retrieved from the anvil of the circular stapler should be observed. B. The endoscopy should be inserted through the anus, and the anastomosis should be thoroughly inspected by visualization (Endoscopic hemostasis if necessary; 5 %) C. Leak test by luminal air insufflation during colonoscopic procedure 3) Insertion of transanal drain 4) Insertion of intra-abdominal drain around anastomosis Results: The mean operation time was 312 min, mean blood loss 50 ml, incidence of anastomotic leakage was 3.6 % (2/55), and the 3-year local recurrence rate was 4 %. Conclusions: Laparoscopic surgery for lower rectal cancer after CRT was acceptable with small blood loss, reasonable operation time, and good local control. Our procedure resulted in a very low incidence of anastomotic leakage.

S. Homma, S. Shibasaki, N. Minagawa, H. Kawamura, N. Takahashi, A. Taketomi Hokkaido University Hospital, Sapporo, Japan Background: Reduced port laparoscopic surgery is the latest innovation in minimally invasive surgery. We have started using laparoscopic single port access (SPA) surgery in colorectal surgery. Here we report our initial 10 experiences with SPA abdomino-perineal resection (APR) by using a single port with a multichannel port. Methods: 10 patients requiring APR with colostomy gave informed consent for operation. A SPA device was placed at the future stoma incision and additional 5-mm trocar at the umbilicus for the scheduled pelvic drain. At first laparoscopic abdominal proctectomy was performed, secondly transanal intersphincteric resection. Finally the stoma fashioned within the site preoperatively marked. Results: Four patients had some history of a surgical procedure (appendectomy and inguinal hernia repair). Eight patients were carried out in SPA APR, including six rectal cancer patients, two Crohn’s disease patients with vaginal fistula and rectal stenosis. Two patients were performed by SPA total proctocolectomy for ulcerative colitis and rectal cancer. The average of operative time was 274.9 (range, 195–391) minutes and mean estimated blood loss was 67 (range, 0–180) ml. There is no conversion to open surgery, reoperations, intraoperative and postoperative complications. The mean length of postoperative stay was 18 (range, 9–29) days. Conclusions: SPA APR similar to conventional laparoscopy can be performed safely and is feasible within the selected patients. Our procedure of SPA device placed at the future stoma and 5-mm trocar at the umbilicus offers more cosmetic than conventional laparoscopic procedure and using two port sites make it easy and safety.



Delayed Coloanal Anastomosis for Lower Third Rectal Cancer

Long Term Results of Laparoscopic Surgery for Ulcerative Colitis

A. Miron, V. Calu, C. Giulea Elias Hospital, Bucharest, Romania Aims: The aim of this study was to assess feasibility and functional result of delayed coloanal anastomosis for a lower third rectal cancer as an alternative to coloanal anastomosis with protective ileostomy. Methods: From January 2005 to December 2013, 8 patients with an adenocarcinoma of the lower third of the rectum underwent a laparoscopic colorectal resection, combining an abdominal and transanal approach. Colorectal resection was performed about 45 days after the end of the neoadjuvant radiotherapy. Two cases were operated for benign pathology. Laparoscopic dissection and TME resection were performed in the usual manner. The distal colon stump was pulled through the anal canal. Postoperatively, within 5 to 7 days, the colonic stump was resected and a direct coloanal anastomosis performed without ileostomy. In 2 cases the procedure was chosen as an alternative solution to a misfire during a colorectal stapled anastomosis. Results: There was no mortality, nor anastomotic leakage. One patient had a pelvic abscess due to a necrosis of the left colon requiring reoperation. Another delayed coloanal anastomosis could not be performed and the procedure was transformed in a left end colostomy. Functional results were considered good with appropriate fecal continence. No pelvic recurrence was encountered in oncologic patients. Conclusions: This procedure is a safe and feasible sphincter-preserving operation for patients with rectal cancer of the lower third of the rectum. It can be successfully used as an alternative to coloanal anastomosis with protective ileostomy. This technique is well adapted for patients receiving preoperative radiotherapy, with good functional results. The procedure can be performed in open or laparoscopic surgery.

´ braha´m, K. Farkas, Gy. Lazar, J. Tajti, Zs. Simonka, A. Paszt, Sz. A Z. Szepes, T. Molnar, F. Nagy, T. Wittmann University of Szeged, Hungary Introduction: For the surgical treatment of ulcerative colitis (UC), laparoscopy is used more widely, but less data are available on long-term results. The objective of our study is to compare the 3-year (38-month; 1–92) follow-up results of patients treated with conventional and minimally invasive surgical methods. Patients and Methods: Between Jan 01, 2005 and May 31, 2013 a total of 45 patients (27 women, 18 men) received surgery for UC, out of which 16 (35.5 %) were emergency (total colectomy with mucous fistula) and 29 (64.5 %) were elective cases (proctocolectomy and ileal pouch-anal anastomosis). Laparoscopy was used in 23 (51.1 %) and conventional method in 22 (48.9 %) cases. No difference was found between the two groups when comparing ASA class and mean BMI and age. Results: During the mean follow-up, significantly fewer surgeries were performed in the laparoscopy group because of intestinal obstruction (p = 0.005), septic condition (p = 0.007) and other complications such as anastomotic stenosis, anal bleeding, and pouch-vaginal fistula (p = 0.001). In regard to postoperative hernias, however, there was no difference between the two groups (p = 0.349). There were significantly fewer urgent admissions to a medical unit in the laparoscopy group (1 vs. 6, p = 0.034). A significant improvement in quality of life was measured in both groups after the surgery, but there was no measurable difference between the two groups. During our follow-up, a significant improvement was detected in the daily number of stools, the body weight in both groups, but better cosmetic results were observed in patients treated with laparoscopy. Conclusion: In UC, laparoscopy can be used for both emergency and elective cases, it provides good quality of life and better cosmetic results, and the long-term rate of complications is lower as compared to open surgery.

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Four-Step Strategy in Laparoscopic Surgery for Transverse Colon Cancer

Short-Term Outcomes of Laparoscopic Surgery for Colon Cancer in Oldest-Old Patients (]85 years old)

N. Matsumura, H. Tokumura, F. Saijo, K. Yabuki, Y. Mochizuki, H. Chitose, K. Sawada, M. Shibahara, A. Yasumoto, M. Muto, F. Ikezawa, R. Nomura, K. Takahashi, T. Toshima, Y. Funayama

Y. Okumura

Tohoku Rosai Hospital, Sendai, Japan Background: Laparoscopic surgery for transverse colon cancer (LSTC) is difficult. The transverse mesocolon anatomy is complex due to multiple vessels with various branches and numerous surrounding organs and layers. We present our four-step mobilization technique for LSTC. Definition of Anatomy and Strategy: The transverse mesocolon is divided into left, right, anterior, and posterior directions around the middle colic artery (MCA) areas, as follows: Area 1 is anterior left, Area 2 is posterior left, Area 3 is posterior right including divided vessels, and Area 4 is anterior right. LSTC involves mobilizing these areas in numerical order focusing on the layers which constitute organ borders and support veins. Strategy and Procedures: In Area 1, the greater omentum is divided leftward from the middle to the splenic flexure to open the omental bursa. The posterior wall of this bursa and the anterior transverse mesocolon layer are divided along the pancreatic inferior margin. The transverse mesocolon is taken down and thinned to place gauze on the divided mesocolon. In Area 2, with a cephalad transverse mesocolon, gauze can be seen through the thinned mesocolon. The posterior transverse mesocolon layer is divided from the third portion of the duodenum to the ligament of Treitz at gauze, where an opening in the mesocolon is made and enlarged safely while observing the pancreas. In Area 3, after detachment and mobilization of the transverse mesocolon from the duodenum and the pancreatic head, the superior mesenteric vein and the gastrocolic trunk (GCT) are exposed. The accessory right colic vein (ARCV), branching from GCT, is seen through the subperitoneal fascia under the posterior mesocolon layer. ARCV is safely divided with minimum fascial dissection to avoid injury and splitting. MCA is then dissected, if possible, keeping a left or right branch. Gauze is then placed on the pancreatic head. In Area 4, with a caudal transverse mesocolon, after the remaining right greater omentum is divided, gauze is visible through the anterior mesocolon layer. Mobilization is completed by simply dissecting, regardless of vessels, the remaining right anterior mesocolon from the pancreas. Conclusions: Four-Step Strategy in LSTC is safe and reproducible.

Osaka General Medical Center, Osaka, Japan Aims: The efficacy and safety of laparoscopic colon surgery in oldest-old patients (?85 years old) is unclear. This study aimed to evaluate the short-term outcomes of laparoscopic colon cancer surgery in oldest-old patients (]85 years old). Methods: A total of 314 colon cancer patients who had undergone laparoscopic surgery for colon cancer (fifteen patients were 85 and over, 299 patients were under 85) between 2008 and 2012 were retrospectively analyzed regarding clinicopathological and surgery-related factors, perioperative course and pre- and postoperative complications. Results: There were no significant differences in background factors. The mean operating time was shorter in oldest-old patients (p \ 0.05). Because the degree of lymph node dissection was less in oldest-old patients, but among D2 or D3 groups, there were no differences in all perioperative factors. Among these groups, the mean time to diet and length of postoperative hospital stay was rather shorter in oldest-old patients. Conclusions: Laparoscopic surgery for colon cancer in oldest-old patients is feasible, and can be safely performed by choosing good performance status.



Significance of Laparoscopic Surgery for Resecting Primary Lesion of Stage IV Colorectal Cancer

Clinical Feasibility of Laparoscopic Pelvic Lymph Node Dissection Following Total Mesorectal Excision for Advanced Rectal Cancer

S. Okamura Suita Municipal Hospital, Suita, Japan Background: With regard to unrespectable advanced colorectal cancer, resection of primary lesion should be considered with symptoms such as bowel obstruction and/or bleeding. For early introduction of systemic chemotherapy for advanced colorectal cancer after surgery, resection of primary lesion is required to undergo with minimal invasion. In this sense laparoscopic surgery could be good indication as a less invasive surgery for Stage IV colorectal cancer. Aims: To investigate safety and validity of laparoscopic surgery for resecting primary lesion of Stage IV colorectal cancer retrospectively. Patients and Methods: Sixty-nine cases of Stage IV colorectal cancer underwent resection of primary lesion from April 2006 through December 2011 in our hospital were divided into two groups; laparoscopic colectomy (LAC) group and open colectomy (OC) group. Following patient characteristics of the two groups were examined; backgrounds (sex, age, metastatic organs, rate of bowel obstruction, ASA-PS), factors during operation (operation time, amount of bleeding, extent of lymph node dissection, rate of ostomy, rate of conversion) and factors after surgery (days of hospital stay, rate of complications, days until start of chemotherapy, overall survival). Results: Among the backgrounds of the patients, no other factors had significant difference between the two groups except rate of bowel obstruction. Operation time and extent of lymph node dissection in LAC group were shorter and larger than those of OC group with regard to the factors during operation. Rate of complications and days of hospital stay were better in LAC group among the factors after surgery. Conclusions: As for the safety, there were any problems indicated with laparoscopic resection of primary lesion in Stage IV colorectal cancer in our study. Laparoscopic surgery might be less invasive than open surgery, so that laparoscopic resection of primary lesion appeared to be adequate to maintain quality of life in Stage IV colorectal cancer patients.

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F. Furuhata Sapporo Medical University, Sapporo, Japan Aims: To evaluate the technical feasibility, safety, and oncological outcomes of laparoscopic pelvic lymph node dissection (PLND) following total mesorectal excision (TME) in patients with advanced low rectal cancer. Patients and Methods: Laparoscopic PLND were performed in 35 patients from April 2009 to December 2013. Data regarding patient demographics, operating time, perioperative blood loss, surgical morbidity, lateral lymph node status, and functional outcome were analyzed. Surgical Procedure: Port placement for laparoscopic PLND is the same as that for TME. Five ports are set: a para-umbilical port for the laparoscope, two ports at the anterior axillary line over the right lower abdominal quadrant for working ports; and the other two for working ports in the left lower abdominal quadrant, symmetric to the right ports. An operator stands on the right side of the patient for left PLND and on the left side for right PLND. Laparoscopic PLND is performed before reconstruction of bowel continuity in cases of sphincter muscle-preserving operations and after closure of the perineal wound following rectal resection in cases of abdomino-perineal resection. Firstly, the ureter and the hypogastric nerve are confirmed and picked up before PLND in order to prevent injuring them. Then, the lymph nodes are dissected in order, along the common iliac vessels, in the obturator fossa, and along the internal iliac vessels, carefully preserving the hypogastric and obturator nerves. Results: In all 35 patients, the procedures were completed without conversion to open surgery. Mean operative time and blood loss were 592.2 min (434–746 min) and 358 ml (10–1290 ml). The mean number of uni-lateral pelvic lymph nodes harvested was 8.6 (range 2–17), and seven patients (20.0 %) had lymph node metastases. Postoperative mortality and morbidity were 0 and 31.4 %, respectively. Four patients developed urinary retention following removal of the catheter and required catheterization. Conclusions: Laparoscopic TME with PLND is safe and feasible, with the advantage of a minimally invasive approach. Prospective controlled study comparing laparoscopy and conventional open surgery with long-term follow-up evaluation is needed to confirm the authors’ results.

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Endo-Relieftm Needle Forceps Enables Safe Reduced-Port Laparoscopic Appendectomy

Laparoscopic Reconstruction of the GIT Following the Open Abdomen Operation

S. Nakazawa

D. Simeckova, M. Vrany, M. Man, J. Schroder

University of Gunma, Maebashi, Japan

Hospital Jablonec nad Nisou, Jablonec nad nisou, Czech Republic

Purpose: We introduced a novel needle forceps, Endo-ReliefTM (ER), for reduced-port laparoscopic appendectomy (LA). ER is a needle forceps with a 2.4 mm shaft but jaws equivalent to 5-mm forceps, and does not necessitate the use of port. The aim of our study was to evaluate surgical outcomes of reduced-port LA with ER compared to conventional 3-port LA. Methods: From May 2011 to September 2013, fifty-five patients underwent conventional LA (C-group), and forty-four patients underwent reduced-port LA (ER-group). In the ERgroup, one ER forceps was directly inserted at the suprapubic area with a single port system at the umbilicus, instead of the three 5-mm ports in the C-group (suprapubic area, right lower quadrant, and umbilicus). Results: Patient characteristics were as follows (C-group and ER-group, respectively), male:female ratio 3:2 vs. 3:2 and mean age 28 ± 20 vs. 33 ± 23 years. There were no significant differences between the two groups in operative and postoperative data (C-group and ER-group, respectively): mean operation time 86 ± 41 vs. 82 ± 32 min, blood loss 11 ± 44 vs. 14 ± 43 ml, initiation of postoperative oral intake 1.2 ± 0.7 vs. 1.8 ± 1.9 days, postoperative hospital stay 4.3 ± 3.2 vs. 5.4 ± 3.0 days, and postoperative intra-abdominal abscess 8.5 % vs. 7.3 %. Conversion to open appendectomy was seen in 1 case in the C-group, and 2 in the ER-group. Conversion to 3-port LA was seen in 1 case in the ER-group. Conclusion: Reduced-port LA using the novel ER forceps is a safe procedure and provides favorable cosmetic results compared to conventional LA.

Aims: Reconstruction of GIT after open abdomen operation resulting with colostomy demands extensive laparotomia, which involves significantly higher risk of morbidity. The aim of our video is to present renewing continuity of the bowel in laparoscopic way. Methods: Case report - laparoscopic reconstruction of the GIT following the bowel resection sec Hartman (in patient history she suffered from stercoral peritonitis because of perforated diverticulitis prior to bowel resection sec Hartman). In video presentation we would like to stress the key moments we had to deal with during the operation. Results: We will review the results obtained on patients, who underwent reconstruction of the GIT in retrospective study. We considered the early postoperative outcome, duration of the operation, type of the operation, peroperative data and postoperative follow up. Conclusion: Laparoscopic reconstruction of the GIT is demanding performance not only due to the numerous adhesions because of the previous diseases and revisions. Our video shows, that this operation can be done safely with relatively low morbidity. That is why the laparoscopic way is a very good option to open access.



Introduction of Laparoscopic Colorectal Resections: No Difference in Postoperative Complications or Oncological Results Compared to Open Procedures.

Preoperative Evaluation of the Distance of Left Colon Tumors from the Anal Verge: CT-Scan vs. Colonoscopy

Y.C. Williams1, F.M.H. van Dielen1, R.M.H. Roumen1, F. Aarts2, O.J. Repelaer van Driel1, P.M.M. Reemst1, G.D. Slooter1

R. Costi, A. Rollo, F. Tartamella, F. Beggi, E. Melani, C. Rapacchi, V. Pattonieri, V. Violi, L. Roncoroni, L. Sarli Universita` di Parma, Italy

1

Maxima Medisch Centrum, Veldhoven, The Netherlands; 2Elkerliek, Helmond, The Netherlands Aims: Analysing medium term peri-operative morbidity and oncological follow up after laparoscopic colorectal surgery in a medium-sized hospital. Methods: In this retrospective study all laparoscopic oncological colorectal interventions from 2004 till 2012 were analyzed. The parameter which were studied were peri-operative morbidity, oncologic outcome and follow up. Results: In total 626 laparoscopic colorectal interventions were performed in which conversion to an open procedure was required in 141 casus (23 %). The peri-operative morbidity was 28,2 % of which 48 % were minor complications and 52 % major complications. Anastomotic leakage occurred in 6,3 %. In terms of oncologic results there was a median lymph node yield of 13.4 nodes. The median follow up was 24 months. Survival per stadia was significantly reduced in stadium 3 and 4 colorectal carcinoma compared to stadia 0–2 (p \ 0,001). No differences were seen in survival between the different surgical interventions as well as the laparoscopic and the converted group. Conclusion: The implementation of laparoscopic oncological surgery in a medium sized hospital was successful. The peri-operative morbidity and oncological results are comparable to open surgery and congruent to results of international published literature.

Background: Defining the right distance from the anal verge (DAV) of colorectal cancer (CRC) has pivotal importance in modern colorectal surgery, since early diagnosis and neoadjuvant treatment may reduce the size of CRC, and consequently the possibility of detect it at surgery, where intrinsic limitations of laparoscopy do not allow for a precise intraoperative tumor localization. The effectiveness of colonoscopy in quantifying the correct (DAV) of CRC is suboptimal, whereas colonic tattooing and clips have intrinsic drawbacks that limit their effectiveness. Such an incertitude may put the laparoscopic surgeon in the challenging situation of not finding the tumor in the colorectal specimen. Methods: The DAV of CRC reported by the endoscopist during preoperative colonoscopy of 28 patients undergoing left colectomy were retrospectively compared to the DAV calculated from the radiologist with an original method while performing preoperative CTscan. Both radiological and endoscopic DAVs were then compared with the DAV recorded by the surgeon at the end of surgery (distance of the colorectal anastomosis from the anal verge, measured with the circular stapler, plus the distance of tumor from the distal end of resected colonic specimen) and the pathologist. Endoscopist, radiologist, surgeon and pathologist were blind to each other. Results: CT-scan and endoscopy both overestimate DAV, with the first apparently but not significantly more inefficient that the latter (4.2 ± 6.9 cm and 3.1 ± 6.3 cm respectively; ANOVA with Bonferroni’s multiple comparison test p value [0.05); CT-scan results are also significantly different from surgery-pathology results (p \ 0.01), whereas endoscopy do not (p [ 0.05). Conclusion: Although colonoscopy seems superior to CT-scan in defining the DAN of CRC located in the left colon, accuracy of both colonoscopy and endoscopy is suboptimal, since a mean overestimation of [3 cm may be attended. Although the overestimation may be possibly corrected, the wide range of results (standard error) limit the interest of those examinations in defining preoperatively the real DAV of the tumor.

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When to Perform Laparoscopic Resection Rectopexy for Rectal Prolapse - Our Experience

Laparoscopic Right Hemicolectomy for the Treatment of Benign Colon Tumors

I.P. Zhivkov, G.B. Gurbev, D.M. Banchev

T. Galicia Gomez, S.J. Salgado

First MHAT, Sofia, Bulgaria

ISSSTE, DF, Mexico

Background: As one of the most common benignant diseases of the modern time the rectal prolapse is quite a significant problem for the countries with lower consummation of fiber rich food. The delicacy of this kind of morbidity is the main reason that a great number of patients look for medical help when the disease is advanced. The choice of appropriate operative technique is the most significant to achieve good short and long term results. Aims: Determine the cases in which we consider the resection rectopexy technique is suitable. Material: We are observing a group of patients including 136 persons with rectal prolapse. They were observed and passed operative treatment in 17 years period from the beginning of 1997 till present days. The gender distribution is approximately 4:1–104 female and 32 male patients. The exact number of patients with complete rectal prolapse is 75. Operation distribution in the control group is: Anal encirclement- 8 patients; Mucosal sleeve resection (Delorme’s procedure) - 13; Mucosal sleeve resection (Longo procedure) - 43; Perineal rectosygmoidectomy (Altemeier) - 12; Open surgery suture (rectopexy) - 4; Open surgery anterior sling (Ripstein) - 6; Open surgery posterior sling (Wells) - 9; Open surgery resection- 3; Open surgery resection and rectopexy (Frykman- Goldberg) - 4; Laparoscopic rectopexy- 10; Laparoscopic anterior sling - 10; Laparoscopic posterior sling- 7; Conclusions: By observing the short and long term results, we consider that the laparoscopic resection rectopexy is an operative technique of choice in patients under age of 70 years, in whom accompanying severe heart, vascular, pulmonary or endocrine diseases do not present. The presence of previous open surgery or laparoscopic operation is not significant reason for not performing laparoscopic resection rectopexy. Although the need of adhesions liberation is time consuming and sometimes quite difficult it is reasonable because of the better results after laparoscopic resection- rectopexy vs. open surgery operative techniques. The better patient selection is most significant for better short term results.

Female patient of 61 years old with acute onset of bowel obstruction and History of undernourishment of six months due to nausea and feed intolerance accomplished with loss weight of 33 pounds in six months to the date of her admission to the Emergency room. Colonoscopy showed a pedunculated tumor in the hepatic angle of right colon that shows be the primary cause for bowel obstruction who was treated with nasal decompression and IV Nutrition once the panel for tumor markers was negative and the patient gain 22 pounds in 20 days of medical treatment. The patient goes to a laparoscopic right hemicolectomy for the resection of the right flexure of the colon, the pathology department report a submucosal benign tumor and the anastomoses was performed extracorporeal. The patient tolerated oral feeding at the 8 eight of the post operatory and was discharged at the 10 days of the surgery. Definitive pathology report a submucosal lypoma of the right hepatic flexure, the patient gained 33 pounds 6 months after the surgery. Lipomas are the most frequent benign tumours of the digestive tract and 50 % are localized in the colon. Most are found in the submucosa and may vary in their incidence, localization, symptoms and pathogenesis



T1 Colon Cancer: The Balance Between Oncologic Benefit and Operative Risk of Complementary Surgical Treatment to the Endoscopic Resection

Laparoscopy as a First Line Treatment in Stage III Colorectal Malignancies-Is it Feasible?

D. Saavedra-Perez, M. Fernandez, S. Delgado, R. Almenara, D. Momblan, A Ibarzabal, R. Bravo, R. Corcelles, A.M. Lacy Hospital Clinic of Barcelona, Spain Aims: Treatment of early-stage colorectal cancers removed endoscopically depends on histopathologic findings but remains controversial. This study aimed to assess the benefitrisk balance for patients who underwent complementary surgery after endoscopic resection of a T1 carcinoma with unfavorable histology. Methods: From January 2008 to December 2012, 41 consecutive patients were included in this retrospective study. Specimens resected after endoscopic polypectomy showed at least one of the following unfavorable factors: no free margin, lymphovascular invasion, poorly differentiated grade, deep submucosal invasion, sessile morphology, and piecemeal resection. The main objective was to assess the benefit-risk balance of an oncological resection performed after the polypectomy. Oncological benefit was measured by the lymph node metastasis rate and the persistence of a residual adenocarcinoma on the specimen. The risk was measured by the occurrence of postoperative severe complications of grade III-IV or death. The associations between these end points and clinicopathologic variables were evaluated by univariate analysis and logistic regression. Results: Mean age was 65 years (range, 40–88 years). Comorbidities were present in 55 % (22/41) of the patients. Peripheral vascular disease was the most frequent comorbidity (15 %). Sigmoid colon harbored the primary lesion in the 66 % (27/41) of the patients. All resections were approached by laparoscopy with need of conversion to open surgery in only 1 case (adherences), without intraoperatory complications. Median for resected lymph nodes was 12 (range, 10–17). Six patients (15 %) had lymph node metastases and seven (15 %) had residual carcinomas. Only one patient (0.2 %) had grade III morbidity. There were no postoperative deaths. Patients with lymph node disease received adjuvant treatment. At 5 years of follow-up neither recurrence, nor deaths have been present. Conclusions: In this series a high rate of lymph node metastatic disease was present even without residual carcinoma on the colon wall, thus complementary surgery should be performed in patients with adverse histopathological criteria of endoscopically resected malign polyps of the colon. The laparoscopic approach by diminishing the postoperative morbidity rate, could improve the oncological benefit of a complete resection.

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I. Diaconescu, M.R. Bratu, R. Craciun, G. Andrei, I. Vacaroiu, C. Tudor, A. Spatariu, M. Beuran, B.V. Martian Emergency Clinical Hospital, Bucharest, Romania Aims: The purpose of the study was to evaluate the feasibility and efficacy of laparoscopy in STAGE III colorectal malignancies. Methods: A retrospective study of 72 patients who underwent open (OCR group) or laparoscopic (LCR group) surgery for STAGE III colorectal malignancies, between 2008 and 2013, was performed using SPSS v19. The operations were executed by the same surgical team and using ‘no-touch’ oncological principle. We analyzed demographic data, BMI, operation type (OP), blood loss (BL), lymph node harvested (LN), postoperative complications (PC), hospital stay (HS), bowel ileus (BI) and days of total parenteral nutrition (TPN). A p-value smaller than 0.05 was considered statistically significant. Results: From 72 patients, 45 underwent OCR and 27 LCR. There were no statistical differences between the demographic characteristics of the patients. The most frequent OP was abdominoperineal resection for both groups. We observed a smaller mean BL in LCR group (p = 0.001). During both types of operation there were harvested approximately equally amounts of LN (p = 0.67). In postoperative period, the LCR patients recovered faster with a smaller BI period (p = 0.01) and fewer TPN days (p = 0.02). We also found a significant shorter HS in the LCR group (6.67 days) compared to OCR group (10.69 days) with p = 0.02. After laparoscopic procedures we had 2 cases of thrombocytopenia while after open colectomies we encountered 2 fistula, 1 evisceration and 1 anastomosis dehiscence. Conclusions: Laparoscopy has strong advantages over open surgery in perioperative and postoperative period while there were no differences in the oncological standards. According to our study laparoscopy is feasible, safe and can be used as a first-line treatment for STAGE III colorectal malignancies.

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Optimal Time for Surgery Following Preoperative SelfExpandable Metallic Stent Insertion in Patients with Left-Sided Obstructive Colorectal Cancer

Laparoscopic Total Mesorectal Excision for Rectal Cancer After Neoadjuvant Treatment: A Single Center Experience

Y.A. Park1, J.K. Shin2, J.S. Park2, Y.M. Chae2, J.W. Huh2, Y.B. Cho2, S.H. Yun2, H.C. Kim2, W.Y. Lee2, J.A. Yun2 1 Samsung Medical Center, Seoul, Korea; 2Sungkyunkwan University School of Medicine, Samsung Medical Center, Seould, Korea

Background and Purpose: Self expandable metallic stent (SEMS) has been increasingly used for the purpose of preoperative bowel decompression for obstructive colorectal malignancy. This study was aimed to determine the optimal time of surgery after preoperative colonic stent insertion for left-sided colorectal cancer with obstruction. Methods: A total of 225 patients who had left-sided obstructive colorectal cancer were operated following SEMS insertion. Excluding patients with stage IV disease (n = 73), hereditary colorectal cancer (n = 7), inflammatory bowel disease (n = 1), and post-procedure colonic perforation (n = 5), 139 patients were included. Patients were categorized into two groups according to the time interval between SEMS insertion and operation: Group A (\14 days, n = 86) vs. Group B (=14 days, n = 53). Clinicopathologic parameters including comorbid diseases, postoperative morbidity such as surgical site infection (SSI) and ileus, and length of hospital stay (LOS) were analyzed. Results: Mean time interval between SEMS and operation was 14 days (8 days in Group A vs. 23 days in Group B, p = 0.000). Patients of Group B possessed larger number of comorbid diseases (0.7 ± 0.86 vs. 0.5 ± 0.68, p = 0.052) and they had SEMS inserted in outside hospital more frequently (54 % vs. 19 %, p = 0.000). Other clinicopathologic parameters were not different. Rate of SSI including anastomotic leakage (n = 1) and intraperitoneal abscess (n = 1), and ileus was not different between Group A and B (9.3 % vs 3.7 %, p = 0.318 and 5.8 % vs. 5.6 %, respectively). However, LOS was significantly longer in Group A (15 ± 5.5 vs. 12 ± 7.4 days, p = 0.0009). On multivariate analysis, time interval between SEMS and operation less than 14 days (p = 0.015) and two or more comorbid diseases (p = 0.016) were significant factors for longer LOS. Conclusions: This study demonstrates that short time interval between SEMS insertion and operation, and higher number of comorbid diseases are associated with longer LOS, even though postoperative morbidity was not different. We suggest sufficient time interval more than 14 days for operation following SEMS insertion to enhance fast recovery.

C. Duta, C. Lazar, D. Barjica, A. Dobrescu, F. Lazar University of Medicine and Pharmacy ‘V. Babes’, Timisoara, Romania Background: Laparoscopic total mesorectal excision for rectal cancer is still under scrutiny. This study aimed at analyzing feasibility, adequacy of resection, impact on early outcomes after neoadjuvant chemoradiation therapy, and to investigate trend towards indication of laparoscopy for sphincter-preservation. Method: Patients with low and ultra-low rectal cancer submitted to neoadjuvant treatment followed by laparoscopic total mesorectal excision were enrolled. The studied parameters were: demographics, previous surgery, BMI, duration of surgery, conversion, specimen retrieval, lymphadenectomy, distal and radial margins, intra and postoperative morbidity, reoperations, hospital stay, and mortality. Results: From 2002 to July 2012, 28 patients were enrolled. Mean age was 59 (29–78) years. There was a trend (p = 0.003) towards more sphincter-preserving surgery. Conversion was 7.1 % (2 pts). Intraoperative complication was 7.1 % (2 pts). Postoperative complications occurred in 10.4 % (3 pts). No mortality. Lymph-node harvest was 17 (11–33). Mean distal margin was 2.5 cm (1–4). Radial margins were positive in 1 (3.6 %) case. Conclusions: Laparoscopic total mesorectal excision after neoadjuvant treatment is feasible and safe. Sphincter-preserving laparoscopic oncologic rectal surgery has been accomplished more frequently.



Marking and Localisation in Colorectal Laparoscopic Surgery

Conversion Rates in the Laparoscopic Treatment of Crohn’s Disease

K. Dede, D. Csiko´s, I. Besznya´k, T. Mersich, A. Bursics Uzsoki Hospital, Budapest, Hungary In laparoscopic colorectal surgery, marking and intraoperative localisation are particularly important. The palpation is possible only with an instrument, and many leasions are unvisible because of the lack of serosal invasion, or because of the mesenterial localisation. Identification could be more problematic in the rectum or in obes patients. To find the leasion and to be sure, that the leasion is removed, this is the most important for a surgeon in the operating room. Benign polyps, small tumours, rectum tumours responding for neoadjuvant chemotherapy usually need some preoperative marking or special intraoperative localisation. To define the extension of a resection by multiplex laesions, diverticulosis, or to precisely mark the inferior border of a tumour in deep rectum tumours is very important. A good marker can show the lymphatic map of a colon segment to plan the skeletisation. A good collaboration with the gastroenterologists, like a diagnostic colonoscopy with adequate marking, can avoid the need for a second colonoscopy before surgery. Authors report the potential markers and localisation methods in their own practice.

Zs. Simonka1, J. Pieler2, J. Tajti2, A. Paszt2, Sz. Abraham2, A. Ottlakan2, Gy. Lazar2 University of Szeged, Szeged, Hungary; 2University of Szeged, Department of Surgery, Szeged, Hungary

1

Introduction: The surgical treatment of Crohn’s disease (CD) mainly involves complications of the condition. In the case of benign gastrointestinal conditions, minimally invasive surgical treatment has long become an acceptable choice of treatment. In our retrospective study our aim was to discuss the possibilities of laparoscopic treatment, frequency-, and necessity of conversion. Patients and Method: At our department we performed abdominal surgery in case of 127 patients with CD, between 1st of January 2005 and 31st of December 2012. Open procedure was performed in 97 cases, laparoscopic surgery in 30 cases. In terms of gender (54f/43 m vs. 17f/ 13 m), BMI (19.09 ± 2.76 vs. 18.21 ± 4.82) there were no significant differences between the two groups. In the laparoscopic group patients at a younger age (37.71 ± 14.45 vs. 31 ± 10.16 years, P = 0.042) were admitted for surgery. In the open procedure group acute surgery was performed in 13 cases. All laparoscopic procedures were performed on elective bases. Results: Due to the heterogeneity of the disease, the type of procedures involved a wide spectrum of surgical interventions (ileocolic resection 45.36 % vs. 60 %, small bowel resection 23.71 % vs. 10 %, colon resection 20.62 % vs. 26.67 %, others 10.31 % vs. 3.33 %). Mean operative time was shorter in the minimally invasive group (144 ± 38.21 vs. 126 ± 40.26 minutes, p \ 0.05). Complications requiring reoperation occured in 6 cases (6.19 %) in the open-, and in 2 cases (6.67 %) in the laparoscopic group. Mortality occured only in the open group (1.03 %). Conversion was needed in 7 cases with a mean operative time of 176 ± 43.32 minutes. The cause of conversion was fistulizing CD form in 85.71 % of the cases. Conclusion: With appropriate surgical indication (taking the extent, and type of disease into consideration) laparoscopic procedures are of equal value to open procedures. Recidive CD is not an absolute contraindication for laparoscopy. Comparing rates of conversion to the ones seen in the laparoscopic treatment of colorectal cancers (14.3 %), a higher rate can be expected in the case of CD (23.33 %). Discrepancy between preoperative diagnostics and intraoperative findings can increase the rate of conversion. Fistulizing and conglomeratum forming CD were the main causes of conversions.

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Postoperative Intestinal Obstruction by an Internal Herniation After Laparoscopic Anterior Resection: A Case Report

Selp Expandable Metal Stent Insertion for Non-malignant Colonic Stricture: Report of Two Cases

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

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

Korea University Anam Hospital, Seoul, Korea

Korea University Anam Hospital, Seoul, Korea

There are multiple factors that contribute to the postoperative intestinal obstruction such as bands, omental or mesenteric weakness, and abnormal bowel rotation. Postsurgical or traumatic defects contribute to increase in acquired internal herniation. Although majority of acquired internal herniation come from incomplete closure of the mesenteric windows postoperatively, it is basically a rare cause for the postoperative intestinal obstruction. This is our first experience to have internal herniation post laparoscopic anterior resection where the small bowel herniates between neorectum and pelvic floor. A 79 years old man presented to us with abdominal pain and distension for 1 day. He had a past history of laparoscopic anterior resection for rectal cancer 1 year ago. His vital signs were stable, but his blood tests on admission revealed leukocytosis (11.7 9 103) and elevated CRP level (254.16 mg/l). Abdominal CT scan showed dilated small bowel loop in the pelvic cavity. After resuscitation, he underwent laparoscopic exploration and dilated bowel loop was noted in the pelvic cavity. We converted to open surgery with lower midline incision. There are a loop of small bowel about 80 cm herniated and twisted between the neorectum and pelvic floor defect. Herniated small bowel was segmentally resected, and the defect between the neorectum and the pelvic floor was closed. He recovered uneventfully and discharged on day 13 postoperative day. Early diagnosis and management in postoperative intestinal obstruction is very important in order to reduce morbidity and mortality. High index of suspicion by clinician based on clinical finding is mandatory to avoid delay in managing intestinal obstructions especially in postoperative patient. CT scan is promising in giving valuable information for diagnosing intestinal obstruction in postoperative internal herniation.

Introduction: Self expandable metal stent for malignant obstruction is widely used for palliation of unresectable disease or bridge to surgery because of its safety and efficacy. However, there are few reports about stent insertion for non-malignant conditions of colonic strictures. We reports 2 cases performed stent insertion for colonic stricture following resection. Case 1: A 73-year-old woman underwent laparoscopic anterior resection and right adrenalectomy for sigmoid colon cancer and functioning adrenal mass. After the resection, she complained about abdominal pain and discomfort constantly. Colonic dilatations on abdominal X-ray had shown no improvement. After 1 month later, a stricture above the anastomosis occurred based on CT scans and sigmoidoscope. We concluded that benign stricture occurred in Griffiths’ point. A covered self expandable metal stent was placed across the stricture under endoscopic and fluoroscopic guidance. She remained asymptomatic for 8 months and satisfied with the outcomes. Case 2: A 71-year-old man underwent laparoscopic anterior resection for sigmoid colon cancer. He had received pills for antiplatelet agents owing to CVA history. Postoperative day 2, he had fever and hematochezia. Mucosal ischemia on descending colon was shown in CT scans and sigmoidoscope. He had developed to colonic obstruction because of anastomosis stricture after 3 months postoperatively. An uncovered self expandable metal stent was placed across the stricture under endoscopic and fluoroscopic guidance. He remained asymptomatic for 3 months. Conclusions: The use of self expandable metal stent for non-malignant colonic stricture is also safe and efficient. Especially, stents for anastomotic strictures enable to avoid unwanted operation. Long term efficacy and safety requires further studies.



Effectiveness of Laparoscopic Reversal After Hartmann’s Procedure for Hinchey 4 Complicated Diverticulitis

Laparoscopic Approach to Large Bowel Obstruction

F. Roscio, A. de Luca, P. Frattini, F. Galli, S. Vellini, I. Scandroglio Galmarini Hospital, Tradate, Italy Aims: Hartmann’s procedures (HP) remains a widespread surgical approach for the treatment of Hinchey 4 (H4) acute diverticulitis. Laparoscopic Hartmann’s reversal (LHR) is a challenging procedure that requires advanced skills but potentially allows to achieve effective outcomes. Methods: A consecutive unselected series of eleven (N = 11) patients undergoing elective LHR at our Division from January 2008 to December 2012 was analyzed. All patients had previously been treated by HP for H4 diverticulitis, 8 of these (72.7 %) with open approach, 3 (27.3 %) with laparoscopic technique. We used a standardized technique with four ports, one of which is placed at the site of colostomy abolished. Surgical technique, instrumentation and post-operative cares were standardized. Comorbidity of each patient was assessed by Charlson Comorbidity Index (CCI). All the operations were performed or supervised by the same team, fully trained in minimally invasive colorectal surgery. Complications were classified using the Clavien-Dindo system (CDS). Follow-up was conducted at 30 days and 6 months. Results: Mean age of our cohort was 64.6 ± 9.1 years with a CCI of 1.5 ± 0.8. We had no conversion to open laparotomy. Mean operative time was 204.5 ± 56.1 min while estimated blood loss was 76.8 ± 35.9 mL. Tim in of first stool was 3.5 ± 1.0 days. The rates of postoperative complications was 45.4 %and 18.1 % respectively for grades 1 and 2 according to the CDS system. Length of hospital stay was 8,2 ± 1,7 days and we have not recorded read missions in patients discharged within 60 days after surgery. We observed no recurrence of diverticular disease at the follow up while there was evidence of 1 case of incisional hernia (9.0 %). Conclusions: Elective laparoscopic reversal after HP for H4 acute diverticulitis represents an effective option, which produces adequate post-operative results.

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R. Johanes1, I. Maretta1, K. Kroupa2 DONsP Dolny´ Kubıń, Slovak Republic; 2ZIlina, Slovak Republic

1

Material and Methods: Main cause of ileus was carcinoma of large bowel. They compare this approach and procedure with acute resection and with stenting of stenotic part of large bowel. After 4–11 days they underwent laparoscopic radical resection after nutritional and metabolic preparation including cleaning and detoxication of large bowel. Large bowel stomies were kept. Closing of stomy was performed on third procedure, after definitive staging of carcinoma and consultation with oncologist - interval 1–3 months Results: From 2008 to 2013 group of 36 patients from two departments was created. Patients are feeling very well after first and second procedure with advantages of minimally invasive approach. Main procedures were left hemicolectomy, Sigmoid segmental resection and Low anterior resection. Then patients were sent off from hospital and mainly start first courses of oncological therapy. In their interval closing of stoma was planned according to status of patients and circumstances of therapy. Oncological radicality was satisfactory measured by number of harvested lymph nods. Comparison of number of harvested lymph nodes was with other study from these departments - varies according to type of procedure from 12–28 lymph nodes. This method becomes a method of choice in these departments and replaces other procedures like Hartman resections, subtotal colectomy. Alternative such endoscopical stenting of were not present in these departments. Reasons are mainly economical and due to organisation of 24 hour presence of acute endoscopy. Long term results of survival are not presented due to short time of study. Authors recommend this procedure as a method of choice in departments with adequate laparoscopic mastership in elective and acute surgery too Discussion: Group is too small to create a serious conclusion according to EBM. But postoperative course and benefit of radicality of procedure including wider support of immunity to this process is undoubted. Endoscopical approach as an alternative can cause ileus prolonging or perforation of bowel in time of endoscopy. Real availability of gastroenterologist 24 hours with adequate stent is problematic. After solving such way can by resection problematic due to fixation of stent to tumor. Cleaning of oral part can be problematic.

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The Individual Surgeon’s Performance: 10 Years of Laparoscopic Colorectal Surgery for Benign Diseases

Is the Modified Laparoscopic Ventral Mesh Rectopexy an Evolution of Technique or a Reaction to Erosion?

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

T. Ekere1, K. Subramanian1, A. Clarke2, M. Lamparelli1

Queen’s Medical Centre, Nottingham, United Kingdom

1 Dorset County Hospital, Dorset, United Kingdom; 2Poole Hospital, Poole, United Kingdom

Aims: The public disclosure of individual-surgeon data in June 2013 by the National Health Service in the United Kingdom, has been hailed a seminal moment in surgery. We aim to evaluate individual surgeon performance in laparoscopic elective colorectal operations for benign disease, from a national laparoscopic training centre in the United Kingdom. Methods: Data was gathered and analysed from a prospectively validated database for laparoscopic colorectal operations, performed by an individual consultant surgeon from July 2003. Outcomes for benign-neoplastic disease and non-neoplastic disease were compared. Results: A total of 96 patients with a mean age of 55.7 years (19–85), and mean BMI 26.1 kg/m2 (17.8–46) underwent laparoscopic resection for benign disease. The majority were ASA grade 2. Fourteen resections were for benign neoplasia (5 right-sided, 5 rectal, 2 left-sided and 2 subtotal colectomies). The 82 resections for non-neoplastic diseases were 11 left sided, 28 rectal, 10 right-sided, 12 restorative and 11 right and left sided resections. The common non-neoplastic pathologies were inflammatory bowel disease (32.9 %) and diverticular disease (24.4 %). The median follow-up for the benign neoplastic and nonneoplastic groups were 528 and 339 days. Seventy four percent (71 patients) had an anastomoses (benign neoplastic - 10; non-neoplastic - 61). The anastomotic leak rate was 2.8 %, with all leaks occurring in the non-neoplastic group. Median length of stay was 4 days (1–27) in the neoplastic group as against 5 days (2–34) for the other. Conversion rate was higher for non-neoplastic group (15.9 % vs. 7.1 %). The 30 day morbidity was 14.3 % with no in-hospital mortality in the neoplastic disease as against morbidity of 28.0 % and 1 in-hospital death. There were no readmissions or reoperations in the neoplastic group while that for the other were 3.7 % and 9.8 % respectively. Incisional hernia rates were higher in the non-neoplastic group (15.6 %) compared with benign neoplastic (1.0 %). Conclusions: The data supports laparoscopic colorectal surgery to be safe and feasible for benign disease. The poorer outcomes for the non-neoplastic group are reflective of the casemix. With patient selection and increasing surgeon experience laparoscopic surgery is increasingly being offered for benign disease.

Introduction: Erosion is a major complication after laparoscopic ventral mesh rectopexy (LVMR). We previously utilised a similar technique to that described by D’Hoore and Penninckx 2006, involving synthetic Prolene (Atrium) or polyester (Covidien) mesh fixation to the vaginal fornix (or posterior vaginal vault) using non-absorbable Ethibond (Ethicon Johnson & Johnson) sutures. We recently reported an incidence of erosion of 1.9 % over a 5-year period in a case series of 309 patients. We noted involvement of the non-absorbable suture in 67 % of patients with erosion. And erosion occurring at the vaginal vault in 83 % of patients. Method: During our analysis, the suture was implicated in 2/3rd of the cases and as such we have now modified the LVMR technique to use absorbable PDS (Ethicon) sutures. We also noted 83 % of erosions occurred at the vaginal vault. This suggested the possibility that this part of the vaginal wall was exposed to increased mechanical stress from the repair or was an area of anatomical weakness in the repair. To prevent this, we modified our technique of mesh fixation superiorly, suturing unto cervical fascia (medial continuation of the cardinal ligaments) prior to penultimate suture placement on rectum spreading the mechanical stress. (See diagrams). Discussion: We report a novel modification to the LVMR operation described by D’Hoore and Penninckx in 2006 and subsequently utilised by many surgeons who learnt this procedure. We believe these modifications will result in a reduced incidence of erosion post operatively and we continue to monitor our outcomes.



Laparoscopic Selective Extralevator Abdomino-Perineal Resection for Perforated Low Rectal Cancer

Laparoscopic Management of Appendicular Mass

J.H. Lai

Ain Shams University, Faculty of Medicine, Cairo, Egypt

Singapore General Hospital, Singapore Aims: Extralevator abdomino-perineal resection (APR) has been advocated due to its oncological superiority but has significant perineal wound and functional morbidity. We present a video documentation of the laparoscopic approach to a selective extralevator APR in a perforated low rectal cancer. Methods: A 47 year-old male patient presented with localized perianal sepsis from a low rectal cancer that had involved the upper anal canal and invaded the left levator ani. He was planned for upfront surgery after staging, combined oncology review, and a period of antibiotic treatment. Laparoscopic APR was performed with selective extralevator excision of the left levator and ischiorectal fossa for cancer clearance. Video recording of the operative process was routinely done and the key events edited for video review. Results: (Description of Video): Laparoscopic APR started with the routine insertion of subumbilical camera port and 4 working ports. The operation proceeded with the medial to lateral dissection of the mesosigmoid with the use of the ultrasonic dissector. The inferior mesenteric artery and vein were ligated high and divided between clips. Total mesorectal excision (TME) was commenced with the aid of cotton tape at the rectosigmoid for cephalad retraction. TME was completed to the pelvic floor on the right side and anteroposterioly. The TME stopped short of the pelvic floor on the affected left side to prevent ‘waisting’. Proximal transection was done at the sigmoid with an endoscopic linear stapler. The perineal phase of the APR was done in the lithotomy position. Resection of the left ischiorectal fat and the left levator ani at its ischial origin was done. The APR specimen was delivered perineally. Re-peritonealisation of the pelvis was done, with end colostomy brought out in the left abdomen. The perineal defect was closed with a vacuum-assisted closure dressing. The patient recovered well with no wound or genitourinary complications, and had secondary perineal wound closure with 2 weeks of the primary surgery. Histology showed that resection margins were clear. Conclusion: A selective extralevator approach to APR can be done well in a minimallyinvasive fashion with good outcomes.

H.M. El-Barbary

Emergency laparoscopic appendicectomy is emerging as a new safe treatment modality for the appendiceal mass, and may prove to be more cost-effective than conservative treatment even without interval appendicectomy as it is associated with a much shorter hospital stay and obviates the need for long intravenous antibiotic therapy. If emergency laparoscopic appendicectomybecomes the standard of care, interval appendicectomy will certainly become ‘something’ of the past. Aims: evaluation of the feasibility and outcome of laparoscopic treatment of complicated appendicitis namely appendicular mass Methods: retrospective review of patient data in a tertiary referral, university hospital, including all patients who were treated with laparoscopic appendectomy from October 2012 till november 2013 Results: one hundred fifty two cases were subjected to laparoscopic appendicectomy, 21 of them were diagnosed with appendicular mass preoperatively, average operative time was 62.5 minutes, average hospital stay was 4.2 days. Two patients had postoperative complications, one with port site infection, and the other patient had prolonged postoperative fever which all resolved by antibiotics. One patient was converted to open. There was no readmissions or mortality in our series. Conclusion: laparoscopic treatment of appendicular mass is feasible and safe in experienced hands.

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Laparoscopic Small Bowel Resection for Duodenojejunal Flexure Gastrointestinal Stromal Tumour (GIST)

Laparoscopic Tumor-Specific Mesorectal Excision for Lower Rectal Cancer

L.F. Doran, K. Moorthy

K. Ueda


Kinki University Faculty of Med, Osaka Sayama, Japan

58 year old lady presenting with a symptoms of a small bowel tumour. Pre-operative investigations consistent with the presence of a GIST at the duodenojenunal flexure. Laparoscopic small bowel resection and primary stapled anastomosis was performed. The patient made an uneventful recovery and was discharged from hospital on post-operative day 1. Subsequent histology revealed that the tumour was a small bowel GIST of low malignant potential

Purpose: The aim of this study is to assess the oncologic outcomes after the laparoscopic tumor specific mesorectal excision (LAP-TSME) of resectable lower rectal cancer in a single institution. Methods: We reviewed the database of 47 consecutive lower rectal cancer patients undergoing LAP-TSME between January 2005 and December 2013. All the data was analyzed using JMP ver.10.0.2 (SAS Institute Inc., Cary, NC, USA). Results: LAP-TSME was completed successfully in 47 patients, whereas conversion to an open approach was required in 3 cases (6 %). Mean age was 65 (37–85) years and 1:3.3 of female/male ratio. All tumors were located on the lower rectum and diagnosed adenocarcinoma. The procedure was performed low anterior resection (LAR) in 43 patients and intersphincteric resection (ISR) in 4 patients laparoscopically. Stoma creation was performed in 15 patients (32 %). Men operative time and established blood loss were 245 (160–400) minutes and 83 (9–391) g. Mean postoperative stay was 18 (7–85) days. The overall morbidity and mortality rates were 40 % and 0 %, respectively, with an overall anastomotic leakage rate of 13 %. All tumors were considered curative resection according to the pathological findings. Pathological stage was as follows; 0 4, I 27, II 5, III 10, IV 1. Mean follow-up was 37 (1–88) months. The disease free survival rate was 86 % at 3 years. The overall survival rate was 96 % at 3 years. Conclusion: LAP-TSME was feasible and safe. However, the early rectal cancer was included 66 % in this study. We need more cases for advanced rectal cancer treatment.



Schwannoma of the Rectum - Report of a Case Resected Through Transanal Endoscopic Microsurgery and Literature Review

Three Port Laparoscopic Colorectal Cancer Surgery; 5 Years Tertiary Hospital Experience

M. Paquin-Gobeil, H. Moloo

M.T. Alqubtan

The Ottawa Hospital, Ottawa, Canada

Royal Hospital, Muscat, Oman

Schwannomas of the gastrointestinal tract remain a rare entity, accounting for 0.1 % of the gastrointestinal tract cancer. It is normally found in subcutaneous tissue or in the central nervous system. They originate from mesenchymal stem cells but are constituted of specific ultrastructural difference. In fact, immunohistochemically, they generally show strong S100 protein immunoreactivity. The most common location for gastrointestinal Schwannnoma is the stomach, but few case-report described them in the colon and rarely in the rectum (8 cases published). A 61-year-old male was referred to surgery for anorectal discomfort that was ongoing for 6 months. A biopsy was performed during a diagnostic colonoscopy and revealed a GIST (Gastrointestinal Stromal tumor) of the rectum. Therefore, the patient underwent resection through transanal endoscopic microsurgery (TEM), also classified as natural orifice transluminal endoscopic surgery (NOTES). At final pathology, a diagnosis of intramural Schwannoma was made. The tumor was composed of spindle cells with nuclear palisading, mitosis rate = 1 per high power field as well as diffuse expression of S100 and vimentin. The tumor measured 2.2 9 2.0 9 1.4 cm, was well circumscribed and encapsulated. Two lymph nodes were retrieved with the specimen and appeared normal. To our knowledge, this is the first case reported of Schwannoma resected via TEM. Tumors such as these behave in a uniformly benign fashion. However, the risk of local recurrence is as high as 30 %, while 2 % for distant metastases. It has been 20 months since the procedure was performed and the patient appears to have normal continence and no evidence of recurrence or distant metastases.

Aims: To assess the feasibility and safety of performing 3-port laparoscopic colectomy in patients with colorectal cancer. Methods: All patients with diagnosis of colorectal cancer with no peritoneal metastasis presented to Royal Hospital from period of December 2008–December 2013 were enrolled in 3 - port laparoscopic colorectal surgery study. Demographic data along with location, stage of the tumor, number of port used, duration of surgery, number of blood transfused, margins and number of lymph nodes retrieved with stay in the hospital and complications were registered. Results: Two hundred and four cases of colorectal cancer where enrolled in the study where surgery was performed by the specialized colorectal unit. Age varies from 20 to 85 years with mean of 52.8 years. The mean Surgical duration was 196.8 (80–360 minutes), mean blood utilization was 0.24 with mod of 0 (0–4 units), the mod of number of ports was 3 (3–5) with 3-port 87.7 %, 4 ports 3.9 % and 5 ports 8.3 % and length of stay mean was 5.69 day (4–22) with mode of 5 days. Oncologically, tumor stages were stage one 10.3 %, stage two 13.2 %, stage three 49.5 % and stage four 27 %. 69.6 % of cancers were left sided and right side comprise of 30.4 %. The mean lymph node retrieval was 15.8 (9–29) with 4 % margin involved. Conclusion: 3 port laparoscopic surgeries are safe and feasible in colorectal cancer surgery and can be used as step to follow single incision laparoscopic surgeries.

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P438 - Liver and Biliary Tract Surgery

Results of RCT on Hybrid Notes Colectomy

Is a Drain Necessary Routinely After Laparoscopic Cholecystectomy for an Acutely Inflamed Gallbladder? A Retrospective Analysis of 457 Cases

H.C.Y. Shan, M.K.W. Li Pamela Youde Nethersole Eastern Hospital, Hong Kong Objective: For the treatment of left-sided colonic tumor, the best treatment is surgery as it offers the only means of cure and prolonged survival. In performing conventional laparoscopic colectomy (CL), specimen retrieval necessitates a mini-laparotomy which often is the cause and evil of postoperative pain, wound infection as well as other pain related complications. We have described a new technique of hybrid NOTES colectomy (HNC) without mini-laparotomy, where total laparoscopic transection and intra-corporeal anastomosis was performed as usual but the specimen was delivered through the anus via the use of the Transanal Endoscopic Operations (TEO) device set-up without the mini-laparotomy wound. In order to compare the short-term benefits in terms of wound pain and woundrelated complications, a randomized controlled trial was undertaken to evaluate and compare the conventional laparoscopic colectomy with this hybrid NOTES colectomy. Patient and Methods: Patients diagnosed to have left-sided colonic tumor from splenic flexure to upper rectum were recruited and randomized into two groups: (1) conventional laparoscopic colectomy (CL), and (2) hybrid NOTES colectomy (HNC). All operations were carried out by the colorectal team specialists. In the CL group, the specimen was delivered through a mini-laparotomy wound while in the HNC group; the specimen was delivered through the anus without mini-laparotomy wound. Operative data and complications were recorded, and patients were followed up using a structured proforma. An independent assessor was assigned to obtain postoperative pain scores.

E.Y. Kim, T.H. Hong, D.G. Kim, Y.K. You, G.H. Na, J.H. Han, S.H. Lee St. Mary’s Hospital, Seoul, Korea Background: During laparoscopic surgery for an acutely inflamed gallbladder, most surgeons routinely insert a drain. However, no consensus has been reached regarding the need for drainage in these cases, and the use of a drain remains controversial. In this study, we reviewed our experience to assess the value of drain use in patients who underwent laparoscopic cholecystectomy for acutely inflamed gallbladder. Methods: This retrospective study included 457 cases of laparoscopic cholecystectomy that were performed at Department of Surgery, Seoul St. Mary’s Hospital due to acutely inflamed gallbladder from March 2009 to April 2013. We divided them into two groups according to whether or not a drain was inserted and reviewed the surgical outcomes and perioperative morbidity. Results: In this study, 231 patients had no drains and 226 had drains. Both groups were comparable in terms of pathology, demographics, and operative details. There was no statistical difference in operating time, visual analog scale for pain, or postoperative hospital stay. Morbidity occurred in 49 cases (10.7 %), and did not differ significantly between the two groups. No mortality occurred in this study. Conclusions: The routine use of a drain after laparoscopic cholecystectomy for an acutely inflamed gallbladder had no effect on the postoperative morbidity. Therefore this retrospective study supports that it is feasible not to insert a drain routinely in laparoscopic cholecystectomy for patients who have an acutely inflamed gallbladder.



Laparoscopic Cholecystectomy and Mesh Repair Ventral Hernia In Situs Inversus Totalis. Description of Technique

Fluid Collection in Patients Who Underwent Laparoscopic Cholecystectomy

E. Dorado, A. Romero

N. Ozlem

Fundacion valle del lili, Cali, Colombia


Introduction: Situs Inversus Totalis is a rare congenital anomaly, with a ratio 1/5000–20000 cases. Charatized by transpotition of thoracic and abdominal organs. Situs Inversus totalis is a rare congenital anormaly, with a ratio 1/5000–20000 cases. Charatized by transpotition of thoracic and abdominal organs. The biggest challenge in laparoscopic surgery is the mirror position and anatomical difficulties, and to look for a different arrangement trocars compared to standard procedures. Methods and Procedures: Descriptive study. Female patient of 48 years old poorly controlled diabetes, after abdominal hysterectomy has a symptomatic ventral hernia 10 9 12 cm size. the patient was sent at Laparsocopy service for evaluation with CTA scan showing situs inversus totalis, ventral hernia and cholelithiasis. With 4-trocar technique starts cholecystectomy: subxiphoid trocar, supraumbilical and two subcostal supraumbilical. We used for disection a subcostal trocar and for traction subxiphoid and subcostal, camera was positioned in supraumbilial port. It should be noted that the triangle Calot working on mirror. We didnt make a CIO. The same trocar position was use for incisional herniorrhaphy, in to the defect we reduced epiploon and bowel with monopolar and scissors. we used a 15x20 cm physiomesh and fixed with a single crown of securestrap. Results: the patient was discharged the next day with instructions and control at 8 days of surgery. Abdominal binder was ordered for 2 months. Any postoperative complication was presented. Conclusion: Situs inversus total is a rare condition, laparoscopic surgery is a safe technique for these patients. Is important to consider the challenges in the placement of trocars, dissection and mirror vision of the organs to avoid injury. Because of the challenges posed by these procedures, must be performed by an advanced laparoscopic surgeon

Aims: The observation of parameters regarding the existence and progress of fluid collection observed in post operative hepatobilier ultrasound of patients that underwent laparoscopic cholecystectomy in Ankara Atatu¨rk Egitim and Arastirma Hospital’s 1. general surgery clinic. Methods: 250 cases that underwent laparoscopic cholecystectomy were prospectively studied. In the study of medical records following characteristics of cases were noted: age, gender, the story of cholecystectomic attack, complications that arose during surgery application of drain, in drain applications the length of drains existence and cases time of hospital admittance. In hepatobilier ultrasounds performed 1st and 30th days after operation the existence and progress of fluid collection was examined. Results: In 250 cases whose medical records was studied, postoperative 1st day hepatobilier ultrasound in 67 cases (%26.8) were found to have collection of fluid. The average collection volume was calculated to be 8.8 ± 5.2 cc. In cases with post operative 1st day collection, ultrasounds taken on 30th post operative day show only 2 cases of continuing collection both under 5 cc. First day readings of these two cases were 19 cc and 9.1 cc respectively. Conclusion: Fluid collection found in post operative hepatobilier ultrasound of patients that underwent laparoscopic cholecystectomy has no correlations with patients age, gender or the existence of cholecystectomic attack story. In cases of laparoscopic cholecystectomy with suspected subhepatic collection with ultrasound evaluation made in early post operative term that shows levels below 10 cc, no need for further ultrasound follow up is necessary whereas its feasible to do so in cases over 10 cc of collection levels.

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Extrahepatic Glissonean Approach in Laparoscopic Anatomical Resection

Laparoscopic Hepatectomy Segment VII and VIII

F. Ishige, A. Cho, H. Yamamoto, O. Kainuma, H. Arimitsu, H. Yanagibashi, M. Satou, N. Takiguchi, Y. Nabeya, A. Ikeda, H. Souda, M. Nagata Chiba Cancer Center, Chiba, Japan Aims: Recent rapid developments in technological innovations, improved surgical techniques and the accumulation of extensive experience by surgeons have improved the feasibility and safety of laparoscopic liver surgery. However, laparoscopic anatomical liver resection remains a highly specialized field, as major technical difficulties remain, such as hilar dissection and pedicle control. Methods: The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver and the trunks of the secondary branches, and even more peripheral branches run inside the liver. The right, left, anterior, or posterior Glissonean pedicle can thus be tied and divided en bloc extra hepatically during open anatomical liver resection. We performed a novel technique by which each Glissonean pedicle could be easily and safely encircled and divided en bloc extra hepatically during laparoscopic anatomical liver resection. Results: In various types of anatomical liver resections, including right hepatectomy, left hepatectomy, anterior sectonectomy, posterior sectionectomy, medial sectionectomy, and central bi-sectonectomy, Glissonean pedicles could be encircled en bloc extra hepatically, as planned. No serious complications, including major bleeding or injury of the portal triad, were encountered during procedures. Conclusions: Extrahepatic Glissonean access appears feasible and safe for laparoscopic anatomical resection of the liver.


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P.M. Ripa Galvan , J.A. Ruiz Yonser , V.H. Avalos Gomez , M.D. Reyes Salas1 1

American University of Beirut Medical Center, Beirut 1107 2020, Lebanon Aims: More than 20 cases of Lap partial hepatectomies done at the American University of Beirut Medical Center in the past 10 years for malignant and benign disease. Methods: This video will illustrate the steps used to do Laparoscopic Hepatectomy for the difficult anatomic segments VII and VIII. Through 5 trocars without division of the liver attachment and through 30 degree scope using spray caustery, ultracision and intracorporeal suturing with 2-0 prolene sutures for 2 patient one metastatic colon CA to segment VII and VIII and another patient with primary hepatocellular CA Anastomosis segment VII and VIII. Results: Both patients had smooth postoperative course and discharged from hospital 4 days after surgery. Conclusion: Therefore, tumor involving difficult anatomic segments of the liver can be handled safely Laparoscopically in advanced centers of laparoscopy.


Agenesis of Gallbladder 1

M.K. Hussein

2

Laparoscopic Exploration and Stone Extraction of Common Bile Duct Stones M.K. Hussein

TEC de Monterrey, Monterrey, Mexico; UMAE 25 IMSS, Monterrey, Mexico

American University of Beirut Medical Center, Beirut 1107 2020, Lebanon

Introduction: Agenesis of gallbladder is a very rare congenital abnormality that usually has no characteristic symptomatology and maybe associated to other anatomical malformations. Many of these patients develop a typical symptomatology of biliary colic leading the patient and the surgeon to the operating room. When surgical decision is taken it is better to remain at the level of a diagnostic laparoscopy because further surgical investigation may lead to detrimental biliary tract injuries. Methods: A 46-year-old man presented with a 1 month history of right upper quadrant pain radiating to the right scapula. Ultrasonography revealed cholelithiasis, gallbladder wall thickening, and a dilated common bile duct. Results: The patient went to the operating room for a laparoscopic cholecystectomy, but during the laparoscopy the identification of the gallbladder was unsuccessful. The common bile duct (CBD) was identified and found dilated; the gallbladder and cystic duct were inexistent. The CBD was drained and a T-tube was placed during the same procedure. An intraoperative cholangiogram through the T-tube was done with no filling defects and free flow of contrast into the duodenum. Conclusion: The incidence of agenesis of the gallbladder is between 0.01 % and 0.04 %, or 1 in 6,000 live births. Encountering gallbladder agenesis during an operation represents a dilemma since there is no consensus for an adequate treatment when the patient is symptomatic; this prompts the conversion to an open procedure for many surgeons since some physicians have emphasized the need for a thorough surgical exploration. Keywords: Gallbladder; Agenesis of congenital abnormalities; Cholecystectomy.

Aims: CBD Stone is a frequent presentation in-patient with cholelithiasis and treated in 98 % with ERCP, failure of ERCP necessitate surgical intervention. Methods: I report 5 cases done at the American University of Beirut Medical Center successfully that were treated by Laparoscopic exploration through 4 trocars and the use of choledochoscope for stone extraction using dormie basket and Fogarty Catheter 5 French and insertion of T-Tube with no complication. Results: The video will show the various steps used for completion of the procedure. Conclusion: Laparoscopic Exploration of CBD for stone extraction is feasible in Advanced Laparoscopic Centers.

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Laparoscopic Excision of Choledochal Cyst Followed with Hepatojejunostomy Roux-en-Y

Mini-Laparoscopic Cholecystectomy is a Better Option: Review of 7200 Cases

M.K. Hussein

K. Chowdhury


Ibrahim Medical College & BIRDEM, Dhaka, Bangladesh

Aims: This video will illustrate the steps used to excision of choledochal cyst type IV a of 48 year-old female involving the CBD, common hepatic duct and involving the Rt. and Lt. hepatic duct. Methods: Through 5 trocars complete excision of the choledochal cyst and GB with excision of intrahepatic biliary duct dilation followed by Roux-en-Y hepatojejunostomy of Rt. and Lt. duct. Results: Patient had smooth postoperative course discharged from hospital 5 days later. Conclusion: In summary, Laparoscopic choledochal cyst can be done safely in advanced centers in laparoscopic and biliary systems.

Aims: Minimizing scar without compromising safety, has been the driving force to explore the possibilities of Single-incision laparoscopic surgery (SILS) and Natural orifice transluminal endoscopic surgery (NOTES). Mini-lap Cholecystectomy (MLC) also called Needlescopic Cholecystectomy (NC), represents potentially almost as cosmetically effective as NOTES or SILS. This study was done to evaluate the superiority of the MLC. Methods: Author has performed 7200 cases of Mini-Lch from 1998 till July 2013. Hand instruments 2.5–3 mm in diameter and a 3 mm laparoscope were used. A 10 mm laparoscope was used for intraumbilical port to facilitate better vision, dissection & retrieval of gallbladder. Results: Total operating time (OT), postoperative hospital stay (HS), complications, post operative analgesic requirement, patient satisfaction, complications and rate of conversion to conventional LC (CLC) and open cholecystectomy were observed and analyzed. In this series conversion to open surgery was only 0.43 %. Average operating time was 30.22 min. Most of the early acute cases can also be done by this technique. Average post operative hospital stay was 16 hours. There was no mortality in the series. Six patients developed incisional hernia at the umbilical port site and 16 patients had umbilical wound infection. Patient acceptance was excellent, postoperative analgesic requirement was less in comparison to CLC. Conclusion: With MLC better cosmetic result was achieved, recovery was early, post operative HS was less. It is cost effective with a easy learning curve and can claim the Gold standard for Cholecystectomy



Laparoscopic Management of Gangrenous and Perforated Gallbladder at Liaquat University Hospital Hyderabad/Jamshoro -A 2 Years Experience

Primary Duct Closure After Laparoscopic Bile Duct Exploration for Choledocholythiasis

A.H. Abro, A.H. Pathan, A.A. Bhurgiri, F.G. Siddique, A.A. Laghari Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan Objective: To evaluate the laparoscopic management of gangrenous and perforated gallbladder at Liaquat University Hospital Hyderabad/Jamshoro, Pakistan Patients and Methods: This two-years study was conducted in Hepatopancreatobilliary and minimal access surgical Unit 4 at Liaquat University Hospital Hyderabad/Jamshoro. All the patients with cholecystitis, of = 25 years of age and either gender who visited at the surgical out patient department or admitted in surgery ward were evaluate and enrolled. All patients with gangrenous and perforated gallbladder was managed laparoscopically. The frequency and percentage of gangrenous and perforated gallbladder and duration of hospital stay, appearance of intraabdominal abscess and wound infection were recorded. The chisquare test was applied between categorical variables at 95 % confidence interval and the p-value = 0.05 was considered as statistically significant. Results: During two year study period total 840 patients were registered for study, of which 270 (%) patients had acute cholecystitis and were operated. Thirty five subjects were observed gangrenous gallbladder of which 10 (28.5 %) were males and 25 (71.4 %) females [P = \0.01] while perforated gallbladder were identified in 15 patients of which 04 (26.6 %) were males and 11 (73.3 %) were females [P = \0.02]. The patients with perforated and gangrenous gallbladder were managed by laparoscopy. Regarding the outcome the hospital stay was reduced (one day), no intraabdominal abscess and wound infection in subjects underwent for laparoscopy. The mean age ± SD for male and female underwent for laparoscopy was 48.86 ± 9.74 and 55.72 ± 7.93 respectively. Conclusion: It has been concluded that decrease hospital stay, no intra-abdominal abscess and wound infection was observed in patients underwent laparoscopic procedure. Therefore early approach should be considered in patients have onset of symptoms and by considering this we can reduce morbidity and mortality and the patients have early return of their work.

V.V. Grubnik, O.I. Tkachenko, V.V. Ilyashenko, V.V. Grubnik Odessa National Medical University, Odessa, Ukraine Introduction: Traditionally, T-tube drainage is used after choledochotomy and removal of common bile duct (CBD) stones. The aim of the study was to assess the safety and effectiveness of laparoscopic CBD exploration (LCBDE) with primary duct closure. Methods: A retrospective analysis of 196 patients who underwent LCBDE during 10 years period (from 2003 to 2013) was performed. There were 154 women, and 42 men, mean age was 68 years (range, 35–82). The duct was closed in 102 patients (1st group), T-tube was used in 94 patients (2nd group). The mean age and comorbidities were comparable in the both groups. Mean diameter of CBD was 8,6 mm (range, 6–15) in the 1st group, and 10,2 mm (range, 6–30) in the 2nd group (p [ 0,05). Results: CBD exploration was successfully completed laparoscopically in 193 patients (there were 3 cases of conversion to open procedure). The mean number of stones removed was 3 (range, 1–8) in the 1st group, and 7 (range, 1–52) in the 2nd group (p \ 0,05). Mean operative time was 118 min (range, 70–210) in the 1st group, and 124 (range, 80–300) in the 2nd group (p [ 0,05). The mortality rate was zero. The morbidity rate, postoperative bile leak rate, rate of retained stones after primary duct closure were similar in the both groups. The mean postoperative hospital stay was 3,5 days (range, 2–15) in the 1st group, and 5,8 days (range, 4–28) in the 2nd group (p \ 0,05). Conclusion: Primary duct closure is safe as morbidity rate does not exceed T-tube drainage. It has shorter hospital stay compared to T-tube drainage. Thus, primary duct closure can be successfully used in the selected patients alternatively to T-tube drainage.

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Laparoscopic Treatment of Hydatid Disease of Liver - 15 Years Experience

Dynamics of Morphological Changes in Perycyst Areas Echinococcus Cysts in Children

V.V. Grubnik, V.V. Ilyashenko, V.V. Mishenko, V.V. Grubnik

D.V. Fokin, V.A. Dudarev, I.V. Kirgizov

Odessa National Medical University, Odessa, Ukraine

GCB 20, Kresnoyarsk, Russia

Introduction: Echinococcus is considered to be endemic in southern part of Ukraine. Aims: of the study was to evaluate the results of laparoscopic treatment compared to open approach. Methods: Between 1998 and 2013, 416 patients with hydatid disease of liver underwent surgery. There were 284 women and 132 men, mean age was 36,4 ± 10,6 years (range, 18–75). 295 patients (group I) underwent laparoscopic treatment. We used 3 or 4 ports. After puncture of cyst cavity 20 % hypertonic saline with povidone iodine was injected. Using special 11 mm cannula which was pushed inside the cystic cavity, parasite was extracted. After partial pericystectomy remaining cavity was drained. 121 patients (group II) underwent conventional surgery. Results: Conversion to open procedure was made in 4 (1,4 %) patients. The mean cyst diameter was 6,2 cm (range, 3–15) in group I, and 7,5 cm (range, 5–18) in group II (p [ 0,05). The mean operative time was 58 min (range, 35–118) in group I, and 86 min (range, 55–140) in group II (p \ 0,05). The overall complications rate and wound complications rate were respectively 1,7 % and 0 % in group I compared to 15,7 % and 6,6 % in group II (p \ 0,05). The mean hospital stay was 5,7 days (range, 2–11) in group I, and 10,8 days (range, 5–19) in group II (p \ 0,01). The mean follow-up period was 49,8 months (range, 5–120) in group I, and 42,5 months (range, 6–115) in group II (p [ 0,05). Recurrence rate was 1,7 % in group I and 2,5 % in group II (p [ 0,05). Conclusions: Laparoscopic surgery provides a safe and effective approach for hepatic hydatid disease.

The Aim of the Study: Assessment of changes of morphological structure of the liver in an echinococcosis in children depending on the tissue pressure. Materials and Methods: in laparoscopic at 16 patients measurement of fabric pressure in perycysts to a zone with the subsequent puncture biopsy is spent. In a consequence of that it was possible to establish that at cysts in diameter from 4,5 to 5 sm: pressure in perycysts to a zone to 2 sm makes 834 Pa, in bioptatis taken away in this area the raised maintenance of fibrous elements and fatty infiltration in 1,7 times became perceptible. The volume of periportal tracts is enlarged in 1,5 times. Depression of the maintenance of a glycogen and volume of hepatocytes in 1,2 times that speaks about sclerotic changes in a liver parenchyma was thus taped. At measurement of fabric pressure in a zone, from 2,5 to 5 sm fabric pressure is on the top borders of norm and made 825 Pa, and the morphological picture wears admissible changes, at measurement of fabric pressure and a morphological picture in kept away refocal zone, more than 5 sm of changes aren’t taped. Conclusions: Thus, value of fabric pressure as factor reflecting morphological changes in a liver tissue is confirmed. And in the subsequent defines resection volume at cystically-focal liver lesions, with possibility of the subsequent control of its normalization at a resection and to take in a residual cavity.



Modern Opportunities of Endovideosurgical Technologies in the Treatment of Acute Cholecystics Which is Complicated by Mechanical Jaudice

Cholecystectomy in Octogenarians be Carefully

D.V. Fokin, V.A. Dudarev, I.V. Kirgizov GCB 20, Kresnoyarsk, Russia Aims: Estimate possibilities of endovideosurgical technologies in the treatment of acute cholecystics which is complicated by mechanical jaudice. Materials and Methods: In the period from 2006 to 2008 years there were 425 patients with the acute cholecystics in the MIPH Municipal clinical hospital # 20. Some of them 59 patients (11,7 %) have had symptoms of bile hypertension. Diagnosis was fitted by using clinical data and minimum lab observation and ultrasonic scanning (US) of hepatopancreatoduodenal area (HPDA) organs. Immediately patients were got systematic therapy for the correction pathological changes and for preparing probable operative measure. Across one or two days as soon as possible we tried to make the endoscopic retrograde cholangiopancreatography (ERCP) for all patients. We have managed to make ERCP to 50th (84,75 %) patients. Among 9th (2,1 %) patients the trials of ERCP were unsuccessful. Results: of the investigation: The reasons of bile hypertension were managed to disposed by endoscopic papillotomy (EPT) among 39th (66,1) patients. After successful EPT the positive dynamic of the acute cholecystics was reached among 30th (50,8 %) patients. For all patients in the planning regimen were made laparoscopic cholecystectomy (LCT). The operation was made in a harry for 12th (20,3 %) patients because of positive dynamic for acute cholecystics absence. For the fifth patients of them was managed to make LCT. The reasons of conversion among the rest 3d patients were difficulties during the LCT connected to evident infiltrate in a gallbladder neck. The reasons of bile hypertension were not disposed by using EPT among 7th (14 %) patients. It can be explained by high strictures of choledoch and incapability of major duodenal papilla (MDP) full dissection because of anatomy peculiarities. That is why they were operated in the planning order. LCT was made for all of them. Conclusion: ERCP and EPT for acute cholecystics which is complicated by mechanical jaundice allow to get full regression of disease in the major cases and to make LCT in the planning order. If the positive dynamic is absent this tactic allows making minimal invasive surgical intervention.

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Y. Fukami, Y. Kurumiya, K. Mizuno, E. Sekoguchi, S. Kobayashi Toyota Kosei Hospital, Toyota, Japan Aims: Cholecystectomy is the standard of treatment for symptomatic gallbladder stone or acute cholecystitis, and a growing number of elderly patients are undergoing resection. The aim of this study is to evaluate the clinical outcome of elderly cholecystectomy patients. Methods: We retrospectively reviewed the medical records of 337 patients with symptomatic gallbladder stone or acute cholecystitis who underwent cholecystectomy from January 2011 and June 2013. Perioperative data were compared between octogenarians and younger patients. A subgroup undergoing cholecystectomy for acute cholecystitis (n = 146, 43.3 %) was further analyzed, respectively. Results: Octogenarians group included 34 patients (10.1 %) and younger patients group included 303 patients (89.9 %). Octogenarians group was associated with high comorbidities rate and acute cholecystitis rate. Octogenarians group was significantly low laparoscopic completed rate, high morbidity, and longer postoperative hospital stay. Among acute cholecystitis, 24 patients (16.4 %) were octogenarians and 122 patients (83.6 %) were younger patients. No significant difference was found in the morbidity and postoperative hospital stay between the two groups. Only one patient (0.3 %) died of pneumonia, it was the octogenarians. Conclusions: Cholecystectomy for symptomatic gallbladder stone or acute cholecystitis can be safely performed even in octogenarians. However, be carefully because they have comorbidities.

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The Original Devices of Laparoscopic Liver Surgery in Our Institution

The Cases That Required Additional Trocars in Single Incision Laparoscopic Cholecystectomy

M. Kido, T. Fukumoto, A. Takebe, T. Tanaka, H. Kinoshita, K. Kuramitsu, T. Ajiki, I. Matsumoto, M. Shinzeki, S. Asari, Y. Ku

H. Kitamura

Kobe University, Kobe, Japan Laparoscopic liver surgery is categorized into three method-(1) pure, (2) hybrid, and (3) hand assisted. Most surgeons set final goal of (1), and gain experience of (2), (3). But we stuck to (1) from the beginning, and have experienced 17 cases of laparoscopic liver surgery. Breakdown of the surgical procedure was 9 lateral segmentectomy and 8 partial hepatectomy. There was a case of simultaneous resection of the colon cancer and liver metastasis that was performed by pure laparoscopic surgery among them. Mean blood loss was 191 ml, operation time was 6 hours 33 minutes and hospital stay was 13.8 days. There were only two cases of complications-port site hernia and wound infection- which were classified into Clavien-Dindo Classification Grade II. Firstly we developed Endoracter as an organ retraction sponge, and secondary developed KAIMEN. It is difficult to tract, grasp, and exclude the liver in pure laparoscopic hepatectomy, but using these devices could lead a beginner of laparoscopic hepatectomy to operate safely. We use Hramonic Scalpel to coagulate surface of the liver. After that we use CUSA and Biclump to resect the liver. We present some kinds of devices which was developed in our institution.

Ishikawa Prefectural Central Hospital, Ishikawa, Japan Aims: Single incision laparoscopic cholecystectomy (SILC) is a rapidly progressing discipline because of certain advantages associated with the procedure such as cosmesis. However, it also demonstrates certain disadvantages such as limitation of movements and clattering of the hand instruments, which increase the complexity and technical challenges associated with this procedure. The present study analyzed cases that required additional trocars during SILC. In addition the limitations of SILC were also evaluated. Method: One hundred and thirty cases that required SILC for management of cholelithiasis, mild or moderate cholecystitis, gallbladder polyps from July 2009 to December 2013 were analyzed. Mirrizi syndrome, gallbladder cancer, severe cholecystitis and high risk patients were excluded. Surgical procedure: A vertical 2 cm long umbilical skin incision was made. Because we were familiar with certain types of access devices and instruments, the EZ ACCESS (Hakko; Japan) was employed as the access devices along with two standard curved instruments. The surgical procedure was similar to that of a conventional cholecystectomy. Result: The mean operative time was 77 min and the blood loss was minimal. Additional trocars were required for five cases and the procedure was converted to laparotomy for one case. Additional trocars were required for two cases because of the clattering of the hand instruments, for two cases because of the difficulty to dissect the Calot’s triangle, and for one case to dissect the adhesions. The procedure for one case was converted to laparotomy because of excessive blood loss. For the case who suffered from liver cirrhosis, the Glisson’s pedicle was located on the surface of the liver, which was injured during the procedure. Two cases demonstrated wound infection, which resolved without medication and no major post-operative complications were observed. Conclusions: Trocars should be utilized without hesitation in cases that demonstrate severe inflammation of the Calot’s triangle and cases where in severe adhesion of the colon or the duodenum to the gallbladder is observed. The location of the Glisson’s pedicle should be confirmed by computed tomography before performing the surgical procedure.



Intraoperative Biliary Fluorescence Imaging in Laparoscopic Fenestration for Giant Liver Cyst

The Identification of Hepatic Subsegment Which Aimed at Pure Anatomical Laparoscopic Hepatectomy

S. Shirakawa, S. Tsuchida, M. Awazu, Y. Ueda, D. Lee, Y. Harada, W. Wakahara, A. Ashitani, Y. Hasegawa, A. Toyokawa

M. Sakoda, S. Ueno, S. Satoshi, K. Hiwatashi, K. Minami, H. Kurahara, Y. Mataki, K. Maemura, H. Shinchi, S. Natsugoe

Yodogawa Christian Hospital, Osaka, Japan

Kagoshima University School of Medicine, Kagoshima, Japan

Introduction: Symptomatic giant liver cyst is considered for interventional and surgical treatments because of no effective medical therapy. Laparoscopic cyst fenestration (LCF) is recently reported as standard procedure for liver cyst. Although LCF is less invasive and improves cosmetic outcome, it is sometimes difficult to identify bile duct with thinning by liver cyst expansion intraoperatively. The case of intraoperative biliary injury was reported. Recently, fluorescent cholangiography using indocyanine green (ICG) for laparoscopic cholecystectomy and hepatectomy has been developed. We used this technique for LCF in two cases and describe the details. Method: The two cases were 71-year-old man (case 1) and 65-year-old woman (case 2), and approximately 10 cm diameter cysts were observed in both of the two patients with biliary strictures, abdominal symptoms, and abnormal hepatic function (case 2). The cysts indicated for LCF were located in left lateral segment in case 1 and liver segment 4 in case 2. In both of the two cases, 2.5 mg of ICG injected intravenously after induction of anesthesia and laparoscopic fluorescence imaging system (Karl Storz, Germany) was used for conventional imaging and near-infrared fluorescence imaging. Fluorescent cholangiography was conducted to detect bile duct in thinning hepatic parenchyma around giant liver cysts and identify good site for safe puncture. After cyst fluid aspiration using SAND balloon (Hakko, Japan), the cyst wall was dissected. Results: Fluorescent cholangiography clearly visualized and delineated intrahepatic bile duct around the cysts with illumination, and enable to identify the site where we could safely dissect the cyst wall. After fenestration, fluorescent cholangiography also used to check for bile leak. Operative times were 285 (case 1) and 301 (case 2) minutes and intraoperative blood loss was less than 10 ml. Postoperative courses were uneventful in both cases. Conclusions: Intraoperative fluorescent cholangiography using intravenous ICG injection enables LCF safely, and is useful for avoiding biliary injury.

Introduction: It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC) and, consequently, laparoscopic hepatic resection is widely performed. However, most anatomic resections, except left lateral sectionectomy, are still difficult technically and, as an alternative approach, laparoscopy-assisted procedures also have been introduced because of the safety and curative success of the operation. When considering pure laparoscopic subsegmentectomy or segmentectomy of the liver, it seems that two issues may become problematic: the identification of the subsegment or segment and securing the parenchymal transection line. In parenchymal transection of the liver, a safe laparoscopic procedure can be developed using new instruments and devices. On the other hand, although there is a procedure of closing the Glisson’s pedicle in order to determine the transection line, this is technically difficult in a purely laparoscopic operation. Herein, we describe two methods of pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under ultrasound (US). Methods and Results: The first method was performed by blue dye injection under percutaneous US guidance with artificial ascites. The second method was performed by indocyanine green (ICG) injection for optical imaging using near-infrared fluorescence (NIR) under laparoscopic US guidance. In both methods, pure anatomical laparoscopic subsegmentectomy of the liver were completed successfully and the postoperative courses were uneventful. Conclusions: Pure anatomical laparoscopic subsegmentectomy for HCC with a conventional puncture technique under percutaneous US with artificial ascites or under laparoscopic US using NIR by ICG injection is considered to be a useful procedure featuring both low invasiveness and curative success.

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Pure Laparoscopic Right and Left Hepatectomy with Umbilical Zigzag Skin Incision

Remaining Subjects for Standardization of Single Incision Laparoscopic Cholecystectomy. A Surgeon’s Initial Experience with 40 Consecutive Cases

T. Shikano1, T. Mori1, T. Kinoshita2 1 Yokkaichi Municipal Hospital, Yokkaichi, Japan; 2Aichi Cancer Center, Nagoya, Japan

Aims: Laparoscopic hepatectomy is gradually gaining acceptance as an alternative to open resection in selected patients for its less invasiveness and high cosmesis. To achieve higher cosmesis, we performed hepatectomy with umbilical zigzag skin incision. Methods: Between June 2010 and October 2013, 20 laparoscopic hepatectomy with umbilical zigzag skin incision were performed in our hospital. We performed pure laparoscopic major hepatectomy with umbilical zigzag skin incision in 2 patients, 1 right lobectomy and 1 left lobectomy. In an abdominal approach, After marking a zigzag skin incision, the skin was incised along this line. After the peritoneum was opened, camera port was inserted through zigzag skin incision. After multiport hepatectomy was done, the specimen was delivered to outside body through the zigzag skin incision. Results: Intraoperative blood loss was 185 and 540 ml. Operation time was 320 and 380 minutes. The length of post operative hospital stay was 5 and 7 days. There were no morbidities and no mortalities. The umbilical zigzag skin incisions were so small and beautiful that the patients were very happy. Conclusions: The case result confirms that pure laparoscopic major hepatectomy with umbilical zigzag skin incision can be safely performed with high cosmesis.

I. Akiyama, T. Ota, Y. Usui, H. Kunisue, T. Kakishita, S. Tokumo, K. Namba, H. Yamamoto, S. Teruta, T. Fujiwara, M. Naito Okayama Medical Center, Okayama, Japan Aims: As far as some skillful operators are concerned, single incision laparoscopic surgery (SILS) is arising as a novel technique for performing surgical procedures. We describe the results of a surgeon’s initial experience with SILS cholecystectomy through his first 40 cases and focus on some subjects to be resolved for standardization for other operators. Methods: Between October 2009 and June 2012, 40 patients were scheduled for SILS cholecystectomy. Through a 2–3 cm vertical transumbilical incision, three 5-mm ports or, subsequently, a SILS Port (Covidien Ltd. USA) was placed using the Veress technique. One extracorporeal stay suture was utilized to provide cephalad retraction of the gallbladder fundus. Patient demographic data, operation time, blood loss, length of stay and complication were recorded. These factors were analyzed by Chi squares and t-test where appropriate. Results: All but one of 40 patients successfully underwent single -port cholecystectomy. One patient required conversion to 4 ports cholecystectomy. The average patient age was 55.9 ± 14 years (median 56.5 years) and average BMI was 23.5 ± 3.1 kg/m2 (median 23.5). Mean operation time was 117 ± 35 mins (median 109 mins) and mean blood loss was 70 ± 255 ml (median 0 ml). Length of stay was 4.5 ± 0.9 days after surgery (median 4 days). The complication rate was 5 %. Patients were divided into sequential quantiles (n = 10) and all quantiles were found to be comparable for age and BMI. Because there were no significant difference of mean operation time, blood loss and length of stay, our study could not show an initial learning curve. Conclusion: SILS cholecystectomy is a safe alternative to conventional four-port laparoscopic cholecystectomy for skillful operators. Further large scale or operators dependent studies will be required to assess the feasibility of SILS.



Left Sided Gallbladder - Laparoscopic Cholecystectomy

Italian Surgical Societies (ACOI; SICE; SICOP; FCC) and EAES Consensus Development Conference on Laparoscopic Cholecystectomy

J. Moravik, J. Rejholec, F. Galgoczyova Krajska´ zdravotnı´ a.s. -Nemocnice Decıń o.z., Decin, Czech Republic Introduction: We can find several anatomical modifications of ectopic gallbladder. The left-sided gallbladder is stored on the left of the falciform ligament. The incidence is 0.1–1.2 %. Case Report: 57 -year-old women, who was admitted to a planned cholecystectomy because of repeated biliary colic. Ultrasound examination described normal liver, slim bile ducts, small gallbladder. No description of any abnormality in the position of the gallbladder. In laboratory blood tests without pathology. The patient was referred for SILS laparoscopic cholecystectomy. After the introduction of the camera port through umbilicus, we didn’t find gallbladder under the right hepatic lobe where it is normally stored, but to our surprise was on the left side of the falciform ligament. No other abdominal anatomical abnormalities. Due to the left-sided gallbladder and mobile, large left hepatic lobe we gave up SILS and we implemented three additional working ports, as in the standardized laparoscopic cholecystectomy. Secure visualization of the cystic duct and its junction with the common duct. Visualization of the cystic artery. For exclusion of other anatomical abnormalities, we removed the gallbladder from its bed in an anterograde manner. After complete release of the gallbladder and clear anatomical situation we transected cystic artery and cystic duct. The duration of surgery was 40 minutes. The postoperative process was without complication. Discussion: Left-sided gallbladder may occur in two variants. The ‘real’ left-sided gallbladder - that is, if the gallbladder is located on the left hepatic lobe and the position of falciform ligament is normal. The second option is the gallbladder under the right hepatic lobe but to the left of a right-sided falciform ligament. Conclusion: The good preoperative examination is a condition of each operation. In our case, preoperative ultrasound hasn’t found any abnormality that would have warned the surgeon of another anatomical variant. Knowledge of possible variants of storage gallbladder and biliary tract is necessary condition in hepatobiliary surgery. Correct and rapid intraoperative detection with a subsequent change in the operating procedure is a prerequisite for a safe operation. In doubt, there is possibility of intraoperative cholangiography or intraoperative ultrasonography. However in our case it wasn’t necessary due to obvious anatomic situation.

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F. Agresta1, N. Vettoretto2, F.C. Campanile3, G. Silecchia4, P. Maida5, D. Marchi6, C. Bergamini7, P. Narilli8, P. Lombari9 1 Ulss19 del Veneto, Adria (ro), Italy; 2Mellini Hospital, Brescia, Italy; 3Civita Castellana Hospital, Viterbo, Italy; 4Polo integrato AUSL LT - ICOT, Latina, Italy; 5Villa Betania Hospital, Naples, Italy; 6Ospedale Civile S. Agostino-Estense, Modena, Italy; 7Careggi Hospital, Firenze, Italy; 8Nuova Itor Hospital, Rome, Italy; 9Azienda Ospeladiera Sant Aanna e San Sebastiano, Caserta, Italy

Introduction: In January 2012, a Scientific Committee of several main Italian Surgical Societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, with the primary intent of updating the EAES indications of the 1995 and supplement the existing guidelines on specific related topics. Methods: A multidisciplinary panel is critical in order to achieve both guidelines and recommendations. Therefore, besides Surgeons and the Promoting Committee, Radiologists, Epidemiologists, Nurses, Health-services researchers, Endoscopist, Emergency doctors and a patient’s association were also involved. Results (Main): LC is an effective operation for the treatment of biliary disease-related symptoms in patients with cholelithiasis and improves QoL faster than open cholecystectomy, while long-term results are quite similar; LC is safe in obese, pregnant and in the elderly patients; LC is the treatment of choice for patients with acute cholecystitis; In case of cholelithiasis, ERCP should be performed pre-operatively; whereas, intra-operative endoscopy should be reserved to patients with incidental evidence of CBDS, which was not detected pre-operatively; The ‘Critical View of Safety’ strategy can be useful to avoid BDI and vascular lesions; Single incision cholecystectomy has not been proven to have any advantage over LC with the exception of cosmesis; The number of procedures required to reach proficiency in LC has not been clearly defined. The ‘expert’ as defined by the skills and experience, cannot be numerically validated, and it cannot be separated from the concept of hospital me and individual surgeon volume. Conclusion: Practice guidelines have to be regularly updated to be effective. A thorough literature review was necessary to assess whether the recommendations issued almost 20 years ago are still current, taking into account also the exponential growth of knowledge, skill and technology that has taken place in the meantime. In many cases new studies allowed us to better clarify some issues, but during this time new problems and new questions have been raised on which it is not possible to give a recommendation.

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Laparoscopic Liver Cyst Surgery - Evolution for the Last 10 Years

Excision of the Main Bile Duct, a Possible Accident During Laparoscopic Cholecystectomy

M. Nychitaylo, A. Skoums, A. Litvinenko, M. Zagriychuk, I. Lukecha, A. Litvyn, V. Prisyagnyuk

S. Olariu, I. Icma, I. Farca, J. Shekheda, N. Pop

Ukrainian Institute of Surgery and Transplantology name after A.A. Shalimov, Kiev, Ukraine Aims: Laparoscopic treatment is optimal approach in different liver pathology such as for non parasitic cyst, hydatid cyst and liver abscesses. The aim of the study was to assess our own experience in this filed. We discuss different diagnostic approaches and treatment options. Methods: We retrospectively collected data from 2003 till 2013. The data includes demographics, pre-operative diagnosis, and variety of procedures, operative data and surgical outcomes. Results: A total of 458 patients with liver cyst and abscesses were analyzed. 217 with hydatid cyst (47.4 %), 223 non parasitic liver cysts (48.6 %), and 18 patients with liver abscess (3.9 %). The median patient age was 48 ± 1.2 years. The median diagnostic time was 1.5 ± 0.6 days. Diagnostic tests used were: USS, CT of abdomen and MRCP. Most of the cysts in 243 cases (53.2 %) were located in segments VI and VIII. Average size of cyst was 12.3 ± 1.6 cm. All patients tested with CA 19–9, CEA, alfafetaprotein (AFP) and IG for echinococ screening. 212 patients (98 %) with hydatid cyst had pre-operative chemotherapy with albendazol. Mean operation time was 72 ± 12.5 min. All 100 % patient undergone laparoscopic surgery. Laparoscopic cyst fenestration and deroofing were performed in 116 cases (25.3 %), laparoscopic cyst resection in 118 (25.8 %), laparoscopic closed echinococectomy 127 (27.8 %), pericystectomy in 72 (15.7 %), atypical liver resection 18 (3.9 %), left side hemihepatectomy 7 (1.5 %). Conversion to open surgery was in 17 (3.7 %). Conversion rate was significantly higher in parasitic cyst 11 (5.2 %) compare to non-parasitic cyst 5 (2.3 %) and abscesses 1 (1.8 %). Postoperative complications were observed in 19 (4.3 %) cases. Main complications were: bleeding in 12 (2.6 %), bile leak in 19 (4.1 %) of patients. Mean follow-up time was from 1 to 8 years. 31 (6.8 %) of patients diagnosed with radiological recurrence. 10 (32.5 %) of those undergone USS guided drainage and re-operations were performed in 9 patients (1.9 %). Post-operative mortality was 0 %. Conclusions: Laparoscopic operations is treatment of choice in parasitic and non parasitic hepatic cyst and abscesses in carefully selected patients. 97 % had no recurrence and achieved good permanent results. Laparoscopic cyst de-roofing, fenestration and pericystectomy in most cases are technically simple, well tolerated by patients.

University of Medicine and Pharmacy Victor Babes, Timisoara, Romania Aims: Discussion about the common bile duct excision as intraoperative accident possible during laparoscopic cholecystectomy. Material and Methods: We present two cases of serious injuries of main bile duct (gr IV) occured in other surgical services and resolved in our clinic. In the first case was performed hepatic - jejunal anastomosis in Y and in the second, reconstruction of common bile duct on Kehr tube. Results, Discussion: The first case developed an anastomotic stenosis after two years, which required reoperation for recalibration of the anastomosis and the second showed no postoperative complications. This accident is one of the most serious and can be followed by sequels away. The most important is to prevent this type of accident. Conclusions: 1 Excision of the common bile duct during laparoscopic cholecystectomy is possible. 2 It happens either at the beginning of the learning curve or thereafter by negligently or through failure to recognize anatomical landmarks .3 Restoring bile transit is difficult and should be performed in specialized centers by experienced surgeons



Glove Port Technique Versus Three Ports Trans-Umbilical Method in Single Incision Laparoscopic Cholecystectomy Using Conventional Laparoscopic Instruments

Post-laparoscopic Cholecystectomy Bile Leak Treated with Completion Cholecystectomy

A.M. Hassan, M. Mahmoud, M.M. Elsebae Theodor Bilharz Research Institute, Giza, Egypt Introduction: Single-incision laparoscopic surgery is an attractive approach for cholecystectomy. However, its widespread application has many limitations. A significant obstacle of application in developing countries is the expensive and non affordable specialized single port systems and reticulating instruments. Objective: To compare the effectiveness of the glove port technique versus the three ports trans-umbilical method in single incision laparoscopic cholecystectomy (SILC) performed by a single surgeon using the conventional laparoscopic instruments. Method: ology: 80 patients with symptomatic gall bladder stone disease were divided into two groups (40 per each). Group 1 (G1) underwent glove port laparoscopic cholecystectomy (GPLC) while in group 2 (G2) a three ports trans-umbilical method was used. Patient’s demographic data, perioperative outcomes, and early postoperative complications were collected, analyzed and compared between the two groups. Results: The mean operative time was 47.75 min in G1 and 62.16 min in G2. The mean estimated blood loss was 14.5 ml. in G1 while 19.3 in G2. Intraoperative incidents were statistically significant in G2 compared to G1. No conversion of the technique occurred in G1 while four cases in G2 required an additional 5 ml port. Post operative incidents were not significantly different between the two groups. Conclusion: On technical basis; we consider GPLC in preselected cases; a safer, more feasible and convenient method compared to the three ports trans-umbilical method of SILC. Keywords: Gall bladder; Single Incision Laparoscopic Surgery; Glove port laparoscopic cholecystectomy

A. Navarro, J. Samuel, A. Martıńez-Isla Northwick Park and St. Mark’s Hospitals, London, United Kingdom Aims: We would like to present three cases of post-laparoscopic cholecystectomy bile leak after incomplete cholecystectomy treated with laparoscopic completion cholecystectomy. We also identify the factors that could contribute to this problem. Methods: From November 2012 to August 2013 three patients were diagnosed of biliary leak that was caused by an incomplete laparoscopic cholecystectomy. Two patients had elective laparoscopic cholecystectomy for biliary colic and one had an emergency laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomies were performed by two different surgeons using the same surgical technique: patient in the American position using a 0 degree telescope inserted through an umbilical Hasson port. The critical view was considered to be achieved in the three cases. The re-laparoscopy was performed 1, 2 and 4 days after the elective procedures. Results: Three emergency laparoscopies were performed by the same surgeon using the French technique. Four ports were used: a new 10 mm above the umbilicus for the camera with 30 degree telescope, a new 10 mm in left hypochondrium and two 5 mm using the existing incisions in the right flank and epigastrium. Similar findings were found in the three cases: Bile peritonitis was identified to different degree. After washout the bile leak was identified in the hilum coming from a saccular structure where the clips were placed previously. After identification of the bile duct and lateral dissection this structure was recognized as being part of the Hartmann’s pouch with the cystic duct and artery being untouched. Intraoperative cholangiograms were performed and normal in the three cases. Completion cholecystectomy was achieved after identification of the structures and exposure of the critical view. Histopathology confirmed gallbladder tissue in three cases. Patients are currently asymptomatic. Conclusion: Achievement of the critical view is mandatory and the use of a 0 degree telescope introduced through a low umbilicus, as in the presented cases, can make it difficult. We recommend, mainly in the obese patients with a long umbilico-xiphoid distance, the routine use of a 30-degree telescope inserted some 15 cm below the xiphoid to improve the achievement of the critical view and avoid lack identification of the cystic duct.

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Comparison of Methods Laparoscopic Cholecystectomy for Acute Cholecystitis

Exceptional Location of Lipoma: In the Liver!

V. Fedoruk, Yu. Semenjuk Rivne Regional Hospital, Rivne, Ukraine Aims: To evaluate the efficiency of American and own method of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). Methods: Medical records of with 227 patients with AC who underwent LC between January 2005 and December 2008 were reviewed retrospectively. Patients were divided into two groups. The first group - of 115 patients, which have undergone LC executed by own method and the second group - of 112 patients operated by the American method. Technique of own LC: laparoscope placed through the paraumbilical port. Assistant right hand provides cephalad retraction of the gallbladder fundus through the port placed on midclavicular line 7–8 cm below the costal margin, left hand traction of the infundibulum through port placed on anterior axillary line 2 cm below the costal margin. The surgeon carries out the basic stages of operation through the subxiphoid port. The second assistant manipulates the laparoscope. Efficiency of operations was estimated comparing the amount of intra- and postoperative complications. Results: By age, sex, laboratory indexes, thickness of walls of gallbladder and allocation of morphological forms of AC both groups of patients essentially did not differ. Using the own method 1(0,87 %) of conversion has been carried out and American - 1(0,89 %) (p = 0,985). Amount of bleedings with the volume of blood loss of 50 ml and more using the own method of LC was equal to 51(44,3 %) cases and it was for certainly less than in comparison to American method - 62(55,4 %) (? = 0,042). Statistically the essential difference was found out in the amount of perforations of gallbladder. Less perforations, comparing to the American method, which was equal to 30(27,0 %) cases, took place at implementation of LC using the own method 18(15,8 %) supervisions (2X = 4,232, p = 0,040). Duration of operation of LC using the own method was averagely equal to 80,03 ± 27,66 minutes and it was less as compared to the American method 93,48 ± 32,57 (? = 0,001). There were no lethal cases in both groups. Conclusion: The own method of LC, taking into account duration of operation, has advantage over the American method and is accompanied by less of cases of bleeding and perforations of gallbladder.

M. Khalfallah, R. Nouira, C. Dziri Hoˆpital Charles Nicolle, Tunis, Tunesia Introduction: Hepatic lipoma is a rare benign tumor: only 24 cases have been published in literature. It is a lesion that remains asymptomatic and is discovered incidentally. Abdominal computerized tomography and magnetic resonance imaging are very useful for diagnosis. The aim of this work was to report a new case of hepatic lipoma and to precise the modalities of treatment of this benign tumor of the liver. Case Report: A 39 years old female, with no past medical history, has been admitted for pelvic pain. Abdominal computerized tomography showed intraperitoneal effusion a parietal thickening of the last ileal loop with normal appendix. There was also a hepatic tumor of 32 millimeters located at segments IV and V of non specific enhancement Regarding to persisting pain in the right iliac fossa, the patient has been operated on. Intra-operative findings showed a distension of the terminal ileum owing to an adhesion of the small intestine and uterus located at 20 cm of the ileocecal valve which has been resected. Liver palpation revealed a 3 cm tumor that seemed benign fit into the vesicular bed. She had a removal of the hepatic tumor. Postoperative course was uneventful. The patient was discharged on the third postoperative day. Pathological exam concluded to a hepatic lipoma. Abdominal CT scan made two months later was normal. Conclusion: Hepatic lipoma is a rare benign tumor of the liver which is discovered incidentally. Imaging allows to make the diagnosis. The treatment depends on radiological semiology. When the diagnosis of hepatic lipoma is made with certainty after imaging, a single regular ultrasound test is enough. However, in view of diagnostic doubt, a surgical treatment with cardiologic purposes is advisable.



Systematic review of Single incision laparoscopic cholecystectomy (SILC) vs. Conventional Laparoscopic Cholecystectomy (CLC)

Laparoscopic Resection for T2 Galllbladder Carcinoma

M. Hardan1, H. Wegstapl2 1

Ministry of Health of Iraq, Erbil, Iraq; 2Medway Hospital NHS Foundation Trust, Kent, United Kingdom

Background: SILC was first reported in 1995. Single Incision Laparoscopic Cholecystectomy (SILC) seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complication. Methods: Systematic reviews of the current literature were performed from January 2010 to December 2013 by using the Wiley Online Library, PubMed Central PMC, CINHAL, Cochrane Library, Biomed Central, Medline, and Science Direct. Results: Three papers have been identified in this current Systematic Review. Cosmetic scores were higher for SILC compared with 4 ports laparoscopic Cholecystectomy (4PLC). Satisfaction scores were similar in both groups. Though SILC has a higher procedure failure rate with more blood loss and takes longer than CLC. Conclusions: The study showed that SILC limited to a small number of patients. The potential advantage of SILC is cosmoses. However, the safety of SILC needs further assessment. Moreover, the operating costs were higher for SILC (an additional 400$ per procedure).

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H. Arimitsu Chiba Cancer Center, Chiba, Japan Aims: Although the recent developments in technological innovations, improvements in surgical skills and the extensive experience of surgeons have greatly enlarged the applications for laparoscopic liver resection, laparoscopic resection of biliary malignancy has not yet become widely accepted. We herein describe our experience with laparoscopic resection in patients with gallbladder tumor that was diagnosed as T2 carcinoma preoperatively. Methods: One patient underwent a pure laparoscopic resection of the gallbladder together with the gallbladder bed, extrahepatic bile duct, and lymph node around the hepato-duodenal ligament and pancreatic head. The jejunal limb was delivered through a window in the transverse mesocolon. An end-to-side hepaticojejunostomy was performed intracorporeally. Three patients underwent lymph node dissection around the common bile duct, and liver parenchymal dissection of a line approximately 2 cm from the attachment of the gallbladder. Results: Of four patients, there were two males and two females with a median age of 73.5 years (age range, 70–77 years). We successfully performed the present procedures as planed in four patients with gallbladder tumor without any complications. All lesions were well clear of surgical margins. Conclusions: Although our experience is limited and appropriate indications must await future studies, we believe that laparoscopic resection may be one of therapeutic options for carefully selected patients with T2 carcinoma of the gallbladder.

Surg Endosc



Laparoscopic Resection of Biliary Malignancies 1

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O. Itano , G. Oshima , M. Kitago , M. Shinoda , T. Hibi , H. Yagi , M. Odaira2, A. Aiko2, Y. Kitagawa1 1

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Keio University School of Medicine, Tokyo, Japan; Eiju General Hospital, Tokyo, Japan

Trocar Site Hernia Following Laparoscopic Cholecystectomy: A 10-Year Single Center Experience G. Chatzimavroudis, B. Papaziogas, I. Galanis, I. Koutelidakis, A. Ananiadis, P. Evaggelatos, S. Kalaitzis, J. Makris School of Medicine, Aristotle University of Thessaloniki, Greece

Purpose: The purpose of this study was to evaluate short term results of the laparoscopic resection of biliary malignancies Methods and Procedures: From May 2007 to March 2013, there were 32 laparoscopic surgeries for biliary malignaincies carried out at our hospitals. Laparoscopic-assisted pylorus preserving pancreaticoduodenectomy was performed for one ampulla vater carcinoma and seven common bile duct carcinomas. Two laparoscopic-assisted extended left hemihepatectomy and 4 laparoscopic-assisted extended right hemihepatectomies were performed for 6 hilar cholangiocarcinomas. Thirteen laparoscopic extended cholecystectomy (one with Roux-en-Y choledochojejunostomy), 3 laparoscopic(-assisted) liver S4aS5 subsegmentectomies, 1 laparoscopic-assisted left hemihepatectomy and 1 laparoscopicassisted right hemihepatectomy were performed for 18 gallbladder cancers. Laparoscopicassisted procedures consisted of laparoscopic mobilization of the target organs, followed by open resection and reconstruction through an 8–12 cm extraction site. Results: For laparoscopic-assisted pylorus preserving pancreaticoduodenectomy, the median operative time was 650 minutes. The median blood loss was 625 ml. There were no intraoperative complications. Postoperative complications developed in 2 patient (pancreatic fistula), which resolved with conservative management. The median postoperative hospital stay was 20 days. For hilar cholangiocarcinoma, the median operative time was 715 minutes. The median blood loss was 1306 ml. There were no intraoperative complications. One patient died of postoperative liver dysfunction. For gallbladder cancers, the median operative time was 360 minutes and the median blood loss was 180 ml. There were no intraoperative or postoperative complications. The median postoperative hospital stay was 7 days. Pathological examination showed R0 resections in all cases. Recurrence was detected in 4 cases (liver metastasis in two hilar cholangiocarcinoma case and lymph node metastasis in two gallbladder carcinoma case), but no port site metastasis or peritoneal dissemination was observed. Conclusion: Laparoscopic surgery for biliary tract cancer is feasible and safe, but more data may be needed for evaluation of long-term outcome.

Aims: Trocar site hernia is an uncommon but potentially dangerous complication of laparoscopic surgery. The aim of the present study was to evaluate the prevalence of trocar site hernia after laparoscopic cholecystectomy. Methods: The records of all patients that underwent elective laparoscopic cholecystectomy between January 2003 and December 2012 were retrospectively reviewed. In all patients open technique with a vertical incision along the midline was used to establish pneumoperitoneum via a 1.5 cm transverse infra-umbilical skin incision. Two or three other skin incisions were made and bladeless trocars were inserted: a 10 mm incision just below the xiphoid, a 5 mm incision at the right midclavicular line 3–6 cm below the costal margin and a 5 mm incision (optimal) at the anterior axillary line 5–8 cm below the costal margin. After the completion of cholecystectomy the gallbladder was removed through the infraumbilical incision. In all cases only the fascia at the site of infra-umbilical incision was closed with interrupted absorbable sutures 0 Vicryl. Antimicrobial prophylaxis was used in all cases. Results: During the study period 1091 patients [326 males (29.9 %), 765 females (70.1 %)] with a mean age of 58.4 ± 16.3 years underwent elective laparoscopic cholecystectomy. Of these, 11 patients (1 %) [4 males (36.4 %) -7 females (63.6 %)] developed incisional hernia at the infra-umbilical port site, while none of the patients presented hernia at any other port site. Conclusions: The prevalence of trocar site hernia following laparoscopic cholecystectomy is very low. Based on the results of our study closure of fascial incision of 10 mm below the xiphoid is not justified.



Importance of the Node of Calot in Gall Bladder Neck Dissection: A Novel Standardized Approach to Laparoscopic Cholecystectomy

Single-Incision Laparoscopic Cholecystectomy: Single Institution Experience with 189 Cases

S. Nazir, D. Swedler, M. Timoney, G. Ferzli

K. Yamamoto, S. Kitashiro, A. Mori, M. Ohba, K. Iwaki, K. Kato, T. Onoda, Y. Suzuki, Y. Kawarada, S. Okushiba, H. Kato

Lutheran Medical Center, Brooklyn, United States of America

Tonan Hospital, Sapporo, Japan

Introduction: Bile duct injury during laparoscopic cholecystectomy is one of the most feared complications. Iatrogenic BDI can result in the need for major reconstructive surgery, poor quality of life and increased mortality for the patient. It is associated with significant medico-legal repercussions as well as negative professional and psychological consequences. The mainstay of management of BDI is prevention. We introduce a novel landmark, the node of Calot, that, when used reduces the occurrence of BDI in laparoscopic cholecystectomy. Methods: We retrospectively analyzed laparoscopic cholecystectomies using a standardized approach in our practice over a five-year period. The key element of our standardized technique is the identification of the lymph node of Calot, which is used as a landmark to avoid close dissection to and injury of the common duct. Once the node is identified, the structure immediately lateral must be either the infundibulum or gallbladder neck. The peritoneum here is scored horizontally towards the lateral aspect. Dissection then proceeds to divide the peritoneal layer behind the infundibulum. The distal gallbladder is pulled (rotated) medially and cephalad and the peritoneum is sharply and bluntly dissected. This posterior dissection will often identify the posterior cystic artery. The anterior line of dissection will complete the ‘parabola’ started by the horizontal scoring and posterior line. The tubular structure that remains must be either the cystic duct or the infundibulum, which is fully revealed after then developing the critical view of safety. Results: During 5 years period 907 laparoscopic cholecystectomies utilizing the standard steps described with emphasis on recognition of the Node of Calot as a landmark to avoid BDI. We have had no bile duct injury and no cystic duct leak. Conclusion: The main cause of BDI is due to misidentification of the hepatobiliary structures. We propose the important addition of recognizing Calot’s node as the critical anatomical landmark to guide GB dissection and to enhance the safety and effectiveness of laparoscopic cholecystectomy from straight-forward to difficult cases.

Background: Single-incision laparoscopic surgery (SILS) is a well-described technique for many general surgical procedures. SILS has potential for reducing postoperative pain, length of hospital stay and improving cosmesis. The aim of this study was to report the results of the 189 cases of single-incision laparoscopic cholecystectomy (SILC) performed in a single institution. Methods: SILC was performed in 189 patients. We performed a retrospective analysis of the recorded data of SILC performed in a single hospital from December 2008 to December 2013. The cases with cholecystitis were excluded. Results: For the SILC cases, the operative times ranged from 27 to 215 min (mean, 75). The ages of the patients ranged from 21 to 85 years (mean, 55). The mean blood loss was 5 ml (range 5–125). The mean hospital stays were 4 days. No patients were converted to open operations, and no patients had procedure-specific complications. SILC approach left no apparent umbilical scar. There was a high cosmetic satisfaction. No patients complained of severe pain. Conclusion: The findings showed SILC to be feasible, safe, and efficacious. It is an excellent alternative to traditional four-port cholecystectomy for the ideal candidate with benign gallbladder diseases.

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Laparoscopic Cholecystectomy in Patients with Ventriculoperitoneal Shunt

Safety of Laparoscopic Cholecystectomy Following Percutaneous Transhepatic Gallbladder Aspiration (PTGBA) for Acute Cholecystitis

E. Colak, N. Ozlem, G.O. Kucuk, R. Aktimur Samsun Education and Research Hospital, Samsun, Turkey Aims: Ventriculoperitoneal shunt is used in treatment of patient with hydrocephalus. Laparoscopic cholecystectomy reliability is still controversial for this patients. Case reports and series of a few patient were reported in the literature. Method: We offer three cases whom applied elective laparoscopic cholecystectomy with chronic cholecystitis between January 2008-August 2012. A neurosurgery consultation was done prior to surgery to verify the proper functioning of the VP shunt. First patient 23 years old woman was operated with three trocar technique. Scoliosis was present in this patient. Second patient 42 years old man and third patient 53 years old woman were operated with four trocar American tecnique. Intraperitoneal pressure was maintained at 10 mm Hg. Intracraial pressure monitoring and temporary shunt clamping were not implemented. Results: All patients were discharged to home on postoperative first day. Elective laparoscopic cholecystectomy with established VP shunts appears to be safe with routine anesthetic monitoring. Precautions should be taken during trocar placement to avoid inadvertent damage of the shunt. This also applies to the peritoneal portion of the catheter during laparoscopy. In addition it is necessary ensure that the intraperitoneal portion of the catheter is not twisted prior to decompression of the abdomen. Conclusion: Standard technique laparoscopic cholecystectomy can be used safely to manage patients in case of VP shunts presenting with chronic cholecystitis.


Y. Harada, S. Komatsu, S. Shirakawa, S. Tsuchida, M. Awazu, Y. Ueda, D. Lee, T. Wakahara, H. Ashitani, Y. Hasegawa, A. Toyokawa Yodogawa Christian Hospital, Osaka, Japan Aims: Despite early cholecystectomy is the recommended treatment for acute cholecystitis (AC), operative risks are sometimes increased and severe complication or mortality may occur. Several studies reported usefulness of percutaneous transhepatic gallbladder aspiration (PTGBA) followed by cholecystectomy for AC. This study aimed to assess the safety of the treatment strategy: laparoscopic cholecystectomy following PTGBA for AC in a single center. Methods: This study included consecutive 100 patients who underwent cholecystectomy following PTGBA for AC from April 2008 to December 2013 in our institution. We reviewed medical charts of these patients. Results: Open cholecystectomy was performed in 33 of the 100 patients and laparoscopic cholecystectomy was attempted in 67. The conversion rate of laparoscopic to open cholecystectomy was 15 % (10/67). In the 67 patients, median operative time, intraoperative blood loss, and postoperative hospital stay were 188 minutes (75–330), 50 ml (5–600), and 4 days (4–38), respectively. Through preoperative examination, newly-detected malignancies were noted in four of the 100 patients. Conclusions: While relatively long operative time and increased blood loss was found in laparoscopic cholecystectomy in this study, prolonged hospital stay was not observed. Safety of this strategy is demonstrated in this study, despite increased difficulty in the procedure that may be induced by severity of AC required PTGBA and inflammatory fibrosis due to PTGBA. Newly-detected malignancy through preoperative examination is worthy to note. This elective treatment strategy for AC can thus become a standard treatment option in the future.


Drain Placement After Laparoscopic Cholocystectomy A. Andreou1, S. Antoniou1, G. Antoniou2, O. Koch3, K. Ko¨hler3, C. Chalkiadakis4, R. Pointner3, F. Granderath5 University Hospital of Heraklion, Greece; 2Department of vascular surgery, Red Cross Hospital, Athens, Greece; 3Department of general and visceral surgery, Hospital of Linz, Austria; 4Department of general surgery, university hospital of Heraklion, Greece; 5Center for Minimally Invasive Surgery, Neuwerk Hospital, Mo¨nchengladbach, Germany 1

Aims: Routine drainage of the subhepatic space has been a surgical trend of open cholecystectomy, carried on to the era of laparoscopic surgery without substantial evidence. Avoiding the potentially devastating sequelae of an undetected bile leakage is the main rationale behind this practice. Aims of this meta-analysis was to compare evidence on routine drain placement after laparoscopic cholecystectomy versus no drainage. Methods: A meta-analysis of randomized controlled trials was conducted; outcome variables included postoperative pain, subhepatic collection, 30-day morbidity, wound-related complications, and drainage interventions. The fixed- and random effects models were used in order to calculate combined overall effect sizes of pooled data. Results: Data are presented as the odds ratio (OR) or difference in means with 95 % confidence interval (CI). Six randomized trials including 1167 patients were identified. Pain scores were significantly higher in the drainage group both at 6–12 h (mean difference 1.12, 95 % CI 1.01–1.24, p \ 0.0001) and at 12–24 h after surgery (mean difference 1.12, 95 % CI 0.86–1.39, p \ 0.0001). Conclusions: No difference was found with regard to the incidence of subhepatic collection and drainage procedures. A trend in favor of the no drain practice with regard to 30-day morbidity and wound infection was registered, although this was less pronounced after sensitivity analysis. The possible clinical benefit of routine use of abdominal drainage in uncomplicated laparoscopic cholecystectomies requires larger study populations. The approach is however not encouraged on the basis of the present analysis, as it results in increased postoperative pain and overall morbidity.

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Laparoscopic Major Hepatectomy Versus Minor Hepatectomy for Colorectal Liver Metastasis: A Retrospective Cohort Study H. Lee, D.H. Kim, J. Jeong, S.H. Choi, D.W. Choi, J.S. Heo Samsung Medical Center, Seoul, Korea Background: Laparoscopic hepatectomy is increasing for the treatment of colorectal liver metastasis (CRLM). The aim of this study is to evaluate the outcomes of laparoscopic major hepatectomy compared with minor hepatectomy in the patients with synchronous and metachronous CRLM. Methods: From January 2008 to December 2012, we identified 48 patients who underwent curative intend laparoscopic hepatectomy for CRLM. The patients were divided according to the types of hepatectomy. Wedge resection and lateral sectionectomy were regarded as minor hepatectomy. The perioperative and oncologic outcomes were investigated. Results: Thirty three patients underwent laparoscopic minor hepatectomy and 15 patients underwent major hepatectomy. Laparoscopic major hepatectomy was associated with longer operation time, larger blood loss, and transfusion compared with minor hepatectomy. (p \ 0.001, p = 0.014 and p = 0.048). However, there were no significant differences in complication rate and disease free survival after median follow-up period 22 months (p [ 0.999 and p = 0.790). Conclusion: Laparoscopic major hepatectomy is technically difficult. However, it is as safe and effective as minor hepatectomy for the treatment of CRLM.

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Minilaparotomy Cholecystectomy with Ultrasonic Dissection Versus Conventional Laparoscopic Cholecystectomy - 1 Year Outcome

Conversion in Laparoscopic Cholecystectomy in Acute Versus Chronic Cholecystitis

A. Aspinen1, J. Harju2, P. Juvonen3, H. Kokki3, V. Remes2, T. Scheinin2, M. Eskelinen3 1 University of Eastern Finland/Kuopio University Hospital, Kuopio, Finland; 2Helsinki University Central Hospital, Helsinki, Finland; 3 Kuopio University Hospital, Kuopio, Finland

Aims: The long-term outcome between laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) with the ultrasonic dissection (UsD) technique has not been compared in randomised trials. We therefore investigated the outcome after conventional LC and MC with UsD in 78 patients. Methods: Initially 88 patients with non-complicated symptomatic gallstone disease were randomized into MC (n = 44) or LC (n = 44) over a period of 2-years (2010–2012) and 78 of them (89 %) were reached for a follow-up interview at 12 months after the surgery. Results: Baseline parameters were similar in the two groups, and 1/44 MCs and 2/44 LCs were converted to open laparotomy. The prevalence of chronic post-surgical pain (CPSP) one year after the procedure was quite similar in the two groups: 3/36 (8 %) in the MC group and 2/ 42(5 %) in the LC group (p = 0.502). Residual abdominal symptoms were common but the proportion was similar in both groups (28 % in MC and 33 % in LC group, p = 0.665). Both groups were very satisfied with the cosmetic outcome (Numeric rating scale: 0–10, p = 0.470). The Quality of life (QoL) improved 34/36 (94 %) in the MC group and 33/42 (79 %) in the LC group (p = 0.125) and each patient in both groups were satisfied for the operation overall. Conclusions: Day-case MC and LC patients have a quite similar one year outcome with no significant difference regarding residual abdominal symptoms, cosmetic satisfaction, QoL or CPSP.

E. Colak, N. Ozlem, G.O. Kucuk, R. Aktimur Samsun Education and Research Hospital, Samsun, Turkey Aims: The aim of this study was to evaluate the results of the laparoscopic cholecystectomy in acute versus chronic cholecystitis through determining the conversion rate in open method, Method: A retrospective study was conducted at the Samsun Education and Research Hospital in Turkey between July 2012-July 2013. Results: Thirty (4,1 %) patients with acute cholecystitis (AC) on whom the laparoscopic cholecystectomy was performed in the period from zero to the seventh day from the onset of symptoms. Seven hundred (95,9 %) patients with chronic cholecystitis (CC) who underwent laparoscopic cholecystectomy. There was no difference conversion to open cholecystectomy in the AC (10/30 or 3,3 %) compared with CC group (40/700 or 5,7 %). There was no death in either group. There were no bile duct injury in the AC group 0/30 (0 %) versus 1/700 (0.14 %) in the CC group. Conclusion: There is no difference between conversion and complication rates for elective cholecystectomy and urgent cholecystectomy. In addition early cholecystectomy may reduce hospitalization and medical treatment costs in patients with acute cholecystitis.



Needle Forceps Enables Reduced-Port Surgery in Laparoscopic Cholecystectomy for Gallbladder Diseases

Male Sex and Obesity as Risk Factors for Conversion During Laparoscopic Cholecystectomy

Y. Miyamae

G. Ianosi1, D. Neagoe1, S. Ianosi1, C. Drighiciu2, M. Popescu2, M. Caruntu2, M. Calbureanu3

Takasaki General Medical Center, Takasakishi, Japan Purpose: We have recently introduced reduced-port surgery in laparoscopic cholecystectomy (LC) for inflammatory gallbladder diseases by using a novel needle forceps, Endo ReliefTM (ER). The aim of this study was to evaluate surgical outcomes of reduced-port LC using ER compared with conventional 4-port LC. Methods: Twenty-nine patients underwent conventional 4-port LC from January to September 2012 (C-group), and fifty-seven patients underwent reduced-port LC from October 2012 to October 2013 (ER-group). ERs were directly inserted into the right middle and right upper abdomen instead of placing 5-mm ports. Results: Patient characteristics were as follows, male:female ratio 11:18 vs. 28:29, and mean age 59.9 (range 17–80) vs. 62.5 (range 35–85) years, in the C-group and the ERgroup, respectively. There were no significant difference in mean operation time (113.6 ± 31.1 vs. 127.3 ± 27.8 min), blood loss (7.0 ± 11.3 vs. 40.2 ± 54.3 ml), initiation of postoperative oral intake (1.4 ± 0.5 vs. 1.3 ± 0.5 days), and postoperative hospital stay (4.3 ± 1.4 vs. 4.2 ± 1.7 days) between the C-group and the ER-group, respectively. There were no major intraoperative complications. Two patients were converted to open laparotomy. Although low-grade fever prolonged hospital stay in 4 patients (2 in the C-group and 2 in the ER-group), all cases improved with conservative treatment. One patient in the ER-group had postoperative jaundice because of common bile duct stones, which improved by endoscopic sphincterotomy. Conclusion: Reduced-port LC using ER is safe and feasible, and provides favorable cosmetic results with less invasiveness compared to conventional LC.

1 University of Medicine and Pharmacy of Craiova, Craiova, Romania; 2Military Hospital, Craiova, Romania; 3University of Craiova, Romania

Introduction: Despite of advances in hepatic-biliary diagnosis and treatment, there are multiple risk factors for conversion in laparoscopic cholecystectomy. The aim of our study is to evaluate the conversion rate of laparoscopic cholecystectomy relating to sex and obesity. Patients and Methods: 328 patients operated by a single surgeon were divided into three groups: group A (72 male patients), group B (214 female patients) and controls (42 patients, 20 males and 22 females) that were considered patients in which cholecystectomy was made for other reason than cholecystitis. Secondary, all these groups were divided in an obese group (46 men and 156 women with BMI over 40 kg/m2) and a non-obese group (26 men and 58 women). Results: Conversion rate was greater in men (5.55 %) than in women (1.40 %) (p = 0.002). Histological evaluation showed a greater number of inflammatory cells (macrophages, mast cells and eosynophils) in men (p = 0.001) without differences in terms of lymphocytes count (p = 0.09); collagen accumulation in submucosal region of the gallbladders wall was significant in 33 men (45.83 %) and in 21 women (9.81 %) (p = 0.001) There were no differences between obese and non-obese groups. Conclusions: 1. Males presenting for cholecystectomy are more likely to have severe disease. 2. Our observation confirmed an intense inflammatory process in men comparing with women and a greater collagen accumulation in submucosal region of the gallbladders wall in men. 3. Obesity didn’t modify the percent of conversion in our study even there were difficulties related to laparoscopic approach in these patients.

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Laparoscopic Cholecystectomy: Prevention of the Inflammatory Complications

Introduction of Single Site Laparoscopic Partial Hepatectomy in Patient with Hepatocellular Carcinoma

R.V. Bondarev, S.S. Selivanov, R.N. Gluschenko, Ya. Maslov

T. Kimura, Y. Matuda, M Inoue, S. Koida, N. Matsuoka, Y. Ushimaru, Y. Kato

State Medical University, Lugansk, Ukraine Aims: To improve the outcome of patients with acute destructive cholecystitis (ADC) by preventing of the inflammatory complications using by Pyobacteriophagum polyvalentum (PP) during laparoscopic cholecystectomy (LCE). Methods: The study involved 285 patients with ADC (abscess form - n = 225, gangrenous - n = 48, perivesical abscess complicated - n = 12) who underwent LCE and topically applied PP. The age of patients was from 28 to 83 years, women - 262, men - 23. All patients received conservative therapy, including antibiotics. After LCE reorganize subhepatic space with isotonic solutions, and then irrigated PP up to 50 ml. After extraction of the container with the destructive gallbladder (DGB), through the trocar wound was irrigated last PP in the amount of 3–5 ml. Results: purulent complications of abdominal wounds was not detected. In 5 patients in the trocar wounds (place extraction DGP) formed seroma, which drained, followed by readjustment of the PP. Clinical manifestations of the application of PP were: normalization of body temperature, the absence perifocal flushing wounds, a sharp decline of wound exudates, normalization of laboratory indications. Marker of the efficacy of PP was no clinical indication for long-term administration of antibacterial drugs. Conclusions: The use of PP at LCE in patients with ADC can prevent the occurrence of septic complications and abdominal troacar wounds.

Yao Tokushukai General Hospital, Yao, Osaka, Japan Introduction: Laparoscopic partial hepatectomy in patient with hepatocellular carcinoma (HCC) has been gradually accepted as an alternative to open surgery. Recently, we start to introduce single site laparoscopic partial hepatectomy in patient with HCC associated with liver cirrhosis. Patient and Method: The indications of single site laparoscopic hepatectomy are below: Tumor less than 5 cm in a diameter which located lower part of liver, Patient liver function according to Child-Pugh score A or B who can be well tolerate general anesthesia. We prefer to use GelPOINTÒ (Applied medical, USA), which can use 4 trocar, as a device of single site laparoscopic surgery. GelPOINTÒ placed at an umbilicus, and 10 mm 45 degree camera inserted through device. Tumor size and site has been carefully examined by means of ultrasound using contrast medium as well. Conventional laparoscopic tools has been use for partial hepatectomy including CUSA, saline enhanced bipolar coagulation, laparoscopic coagulation shears. Surgical bag used for retrieval of specimen. Results: Three patient with HCC associated with cirrhosis has been introduced single site laparoscopic surgery. Age are ranged from 72 to 84 years old, and two of them are male. All of them are associated with HCV liver cirrhosis, and Child-Pugh score are A. ICG 15( %) are ranged from 20.8 to 44.2, and AFP are ranged from 20.6 to 431.8 ng/ml. Tumor are located at S4 in all cases, and diameter ranged from 14 to 28 mm. Operation time are 221, 223, 253 minutes, and bleeding amount are 10, 15, 170 ml, respectively. None of them required additional port placement or open conversion. Complication did not observed, and all of them discharged within 6 days after operation. No recurrence has been observed during postoperative follow up period. Conclusions: We have been initiate single site laparoscopic partial hepatectomy in a selected patient. Since, mortality and morbidity has not been observed our initial experience, single site laparoscopic partial hepatectomy can be performed safely, however, further experiences are required to establish this procedure as an standard alternative to conventional laparoscopic surgery.



Improvement of the Patients Treatment Efficacy After the Laparoscopic Cholecystectomy

Single Incision Laparoscopic Completion Cholecystectomy for Retained Gallbladder After Four Port Laparoscopic Cholecystectomy

Ye. Vansovich, V.I. Pshenichny National Medical University, Odessa, Ukraine Aims: To evaluate the efficacy of the postoperative treatment of patients after laparoscopic cholecystectomy (LChE) with the help of nitric oxide donator ‘Tivortin’. Methods: 48 patients suffering from the intensive pain syndrome were examined in the Surgical department of the Odessa Municipal Hospital #9. 41 of them were undergone to LChE according to diagnostic events, 7 patients continued conservative treatment. Operated patients were randomized on 2 subgroups: the 1st group patients (n = 13) received general therapy according to the issued protocols of treatment during the postoperative period. The 2nd group patients (n = 28) additionally received ‘Tivortin’ that was included into general therapy during the postoperative period. Hepatic specific enzymes activity [alanine aminotransferase (ALAT), aspartate aminotransferase (ASAT) and base phosphatase (BP)] together with plasma total protein and urea content was evaluated during the postoperative period. Results: There were no episodes of the hepatic failure among the patients of the 2nd group. There were 2 cases of hepatic insufficiency in the 1st group patients. The day-in duration in the 2nd group patients was 2.2 times less pertaining the same index in the 1st group patients. On the day 2 after LChE the 2nd group patients showed insignificant protein (+23 %) and urea (+19 %) content increasing and BP (-26 %) decreasing together with both ALAT (in 1.7 times, p \ 0.05) and ASAT (in 2 times, p \ 0.05) activities decreasing pertaining the same indexes in blood samples from the patients of the 1st group without ‘Tivortin’ administration. The forthcoming clinical observation showed better clinical condition and more improved hepatic parenchyma functional activity in the 2nd group patients. Conclusions: These data are in favour of ‘Tivortin’ administration in patients during the postoperative period. One could see that hepatoprotective treatment earliest start in patients after the LChE resulted in earlier and more effective hepatic parenchyma functional state improvement in the operated patients.

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K.H. Kim, C.H. An, J.S. Kim, I.Y. Park, D.G. Kim Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu, Korea Aims: In recent years, single-incision laparoscopic cholecystectomy (SILC) has spread widely and become more attractive with technical improvement and new devices. However, SILC still has limitation on adequate traction and visualization. In our center, needlescopic grasper and snake liver retractor have been used for overcoming this limitation. Methods: We report the case of a patient who previously underwent 4-port laparoscopic cholecystectomy for symptomatic gallstone disease. After a brief symptom-improved interval, he developed acute pancreatitis. At evaluation, imaging results of CT and MRCP demonstrated a retained gallbladder with pancreatitis. The patient was subsequently referred to our hospital, where he underwent further evaluation and surgical intervention. Results: Our patient underwent single incision laparoscopic remnant cholecystectomy. Operative exploration demonstrated a remnant gallbladder with severe fibrotic adhesion. The procedure took 125 minute, with no blood loss. The patient’s postoperative course was uneventful. Final pathology results demonstrated a remnant gallbladder with chronic cholecystitis. Conclusions: This report is the first in the literature to describe successful single incision laparoscopic remnant cholecystectomy. Single incision laparoscopic procedures may achieve the safe and good result in retained gallbladder after conventional laparoscopic cholecystectomy.

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Laparoscopic Complete Excision of Choledoachal Cyst in Children with Internal Stenting of Hepatico Doudenostomy Anastomosis

Extrahepatic Bile Ducts Injuries in Laparoscopic Surgery. 8 Year Experience

M. Ismail lotfalla, R. Shalaby Al Azahar University, Giza, Egypt Aims: Evaluation of internal stenting of the hepatico- doudenostomy anastomosis after laparoscopic complete excision of chledoachal cyst in children Methods: Laparoscopic complete excision of eight cases of choledochal cyst with enteric anastomosis was done. Biliary drainage was achieved by hepatico duodenostomy with internal stenting of the anastomotic line. 12 cm catheter (10 Ch)was used, 2to 3 cm within the common hepatic duct and the remaining part of the catheter was introduced to the distal doudenum Their age ranged from 1 to 8 years (2.5 years on average). The outcome measurements include visibility, safety, post-operative biliary leakage, and stricture following internal stenting of the anastomosis. Results: The technique is safe easy, applicable, and rapid. Spontaneous expulsion of the stent with stool occurred within 2 to 3 weeks postoperatively. Conclusion: Internal stenting applying this technique is simple, safe, effective in preventing postoperative leakage, without any complications and with spontaneous expulsion of the stent within 3 weeks.

V. Fomin, O. Danilevskaya, M. Fomina MSMSU, Moscow, Russia Objective: to carry out the analysis of extrahepatic bile ducts injuries (EhBDI) and postoperative biliary complications after laparoscopic cholecystectomy (LC) in treatment of cholelithiasis. Materials and Methods: 2006–2013 1175 patients underwent LC routinely (49.1 %) or urgently (50.9 %). Women (78 %) were predominant. An average age of the operated patients made 46.32 ± 4.64 years. Conversion frequency in the group of the urgently operated (acute cholecystitis - AC) made 5.1 %; at planned interventions (asymptomatic gallbladder - AsG) - 0.5 %. Results: EhBDI was established in 7 cases (0.6 %): at AC in 5 (0.83 %) cases and in 2 (0.35 %) cases at AsG; minor injuries were noted in 2 cases of ?. The classical 1 type of the EhBDI was revealed in two cases: during planned surgery (diagnosed intraoperatively, recovery operation using T-tube drainage), during emergency surgery (diagnosed intraoperatively, reconstructive hepaticojejunostomy (RHjS) on Roux-loop). The second type of major choledochial injuries was observed in two patients: in one case it wasn’t revealed intraoperatively, that was the reason of the development of bilious peritonitis and the RHjS on Roux-loop was executed. In other observation endoclips from bile duct were removed and the cystic duct remnant was clipped. The third type of EhBDI was revealed on the 2nd month after the operation due to the obstructive jaundice caused by endoclips. RHjS on Roux-loop was performed after the transcutaneous biliary decompression. The minor injuries registered in 2 cases and were characterized by a coagulative necrosis of choledoch serosa that demanded a laparotomy and T-tube choledoch decompression. In all cases there was no fatality, passability of biliary tree according to MRCP research was satisfactory 1 year later. Conclusions: In our opinion the main requirement when performing LC is careful and laborious preparation in a zone of Calot’s triangle and also conversion or ‘hand change’ after down time in a neck of gall bladder more than 30 minutes. Following these conditions the risk of postoperative complications will be minimized. Video record of the operation we also consider as a very important stage (we apply this rule since 2012) for the analysis of the errors and technic of a surgeon.



Needle-Scopic Grasper Assisted Single Incision Laparoscopic Cholecystectomy for Gallbladder Disease: Comparison with Three Port Laparoscopic Cholecystectomy.

Venous Haemorrhage from Gallbladder Bed During Laparoscopic Cholecystectomy and Intraoperative Hemostatic Measures

K.H. Kim, C.H. An, J.S. Kim, I.Y. Park, D.G. Kim

A.A. Laghari, A.K. Sangrasi, A.H. Abro, Z. Memon

Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu, Korea

Liaquat University of Medical & Health Sciences Jamshoro, Jamshoro, Sindh, Pakistan

Aims: In recent years, single-incision laparoscopic cholecystectomy (SILC) has spread widely and become more attractive with technical improvement and new devices. However, SILC still has limitation on adequate traction and visualization. In our center, needlescopic grasper and snake liver retractor have been used for overcoming this limitation. In this study, we reviewed our experiences of needlescopic grasper assisted SILC (nSILC) through comparison with conventional 3-port laparoscopic cholecystectomy (CLC). Methods: Four hundred and eighty-five patients undergoing laparoscopic cholecystectomy for gallbladder disease at Uijeongbu St. Mary’s hospital between October 2011 and December 2012 were retrospectively reviewed. Needlescopic grasper assisted SILCs were performed in 233 patients and CLCs were performed in 252 patients. Demographics and operative outcomes of these patients were compared between groups. Surgical techniques standardized and all operations were performed by one experienced surgeon. Results: nSILCs were more frequently performed in young and female patients, while the patients with acute inflammation and difficult case underwent CLCs more frequently. There were no significant differences between groups in overall surgical outcomes. In subgroup analysis according to the operation difficulty, nSILC group required more time than CLC group for critical view of safety (CVS) identification and total operation in grade I & II. However, there were no differences between groups in other surgical outcomes such as bile spillage, intraoperative complication, conversion to open surgery, postoperative pain and hospital stay. Conclusions: This study showed that nSILC can be an alternative to conventional laparoscopic cholecystectomy through the confirmation of safety and feasibility. No differences between groups in terms of complication, conversion, and postoperative pain were seen in this study.

Objective: To evaluate the sites of venous bleeding and their intraoperative control and preventive measures Patients and Methods: This one year study was conducted in Hepatopancreatobilliary and minimal access surgery at Liaquat University Hospital Jamshoro and Rajputana hospital Hyderabad Sindh Pakistan. The patients, of = 10 years of age and either gender visited at the surgery OPD or admitted in surgery ward were evaluate and enrolled. The subjects were operated and carefully evaluated for any venous bleeding and its preventive parameters. The frequency and percentage was calculated for venous bleeding sites, its preventive measures and operation time. The chi-square test was applied between categorical variables at 95 % confidence interval and the p-value = 0.05 was considered as statistically significant. Results: During one year study period total 580 patients were registered for study, of which 105(18.1 %) were males and 475 were females (81.9 %). Of, 580 sixty two patients (10.6 %) were evaluated, of which 15(24.1 %) were males and 47(75.8 %) were females [p = \0.01]. Out of sixty two patients, 24(38.7 %) had uncomplicated gallbladder, 07(11.2 %) have acute cholecystitis, 10(16.1 %) had chronic cholecystitis, 06(9.6 %) had buried gallbladder, 05(8 %) had mucocele and 04(6.4 %) had gangrenous gallbladder. The bleeding at venous site was detected in 18(29 %) cases while others are medical 1/3 in 05(8 %) patients, middle 1/3 in 11(17.7 %) patients and lateral 1/3 in 28(45 %) patients respectively. [p = 0.04] The bleeding controlled in 44(70.9 %) patients by cautery 05(11.3 %), clips plus gauze pressure 26(59 %), gauze pressure only 06(13.6 %), surgical 04(9 %), Hormonic scalpel 03(6.8 %) patients. [p = \0.01]. The mean age ± SD for male and female was 59.98 ± 7.81 and 62.91 ± 6.84 while the mean ± SD for operative time was 40.12 ± 5.82 minutes whereas no any mortality was observed. Conclusion: It has been observed that measures to control bleeding are Good surgical technique, awareness, early recognition, management with clips, gauze pressure and cautery.

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Factors Affecting Conversion Among Patients Undergoing Laparoscopic Cholecystectomy at a Tertiary Care Institution in North India

Preoperative Evaluation of Risk Factors of Bile Duct Trauma During Laparoscopic Cholecystectomy in Complicated Acute Cholecystitis

A. Prakash1, H. Yadav2, R. Singh2, A. Kumar2, V. Kapoor2, R. Saxena2

V. Kolomiytsev, O. Syroid Lviv Medical University, Lviv, Ukraine

1

SGPGIMS, Lucknow, India

Aims: Laparoscopic cholecystectomy is the gold standard among patients with symptomatic cholelithiasis. Conversion to an open procedure may be required in 5–10 % of patients. The study was undertaken to analyse the factors affecting conversion in a centre with high endemicity of the gallbladder cancer. Methods: We retrospectively analysed 1956 patients undergoing laparoscopic cholecystectomy at our institution from a prospectively maintained database between January 2007 through December 2011. Incidence of conversion to open procedure and underlying factors were analysed. Results: Conversion was required in 156 patients (7.9 %). The main intraoperative factors affecting conversion were the inability to delineate the anatomy due to severe inflammation or dense adhesions (76.9 %), cholecystoduodenal fistula (5.7 %), bile duct injury (3.2 %), iatrogenic bowel perforation (2.5 %), cholecystocolonic fistula (2.5 %), bleeding (2.5 %), cirrhosis (2.5 %), suspected malignancy (1.9 %), cystic duct calculi (1.2 %), cholecystopseudocyst fistula (0.6 %) and extensive pericholecystic collaterals (0.6 %). Xanthogranulomatous cholecystitis (31.4 %) and carcinoma gallbladder (3.2 %) were present in a significant proportion of these patients. Multivariate analysis identified male sex, history of complicated gallstone disease, gall bladder wall thickness [ 4 mm and suspicion of malignancy as independent predictors of conversion. Conclusion: Referral bias and a higher suspicion of gallbladder malignancy among our patients are the factors accounting for higher rates of conversion in our institution. Despite all the advances in imaging, it is difficult to differentiate Xanthogranulomatous cholecystitis and gallbladder malignancy and that led to a low threshold for conversion in such cases. This would be an indicator of sound surgical judgement rather than a technical failure.

Background Empirical evidence suggests that the number of bile duct trauma (BDT) during laparoscopic cholecystectomy (LC) is higher in case of patients, which suffer from complicated acute cholecystitis. The aim of current study is to investigate and predict the determinants of BDT during LC in case of acute cholecystitis, complicated by choledocholitiasis (ACCC). Patients and Methods: During the period 2001–2012, 351 patients (age range: 19–87; 248 females - 70.7 %) with ACCC underwent LC in the surgical department. The patients had an ERCP with bile duct clearance before LC, due to choledocholitiasis. Hard paravesical masses were detected in 308 (87.7 %) patients, paravesical abscess - in 31 (8.8 %), empyema of gallbladder - in 12 (3.4 %), total peritonitis - in 3 (0.9 %) patients. Obstructive jaundice was diagnosed in 192 (54.7 %), acute cholangitis - in 84 (23.9 %), acute biliary pancreatitis - in 76 (21.7 %) patients. Results: BDT was detected in 16 (4.6 %) cases: ‘major’ - in 3 (0.9 %), ‘minor’- in 13 (3.7 %). In order to determine the risk factors of BDT, there were analyzed anamnesis data, clinical signs, laboratory tests, ultrasonographic changes of gallbladder, and hepatoduodenal ligament. BDT were detected more often in patients in the physical condition ASA III/IV (OR = 4.92; 95 % CI = 1.27–19.14), if gallbladder wall thickness was = 10 mm (OR = 4.17; 95 % CI = 1.44–12.07), and in the presence of hard paravesical masses (OR = 4.79; 95 % CI = 1.51–15.17) or masses of hepatoduodenal ligament (OR = 17.67; 95 % ? = 5.45–57.35). Conclusions: Bile duct trauma during LC were ascertained in 4.6 % of patients with ACCC. Among the risk factors of BDT, there were identified: severe physical condition of a patient, gallbladder wall thickness = 10 mm, the presence of hard paravesical masses and masses of hepatoduodenal ligament.



Common Bile Duct Stones Resolved by Choledocoscopy

Comparison Between Two SILS Cholecystectomy Techniques

G.E. Dejeu, A.M. Maghiar, T.T. Maghiar, A. Suta

G.E. Dejeu, A.M. Maghiar

Spitalul Pelican Oradea, Oradea, Romania


Although it is known for years that laparoscopic approach to common bile stones is feasible, few centers with experience in advanced laparoscopic surgery approach this pathology. In our country common bile lithiasis is commonly treated by the gastroenterologist by ERCP, only in complicated cases that do not resolve by ERCP does the surgeon have a role. We have an experience of 15 choledochoscopy’s with the extraction of common bile stones using the Dormia or Fogarty probes. In our technique we use a flexible one working channel choledochoscope that is introduced in the abdomen through a 10 mm trocar placed under the right costal margin. In 5 cases we used Kehr tube choledochal drainage for 2 weeks postoperatively, and in the remaining cases we used primary closure of the choledochotomy with resorbable sutures. All cases had favorable outcomes with a mean hospital stay of 5 days, and mean operation duration 90 minutes. Our results are in line with other published data concerning one stage treatment of common bile stones and gall bladder stones by laparoscopic approach.

From August 2011 till Dec 2013 we evaluated all patients admitted in our hospital for biliary lithiasis using ultrasonography. We proposed SILS cholecystectomy to 450 patients we found suitable (no signs of acute cholecystitis). We randomly divided 200 patients (after the first 100 cases) into 2 groups, group A for SILS cholecystectomy using the puppeteer technique and the group B for SILS cholecystectomy using the Dapri Storz double curved forceps and the EndoGrab. Our technique involves a 2 cm transombilical incision, through which we introduce our first 10 mm trocar and perform a exploratory laparoscopy. We continue by placing a second 10 mm trocar just anterior and lateral to the first one. We had 4 operations that needed the introduction of at least one extra trocar for bleeding difficult to control through the SILS technique. The mean operation duration was 38 minutes for the puppeteer technique and 33 for the technique using the Dapri forceps. Most patients were female in both groups (78 % in group A and 82 % in group B). There was no statistically significant difference in pain score and cosmetic result (as judged by the patients) between the groups (pain score of 3.4 out of 10 for group A and 2.8 for group B, at 2 hours post op; and 2.5 for group A and 2.1 for group B at 24 hours postop; the cosmetic result score at one month postop of 9.3 out of 10 for group A and 9.4 for group B). Single incision laparoscopic surgery is not a new concept anymore, and will definitely be in great demand in the near future. The puppeteer technique is an economic way of performing SILS cholecystectomy and can be performed in all surgery clinics that are performing laparoscopic procedures. The introduction of curved instruments comes in the aid of surgeons ergonomics and shortening the operating time without the sacrifice of patient safety. Large, randomized controlled trials are needed before one technique or the other should be proposed as better than the other.

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Choledochocele Causing Postoperative Cholestasis: A Case Report

Treatment of Post-LCE Intraabdominal Bile Leaks

I. Tsechpenakis1, E. Lampropoulos2, P. Michail1, I. Tsigkritis1, I. Basios2 Athens Euroclinic, Athens, Greece; 2Metropolitan Hospital, Athens, Greece

R.M. Smachylo, V.V. Boyko, A.M. Tischenko, S.V. Sushkov, I.V. Belozyorov, A.V. Maloshtan, G. Mylovydova Institute of General and Urgent Surgery, Kharkiv, Ukraine

1

Aims: The purpose is to be demonstrated the interesting case of postoperative cholestasis, potentially implying bile tree trauma. Methods: We report a case of a 56 years old female Caucasian patient with an incidental finding of choledochal cyst type II, following laparoscopic cholecystectomy. Results: The patient was admitted to our hospital for routine laparoscopic cholecystectomy due to symptomatic cholelithiasis with a slight increase of ?-GT (140 IU/L). The operation was uneventful and the patient was discharged the following day. The 3rd post-operative day the patient was re-admitted with epigastric pain and a further increase of ?GT (160 IU/ L). Ultrasound examination showed slight dilatation of the common bile duct (1.2 cm), while MRCP showed no discontinuity of the bile tract. Due to continued increase of ?-GT value, the patient underwent ERCP and a choledochal cyst type III (or Choledochocele) was revealed. A plastic stent was placed in the common bile duct and removed three weeks later. The patient remained asymptomatic thereafter, with normal values of ?-GT. An asymptomatic choledochal cyst became symptomatic following cholecystectomy. This could be explained due to enhanced prolapse of the common bile duct and loosening of the anatomical structures, following cystic duct ligation and transection, as required for laparoscopic cholecystectomy. Conclusion: Choledochal cysts are rare congenital malformations, involving cystic dilatations of the biliary tree. The classic triad in adults with choledochal cysts is abdominal pain, jaundice, and palpable right upper quadrant abdominal mass, found in 10–20 % of patients. A high index of suspicion, appropriate investigation, such as MRCP and ERCP can help in reaching an early diagnosis in this rare congenital condition.

Bile leaks after laparoscopic cholecystectomy (LCE) may present with life threatening complications like bile peritonitis, biomass, abscesses, sepsis. Objective. To evaluate different methods of treatment of intraabdominal bile leaks. Materials and Methods: Intraabdominal bile leaks were observed in 67 patients after LCE from 2000 till 2013. Among them 47 were operated in the Institute, 20 were transferred from other hospitals. Patients were divided into two groups. I group - 34 patients were operated on by open approach, II group - 33 patients were operated by relaparoscopy or percutaneous drainage. Postoperative complications, mean hospital stay, mortality were analyzed. Results: There were 9 and 8 bilomas in patients of I and II group respectively, bile ascites was diagnosed in 17 and 18 patients and bile peritonitis in 7 and 8 patients of I and II group respectively. Gender, mean age, concomitant diseases do not differ significantly between groups. Laparotomy with revision of area of operation, lavage and drainage of abdominal cavity was performed in I group. Relaparoscopy with revision and abdominal drainage was performed in 25 patients and percutaneous drainage in 8 patients of group II. There were 15 complications in group I: intraabdominal abscess - 3, tertiary peritonitis and MOF - 1, wound infection - 6, pneumonia - 3, persisting external bile leak - 2. There were 5 complications in group II: intraabdominal abscess - 1, persisting external bile leak - 2. Conclusion: Early detection of intraabdominal bile leakage with subsequent minimally invasive treatment (percutaneous drainage or relaparoscopy) is highly recommended in patients with post-LCE bile leakage.



Pre-operative Evaluation of Conversion in Laparoscopic Cholecystectomy

Laparoscopic Cholecystectomy in Obese Patients

E. Picone1, G.P. Angelucci1, M.C. Fioriti2, C. Arcudi1, S. Colizza2, A.L. Gaspari1, N. di Lorenzo1 1

University of TorVergata Department of Surgery, Rome, Italy; Hospital ,,San Giovanni Calibita,, Fatebenefratelli, Rome, Italy

2

Aims: Laparoscopic cholecystectomy is the gold standard surgical approach in emergency and in elective settings for the treatment of symptomatic cholelithiasis. However conversion is sometimes required. The aim of our study is to understand how pre-existing conversion risk factors can be recognized to allow a better preoperative planning and lowering operative cost. Material and Methods: We performed a retrospective analysis on 1196 consecutive patients who underwent a laparoscopic cholecystectomy between 2009 and 2012 at the Hospital ‘San Giovanni Calibita’ Fatebenefratelli of Rome. Age, sex, BMI, previous surgery, pre-operative diagnosis and conversion rate were evaluated. Results: In 75 % of patients the diagnosis was cholelithiasis or adenomyomas, in 24 % patients was acute cholecystitis, in 0.6 % a gallbladder neoplasia, in 0.4 % there was an association with abscesses. We didn’t find a correlation between age, sex, BMI and the conversion rate (p = NS). The conversion rate was 2.2 %. 50 % of patients that required a conversion during the operation has had previous major upper abdominal surgery (p \ 0.0001). The most frequent reasons for conversion were infiltration/fibrosis of Calot’s triangle and adhesions. 88.5 % of converted patients has had diagnosis of acute cholecystitis (p \ 0.0001). Conclusions: In our experience pre-operative diagnosis of acute cholecystitis was found to be correlated with an increased conversion rate. Also previous abdominal surgery seems to be associated with an higher conversion rate. Accordingly whit these risk factors for conversion, preoperative patient counselling can be improved.

A. Cotirlet1, A. Gavril2, D. Nedelcu3, P. Tincu4, M. Popa4 1 Vasile Alecsandri University of Bacau/ Municipal Emergency Hospital Moinesti, Moinesti, Romania; 2Gr. T. Popa university of Iasi, Romania; 3Hopital Civil Strasbourg, France; 4Municipal Emergency Moinesti Hospital, Moinesti, Romania

Aims: Laparoscopic cholecystectomy is the treatment of choice for gallstones. Obesity was initially considered a contraindication to this approach. The aim of this report is to review our experience and to evaluate the role of BMI in the outcome. Methods: The records of 3357 patients who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis from January 2009 to December 2013 were analyzed. Patients were divided into 5 groups according to their BMI: \ or =24.9, 25.0–29.9, 30.0–34.9, 35.0–39.9 and [ or = 40 kg/m2. Results: Of the 3357 patients 2376 females (70,8 %) and 981 males (29,2 %) who underwent laparoscopic cholecystectomy, 833 (24,8 %), 1655 (49,3 %), 728 (21,7 %), 118 (3,5 %) and 23 (0,7 %) had BMI values of \or =24.9, 25.0–29.9, 30.0–34.9, 35.0–39.9 and [ or = 40 kg/m2, respectively. Conversion to open cholecystectomy was required in 188 patients (5,6 %), and complications occurred in 64 patients (1,9 %). There was no correlation between BMI, the conversion rate and complication rate, while the hospital stay was similar between the groups with successful laparoscopic cholecystectomy. The only significant difference was the longer operating time in the two obesity groups. Conclusions: Laparoscopic cholecystectomy is effective and safe in patients with morbid obesity. As it carried low risks of conversion and perioperative complications, we suggest that laparoscopic cholecystectomy is the select approach for these patients. Moreover, the rapid mobilization and hospital discharge following the surgical procedure may provide extra benefit to these patients.

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Safety of Laparoscopic Cholecystectomy for Symptomatic Gallstone Disease in Elderly Patients

A Case Report of a Laparoscopic Surgery for CholecystoDuodenal Fistula

A. Alabi, N. Manimaran

R. Ganeko, H. Fujii, M. Nio, T. Minagawa, M. Yoshida, K. Doi, Y. Kawakami, T. Aotake, F. Tanaka, Y. Hirose

Inverclyde Royal Hospital, NHS Greater Glasgow and Clyde, Inverclyde, United Kingdom

Fukui Red Cross Hospital, Fukui pref, Japan

Background: The increasing age of the population is associated with an increased prevalence of gallstone disease. The management of this cohort of patients is challenging, as they tend to have a limited functional reserve and significant co-morbidities. This increases the morbidity and mortality associated with surgical intervention. The aim of this study was to evaluate outcome of the surgical intervention of elderly patients with symptomatic gallstone disease in a District General Hospital. Methods: The medical records of consecutive patients over the age of 75 who underwent laparoscopic cholecystectomy over a 6-year period were analyzed retrospectively. The primary outcome measure was 30-day morbidity and mortality. The secondary outcome measures were conversion to open surgery, discharge destination and length of hospital stay. Results: Sixty-nine patients were identified with a median age of the 79 years (IQR 76–81). Forty-three of these patients were women. The overall mortality rate was 1.4 %. Fifty-seven patients underwent elective and 12 patients underwent emergency cholecystectomy. There were 6 conversions to open cholecystectomy in the elective setting and 3 in the emergency setting. The overall conversion rate was 13 %. Most of the patients (91.3 %) were discharged directly to their own homes following their surgical procedure. The median overall hospital stay was 4.0 days (IQR: 2.0–6.8 days). Conclusion: Surgical treatment of symptomatic gallstone disease may be safely offered in elderly patients if deemed necessary.

Background: Cholecysto-duodenal fistula is a rare complication of gallbladder diseases, but is the most frequent type of the fistula between gallbladder and intestine. It sometimes develops to gallstone ileus, without any symptoms. We report a case of asymptomatic cholecysto-duodenal fistula, which could be preoperatively diagnosed and was successfully managed by an elective laparoscopic surgery. Patient and Surgery: A sixty-year old male patient had been previously diagnosed to have an asymptomatic gall stone, 3 cm in diameter, seven years ago, however, a screening CT examination for health check revealed a disappearance of gallstone and an air cholecystogram. The patient was referred for a laparoscopic cholecystectomy via through four ports according to the conventional procedure. The surgery was done without complications. The fistula was easily detected and repaired using an endoscopic stapler. In contrast, a cholecystectomy was successfully performed without a conversion to open cholecystectomy, but with difficulties due to its chronic inflammation. The postoperative course was uneventful. Conclusion: Cholecysto-duodenal fistula is an uncommon complication associated with chronic gallbladder diseases and can be safely managed by a laparoscopic surgery but it should be kept in mind that an accompanied chronic inflammation sometimes makes cholecystectomy difficult beyond expectation.



Laparoscopic Cholecystectomy - Ambulatory Treatment- Our Experience

Early and Late Complications of Laparoscopic Cholecystectomy in Our Practice

B. Jovanovic, V. Pejcic, S. Jovanovic, A. Pavlovic

K.N. Haxhirexha1, N.I. Baftija2, F.N. Dika-Haxhirexha3, F.I. Besimi1, X.H.N. Elezi1

Clinical Center Nis, Nis, Serbia

Clinical Hospital - Tetove, Diber, Macedonia; 2Clinical University Center Prishtina, Prishtina, Kosova; 3ALBAMED - Diber, Diber, Macedonia

1

Introduction: Laparoscopic cholecystectomy (LC) is becoming an ambulatory procedure in developed countries. Its advantages are: less postoperative pain, shortened hospital stay, quick recovery and return to normal activities, lower hospital costs. The aim of this study is to assess feasibility of ambulatory laparoscopic cholecystectomy in Clinic of Surgery, Nis. Material and Methods: From 01.01.2004 till 31.12.2013., 2368 patients with cholecystolithiasis underwent ambulatory (LC). We used following criteria: ASA I and II, age \ 65, absence of upper abdominal operations, low risk for common bile duct stones, gallbladder wall \ 5 mm (US), educated patients from urban environments (\30 km away). Operations started not later then 12 AM, on admission day. Patient satisfactory was assessed by independent telephone questionnaire 4 weeks postoperatively. Results: There were 1610 (68 %) women and 758 (32 %) men. (LC) was successfully accomplished in all patients. Average operating time was 40 minutes (25–60). All patients were discharged the same day. Average hospital stay was 11 h (10–12). Twenty patients (80 %) required postoperative analgesia. There were no postoperative complications. Twenty-four patients (96 %) described their experience as ‘pleasant’. All patients stated that they would recommend this operation. Conclusion: In well-selected patients, ambulatory laparoscopic cholecystectomy is safe and feasible in developing country.

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The last decade laparoscopic cholecystectomy (LC) has gained wide acceptance in treatment of cholecystolithiasis. This technique, not only replaced open surgery but also has changed the spectrum of complications and their incidence. Keywords: Laparoscopic cholecystectomy; Complications. Objective: To show our experience in the laparoscopic management of cholecystolithiasis through assessment of outcomes of patients operated with laparoscopic cholecystectomy Methods: This study was carried out at the Department of General & Laparoscopic Surgery in Clinical Hospital Center of Tetove. All the patients who underwent laparoscopic cholecystectomy in our department in a period between 2009–2013 were included in this study. Result: Out of 345 patients who undervent laparoscopic cholecystectomy in this period 305 were females (88.4 %) and 40 (11.6 %) were males. The age of patients varied between 21–78 years with average age of 41.5 years. The commonest problems occurred during the intervention was bleeding from trocar site in 31 patients (8.98 %), hemorrhage from vascular injury in Callot’s triangle in 15 patients (4.34 %) (which is stopped by ligation of the cystic artery or placement of the clip) and hemorrhage from liver bed in 36 patients (11 %) treated by electrocautery. Biliary leakage was registered in 5 patients (1.45 %). In three of them the leakage arised from cystic duct and in two from liver bed. Small bowel injury occurred in only one case during the trocar insertion. Spilled gallstone during cholecystectomi is noted in eleven patients and mainly at the beginning of our experience with laparoscopic cholecystectomi, while conversation to open surgery in eight cases because of inability of safe preparation of the Calot’s triangle. Port site infection was seen in 15 patients. Late complications such as umbilical port hernia is registered in three patients. Mortality rate was 0.29 % respectively one patients died because of pulmonary embolism developed the second day after intervention. Conclusion: Laparoscopic cholecystectomy is a safe and effective technique in the management of gallbladder stone disease. The surgeons experience and the use of standard equipment remain the main factors for ensuring a good results in laparoscopic surgery.

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Laparoscopic Treatment of Hepatic Hydatid Cysts

Optimising One-Stop Management of Biliary Emergencies? A Service Model

I. Diaconescu, M.R. Bratu, G. Andrei, I. Vacaroiu, R. Craciun, C. Tudor, A. Spatariu, M. Beuran, B.V. Martian

K. Nassar, K. Knight, Z. Ahmed, A. Mirza, S. Zino, A. Nassar

Emergency Clinical Hospital, Bucharest, Romania

Monklands Hospital, Glasgow, United Kingdom

Background: Surgery has remained the base for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several studies have confirmed the feasibility of laparoscopic surgery for hydatidhepatic cyst. The aim of this video was to describe the technical details of a laparoscopic approach. Results: Because of limited experience worldwide, controversies about the laparoscopic treatment of liver hydatid cysts have not been resolved. Conclusion: We consider that the laparoscopic treatment of hydatid disease is feasible in selected patients respecting the principles of open surgery and is beneficial concerning postoperative comfort, hospital stay and return to daily activities.

Aims: To demonstrate that the provision of one-stop biliary surgery to all comers with biliary emergencies, who are fit for surgery, is possible within the index admission given a clear referral protocol and supporting logistical set-up. Biliary emergencies are a major drain of resources and their clinical and health economics outcomes are less than optimal. Methods: An eleven-year prospective database of 2793 cholecystectomies, including 1482 emergency admissions (53 %) was maintained. Most biliary emergencies are referred as a matter of protocol. The workload is recognized in job planning, with agreement to 40 % elective surgery. Theatre utilization is maximized through using on call and CEPOD lists. Results: Other consultants or hospitals referred 87 %. 72 % were first presentations. Admission-to-referral was 3.9 days, 68 % undergoing surgery within 5 days. 67 % had suspected choledocholithiasis, 35 % undergoing ductal explorations. 47 % of cholecystectomies were done on open elective lists, 28.4 % while on call and 24.6 % in CEPOD theatre. Trainees performed part or all of the procedure in 406 case (27.3 %). 50 % of the cases were grade III, IV or V on a difficulty scale described by us in 1994. The mean operation time was 84 minutes and mean hospital stay 6.9 days. We recorded 4.5 % complications, 6 re-laparoscopies, 3 deaths and one conversion. Conclusions: Emergency biliary surgery during the index admission for all patients presenting with cholelithiasis with or without CBD stones is possible with low rates of complications if a dedicated team exists, timely referral occurs and access to theatre is made flexible by the provision of open lists. There are clear benefits to clinical and to other outcome parameters such as waiting times, number of episodes, hospital stay and presentation to resolution intervals.



Prospective Study Comparing Retrieval of Gallbladder With Bag vs With Out Bag in None Complicated Laproscopic Cholecystectomy With Intact Gallbladder

A Difficulty Grading Scale for Laparoscopic Cholecystectomy, the Rationale and the Benefits

M.H. Majeed, H.A. Khokhar, S.A. Khan, S. Elmasry Our Lady of Lourds Hospital Drogheda, Drogheda, Ireland Background: laparoscopic Cholecystectomy is one of the most common procedure done in surgical units world our. Most of units use endo bag to retrieve the gallbladder. We did prospective study from July 2010 to July 2013 comparing retrieval of gallbladder with and with out bag. Aims: Primary aim of the study was to compare cost, wound infection and time period for both procedures. Methods: A total of 373 patients were included in study, patients with age below 18, acute cholesystitis, leak in gallbladder were excluded from study. Consultants or senior registrars performed surgery. One surgeon and his team always retrieved gallbladder with out bag if set criteria were full filled. All other consultants used the bag. Cost of procedure, wound infection and time consumed were noted. Results: Less time and was needed when bag was not used and there was no increase in wound infection Conclusion: Routine use of retrieval bag is not required in laparoscopic Cholecystectomy.

S. Zino, A. Mirza, K. Nassar, H. Qandeel, A. Nassar Monklands Hospital, Glasgow, United Kingdom Aims: The aim of this study was to describe a difficulty grading system for laparoscopic cholecystectomy aiming at standardizing the description of operative findings, planning the management, predicting the outcomes, and facilitating comparison of studies from different centers. Methods: Prospectively collected data for patients undergoing biliary surgery over 20 years (n = 3607) was analyzed. Laparoscopic cholecystectomies (LC) were classified prospectively into five difficulty grades based on the appearance and condition of the gallbladder (GB), the anatomy and ease of dissection of the cystic pedicle, and the presence of adhesions around the gallbladder. Results: Difficulty grading was recorded for 3563 LC as follow: Grade I in 34.3 %, Grade II in 31.1 %, Grade III in 19.3 %, Grade IV in 14.3 % and Grade V in 0.78 %. Mean age was 50 years, 23 % of patients were males, and 37.4 % of cases were emergencies. Difficult gallbladders were associated with male gender (41 % in GIV), age above 50y (73 % in GIV and 85 % in GV), emergency admission (65 % in GIV and GV), acute cholecystitis (29 % in GIV), previous cholecystitis (17.5 % in GIV and 23 % in GV), thick walled GB in preoperative US (42 % in GIV and GV). Intraoperative, difficult gallbladders were associated with cystic duct stone (20 % in GIV and GIII), common bile duct stones (35 % in GIV and GV). Fundus first dissection of the gall bladder was performed more frequently in GIV 11.3 % and GV 39 %. Conversion to open rate was significantly higher in GV 32 % and in GIV 2.1 %, when compared to overall rate of 0.7 %. Surgical drain was used more frequently in GIII 70 % and GIV 92 % and GV 85 %. Surgical gallbladder perforation, operative time, hospital stay and morbidity were consistent with increasing difficulty grading. Conclusions: Preoperative risk factors for difficult GB were male gender, age above 50y, emergency admission, previous and acute cholecystitis and US finding of thick walled GB. Difficulty grading may help the surgeon planning surgery and avoiding complications. It is a useful classification of laparoscopic cholecystectomy for descriptive, training and audit purposes.

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Liver Abscess Caused by Fishbone: Laparoscopic Management

Emergency Laparoscopic Cholecystectomy in the Elderly is Safe and Feasible: A District General Hospital (DGH) Experience

E. Martıń Martıń, A. Go´mez Portilla, A. Reyhani Calvo, B. Ezurmendia Sinisterra, E. Lo´pez de Heredia Armentia, L.A. Magrach Barcenilla, L. Ibiricu Oroz, E. Palacios Bazan, M. Larranãga Zabaleta, A. Etxart Lopetegui HUA -Santiago, Vitoria, Spain Introduction: The accidental ingestion of a foreign body is not uncommon, but less than 1 % of these cases develop complications such as gastrointestinal tract (GIT) perforation. The ingestion of a foreign body that penetrates the GIT wall and migrates to the liver causing an abscess is exceptional. Surgical management still remains the most appropriate treatment and laparotomy is usually required. To the best of our knowledge, this is the first case of a patient who had a laparoscopic hepatic resection for a hepatic fishbone causing sepsis and multiorgan failure. The authors present a case of a 59-year-old woman who suffered from sepsis and a liver abscess because of the migration of a fishbone that lodged in the left hepatic lobe treated with laparoscopic management. Case Report: A 59-year-old woman was admitted from the emergency department for recurrent episodes of epigastric pain associated with fever (39 °C), vomiting and hypotension. Hematological panel revealed leukocytosis, abnormal liver function tests and coagulopathy. Abdominal ultrasonography (US) and computed tomography (CT) of the abdomen revealed a hepatic abscess. She was treated for multiorgan failure because of sepsis with parenteral antibiotics and percutaneous abscess drainage. Follow-up CT imaging revealed a low-density area with a linear calcified lesion in the left lateral segments of the liver atrophied due to left portal vein thrombosis. The patient was scheduled for an elective exploratory laparoscopy. Laparoscopic left lateral segmental resection was performed. Inspection of the surgical specimen revealed the presence of a fishbone. Results: There were no intraoperative or postoperative complications, and she was discharged on her 4th postoperative day. After 2 years follow-up, the patient remains asymptomatic. Conclusions: The development of a hepatic abscess secondary to penetration by a fishbone in the liver is very unusual. Most patients have non-specific symptoms. US and CT scans are the most sensitive imaging tests for localisation of suspected foreign bodies in solid organs. Treatment consists of drainage of the abscess, administration of appropriate antibiotics and removal of the foreign body. We believe that laparoscopic technique is feasible, safe and effective for treatment this entity with advantages of this approach

M.D. Hillen, C. Grant, J. Whing, P. Nesargikar, P.J. Driscoll NHS Fife, Dundee, United Kingdom Aims: Emergency surgery in the elderly is usually associated with high risk of morbidity and mortality. Many centers’ advocate adopting a conservative approach for managing acute biliary pathology, but even this approach is fraught with risks. The aim of this study was to analyse outcomes following emergency cholecystectomy (EC). Methods: All patients who underwent EC over the age of 70 over a three-year period (2010–2013) were included in the study. Patient demographics, indications, ASA status, morbidity and mortality, gallbladder pathology, post-operative length of stay, complications and readmissions were analyzed. Results: 33 patients (17F:16 M) underwent EC, out of which 28 were performed laparoscopically and 4 required conversion to open. The most common indication for surgery was acute cholecystitis (n = 18) followed by gallstone pancreatitis (n = 10). The majority of patients (n = 17) were ASA Grade 2 (range 1–4), with a mean BMI of 27.6 Kg/m2 (range 19.4–36.0). Nearly 80 % of patients were discharged within a week of the operation. 15 % had minor post op complications that were managed conservatively. Conclusions: In our experience, EC could be safely performed in the elderly population with acceptable morbidity even in a relatively busy DGH.



Common Bile Duct Injuries During Laparoscopic Cholecystectomy - Review of the Case Histories in a Single District Hospital in Budapest

Cystic Duct Stones, a Significant Operative Risk Factor for Bile Duct Stone

B. Ba´lint, R. Ro´zsa, B. Brenner, M. Ma´te´

S. Zino, A. Zeineldin, A. Mirza, A. Yehia, K. Nassar, H. Qandeel, A. Nassar

St. Emeric University Teaching Hospital, Budapest, Hungary

Monklands Hospital, Glasgow, United Kingdom

Introduction: The ‘gold standard’ treatment of gall bladder stones is laparoscopic cholecystectomy. This is one of the most frequently performed procedure in Hungary; annually approx. 25000 procedures are carried out. The injuries of the bile ducts can cause severe long course alteration of quality of life of the patients and occasionally can cause even life threatening condition. The incidence of bile duct injuries following laparoscopic cholecystectomies is higher than after open procedures. According to the literature its frequency after open surgery is approx. 0,1–0,2 % while following laparoscopic surgery is 0,4–0,7 %. This fact supports the effort of surgeons to diminish the appearance of this severe complication. The two main forms of complications are: bile duct obstruction and bile duct injury - leakage. The risk factors of bile duct injuries are: the surgeon, the poor quality of devices, the gall bladder pathology (the lack or presence of inflammation), hemorrhage, obesity, anatomical variation (aberrant right hepatic duct). Material and Methods: Between January 2009 and December 2013, 4 of 1771 patients suffered bile duct injury at our department (0,22 %). One of these four patients underwent SILS. Each procedure was elective surgery. Reviewing the documentation of procedures we could see that each procedure was carried out electively and the main cause of the complication was the so called cognitive failure of surgeon. In three of four cases the injury was recognized during surgery, in one case on the first postop. day by means of ERCP. The lesions were classified as Strasberg E1 lesions. In each cases direct bilio-bilio anastomosis was carried out. In two cases because of progressive narrowing of bile duct anastomosis a second surgery (bilio-digestive anastomosis) were done. From the point of view of long run outcome is important the early recognition of bile duct injury. Conclusions: The injuries of bile ducts are rare but severe complications of laparoscopic cholecystectomies. The possibilities of the prevention are: 1. The so called infundibular technique, 2. Critical view technique (Strasberg) 3. Intraoperative cholangiography. It is very important the early recognition and adequate treatment of complication.

Aims: Cystic duct stones (CDS) are occasionally encountered during laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the association between CDS and common bile duct (CBD) stones. Methods: Prospectively collected data for patients undergoing laparoscopic biliary surgery over 20 years (n = 3607) was analysed. We reviewed the data for patients who were found to have cystic duct stone. Results: Cystic duct stones were documented in 529 cases (14.6 %). The average age was 57 years (range 15–89 years). 73 % were females and 27 % were males. The preoperative risk factors were acute biliary pain (32 %), acute cholecystitis (8 %), pancreatitis (11 %), jaundice (22.4 %) and acute cholangitis (3.4 %). American Society of Anesthesiologists (ASA) score was as follow: ASA1 (37.6 %), ASA2 (41.2 %) ASA3 (12.9 %) and ASA4 (0.4 %). Difficulty grading of gallbladder was GI in 113 cases (21.3 %), GII in 156 cases (29.4 %), GIII in 143 cases (27 %), GIV in 105 cases (19.8 %) and GV in 4 cases (0.7 %). Gall bladder dissection had to be carried out fundus-first in 24 cases (4.5 %). The CD was reported to be wide in 181 cases (34 %). Simple removal of the stones was possible in most cases occasionally CDS needed be crushed or the CD incised in order to facilitate delivering the stone. Conversion to open surgery was necessary to deal with a difficult Gall bladder in 2 cases (0.3 %). Intraoperative cholangiogram (IOC) was attempted in all cases; it was normal in (53 %), and failed in (1.8 %). CBD stone were found in (37.4 %) of CDS cases. Preoperative risk factor for CBD stones were present in 268 cases (50 %), only 141 cases (52 %) proved to have CBD stones. 57 patients (28.7 %) with cystic duct stones and bile duct stones had no preoperative risk factors for BD stones. Conclusions: 37.4 % of cystic duct stones were associated with bile duct stones. Moreover the CDS was the only risk factor for CBDS in (28.7 %). Therefore even if IOC is not carried out on a routine basis, it becomes mandatory if CDS are encountered intra operatively.

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Patient Satisfaction and Long Term Results: Of Single Incision Laparoscopic Cholecystectomy

Risk of Common Bile Duct Stones When Deranged Liver Function Tests (LFTS) Have Returned to Normal

T. Artis1, A. Akay2, F. Buyuker3, S. Orman3, H. Yalman3, O. Alimoglu4

A.I. Awopetu, J. Williamson, W. Hameed, S. Sagni, R.J. Morgan Ysbyty Glan Clwyd Hospital, North Wales, United Kingdom

1

Istanbul Medeniyet University Medical School, Istanbul, Turkey; 2 Agri State Hospital, Agri, Turkey; 3Istanbul Medeniyet University Goztepe Research Hospital, Istanbul, Turkey; 4Istanbul Medeniyet University Medical school Goztepe Research Hospital, Istanbul, Turkey Aim: Single incision laparoscopic surgery (SILS) has been gaining popularity as its better cosmetic results and less parietal trauma. Although SILS cholecystectomy is the most common procedure, advantages over standard laparoscopic cholecystectomy is still controversial. In this study we aimed to analyze the long term outcomes of SILS cholecystectomy emphasizing patient satisfaction and incisonal hernia occurrence. Material and Methods: Between June 2009 and June 2011, we analyzed the surgical outcomes of 30 patients who underwent SILS cholecystectomy. All patients except 4 had chronic gallstone cholecystitis. (16.6 %). SILS cholecystectomy was performed by one single surgeon (TA). In 15 patients in SILS group specific SILS port (Covidien, Norfolk, CT, USA)and articulating instruments were used, and for the rest of the patients single incision and multiport with standard laparoscopic instruments were used. Outcome measures were incisional hernia occurrence and patients’ cosmetic satisfaction in long term follow up. Three questions were asked to the patients: 1. How would you score your cosmetic satisfaction rate over 10(10 was the highest score) 2. How would you score overall satisfaction including early postoperative pain, hospital stay and late postoperative period life quality with the scoring rate over 10 (10 was the highest score) 3. Finally would you suggest SILS for other patients? Results: SILS cholecystectomy could be performed on 27 of 30 patients (90 %). Four (13.3 %) patients form SILS cholecystectomy had acute cholecystitis. Mean operative time was 50 ± 18 min. Mean follow-up time was 28 months. In this period of time incisional hernia occurred only in one patient (3, 3 %). Mean cosmetic satisfaction score was 8.2 over 10. Mean overall satisfaction from SILS was 8.9 over 10. All the patients except two (92.5 %) were positive about suggesting SILS for other patients. Conclusion: Although SILS cholecystectomy seems challenging, it has a short learning curve for the surgeons who perform advanced laparoscopic surgery. Patient satisfaction rate in terms of cosmetic result and overall postoperative life quality was convincingly high. Incisional Hernia occurrence rate seems low in the long term follow-up. More studies are needed with large number of patients to acquire more consistent conclusion.

Aims: Patients presenting with symptomatic gallstones are commonly found to have deranged LFTs which return to normal prior to cholecystectomy, suggesting passage of a common bile duct (CBD) stone. The aim of this study was to investigate the incidence of persistent CBD stones in this group of patients, and to identify risk factors for CBD stones found at the time of surgery. Methods: A retrospective review was undertaken, of patients who underwent laparoscopic cholecystectomy and cholangiography for symptomatic gallstone disease, in whom the LFTs had been deranged at presentation, but had returned to normal prior to surgery. Clinical data collected prospectively over a 9 year period were used for the study. Potential risk factors for bile duct stones were considered to be pre-operative biliary dilatation, age, pancreatitis at presentation, degree of rise of individual liver LFTs, and pattern of LFT derangement. Results: Some 288 patients underwent laparoscopic cholecystectomy with operative cholangiogram. All had deranged LFTs at presentation, but normal LFTs at the time of surgery. 62 had acute pancreatitis at presentation. Overall, 62 patients were found to have bile duct stones (21.5 %). CBD dilatation was a pre-operative finding in 96 patients; of these, 34 (35 %) had CBD stones. CBD stones were found in 28 of the 192 (15 %) patients who did not have CBD dilatation. No significant correlation was identified with age, occurrence of pancreatitis, or degree or pattern of LFT derangement. Conclusions: Bile duct stones at the time of surgery are an unusual finding in this group of patients who present with biochemical evidence of a CBD stone, but who appear to pass the stone. In these patients, CBD stones are more common in patients with biliary dilatation on pre-operative imaging. Even with a non-dilated biliary tree, CBD stones are found in a small but clinically significant number of patients, and it was not possible clinically to predict which patients would have them. Routine operative cholangiography (or another biliary imaging modality) is therefore recommended in this group of patients, to prevent post-operative problems caused by retained CBD stones.



Cholecystectomy in the Octogenarians: Ageism is Not a Risk Factor

Laparoscopic Common Bile Duct Exploration - One Single Center Experience

P. Nesargikar, M. Hillen, C. Grant, J. Whing, P. Driscoll

P.N. Brandaõ, V. Costa Simo˜es, A. Canha, P. Soares, D. Sousa Silva, J. Daniel, J. Davide

NHS Fife, Edinburgh, United Kingdom Introduction: Frailty is often considered an independent risk factor for predicting outcomes after surgery. Cholecystectomy in the octogenarians is often selectively advocated due to the risks involved, but conservative approach to biliary pathology is also fraught with morbidity and mortality. The aims of this study were to analyse outcomes following elective and emergency cholecystectomy, and ascertain the role of frailty score index in risk stratification. Methods: Octogenarians who underwent cholecystectomy over a three-year period (2010–2013) were included in the study. Patient demographics, indications, ASA status, morbidity and mortality, post-operative length of stay, complications and readmissions were analyzed. The 8 variables that constituted the frailty score index (Robinson et al, Annals of Surgery, 2009) were: age, cognition, weight loss, BMI, albumin, hematocrit, falls and depression Results: 23 patients over the age of 80 underwent cholecystectomy, 13 (5 M: 8F) in the elective group and 10 (4 M: 6F) in the emergency group. Mean age was similar in both groups (82.69 vs. 82.1). The frailty score index was significantly higher in the emergency group compared to the elective group (p = 0.02). Laparoscopic approach was carried out successfully in 12 (n = 13) elective patients, while conversion rate from lap to open in the emergency group was 22 %. Mean length of stay post-operatively was 3.38 days in the elective group compared to 8 in the emergency group (two outliers: 19 and 36 days). There were 2 complications in the elective group (classified as Dindo-Clavien I - II) compared to 3 in the emergency group (Dindo-Clavien I- IV). Conclusion: The fraility score index was significantly higher in the emergency group, which positively correlates with the ASA scores. Emergency group had a higher lap to open conversion rate, but was not linked with any increased morbidity or mortality. From this study, albeit small, we can conclude that laparoscopic cholecystectomy is safe in the elderly population with acceptable rates of morbidity.

Hospital de Santo Antońio, Centro Hospitalar do Porto EPE, Porto, Portugal Aims: To evaluate the role of laparoscopic common bile duct exploration (LCBDE) in the management of common bile duct stones. Methods: Retrospective analysis of patients underwent LCBDE from 2010 to 2013. Results: A total of 134 LCBDE were performed (56 % female, mean age of 65.79 years), 78.3 % with pre-operative suspicion of bile duct stones. Clinical presentation was cholangitis in 67.0 % of cases. Transcystic approach was performed in 38 and transcholedocal in 96 patients. Biliodigestive anastomoses were done in 38 patients. Conversion was needed in 24 patients, due to technical difficulties (8), anatomical aspects (9), and for other miscellaneous reasons (7). Successful clearance of common bile duct was obtained in 91 % of cases. Biliary residual lithiasis was more frequent in patients with sonographic evidence of stones (p = 0.000) and after transcystic exploration (p = 0.009). Morbidity was 11.1 % with a need for reintervention in 5 % patients. There was no mortality. Conclusions: LCBDE is a safe and highly effective procedure in the management of patients with bile duct stones. In experienced centres, allows to achieve satisfactory ductal clearance with low morbidity rates.

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Indication and Advantage of Laparoscopic Hepatectomy for Hepatic Malignancy

Single Incisional Laparoscopic Hepatectomy (SILH): Initial Experience; Could it be a Routine Procedure?

M. Inagaki

M.T. Huang

National Organization Fukuyama Medical Center, Fukuyama, Japan

Shuang Ho Hospital- Taipei Medical Hospital, New Taipei City, Taiwan

Background: Recently laparoscopic approach has become popular for hepatic malignancy. The important considerations in determining indications for laparoscopic hepatectomy included tumor size, type, and location. Hereien we outlined the indications, evaluated the degree of invasiveness. Indications: 1) Tumors were located in lateral segment, margin or liver surface of segment 4, 5 and 6, and liver surface in segment 7 and 8. 2) Tumor size was less than 3 cm. 3) Tumor had no vascular invasion. Operative Methods: Pneumoperitoneum was established at a pressure of 10 * 12 mmHg and four trocars were inserted below the costal arch from the right or left linea axillaris media to the midline. The patients was placed in a semirecumbent (right side hepatectomy) or spine (left side hepatectomy) position. Before liver transaction, precoagulation of cut surface line was done using microwave coagulation system. Liver resection was performed using CUSA, Ligasure-V and BIO coagulation system. Results: We performed laparoscopic hepatectomy in eleven cases for 14 regions. Pure laparoscopic approach was performed in 10 cases and laparo-assited approach in one case. Partial hepatectomy was done for 13 lesions in 10 cases and segmentectomy in one case (left lateral sectionectomy). Indications for laparoscoic approach were hepatocellular carcinoma in 2 cases and metastatic liver tumor in 9 cases. All of metastatic liver tumors were originated from colorectal cancer. In 6 cases, laparo-assited colectomy was done simultaneously. Locations of liver tumor were segment 6 in 3cases, segment 3 in 3 cases, segment 8 in 2 cases, segment 2 in 2 cases, segment 7 in one case and segment 5 in one case. Mean tumor size was 1.3 cm (0.3–3.5 cm). Mean blood loss during operation was 35 ml (0–100 ml). Mean operation time was 170 min (107–268 min). Postoperative complications were bile leak in one case and bronchitis in one case. Mean hospital stay was 18.6 days (8–35 days). Conclusions: Laparoscopic hepatectomy was less surgically invasive by reducing blood loss and cosmetically favourable. Laparoscopic hepatectomy is a minimally invasive procedure and beneficial for patient’s safety.

Objective: To prove the feasibility of single incisional laparoscopic hepatectomy for peripheral segment of liver. Methods: Between January 2011 and December 2012, a total of 20 patients with hepatic tumors involving the peripheral liver segments underwent single incisional laparoscopic hepatectomy (SILH) at our hospital. Surgical techniques used the creation of a 2.5 cm wound on the umbilicus for port placement. The transection margin was decided by laparoscopic ultrasound. The liver resection was performed using the Harmonic Scapel and endovascular staple for vascular pedicle in left lateral segmentectomy, with the specimens obtained then placed in a bag and removed directly via the umbilical port. Results: The 7 male and 13 female patients ranged in age from 24 to 86 years (mean 55.8). Surgical procedures included partial hepatectomies for 7 patients and segmentectomies for the other 13 patients, all successfully completed using the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 128 ± 61 minutes (35–165). The blood loss during surgery was ranged from minimal to 200 ml, without any requirement for intraoperative or postoperative transfusion. Pathology revealed 7 patients with HCC, two with cholangiocarcinoma, two with breast cancer metastasis, two with FNH, three with hemangioma, two with biliary cyst, one with adenoma, one with liver cyst bleeding. There were no deaths or complication postoperatively. Mean hospital stay was 4.6 ± 1.3 days postsurgery.



Clinical Outcome of Liver Resection in Single Center Experience; Laparoscopic vs Open Procedure

‘Tips and Tricks to Get Best Results in Laparoscopic Cholecystectomy’ -20 Years Single Surgeon’s Experience

T. Irei

K. Singh1, R. Singh2

National Hospital Organization, Kure Medical Center, Chugoku Cancer Center, Hiroshima, Japan

1

Introduction: Minimally invasive surgery for liver resection still remains controversial. The present study was designed to compare open versus laparoscopic surgical approaches for liver resection. Method: Between January 2012 and December 2013, Laparoscopic liver resection (LLR) was performed in 30 patients with hepatocellular carcinoma (n = 27), metastatic liver carcinoma (n = 2), angiomyolipoma (n = 1). In our institution, we performed partial hepatectomy by pure laparoscopic method (pure) and anatomical hepatectomy by laparoscope assisted method (hybrid). All procedure performed in lithotomy position regardless of tumor location. We applied pringle method for all cases. We performed a retrospective review of these patients. Result: The study comprised 25 men and 5 women with a mean age of 70.5 years (range; 52–86). All patient have liver function as Child-Turcott-Puph classification A. Mean ICG R15 was 15.4 % (range; 3.1–31.5). Mean diameter of the tumor was 20.8 mm (range; 10–55). 13 cases were resected by pure method and 17 cases underwent hybrid method. 19 patients underwent partial hepatectomy, 8 patients underwent subsegmentectomy, and 3 patients underwent segmentectomy. The mean blood loss was 403.7 ± 425.6, and the mean surgery time was 316.4 ± 123.3. No patients developed postoperative complications. We compared 19 laparoscopic partial hepatectomies (LLR-P) with 9 open partial hepatectomies in same research period. Although, no significant differences were observed in perioperative factors, including surgery time, estimated blood loss, weight of liver samples and surgical margin, both hospital length of stay and administration length of analgesic were significantly reduced in LLR-P. Furthermore, we compared 13 laparoscopic (sub) segmentectomies (LLR-S) with 11 open cases having equivalent resections in same research period. Surgery time of LLR-S were longer than those of open cases, whereas no significant differences detected in estimated blood loss in these procedures. Fortunately, all length of both hospital and analgesic administration favored the laparoscopic group. Conclusion: In these series comparing laparoscopic and open liver resections, there were fewer complications, significant rapid recovery in laparoscopic group, even for those resections involving (sub) segmentectomy by hybrid method. Accordingly, the laparoscopic approach is increasingly extended to major hepatectomy. Further accumulation of clinical experience and technical refinement will make these procedures more reproducible and safer.

Laparoscopic Cholecystectomy in complicated cholecystitis is still a challenge and the conversion rate (2–11 %) & Bile duct injury continued to be high because of technical difficulties of dissection in friable, oedematous & chronic fibrotic tissue in difficult situations. Our aim was to analyse the underlying factors and technical difficulties and to evolve strategies for the successful outcome in difficult situations. Since 1992, we have operated more than 9425 cases of cholecystectomy in a single centre and 3215 were categorized into difficult cases like: acute cholecystitis, acute and chronic empyema, gangrenous, cirrhotic, mirrzi and having fistulas. Our policy has been to take up acute cholecystitis within 05 days and gangrenous cholecystitis as and when patients are diagnosed. We advocate blunt dissection, cautiously use of diathermy, cutting the adhesions rather than pulling and tethering, following anatomical landmarks of dissection beginning from defining the gall bladder embedded in the adhesions, dissection of Hartman pouch, Calot’s triangle and finally gall bladder bed dissection in proper plane reproducing conventional cholecystectomy operative steps. The Operative options included sub total cholecystectomy, fundus first method and leaving posterior wall of gall bladder in situ. In the initial 5–7 years the conversion rate and the bile duct injury were 3.7 % & 0.13 % and in the last nearly 5000 cases the conversion rate & bile duct injury has been 1.5 % & 0.08 %. We conclude that if basic principles of surgery are followed and the operative steps of conventional cholecystectomy are reproduced laparoscopically, one is going to get the best results without disasters

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Dayanand Medical College and Hospital, Ludhiana, India; 2MGM Medical College and Research Institute, Aurangabad, India

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Achieving ‘Critical View of Safety’ in Difficult Cholecystectomy An Innovative Technique

Mini Laparoscopic Cholecystectomy

R. Singh, P. Suryavanshi MGM Medical College and Research Institute, Aurangabad, India Bile duct injury (BDI) is the most serious iatrogenic complication during Laparoscopic cholecystectomy (LC). Surgical experience, skill and adopting different strategies are the important preventive factors to avoid such a disastrous complication in a benign biliary disease. Achieving Critical view of safety (CVS) introduced by Strasberg in 1995 is the key to prevent BDI during LC. Though, CVS is achieved in uncomplicated GB disease in a routine practice by many experienced surgeons, however it becomes a difficult task in chronically inflamed Gall bladders (GB), where the structures and GB are struck up to the liver bed very badly due to the chronic inflammation. We use blunt dissection with a specially designed blunt dissector, suction canula, diathermy and gauge to establish CVS. In some difficult cases, we have to resort to establishing a nearly CVS to be sure of safety of the ductal or vascular structures. Since 1992, a total of 9425 cases were operated and out of which 3215 were difficult cholecystectomies. There have been no BDI in the last nearly 2000cases of difficult cholecystectomies over a period of 10 years. We conclude that our method of achieving CVS in LC is - simple to perform, learn and is on the basis of reproducing the operative steps of cholecystectomy by Langen buch.

P517 - Liver and Biliary Tract Surgery Does Low Intra Abdominal Pressure Decreases Post Operative Pain in Laparoscopic Cholecystectomy R. Singh, P. Suryawanshi MGM Medical College and Research Institute, Aurangabad, India The main advantages of laparoscopic surgery are: reduced postoperative pain, shorter hospital stay and rapid return to normal activity. Although reduced, post operative pain is still substantial and constitutes the main clinical problem after laparoscopic cholecystectomy. Intra abdominal pressure by insufflation of CO2 during laparoscopic cholecystectomy is responsible for physiological changes and postoperative pain especially shoulder tip pain, thereby prolonging hospital stay and convalescence. Recent studies using low pressure pneumoperitoneum (7–8 mm) seems to result in significant reduction in postoperative pain especially shoulder tip pain. However surgeons experience difficulty in dissection under low pressure (7–8 mm) and hence convert to high pressure for successful outcome. Keeping in view of the above observations a prospective study was conducted to assess the outcome of low pressure pneumoperitoneum (10 mm) compared with standard pressure (14 mm) in terms of operative feasibility, post operative pain, analgesic requirements and hospital stay and, also could it be taken as a standard pressure for uncomplicated Laparoscopic cholecystectomy. Methods: A total of 50 patients undergoing laparoscopic cholecystectomy in uncomplicated cholecystitis have been studied in 2 groups. Each group contains 25 patients with low pressure (10 mm) and standard pressure (14 mm). Pain score was measured by visual analog scale, and surgeon comfort level was recorded. Postoperative analgesia requirement, nausea/vomiting, complications and hospital stay were recorded. Results: The operative time and surgeon comfort in both the groups were equal. Though in low pressure group experienced surgeon operated all the cases. There was significant reduction in postoperative pain. Low pressure group required an average of 2–3 injections during their stay. High pressure group required an average of 6 injections during their hospital stay. Two patients in high pressure group needed ICU observation due to disturbances in cardiopulmonary parameters. Conclusions: Low pressure pneumoperitoneum (10 mm) facilitates adequate working space for the surgeon, reduces significant postoperative pain, and goes well with marginal cardiopulmonary compromised patients. It could be taken as standard pressure for laparoscopic cholecystectomy in uncomplicated cholecystitis.

A. Szabolcs, S. Zsolt, A. Paszt, A. Ottlakań, G. La´za´r University of Szeged, Hungary Aims: Benefits of part minimally invasive laparoscopic procedures include not only safety, short operative time and low overall costs, but also remarkable cosmetic results. In the present study, we applied a mini laparoscopic approach during laparoscopic cholecystectomy (LC) (using the maximum size of 5-mm trocars (if it is possible) with the simultaneous intention to reduce their number to the minimum). We examined the advantages and disadvantages of mini LC and compared these features to those of traditional LC. Methods: During mini LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm), a 5-mm clip applicator (Challenger Ti-P), Hem-o-lock clip applicator (ML, green), and a 5-mm camera. We performed mini LC in 10 cases, and compared the results to those of 10 randomly chosen traditional LCs. The comparison criteria included gender, age, operation time, the need to use an extra port, conversion rate, and pain (based on a subjective scale of 1–10). Furthermore, financial costs and level of invasiveness were calculated and cosmetic results estimated. Results: There were no significant differences in terms of operative time. In case of mini LC, extra trocars were needed in two cases when inflammation was diagnosed. Conversion was needed in neither group. The level of subjective pain was 1.6 with mini LC-, and 2.5 in the LC group. The financial costs were not significantly different. Cumulative size of incisions was 19.5 mm with mini LC- and 41 mm in the LC group, which also indicates the difference in cosmetic results. Conclusion: Mini LC is a safe and cheap procedure and the relating operative skills can easily be acquired. Although in complicated cases (such as after ERCP or in severe cholecystitis) mini LC can not represent a real alternative of traditional LC, but in selected patients (with no signs of inflamed, stratified gallbladder) it can highly be recommended owing particularly to aesthetic considerations.

P519 - Morbid Obesity Laparoscopic Revision of Roux-en-Y Gastric Bypass for Recurrent, Perforated Marginal Ulcers and Anastomotic Stricture 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: One of the known complications of gastric bypass is the development of marginal ulcers. Without appropriate surveillance and management, these ulcers can have severe consequences, including stricture and perforation. This video presents a patient with these complications, resulting in the need for revisional surgery. Methods: The case is a 53 year-old woman with morbid obesity who underwent Roux-enY gastric bypass 6.5 years ago. She developed recurrent, perforated marginal ulcers requiring operative intervention prior to her presentation. Repeat endoscopy did not reveal any residual ulcers, and preoperative esophagram showed a dilated gastric pouch. The patient underwent resection of the strictured anastomosis and recreation of the gastrojejunostomy, as highlighted in the video. Results: An esophagram on the first postoperative day showed a markedly smaller gastric pouch without leak or obstruction. The patient was able to tolerated thin liquids, and was discharged to home on postoperative day 3. At her most recent office visit 2 months postoperatively, she has recovered well and is tolerating a diet. Her current BMI is 25. Conclusions: Marginal ulceration can be seen after Roux-en-Y gastric bypass surgery, and if left untreated, can result in major morbidity including stomal stricture and gastric perforation. Laparoscopic revision of the gastrojejunostomy can be performed safely and effectively.

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P520 - Morbid Obesity


Treatment of Delayed Gastric Bypass Bleeding by Combined Endoscopic & Laparoscopic Approach

Complications After Laparoscopic Sleeve Gastrectomy. 8 Years Experience

M.K. Hussein

M. Kasalicky1, R. Dolezel1, E. Koblihova1, E. Vernerova1, M. Haluzik2

American University of Beirut Medical Center, Beirut 1107 2020, Lebanon Aims: Laparoscopic Gastric Bypass complications are well-known including leak, early postoperative bleeding, jejeunojejunal hernia, jejeunojejunal stenosis, and Peterson defect hernia. Methods: We will present delayed Gastric bleeding 6 weeks post surgery referred from other hospital after transfusion with 6 units of PC due to erosion of left Gastric artery into the suture line. Results: The video will show the steps used by endoscopy to localize the bleeding site and laparoscopic approach to control the bleeding, and redo the anastomosis site. Conclusion: treatment of Gastric Bypass complication is feasible by minimal invasive surgery in advanced center in Bariatric Procedures.

Military University Hospital Prague, Prague, Czech Republic; 23rd Internal Department 1st Medical School, Charles University, Prague, Czech Republic 1

Aims: Laparoscopic sleeve gastrectomy (LSG) is effective and feasible bariatric/metabolic procedure with low rate of the complications. Bleeding or leak from the staple line or abscess occurred most frequently as early complications. Late complications include strictures, nutritional deficiencies and gastro esophageal reflux (GERD). By reason that the number of patients undergoing LSG will continue to rise the understanding of main complications and available treatment options is essential. The range of bleeding has been reported from 1 % to 6,7 %, the staple line leak from 1 % to 5,4 %, strictures from 1 % to 5,7 % and GERD from 2,1 % to 34,9 % respectively. Material and Method: 264 MO patients (198 females, 66 males) underwent LSG from 2006 to 2013. Average age was 43,2 years (19–65), height was 169,3 cm (151–191), weight was 128,7 kg (96–187) and average BMI was 44,9 (34,1–71,9). T2DM was pre-operatively diagnosed in 62 (23,6 %) patients. 36F bougies were used and all LSG were done without reinforcement or over sewing of the staple line. Results: Data were collected prospectively and evaluated retrospectively. Average operating time was 86,7 min, two conversion into open surgery because of the bleeding from the spleen. Bleeding from the staple line occurred in 0,8 % (n = 2), leak occurred in 0,8 % (n = 2), stricture of the sleeve occurred in 0,4 % (n = 1) and GERD occurred in 11,8 % (n = 31). The bleeding and leak from the staple line were cured laparoscopically with single stitches and with drainage. The stricture of the sleeve was managed endoscopically with balloon dilatation. The patients after LSG with persist GERD were treated with PPI. Average %EBMIL after 24 months reached 68,5 % (24,2–120,9) and average decrease of BMI was 13,9 (4,5–24,1). Diabetes completely resolved in 74,2 % of preoperative diabetic patients during the postoperative period of 24. Conclusion: The LSG is a safe bariatric procedure with long time good results in both weight loss, and improvement of metabolic co-morbidities with low rate of the complications, which could be managed laparoscopically.



Impact of Laparoscopic Greater Curvature Plication on Weight Loss and Some Metabolic Co Morbidities, Plus Important Recommendations

Laparoscopic Sleeve Gastrectomy - Retro gastric Medial to Lateral Approach is the State of the Art Technique

H. Abou Ashour, M.S. Ammar, A.A.H. Zein Eldin


Minoufiya Faculty of Medicine, Shibin al Kom, Egypt Background: Laparoscopic greater curvature plication (LGCP) is a new bariatric procedure, till now hasn’t wide final acceptance and still practiced by limited number of surgeons with current debates about promising and disappointing results. Aims: Its impact on weight loss, associated metabolic diseases and safety. Patients and Methods: 120 patients, 56 men and 64 females, 50 hypertensives, 48 dislipidaemics, 32 type II diabetes patients, underwent LGCP and followed up for one year. Results: 64 women and 56 men were enrolled in this study. Their mean age was 35.45 years (range 18–63), The average preoperative BMI was 46.7 (range from 36.5 to 69.3), the mean procedure duration was 73 min (range from 57 to 155 min), the mean hospital stay was 42.3 hrs (range from 24 hrs to 26 days). The % EWL for the patients at 3rd, 6th and 12 months was 29.3 %, 42 % and 64.6 % respectively, average BMI at 12 months was 27.7 kg/m2, P \ 0.001. 23 out of 32 type II DM patients (71.8 %) became normoglycaemic, 37 patients (77 %) out of 48 patients showed disappearance of dyslipidaemia, 36 patients (72 %) out of 50 hypertensive patients became normotensive at 6th and 12th months. Patients showed no abnormality in serum albumin, GGT or anaemia across the visits. 25 patients (20.8 %) had sialorrhea, 7 patients (5.8 %) had persistent vomiting, 3 patients (2.5 %) showed gastric stenosis, three patients (2.5 %) had gastric leak. One patient (0.8 %) had partial disruption during the 1st week at the upper end. One patient showed prolapse of the intragastric fold causing obstruction to the pylorus, gastrodudenal intussusception and obstructive jaundice after 8 months. 2 patients (1.6 %) had subcapsular hematoma in the liver. Conclusion: With some avoidable pitfalls and technical recommendations, the reduction in gastric capacity achieved by LGCP was safe and beneficial in weight loss and some associated metabolic diseases.

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M.K. Hussein

Aims: Laparoscopic Sleeve Gastrectomy- Retrogastric Medial to Lateral Approach is the State of the Art Technique. Methods: Through 4 trocars in the different quadrants of the abdomen and the patient placed in semi sitting position and the surgeon is between the legs of the patient. The first step is to create a window in the lesser sac 6 cm from the pylorus at the greater curvature. The stomach resection is done after introduction of 36 French catheter using 3 cartilage of Endo GIA Green 60 mm cartilage until the fundus where another 3 cartilage of Endo GIA blue 60 mm cartilage used to complete the Gastric resection till the angle of HIS which is dissected retrogastric. The suture line was reinforced by a continuous layer of 2-0 prolene suture and using the methylene blue test for detection of leak. The last step is the division of the gastric omentum from the resected stomach using ligasure or ultracision and the resected gastric segment is removed from one of the trocars after extending of the incision to 2 cm. The first 250 cases done by this technique had zero mortality and one leak treated by CT guided drainage and 99 % of the cases discharged within 48 hours. Results: The whole procedure took less than 40 minutes. The excess weight loss in 1 year is 70 %. Conclusion: Therefore, this new technique preserves the blood supply to the remaining stomach and prevents tension at the suture line with no-mortality, minimal morbidity, minimal discomfort and early return to normal activities.

Surg Endosc



Revisional Bariatric Surgery: A Single Center Experience

Endoscopic Trans-Gastric Extraction of Gastric Remnant in Sleeve Gastrectomy

W.N. Abdel Salam, K. Katri, E. Elkayal, M.M. Gamal, H.M. Elkomy, M.I. Gaber

R. Elazary, M. Abu Gazala, A. Khalaileh, Y. Mintz

Alexandria University, Faculty of Medicine, Alexandria, Egypt

Hadassah Hebrew University Medical Center, Jerusalem, Israel

Background: Morbid obesity has become a severe health problem, especially in Western countries. Bariatric surgery is the only proven effective weight loss therapy for severely obese patients. It produces long-term weight loss, improves quality of life, reduces number of sick days and costs. Although effective, inadequate weight loss or development of late post operative complications are not uncommon. Patients and Methods: Among 534 morbidly obese patients who underwent different bariatric procedures-213 Laparoscopic Adjustable Gastric Band (LAGB), 153 Laparoscopic Sleeve Gastrectomy (LSG), 110 Vertical Banded Gastroplasty (VBG), 37 Roux-en-Y Gastric Bypass (RYGBP), 4 Mini Gastric Bypass (Mini-GBP) & 17 Laparoscopic Greater Curvature Plication (LGCP)-15 patients (12 LAGB, 1 LSG, 1 open VBG & 1 LGCP) were presented by failure or late complications of bariatric surgery. In LAGB patients, 6 were complicated by slipped band, 2 with band erosion, 1 with chronic left shoulder pain and tachycardia and 2 patients with inadequate weight loss and 1 patient with band infection. In patients with LSG, open VBG & LGCP, all patients failed to reach optimum weight and started to regain weight. Results: Band removal was successful in relieving symptoms in patients with band erosion through laparoscopic trans-gastric approach, while it was not the rule in slipped band. Out of 6 patients with slipped band, 4 patients had their band removed according to patient’s will, while 2 patients had band repositioning. Both decisions achieved patient satisfaction and relieved their symptoms. After exclusion of all possible causes, left shoulder pain and tachycardia vanished after band removal. Inadequate weight loss-in patients with LAGBwas managed by band removal with subsequent RYGBP. While the only choice for patient with band infection was band removal. In patient with open VBG, Upper GI endoscopy revealed gastro-gastric fistula and MiniGBP was done. In case of inadequate weight loss after LSG, Mini-GBP was also the choice. While in patient of LGCP with inadequate weight loss, LSG was the choice. Conclusion: In the hands of highly experienced laparoscopic bariatric surgeon with the optimum tools available at his fingers’ tips, revisional bariatric procedures can be done safely and effectively.

Aims: Laparoscopic sleeve gastrectomy has become the most common bariatric procedure. Extraction of the gastric remnant through an abdominal wall incision may cause morbidity such as: pain, hernia or infection. Trans-gastric extraction of the gastric remnant may reduce wound complications and yield faster recovery. In this study we describe our experience in this novel technique. Methods: Four 12 mm trocars and a single 5 mm trocar are inserted through the abdominal wall. The greater curvature is dissected from the short gastric vessels and omentum, 5–6 cm proximal to the pylorus up to the esophagogastric junction (EGJ). The Stomach is divided over a bougie using a stapler starting from 8 cm proximal to the pylorus and up to the EGJ, creating a narrow gastric sleeve. The distal staple line is then opened and a gastroscope is passed from the stomach into the peritoneal cavity. The gastric remnant is then grasped and extracted perorally. The gastrotomy site is closed using additional stapler loads which finalizes the sleeve 5–6 cm from the pylorus. Results: Seven patients, with an average BMI of 43 were operated using this technique. Operative course in all seven patients was uneventful. Trans-gastric extraction of the gastric remnant through the gastrotomy was technically feasible, easy and quick. The gastrotomy site was closed without difficulties. Mean operative time was 76 minutes. There were no leaks or long-term complications. Conclusion: Trans-gastric extraction of the gastric remnant in sleeve gastrectomy is feasible and safe. We believe that this approach may reduce the incision related complications. Avoiding the need to enlarge the fascial and muscle incisions may reduce post operative pain and produce better cosmetic results, however dedicated randomizes studies are necessary to prove these assumptions.



Laparoscopic Sleeve Gastrectomy is Effective on T2 Diabetes: Results: About 237 LSG Performed During Two Years With Two Years Minimum Follow-Up

Can Ligasure Be Used to Perform Sleeve Gastrectomy?

P.J. Verhaeghe1, L. Rebibo2, A. Dhahri2, A. Pecquignot2, C. Cosse2, S. Fendri2

J. Lopez1, R. Vilallonga2, E. Targarona3, C. Balague3, J.M. Balibrea2 1 Mexican Institute for Social Security, Delicias, Mexico; 2Hospital Universitari Vall d’Hebron, Barcelona, Spain; 3Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

1

University of Picardy, Amiens, France; 2CHU Amiens, Amiens, France

Aims: Assess efficiency of Laparoscopic sleeve gastrectomy (LSG), performed between 1 January 2009 and 31 December 2010 included. Method: From Amiens cohort (ACOS) performed between 1 January 2009 and 31 December 2010 included, 241 LSG by first intention were programmed only 237 performed for 4 (1.6 %) were explorative laparoscopy because of massive leaver hypertrophy or insufficient pneumoperitoneum. Datas prospectively recorded: age, gender, obesity seniority, BMI, fasting glycemia, Hb A1c, %EBMIL. Patients were separated in three groups: Without T2 diabetes, pre diabetes, diabetes with oral tablets or insulin. Presence or not and T2 diabetes category were recorded before operation, 3 months, 6 months, 1 year and 2 years after. Analysis performed with SAS 9.2 software. Results: cohort includes 237 patients median age: 38 years- sex ratio female/male: 3/1 obesity anteriority was 18 years [2–4] and initial BMI was 47 [35–68]. Non diabetes patients proportion increased (p \ 0.001) after LSG from 3 months: 11.4 %, 6 months: 29.5 %, 12 months: 31.05, 24 months: 27.5 % compared to patients before surgery. After LSG T2 diabetes patients proportion decreased (p \ 0.001): 3 months: 25,9 %, 6 months: 35.3 %, 12 months: 47.7 %, 24 months: 58.1 % compared to patients before surgery. Conclusion: LSG is efficient and reliable. Median term of LSG efficiency on T2 diabetes is firm. Compared to other papers, LSG efficiency is probably a little inferior to by-pass with much less restraint and metabolic risks.

Introduction: LigaSure was developed as an alternative to suture ligatures, hemoclips and staplers for ligating vessels and tissue bundles. In adition to its original purposes, LigaSure has been successfully used in other surgical procedures, such as hepatic resections, laparoscopic adrenalectomy, laparoscopic splenectomy, pancreatic resections, partial nephrectomies, vaginal and abdominal hysterectomies, hemorrhoidectomies, pulmonary resections, and thyroidectomies. The aim of the present study was to determine whether LigaSure can be used as a welding instrument in the performance of laparoscopic sleeve gastrectomy. Material and Methods: Following conventional laparoscopic sleeve gastrectomies, the gastric specimens were carefully retrieved by enlarging one of the 12-mm trocar incisions, with special care to avoid tearing the gastric wall or disrupting the staple line during the extraction maneuvers. Gastric specimens were assigned into four groups. Group 1 - specimens remained with the staple line intact. Group 2 - the staple line was oversewn. Group 3 - the staple line was resected with LigaSure. Group 4 - staple line was resected with LigaSure and the seal was oversewn. In all specimens the pressure tolerance was assessed using a portable sensor. Results: In group 1 the leak pressure was 34.7 ± 11.7 whereas in group 2 specimens the pressure increased three-fold (101.9 ± 21.4). The LigaSure seal alone (group 3) achieved a mean pressure of 13.7 mmHg. However, in group 4 there was an exponential increase on their burst strength up to 142 mmHg (p = 0.0005). Conclusion: According to our results, LigaSure could be used to perform laparoscopic sleeve gastrectomy with reduction of staple-line bleeding and, when reinforced with a running suture, it achieves a strength that approaches that of staples plus oversewing.

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The Use of Knotless Barbed Sutures in Primary and Revisional Roux-en-Y Gastric Bypass for Morbid Obesity

Ethnic Background as a Risk Factor for the Surgical Outcome of Laparoscopic Gastric Banding

H. Mizrahi, N. Geron

Z. Perry, S. Bar, U. Netz, S. Atias, U. Gibor, Y. Glazer, B. Kirshtein, L. Lantsberg, S. Mizrahi, E. Avinoh

The Baruch Padeh Medical Center, Tiberia, Israel Aims: To establish the feasibility and the safety of laparoscopic intestinal anastomosis using endoscopic linear stapler to create gastro-jejunal and jejuno-jejunal anastomoses and barbed suture for the closure of intestinal opening in primary and revisional bariatric gastric bypass. Methods: Prospective cohort study of patients undergoing elective LRYGB for weight loss. Data, including Demographics, body mass index (BMI), length of the procedure, length of stay as well as mortality and morbidity were collected prospectively. Results: Eleven consecutive patients (M/F ratio 3/8) required LRYGB. Median age was 43 years (average 44.6, range 29–57) with preoperative median BMI was 41.0 kg/m2 (average 41.4, range 33–49). Of them, 6/11 had primary procedure, 4/11 had it as a second bariatric procedure (two had previous Laparoscopic Gastric Banding (LGB), one had Sleeve Gastrectomy (SG), one had Silastic Ring Vertical Gastroplasty (SRVG)) and 1/11 had it as a tertiary procedure for weight loss (after SRVG and SG). All cases were performed laparoscopically using endoscopic linear stapler to create gastro-jejunal and jejunojejunal anastomoses. 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for the closure of intestinal opening in both anastomoses. Median length of surgery was 124 minutes (average 154.9, range 101–362). There were no conversions to open surgery and no post-operative anastomotic leaks were documented. Two patients had post-operative fever which required computed tomography. One was diagnosed with left lower lobe pneumonia and the second had small fluid collection near the gastric pouch. Both cases were treated conservatively with antibiotics. Median length of hospital stay was 4 days (average 4.3, range 3–5). All patients were followed at an outpatient clinic. Median follow up period was 6 months (average 6.7, range 4–12). Median BMI is 32.0 kg/m2 (average 32.8, range 29–41) and median excess weight loss is 52.7 % (average 53.9, range 28.9–76.6). One patient was readmitted 10 days after surgery due to melena which resolved spontaneously. Conclusions: LRYGB is technically demanding and application of a knotless barbed suture might simplify the surgery. We believe it is safe to use during LRYGB though more studies are required in order to evaluate long-term outcomes.

Soroka University Medical Center, Beer-sheva, Israel Background/Objective: laparoscopic adjustable gastric band (LAGB) surgery is considered a safe and effective treatment for morbid obesity. The LAGB surgery has a unique set of complications (i.e. slippage, leakage, port infection, port disconnection) that can only be fixed during re-operation. We conducted a retrospective study to evaluate if there is a significant difference in the surgery complication rate between the minorities (i.e. former USSR residents, Beduins) and the general population does exist. Methods: An historical cohort study, which included a research group that composed of patients who have undergone LAGB between the years 2000–2010 at the, Surgery Dept. A, which were from the former USSR, or from a Beduin background. Patients were followed up for at least 2 years. Patients were requested to fill up a questionnaire which included three forms - demographics details, LAGB complications evaluation and quality of life evaluation (BAROS - Bariatric Analysis and Reporting Outcome System). For patients that underwent re-operation, details were later gathered from a computer data base in Soroka Medical Center. Their results were compared to patients from the general population. Results: There was no difference between the pre-operational height, weight and BMI. We found some difference, although not significant (P = 0.09), in the frequent cause of reoperations between the groups. The frequent cause for a re-operation among the former USSR group was repositioning due to slippage whereas the frequent cause for a re-operation among the general population was replacement due to malfunction. Subjectively Former USSR residents were happier with the operation and felt more contributed by it. In the beduin population the results were less encouraging, and patients seemed less content, and their surgical results were less favorable than the general population. Conclusion: We have seen that the LAGB surgery complication rate is lower among the former USSR population in comparison to the general population. Further research is required in order to characterize these patients group, and find, among their characteristics, those who lower the appearance of complications.

P529 - Morbid Obesity P531 - Morbid Obesity Anti-Diabetic Effect and Body Weight Loss Effect of the Sleeve Gastrectomy with Duodeno-Jejunal Bypass in Japanese Obese Patients T. Naitoh, N. Tanaka, T. Miyachi, T. Tsuchiya, T. Morikawa, H. Musha, T. Abe, M. Nagao, S. Haneda, S. Ohnuma, H. Sasaki, K. Kudo, T. Aoki, A. Kohyama, H. Karasawa, K. Nakagawa, H. Yoshida, F. Motoi, Y. Katayose, M. Unno Tohoku University Hospital, Sendai, Japan Backgrounds: In Japan, a bariatric surgery had been uncommon surgery. However, morbid obese patients and type II diabetes (T2DM) patients are increasing as well as in western countries. Moreover, in Japanese obese patients, T2DM tends to become severe with a relatively low BMI. Roux-en Y gastric bypass (RYGB) is the most common procedure in the world though the sleeve gastrectomy is the only one officially approved procedure in Japan. Besides, since a rate of gastric cancer is high, the RYGB is not accepted by many Japanese surgeons. Therefore, we are performing the laparoscopic sleeve gastrectomy (LSG) and LSG with duodeno-jejunal bypass (LSG/DJB) instead of RYGB. The aim of this study is to assess the body weight loss and anti-diabetic effect of the LSG and LSG/DJB in our institute. Patients and Methods: Since October 2010, we have performed 17 bariatric surgery. Eleven patients underwent LSG, and 6 patients underwent LSG/DJB. The limb length of the duodeno-jejunal bypass was as follows: The bilio-pancreatic limb length is approximately 100–120 cm, and the alimentary limb length is about 120–150 cm. Of those patients, we assessed perioperative outcomes, weight loss and anti-diabetic effect. Results: BMI is 44.1 kg/m2 in average. Twelve of 17 cases had T2DM. Operation time was 145 min in LSG, and 274 min in LSG/DJB. No postoperative complication or mortality was observed. EBWL % at 12 months was 42.3 % in LSG, and 51.3 % in LSG/DJB. However, 5 cases of LSG gained weight again thereafter. In patients with diabetes, preop HbA1C is 7.4 % in LSG, and 8.0 % in LSG/DJB. Preop HOMA-IR is 5.5 in LSG, and 3.4 in LSG/DJB. HbA1C at 12 months are 5.8 % in LSG, and 6.1 % in LSG/DJB. Only one patient in LSG/DJB requires postoperative medical treatment for diabetes, who previously received over 70 IU of Insulin injection, while other patients does not take any medicine after surgery. Conclusion: Both LSG and LSG/DJB have good effect on both weight loss and T2DM in Japanese patients. However, rebounding rates seemed higher in LSG alone, it is essential to have a bypass surgery as a surgical option.

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The Effect of Bariatric Surgery Upon Diabetic Patients 7–10 After Surgery Z. Perry, S. Tzelnick, U. Netz, S. Atias, U. Gibor, Y. Glazer, B. Kirshtein, S. Mizrahi, L. Lantsberg, E. Avinoh Soroka University Medical Center, Beer-sheva, Israel Background: Laparoscopic Adjustable Gastric Band (LAGB) surgery is a known treatment for morbid obesity. In addition, this surgery is known to be effective in the treatment of the comorbidities of morbid obesity, and primarily DM type 2 and thus is indicated for the treatment of these diseases as well. This study is an historic cohort study about LAGB as the treatment of DM2 for long periods comparing the long term (10 year) effect of bariatric surgery upon DM2 status Methods: The list of patients was taken from the OR and the department’s database. All of the patients in this study had DM type 2 before the surgery and had the surgery 7–10 years prior to the day of the interview. We used a comparison group comprised of DM2 patients who were under observation in our Diabetes clinic. The patients were interviewed by a set of questionnaires, which included questions about their demographics details, health condition prior and after the surgery and a quality of life evaluation. Results: 197 people participated in the study, 96 of them underwent LAGB. Average time since the surgery was 6.9 years (± 0.97). The average HbA1c In the surgical group was 6.594 (±1.2082), which was significantly lower (p \ 0.001) the HbA1c of the control group which was 8.359 (±1.6). Prior to the operation and at the start of the follow-up period the HbA1c did not differ between the groups. Regression analysis has shown that patients who underwent LAGB were 6 times more likely to have a balanced glycemic index than patients who were treated by conventional medical therapy. Conclusion: We have shown in this study that LAGB is an effective treatment for morbid obesity, as well as the comorbidities that comes with it- DM type 2, in a longer period of time than was proven until this study. From this study we can conclude that LAGB as a treatment for Morbidly Obese patients who suffer from DM is a long-term treatment that enhance their ability to have a balanced glycemic index.

Surg Endosc



The Use of Laparoscopic Gastric Banding in Pediatric Patients in Comparison to Morbidly Obese Children Who Did Not Undergo Surgery

Is Laparoscopic Surgery Cost-Effective in Morbidly Obese Patients? Analysis of the Factors Determining the Socioeconomic Outcome of Bariatric Surgery

Z. Perry1, I. Tilbor2, U. Netz1, S. Atias1, U. Gibor1, Y. Glazer1, B. Kirshtein1, L. Lantsberg1, S. Mizrahi1, E. Avinoh1, T. Zioni1

A. Schoucair, B. Kraemer, M. Ried, M. Langhans, J. Essen MDK Hessen, Frankfurt am Main, Germany

1

Soroka University Medical Center, Beer-sheva, Israel; 2Ben-Gurion University, Beer-sheva, Israel

Background/Objective: The current study is a retrospective cohort study designed to examine the efficacy of LAGB surgery as treatment for adolescent obesity. Methods: The study population was adolescent who had LAGB as treatment for obesity at Surgery A, Soroka Medical Center, between 2006–2012. The BAROS (Bariatric Analysis and Reporting Outcome System) questionnaire was performed. The control population was based on individuals who were diagnosed with obesity during childhood and did not refer to surgery- but only continued under observation between the years 2000 and 2012, as their data was recorded by the Child and Adolescent Health Care Center of the HMO Klalit at Beer-Sheva. Results: 58 patients had LAGB before the age of 18 were the study group. Average time from operation to day of interview was 3.17 years (±1.28 years). Average weight before surgery was 124.17 kg (±20.07 kg), and average BMI was 44 kg/m2 (±5.4 kg/m2). At the day of the interview- average weight was 88.27 kg (±19.7 kg) (Pv \ 0.001) and the average BMI was 31.2 kg/m2 (±6.6 kg/m2) (Pv \ 0.001). The Excess weight loss was 28 %. Throughout the years of follow up- 7 patients (12 %) developed long-term complications which required re-operation. BAROS questionnaire summarization demonstrated overall improvement with quality of life, as evident of the final score) BAROS score Revised = 2.41 ± 0.61). N = 89 individuals who were not operated were included the control study group. At the end of follow-up period, the maximal BMI percentage measured was 97.1 (±1.1) and it differed (Pv \ 0.001) from the last BMI percentage measured, which was 90.6 (±11.1). However, the BMI percentages of N = 95 individuals with 3 or more measurement throughout follow-up period (not including last measurement) did not differ (Pv = 0.057). Conclusion: Our study suggests that LAGB surgery is an effective long term treatment for adolescent obesity, includes low and reasonable long-term complication rates, while improving the quality of life of the patient. The improvement of the quality of life and satisfaction of treatment are proportional to the weight lost. Further study for longer periods of follow-up is required, as well as to examine the effects of bariatric surgery over comorbidities in adolescents.

Since the early 2000s the number of laparoscopic procedures in bariatric surgery has risen sharply in Germany. Up till now it is not clear whether the costs of bariatric surgery reduce the overall costs in the treatment of morbidly obese patients or not. It is therefore legitimate to ask whether this increase can be justified by looking at the balance between additional costs and the established benefit of laparoscopic bariatric surgery. Considering e.g. the postoperative course in diabetic patients in reducing the need for insulin, one can assume that the costs of bariatric surgery are clearly less than the costs for the therapy of diabetes. Furthermore the attempt is made to establish the magnitude in the reduction of significant health risk factors. Other factors such as increase in physical mobility, reduction of comorbidities, duration of unemployment and possible return to work are analyzed. The socioeconomic influence of bariatric surgery is outlined.



The Use of New Technique in Laparoscopic Gastric Banding Improves Post-op Complication Rate

Single-Stage vs. 2-Stage Sleeve Gastrectomy as a Conversion After Failed Adjustable Gastric Banding: 30-Day Outcomes

Z. Perry1, D. Ramati2, U. Netz1, S. Atias1, U. Gibor1, Y. Glazer1, B. Kirshtein1, L. Lantsberg1, S. Mizrahi1, E. Avinoh1, T. Zioni1

N.R. Obeid, B.F. Schwack, H. Youn, M.S. Kurian, C.J. Ren-Fielding, G.A. Fielding

1

Soroka University Medical Center, Beer-sheva, Israel; 2Ben-Gurion University, Beer-sheva, Israel

New York University Medical Center, New York, United States of America

Background/Objective: Laparoscopic Adjustable Gastric Banding (LAGB) surgery is a known and acceptable treatment for morbid obesity in adults. One known complication is a slippage of the band and different techniques were developed to try and minimize this complication. The current study is a retrospective cohort study designed to examine the efficacy of new LAGB surgery technique as a way to diminish slippage rate. Methods: The study population was patients who had been operated with LAGB as treatment for obesity at the Department of General Surgery A, Soroka Medical Center, between the years 2008 and 2011, in which had undergone the new surgical technique termed abrasion. Each patient was interviewed regarding their health status, weight measurements before and after the surgery, as well as various quality of life estimates. The BAROS (Bariatric Analysis and Reporting Outcome System) questionnaire was performed. The control population was based on individuals who were operated upon between the years 2005 and 2007, and underwent the normal LAGB procedure. Results: We have seen a decrease in LAGB slippage rate in the abrasion group, which was significant. Operative times were the same, and other complications rate did not differ between the groups. Weight loss, as well as subjective evaluation of the operation (BAROS scale) were the same. Conclusion: Our study suggests that LAGB surgery is an effective long term treatment for adolescent obesity, includes low and reasonable long-term complication rates, while improving the quality of life of the patient. The improvement of the quality of life and satisfaction of treatment are proportional to the weight lost. Further study for longer periods of follow-up is required, as well as to examine the effects of bariatric surgery over comorbidities in those who had the new technique.

Aims: Sleeve gastrectomy (SG) is being performed as a conversion after gastric banding (AGB), often in a single stage. However, some argue it should be performed in 2 stages to improve safety. Few studies compare complications between 1- and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups. Methods: We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013, and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, LOS, leak, infection, and bleeding rates, as well as mortality. Results: A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (Bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p-value = 0.702) and LOS (3.1 days vs. 2.4 days, p-value = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage vs. 15 % for 2-stage procedures (p-value = 0.705). Differences in 30-day readmission (8 % vs. 5 %) and reoperation (5 % vs. 0 %) were not statistically significant (p-value = 0.999 and 0.569, respectively). Leak (3 % vs. 0 %, p-value = 0.999), abscess (2 % vs. 5 %, p-value = 0.440), and bleeding rates (2 % vs. 0 %, p-value = 0.999) were not different. There were no deaths. Conclusions: SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

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Triple-Site Suspension Method: An Easy Technique Makes Single Incision Laparoscopic Sleeve Gastrectomy More Feasible

Laparoscopic Weight Loss Surgery in the Super-Super Obese Population (BMI [ 60 kg/m2): a retrospective review

H.C. Huang, H.C. Yeh, C.C. Luo, R.J. Chen

S. Docimo, G. Ferzli, S. Nazir, V. Malhotra

Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan

Lutheran Medical Center, New York, United States of America

Aims: Laparoscopic sleeve gastrectomy (LSG) is more accepted presently. Some institutes performed this procedure with single incision laparoscopic surgery (SILS) method, but the conversion rates were not low due to skill difficulty. We present our experience in performing SILS LSG with triple-site suspension method. Methods: For developing SILS LSG, we used 3-incision method with some SILS skills initially. After familiar with whole procedures, we shifted surgeries to SILS operations with the triple-site suspension method. While doing triple-site suspension method, we used three 2-0 polypropylene sutures to suspend lateral segment of liver for showing the cardiac region, to suspend the middle gastric body for pulling stomach from left to right, and to suspend parasplenic omentum for exposing gastric fundus. Results: From December 2012 to November 2013, we performed 36 LSG with SILS related skills. For the first 11 patients, 3-incision method was used. The homemade glove device (offering multiple trocars) was applied through intra-umbilical wound and the other two 5 mm trocars were used. We shifted our procedure to SILS LSG with triple-site suspension method since the 12th patient. Twenty one SILS LSGs were performed successfully among total 25 attempts. Two operations were converted to 3-port method due to previous surgery related severe adhesion. The other two were converted due to difficult anatomy. For the latest 12 patients, the SILS LSG could be done smoothly. One major complication of delayed colon injury happened and resolved by second operation for colon repair. No mortality happened in our series. Conclusion: LSG is widely accepted nowadays, especially in Orient. Meanwhile, SILS has become an important development goal of gastrointestinal surgery. However, SILS LSG might be restricted due to procedure difficulty. According to our limited experience, we would like to introduce our triple-site suspension method, which seems to make SILS LSG more feasible.

Aims: An increase in the prevalence of super-super obesity (BMI [ 60 kg/m2) in the United States has been noted. Surgical interventions such as gastric banding (LGB), rouxen-Y gastric bypass (LRY), gastric sleeves (LGS) and duodenal switches are often utilized as treatment modalities. We sought to understand the success rates and complications of these procedures in reducing BMI and co-morbidities in super-super obese patients. Methods: A total of 58 patients with a BMI [ 60 kg/m2 were included in the study. Various parameters such as the type of surgery, patient demographics, length of stay, change in weight/BMI, reduction of co-morbidities and the number of intraoperative and postoperative complications were determined. Results: Thirty-sex women and 22 men with an average age of 39.75 years were studied. Forty-eight patients underwent a LRY, six had a LSG, and two had LGB. The pre-surgical BMI’s were 65 kg/m2 for the LRY, 65 kg/m2 for the LSG, and 61 kg/m2 for the LGB. The post-surgical BMI at two years was 44 kg/m2 for the LRY, 57 kg/m2 for the LSG, and 51 kg/m2 for the LGB. The LRY had the greatest percentage weight loss both at 6 months (27 %) and at 24 months (33 %). The LSG had average percentage weight loss of 23 % and 12 % at 6 and 24 months. Patients with LGB had a relative improvement in terms of percentage weight loss after 24 months vs 6 months (17 % vs 13 %). Post-operative follow-up demonstrated a 100 % improvement of HTN and OSA in the LGB patients, 100 % improvement of DM, COPD, and hyperlipidemia in the LRY group, and a 100 % improvement of HTN and GERD in the LSG group. Conclusion: Laparoscopic bariatric surgery presents a feasible option for the super-super obese due to its ability for BMI reduction as well as a decrease in co-morbidities. Laparoscopic roux-en-Y gastric bypass demonstrated the greatest reduction in postoperative weight loss as compared to gastric sleeve gastrectomy or gastric banding with longer postoperative stays being the only drawback. The super-super obese population can be safely and effectively treated laparoscopically with minimal extra considerations and a relatively short length of hospital stay.



Video Presentation on Two Different Techniques of Laparoscopic Roux-en-Y-Gastric Bypass in Bariatric Surgery

Endoscopic Stent in Management of Leaks After Sleeve Gastrectomy

A.M. Oo1, A.N. Koura1, J. Rao1, C.H. Tan2

L. Marx, M. Nedelcu, S. Perretta, A. d’Urso, M. Vix, D. Mutter

1

2

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

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

Aims: Both circular stapler and linear stapler techniques are feasible techniques for the construction of gastric pouch-jejunal anastomosis and outcomes are comparable. Methods: Obesity is the fifth leading risk for global deaths. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the best surgical procedures for obesity. It achieves excellent long term weight loss results with a low rate of post-operative complications and metabolic disorders. There are two different techniques for the construction of the gastric pouch-jejunal anastomosis (GPJA): mechanical (circular or linear stapler) or hand-sewn GPJA. Results: Video presentation on two different techniques of Roux-en-Y gastric bypass: circular stapler technique and linear stapler technique done in Tan Tock Seng Hospital is shown. Conclusion: Both circular stapler and linear stapler techniques are safe and the short term and long term results are comparable.

Introduction: Leaks occurring after laparoscopic sleeve gastrectomy (LSG) are deemed as the most serious complication of this procedure due to difficult healing process with non standardized management including endoscopy and surgery. The aim of this retrospective study was to evaluate the efficiency and tolerance of covered stents in leaks’ management. Methods: Patients with a leak after LSG performed between September 2009 and August 2013 were included. One patient has had a previous bariatric surgery. The leaks were diagnosed by CT scan and visualized during the endoscopy. Diagnosis delay, stent treatment delay, stent migration, number of endoscopic procedure and healing time were analysed. Results: Ten patients, 7 women and 3 men, with a mean age of 32.8 (range 18–54) were included. Three patients were referred after initial treatment in other institution. Eight patients necessitated a surgical drainage, by laparotomy in 5 cases and by laparoscopy in 3. The stent deployment was realized at the time of leak diagnosis in 5 cases, and with mean interval of 11.7 days in 5. A total of 19 stents were used, 1 to 4 stent/patient. Early stent removal due to migration was required in two cases. Treatment was successful in all cases. The average healing time was 43.1 days. For the five patients with simultaneous leak diagnosis and stenting, the average healing time was 34.8 days versus 51.4 days for the five with delayed stent deployment. Conclusion: Leaks after laparoscopic sleeve gastrectomy must be treated in an emergency setting including surgical drainage in some cases and endoscopic stenting of the leak. Early stent placement appears to be associated with shorter healing time.

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Laparoscopic Sleeve Gastrectomy in a Patient with Situs Inversus Partialis and Bardet-Biedl Syndrome

Is Bariatric Surgery Safe in July And August? An Analysis of Short-Term Outcomes

Y. Loh, M. Reddy, G. Vasilikostas, A. Wan

P. Smith, F. Saleh, D. Jackson, A. Quereshy, A. Okrainec

St Georges Hospital, London, United Kingdom

University Health Network, University of Toronto, Toronto, Canada

Aims: This presentation aims to discuss the difficulties of laparoscopic bariatric surgery in patients with situs inversus (totalis and partialis). The authors believe that laparoscopic surgeons can successfully perform bariatric surgery on such patients. The authors also explore bariatric surgery as a treatment option for Bardet-Biedl syndrome. Methods: The authors present a case of a 26 year old female with situs inversus partialis, as a consequence of Bardet-Biedl syndrome, who underwent a laparoscopic sleeve gastrectomy and has successfully lost weight following the procedure. This is followed by a review of the published English literature on both patients with situs inversus and those with Bardet-Biedl syndrome. Results: The literature search revealed bariatric surgery performed on only situs inversus totalis patients: 2 cases of sleeve gastrectomies, 2 cases of gastric bypasses, and 3 cases of gastric bands. Complications include one leak from sleeve gastrectomy performed after a failed gastric band, one band erosion and subsequent removal, while the remainder did not report any postoperative complications. Additionally, there was one case report for a gastric bypass on a Bardet-Biedl patient that did not have situs inversus. This was used as a surgical option to reduce obesity arising from this genetic condition. Conclusions: Laparoscopic bariatric surgery can be performed safely on situs inversus patients, but it is to be expected that it would be more difficult due to the different position of organs. Bariatric surgery may also be a useful option to manage weight loss in patients with Bardet-Biedl syndrome regardless of whether they have situs inversus.

Aims: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically advanced procedure with an appreciable learning curve. Each July, new fellows enter into minimally invasive surgery fellowships with the formidable task of mastering this advanced laparoscopic procedure. Despite conflicting reports in the literature, the myth of the ‘July Phenomenon’ persists. The purpose of this study is to report the short-term outcomes of morbidly obese patients undergoing elective LRYGB during the months of July and August and to compare these outcomes with elective LRYGB during the remainder of the year. Methods: This retrospective cohort study employed a hospital-generated database that captured elective bariatric procedures performed from July 6, 2010 to August 30th, 2013 at a single Ontario Bariatric Centre of Excellence. Patients who underwent an elective LRYGB in July and August of each successive year were compared to patients who underwent an elective LRYGB during the remaining months of those successive years. Outcomes of interest included operative time and unexpected return to the operating room as captured in the database. Results: From July 6th, 2010 to August 30th, 2013, 906 elective LRYGBs were performed by four bariatricsurgeons. During this four-year period, 159 were performed during the months of July and August while 748 were performed from September to June. Mean operative time during July and August was increased by over 12 minutes compared to mean operative during the remainder of the year (150.57 minutes versus 138.21 minutes; p \ 0.001). Despite longer operative times during the summer months, unexpected return to the operating room did not significantly differ between July and August and the remainder of the year (1.90 % versus 2.68 %; p = 0.57). Conclusion: Results from this single-centre retrospective cohort study demonstrate that as new fellows begin fellowship training during the summer months, operative times are increased in July and August as compared to the remainder of the year. Despite longer operative times, unexpected return to the operating room does not differ between these two periods. Additional prospective studies are needed to further define these short-term outcomes in the proposed study periods.



Assessment of Nutritional Status in Patients Treated for Obesity

Sleeve Gastrectomy: Five Years Experience

A. Lehmann, M. Pawlak, M. Orlowski

R. Gonzalez-Heredia

Specialist Hospital. F. Ceynowy, Wejherowo, Poland

University of Illinois Hospital and Health Sciences System, Chicago, United States of America

Aims: Bariatric procedures are among the most common surgical procedures today. Malnutrition might be independent factor influencing the outcome of the operation. The aim of this study was to evaluate nutritional and metabolic profile in morbidly obese patients prior to operation. Methods: The study was conducted in the Department of General Surgery, Ceynowa Hospital in Wejherowo. We have analyzed retrospectively the records of patients operated in 2011 and 2012. The study included 221 patients who met the eligibility criteria for bariatric treatment according to the WHO, and were of legal age at the time of admission to the hospital and did not present any symptoms of infection. On a day before surgery diagnostic blood tests were made for each of the patients qualified for operation. We have taken into consideration hematological, biochemical, coagulation and immunochemical results. Lab indicators of malnutrition in adults: albumin, total protein, total number of lymphocytes (CLL). Results: The group consisted of 159 women and 62 men, with an average age of 39.2 ± 9.7 years and mean BMI 44.8 ± 6.1 kg/m2. Thirty four (17.7 %) patients had a low serum albumin level and total protein was too low in 7 (3.2 %) cases. In the study group, 11 (5.1 %) had a CLL insufficiency, in two the level was found below 800. Conclusions: It has been shown that obese patients scheduled for surgical treatment of obesity show primarily electrolyte disorders, lipid disorders, and anemia. The disorders are primarily associated with weight and gender. The results show no statistical correlation between the studied parameters, and early results of treatment and the number of postoperative complications, except for one. In patients with higher HDL levels significantly more complications occurred. Malnutrition was present in 0.9 % of the study population, a severe degree of malnutrition in 4.5 % - due to the total number of lymphocytes. However when albumin level was taken into consideration mild/moderate degree of malnutrition was found in 15.4 % of the patients.

Introduction: Sleeve Gastrectomy has gained popularity over the past decade due to its safety, feasibility and good results. The purpose of this study is to describe our experience with this procedure. Material and Methods: This study is a nonrandomized, controlled, retrospective review of 362 patients who underwent a minimally invasive sleeve gastrectomy at the University of Illinois Hospital and Health System from January, 2008 to September, 2013. 257 patients underwent a laparoscopic sleeve gastrectomy (LSG) and 105, a robotic procedure with the da Vinci Surgical SystemÒ. Patient demographics, date of surgery, postoperative morbidity and mortality, operating time, length of stay and excess weight loss (EWL) were recorded. These outcomes were compared between groups (the laparoscopic and the robotic) by T-test. Results: Of a total of 362, the mean age was 41.2 years (18–70), with no statistical difference between the 2 groups in terms of age. Preoperative parameters and demographics were similar between (p = .395). There was significant statistical difference between the two groups in terms of operating time p \ 0.5 (163.86 min in the robot-assisted group vs 93.15 min in the laparoscopic one). There was no significant statistical difference between the two groups regarding the perioperative complications, length of stay at hospital and EWL percent. Conclusion: Our experience shows that there is no clear difference for robot-assisted sleeve gastrectomy versus LSG. Robot-assisted sleeve gastrectomy is associated with longer operating time and increased cost. Aside from its use for patients with a high BMI ([50 m2/ kg), there is no clinical advantage to use robotic sleeve gastrectomy.

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Laparoscopic Gastric Restrictive Procedures in the Super-Super Obese (BMI [ 60 kg/m2) Without the use of Prophylactic Inferior Vena Cava Filters

Single-Incision Laparoscopic Bariatric Surgery. A Systematic Review

S. Docimo, S. Nazir, F. Vinces, L. Crankshaw Lutheran Medical Center, New York, United States of America Aims: The incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism in patients following bariatric surgery ranges from 0 %–5.4 % and 0 %–6.4 %. IVC filters have been recommended for use in high risk bariatric patients (defined as BMI [ 55 kg/m2, immobility, venous stasis, pulmonary hypertension, hypercoagulable state and a history of VTE). The purpose of this study is to present our experience with super-super obese patients (BMI [ 60 kg/m2) undergoing laparoscopic gastric restrictive surgery who did not receive prophylactic IVC filters. Methods: A total of 79 patients with a BMI [ 60 kg/m2 and no placement of a prophylactic IVC filter who had undergone laparoscopic weight loss surgery were included in the study. The type of surgery, patient demographics, length of stay, change in weight/BMI, reduction of co-morbidities and the number of intraoperative and postoperative complications were determined. Specific attention to the development of DVT or VTE was noted. Results: Forty-eight (60 %) patients were women and 31 (40 %) were men with an average age of 38 (20–62) years. Of the 79 patients reviewed, 64 (81 %) underwent laparoscopic roux-en-y (LRY), 6 (8 %) underwent a laparoscopic gastric banding (LGB) procedures, and 9 (11 %) had a laparoscopic sleeve gastrectomy (LSG) procedure. The range of surgical times for the LRY was 60–190 minutes, 50–160 minutes for the LGB, and 60–90 minutes for the sleeve. The pre-surgical BMI’s were 75.3 for the LRY, 65 for the LSG, and 61 for the LGB. None of the patients underwent prophylactic preoperative insertion of IVC filters. Postoperatively, no significant DVT or VTE were noted. Discussion: At our facility, patients receive intraoperative and postoperative subcutaneous heparin and also sequential compression devices as DVT prophylaxis. Of the 79 patients undergoing laparoscopic gastric restrictive procedures, each had a BMI [ 60 kg/m2 and none received an IVC filter prophylactically. No complications such as DVT, VTE, or PE were noted intraoperatively or postoperatively. These findings demonstrate BMI may not be a good indication of a high risk bariatric patient. Patients with a BMI [ 60 kg/m2 can safely undergo laparoscopic gastric restrictive procedures without the insertion of prophylactic IVC filters.

C. Moreno-Sanz, A. Morandeira-Rivas, C. Sedano-Vizcaino, M. Clerveus, J.M. Tenıás-Burillo, J.B. Munõz de la Espada, J.S. Picazo-Yeste La Mancha Centro General Hospital, Alca´zar de San Juan. Ciudad real, Spain Introduction: Although single-incision laparoscopic surgery has focused a great deal of interest, we still do not definitively know if this type of surgical approach provides benefits to the patient over conventional techniques without worsening certain important aspects such as the incidence and type of complications. The aim of this study was to evaluate the safety and efficacy of single-incision laparoscopic bariatric surgery (SILBS) when compared to conventional laparoscopic bariatric surgery (CLBS). Methods: We reviewed six databases: Embase, PubMed, Medline, ISI web of Knowledge, Scopus, and Cochrane Central Register of Controlled Trials. Cohorts and randomized clinical trials that compare SILBS to CLBS were included. This systematic review was performed in accordance with the PRISMA recommendations. Results: A total of 14 studies complied with the inclusion criteria for our analysis, which included a total of 2357 patients, 1179 in the SILBS group and 1178 in the CLBS group. The duration of the surgical procedure was longer in the SILBS group and no major intraoperative complications were observer in these series. Postoperative pain showed a small improvement in the SILBS group. The overall morbidity rate was 5 % in the SILBS group and 4.8 % in the CLBS. Only in one study in the AGB group perioperative mortality was observed (1/739; 0.14 %). Percentage excess weight loss and resolution of comorbidities were comparable between groups. When cosmesis was evaluated with SILBS were more satisfied with the scar outcome. Conclusions: SILBS is a feasible technique to use in highly selected patients. However, there is insufficient scientific evidence to recommend its widespread use compared to conventional laparoscopic approaches. After this initial period of implementation and development, more studies are needed to analyze the safety of this technique and its possible benefits. This study has been sponsored by Fundacion Mutua Madrilena, Madrid, Spain.



Control of Type 2 Diabetes in Bariatric Indian Patients Post Laparoscopic Sleeve Gastrectomy: Intermediate Phase Results from a Single Centre

Description of a Weight Curve After Laparoscopic Sleeve Gastrectomy

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 Aims: Type 2 diabetes is a fast rising pandemic along with morbid obesity in the Indian sub-continent. Both run a relentless course with debilitating end organ morbidity. Bariatric surgery has produced the best remission rates for obesity, diabetes and other co-morbidity associated with the metabolic syndrome. Laparoscopic Sleeve Gastrectomy (LSG) is the most commonly performed bariatric procedure at our centre. We present the results from our early experience with LSG in Indian bariatric diabetic patients. Methods: Data from our initial experience with LSG is taken from our prospective bariatric database is presented (Detailed data from January 2010 to March 2012 is presented). Patient metabolic status, follow-up progress of metabolic parameters, especially resolution of diabetes is profiled. Data from April 2012 onwards is summarised separately. Results: A total of 92 patients underwent a LSG during the profiled period, with 77 patients having good follow-up data. 20.8 % of these patients were diabetic with a 12.5 + 6 month diabetic duration and followed up for 27.2 + 4 months post procedure. The patients were aged 44.1 + 10 years with a Body Mass Index (BMI) of 48.7 + 11 kg/m2, FBS 155.3 + 38 mg/dL, PPBS 236.8 + 75 mg/dL, HbA1c 7.6 + 1 %, 56.3 % taking oral hypoglycaemic drugs, and 31.3 % on Insulin replacement therapy. Twelve month post procedure the average - BMI was 34.2 + 10 kg/m2, FBS 96.2 + 30 mg/dL, PPBS 130.8 + 31 mg/dL, HbA1c 6.2 %, with 75 % patients having complete and 20 % partial resolution of diabetes. Conclusions: These intermediate outcomes lend support to the role of LSG being included in diabetes management algorithms. Long-term outcomes in larger groups of patients are needed to evaluate the efficacy of LSG as a standalone procedure in the treatment of type 2 diabetes mellitus associated with morbid obesity in Indian patients.

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A. Molina, F. Sabench, E. Raga, S. Blanco, M. Hernańdez, M. Parı´s, A. Bonada, A. Sańchez, A. Munõz, D. del Castillo University Hospital of Sant Joan. Rovira i Virgili University, Reus, Spain Aims: To describe the evolution of weight during the three years following bariatric surgery for treatment of morbid obesity in patients undergoing Laparoscopic Sleeve Gastrectomy. In addition, we describe a weight curve from our results. Material and Methods: We reviewed retrospectively the medical records of patients operated from 2006 to 2012 in our University Hospital. The weight evolution was assessed using the following weight indicators: weight (kg), body mass index (BMI, kg/m2) and percentage of excess BMI lost (EBMIL %). Surgical team has been always the same. 5 trocars. Bougie size 38Fr. Distance from the pylorus 5 cm. Results: A total of 175 patients, 51 men (29.1 %) and 124 women (70.9 %) were assessed, with a mean age of 48.5 years (95 % CI: 46.8 to 50.1), an average weight of 132.0 kg (95 % CI: 128.3 to 135.8) and a mean BMI of 49.7 kg/m2 preoperatively (95 % CI: 48.4 to 51.0). One year after surgery, patients had a mean weight of 93.6 kg (95 % CI: 90.5 to 96.7), a mean BMI of 35.5 kg/m2 (95 % CI: 34, 4 to 36.5) and an EBMIL 56.3 % (95 % CI: 50.5 to 62.1). Weight evolution at two years of surgery: patients had a mean weight of 92.3 kg (95 % CI 88.5 to 96.0), a mean BMI of 35.2 kg/m2 (95 % CI: 33.9 to 36.5) and an EBMIL 56.6 % (95 % CI 47.8 to 65.5). Weight evolution after three years of surgery: patients had a mean weight of 93.5 kg (95 % CI 89.5 to 97.5), a mean BMI of 35.9 kg/m2 (95 % CI: 34.4 to 37.4) and an EBMIL 47.0 % (95 % CI 30.2 to 63.7). Conclusion: Patients undergoing laparoscopic Sleeve gastrectomy have a good results in terms of weight loss during the two years after surgery, with EBMIL [ 50 %. From the third year, EBMIL suffers a small decrease (47 %). Note that the maximum weight loss occurs already in the first year of the intervention, unlike other surgical groups, and is not modified during the second year.

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Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy

Single-Port Sleeve Gastrectomy for Super Obese Patients

E. Raga, M. Vives, F. Sabench, S. Blanco, M. Hernańdez, M. Parı´s, L. Pinãna, A. Sańchez, A. Munõz, J. Sańchez, A. Molina, J. Dome`nech, D. del Castillo University Hospital of Sant Joan. Rovira i Virgili University, Reus, Spain Aims: Laparoscopic Sleeve gastrectomy has gained prominence as a single option for their results in terms of weight loss and improvement of comorbidities. The leakage of the staple line is an important cause of morbidity and mortality. Its management depends on the severity and clinical presentation. Our goal is to identify some factors that may predispose to postoperative leaks. Also, describe a diagnostic/therapeutic algorithm for its management, reviewing the cases occurred in our University Hospital. Methods: From 2005 to 2012, a total of 207 LSG were performed, using a bougie of 38 Fr. Distance from the pylorus of 5 cm. In all cases, reinforce of the suture line was used (SeamguardÒ). Intraoperative leakage test with Blue methylene and an oral Barium study at 24 postoperative hours were performed in all patients. Results: 8 patients of 207 had a gastric leak (3.8 %), (n = 6) women and (n = 2) men. Mean age of 41.9 years (±8.9), preoperative BMI 48.5 ± 4 kg/m2 and average preoperative weight of 132.3 kg (±26). 50 % of patients with DM2 and 87.5 % (n = 7) with hypertension. 62.5 % (n = 5) patients who had a gastric leak had a previous surgical history of appendectomy or cholecystectomy. 37.5 % (n = 3) leaks were detected by barium test, 12.5 % (n = 1) with upper digestive endoscopy and 50 % (n = 4) by CT scan. The presentation time was early (\2nd day of surgery) in 62.5 % of patients (n = 5). The therapeutic management was conservative by drainage in 87.5 % (n = 7) of patients. Two patients required reoperation due to a sepsis and acute abdomen. In one of these, an endoscopic stent was placed at 11th postoperative day. No cases of mortality. Conclusions: Gastric leak after LSG is a complication whose management should be based on the clinical presentation and the diagnostic suspicion. The presence of comorbidities or previous surgery may be an important factor to take into account. The systematic placement of drainage allows treating conservatively most patients, reserving surgery when conservative measures have failed or when the patient has an acute abdomen or sepsis.

G. Pourcher, W. Akakpo, L. Panagiotis, E. Laumonier, S. Ferretti, H. Tranchart, S. Naveau, I. Dagher APHP/Antoine Beclere Hospital, Clamart, France Background: Laparoscopic sleeve gastrectomy has been proposed as a primary bariatric procedure according to considerable weight loss in super obese patients. Classically, laparoscopic sleeve gastrectomy requires 4–6 skin incisions for placement of multiple trocars. With the introduction of single-incision laparoscopic surgery (LESS), multiple abdominal procedures have been performed using a single incision, with favourable global outcomes for morbid obese patients. Decreasing surgical invasion in super obese patients ([50 kg/m2) should reduce the complication rate for these fragile patients. The purpose of our study was to evaluate the feasibility and safety of LESS sleeve gastrectomy for super obese. Methods: A total of 62 consecutive patients underwent LESS sleeve gastrectomy at the operative Unit of minimally invasive digestive surgery, University of south Paris, from June 2010 to June 2013. Results: Of the 62 patients, 46 were women and 16 were men, with a mean age of 41 years. The mean preoperative body mass index was 52 kg/m2. The mean operative time was 89 minutes. Additional trocars are used for 12 patients. The complication rate is 4,6 %. The mean postoperative stay was 4 days. Seven percent of patients were lost to follow-up. 42 patients have more or equal 1-year follow-up. The mean postoperative body mass index was 31 (25–37) kg/m2 at a mean follow-up period of 21 months. The mean percentage of excess weight loss was 67,8 % (52–100) for the same period. Conclusions: LESS sleeve gastrectomy for super obese patients seems to be safe, technically feasible, and reproducible. A randomized trial comparing single-incision sleeve gastrectomy and conventional sleeve gastrectomy in super obese might be needed to evaluate the postoperative results in relation to the development of abdominal wall complications.



Amylase Value Anomalies After Laparoscopic Sleeve Gastrectomy Procedure - Causes and Implications

Early Gastro-Gastric Fistula Following Laparoscopic MiniGastric Bypass

A. Mahajna, A. Horn, W. Aboud, A. Assalia

N. Natoudi, K. Albanopoulos, N. Memos, A. Merkou, G. Zografos, E. Leandros

Rambam Medical Center and The Bruce Rappaport Faculty of Medicine, Technion, Hifa, Israel In some patients undergoing Sleeve Gastrectomy for morbid obesity, we observed a sharp increase in the level of Amylase enzyme in the Jackson-Pratt drain left in the surgical field. The main purpose of this study is to examine the incidence of Amylase enzyme amount increase, in the blood, the urine and the drain, after Sleeve Gastrectomy procedure, and thereby inference conclusions which may enable the use of this data for optimizing the treatment after the procedure. Methods: A prospective controlled clinical study including all morbidly obese patients undergoing laparoscopic sleeve gastrectomy at our institute during one year period was conducted. The data being collected includes: demographic information such as BMI, age, gender, weight, height, Co-morbidities, Complications during surgery. Laboratory data, which is taken before the operation, a day after it and two days after it. In cases of high Amylase, and a further laboratory testing which includes Amylase is being performed after week. Complete blood counts, outpatient complication, Additional hospitalization due to complications, and Mortality during hospitalization or within 30 days of the procedure. Results: One hundred sexy one patients underwent laparoscopic sleeve gastrectomy were prospectively enrolled and analysed, Hyperamylasemia, increase amylase levels in the urine or the drain were observed in 22 % of the patients. No gastric leak was observed in all patients. Post-surgical complications were observed in 5 (4 %) patients and 2 (5.7 %) patients with normal amylase and elevated amylase, respectively. There were differences which were statistically significant in leukocytosis, neutrophilia, leukopenia, elevated glucose and elevated liver enzymes, in the elevated Amylase group compared to the control group. Discussion: There was no correlation between the increase in Amylase levels and postsurgical complications or leakage from the sleeve.

University of Athens, Athens, Greece Introduction: Pathologic communication between gastric remnant and gastric pouch, is a rare complication following mini gastric bypass. Aims: The purpose of this study is to report a case of gastro-gastric fistula following Lap. Mini-gastric bypass. Case Presentation: A 42 year old female patient with BMI 47.3Kg/m2 was admitted to our clinic for bariatric surgery due to failure of LAGB. The Band has been removed 4 years ago. The patient underwent laparoscopic mini gastric bypass with removal of fibrous ring due to the previous LAGB. The patient had an uncomplicated postoperative course with liquid diet beginning on the first postoperative day. Patient was discharged on the 3rd post-operative day. The patient was readmitted on the sixth postoperative day with fever and leukocytosis. CRP was 331 mg/dl increased almost 4 times in contrast with the discharge value. The patient was hemodynamically stable and treated nil per osdiet, parenteric nutrition andiv antibiotics. The CT scan detected a fistula between the gastric remnant and gastric pouch, at the level below the gastroesophageal junction, probably at the area of previous anchored gastric band. The patient remained hemodynamically stable and afebrile for two weeks. We then performed an upper GI series Xray that revealed the fistula. The patient started per os liquids and remained afebrile, hemodynamically stable and in good general condition. The patient was discharged with peros diet and serial outpatient follow up. The patient’s BMI was 41,6 Kg/m2 one month later and 37,4 Kg/m2 three months after the Laparoscopic minigastric bypass. Conclusion: Pathologic fistula between gastric tube and gastric pouch, following mini gastric bypass, is a rare condition which, following clinical indications, may be treated conservatively.

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Lipid Profile Improvement in Morbid Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy

Learning Curve for Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

K. Albanopoulos1, N. Memos1, N. Natoudi1, G.Z. Vrakopoulou1, V. Papatheofani1, C. Savvidis2, G. Zografos1, E. Leandros1

E. Soricelli, A. Burza, F. Stipa

University of Athens, Athens, Greece; 2Hippokratio General Hospital, Athens, Greece

San Giovanni Addolorata Hospital, Roma, Italy

1

Aims: The aim of the present study was to evaluate the lipid profile in obese patients undergoing laparoscopic sleeve gastrectomy Material and Methods: Ninety nine morbid obese patients underwent laparoscopic sleeve gastrectomy. Preoperative demographic data along with total cholesterol, HDL, LDL and triglycerides were recorded. Patients were followed up in 1, 3 and 6 months postoperatively. BMI and lipid profile was recorded during follow up. Results: Thirty seven patients were males (37.8 %). Mean age was 38.91 ± 1.18 years with mean BMI 48,36 ± 0.81 kgr/m2. Mean preoperative total cholesterol, HDL, LDL and triglycerides were 209.23 ± 4.4 mg/dl, 47.37 ± 2.5 mg/dl, 133.81 ± 3.96 mg/dl and 152.16 ± 9.57 mg/dl with atheromatic index (AI) 3.08 ± 0.11. Nine patients (9.2 %) were treated with antilipidemic medications. Mean BMI postoperatively was reduced at 1,3 and 6 months (42.63 ± 0.74, 38.11 ± 0.72, 34.4 ± 0.71 respectively, p \ 0.001) with EBW% 11.6 ± 0.5 %, 21.1 ± 0.76 % and 28.52 ± 0.85 % respectively (p \ 0.001). Total cholesterol, HDL, LDL, triglycerides and AI were significantly ameliorated during follow up (p = 0.001, p = 0.003, p = 0.009, p = 0.027 respectively). Significant differences were recorded between males and females. At 6 months only 2 (22.2 %) patients still were receiving medication for hyperlipidemia. Conclusion: LSG ameliorates the lipid profile and atheromatic index in morbid obese patients.

Background: To meet increasing demand, many unskilled surgeons are entering into bariatric surgical practice in institutions where these procedures were never performed. Therefore there is a growing interest on the proper definition of the learning curve (LC) in laparoscopic bariatric surgery. Aims: to establish the appropriate LC for surgeons with experience in advanced laparoscopic surgery for two bariatric procedures, laparoscopic Roux-en-Y Gastric Bypass (GBP) and laparoscopic Sleeve Gastrectomy (SG). Methods: We prospectively collected operative data and clinical outcome of the first 100 GBP and 100 SG performed in our Department between 2008 and 2012 by a single surgeon. Patients of each procedure were divided in two groups: group 1 (first 50 patients) and group 2 (last 50 patients). Both groups were comparable in age, gender, body mass index and preoperative co-morbidities. Results: Data from SG patients showed significant differences between the group 1 and group 2 concerning operative time (190 vs 120 min; p = .018) and hospital stay (5.8 vs 4.7 days; p = .002). In GBP patients no significant differences were observed except the operative time (265 vs 225 min; p = .01). Mortality was nil and no intra-operative complications occurred. The incidence of post-operative major complications was reduced, but not significantly, in both SG and GBP between group 1 and group 2. After a mean follow-up of 36 months no significant differences in weight loss and co-morbidities resolution were registered. Conclusions: LSG and LRYGBP can be safely approached by a surgeon with advanced skills in laparoscopic surgery with good results obtained before the learning curve was completed. The 50th patient can be assumed as the turning point of LC for both procedures.



Gastro-Esophageal Reflux Disease Symptoms After Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

Can Gastric Plication Play a Further Role in Morbid Obesity Treatment: Video Presentation

P. Chanswangphuvana, A. Techagumpuch, K. Kitisin, S. Pungpapong, C. Tharavej, P. Navicharern, S. Udomsawaengsup

H. Yigitbas, R. Kutanis, O. Gulcicek, C. Ercetin, E. Yavuz, A. Solmaz, K. Ozdogan, A. Celik, F. Celebi

King Chulalongkorn Memorial Hospital, Bangkok, Thailand

Bagcilar Training and Education Hospital, Istanbul, Turkey

Introduction: Gastro-Esophageal Reflux Disease (GERD) is prevalent in morbidly obese patients. It is well established that Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) produces improvement in GERD symptoms. Laparoscopic Sleeve Gastrectomy (LSG) has become popular in recent years. However, less was known regarding effect on GERD symptoms after LSG. This study compares GERD symptoms after LSG and LRYGB in morbidly obese patients. Methods: A retrospective, BMI-matched analysis was performed on 162 patients who underwent LSG and LRYGB in our institute by one surgeon from January 2010 to December 2013. Patients were matched for BMI 40–60 and interviewed by phone for GERD symptoms. Patients scored GERD symptoms on severity scale from 0 to 3. Outcome measures were postoperative GERD symptoms and percentage of excess weight loss ( %EWL). Results: 35 patients underwent LSG and 49 patients underwent LRYGB. Prior to operation, GERD symptoms were no statistically significant difference (42.8 % in LRYGB and 45.7 % in LSG, p = 0.79). Overall postoperative GERD symptoms were no statistically significant difference (p = 0.48). Subgroup analysis of postoperative GERD symptoms were no statistically significant difference in complete resolution, improvement, progression and new-onset of GERD symptoms. At 6 months follow-up, %EWL was no statistically significant difference (42.9 % in LSG vs 48.5 % in LRYGB, p = 0.14). Conclusion: Laparoscopic Sleeve Gastrectomy has beneficial effect on relieving GERD symptoms and results in success weight loss. However, some has experience in progression or new onset of GERD symptoms. Further randomized studies with objective measurement of GERD symptoms are needed.

Obesity is a serious problem in developed and developing countries. Obesity takes second place after smoking among preventable mortality. Laparoscopic gastric plication is one of the restrictive prosedure for bariatric surgery. We aimed to share our the gastric plication technic. In Bagcilar Research and Training Hospital, morbid obesity patients are evaluated in our council: an endocrinologist, psychiatrist, chest physician and general surgeon are included. In our general surgery department we performed 321 bariatric surgery who were diagnosed as morbidly obese, between March 2011 and March 2013. We performed laparoscopic gastric plication in 258 patients. Patient is 27 years old, female. Body mass index is 48. Her medical history was clear. Preoperatively gastroscopy showed mild hiatal insufficiency. Operations were performed under general anesthesia. Patient were in supine position, legs opened. Low molecular weight heparin used subcutaneous 8 hours before the surgery. Four 10 mm long and one 5 mm long trocars were used. Camera trocar was placed 8 cm cranial to umbilicus, 5 mm trocar was placed right midclavicular line in upper quadrant, one 10 mm trocar was placed under ksifoid for liver retraction, two 10 mm tocars were placed in left upper quadrant in mid clavicular and mid axillary lines. Great omentum dissection begins 5 cm from pylorus to gastroesophageal junction. Plication begins from gastroesophageal junction to distal part of disected greater curvature of the stomach. Inner layer of plication is done with V-loc 2/0, outer layer is with 0 prolene sutures. Operation time is approximately 45 minutes. Postoperative first day patients were followed in intensive care unit and liquid intake was allowed. After 24 hours patients were transferred to clinic. Average time of discharging from hospital is 48–72 hours. Charge of the procedure is less than other restrictive procedures like sleeve gastrectomy. Nevertheless other factors such as hormonal functions of stomach is ignored. Long term follow up is another question. Recovery of weight loss, mucosal changes of plicated stomach are the other questions. In conclusion; we found out that LGP procedure does not increase the morbidity or mortality and makes an improvement in BMI.

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Cholecystectomy in the Same Session in Patients Undergoing Bariatric Surgery

Roux en Y Gastric Bypass Is Superior Than Sleeve Gastrectomy: A Result of 233 Cases With More Than 6 Months Follow Up

H. Yigitbas, A. Solmaz, O. Gulcicek, C. Ercetin, E. Yavuz, M. Tokocin, F. Celebi, A. Celik, R. Kutanis

S. Udomsawaengsup, A. Techagumpuch, P. Chanswangphuvana, K. Kitisin, S. Pungpapong, C. Tharavej, P. Navicharern


Division of Bariatric Surgery, Chula Minimally Invasive Surgery Center, Bangkok, Thailand

In patients undergoing abdominal operation, in order not to increase morbidity and mortality risks, except for the emergent situations, surgical intervention of different organs is controversial. Some surgeons prefer to operate different organ pathologies at different times, but others do not. Advantage of doing more than one pathology is not to give an anesthesia more than once. On the other hand, some authors think that this may increase the risks of the operation. We operated 487 obese patients between March 2011 and December 2013 in our clinic. We choose sleeve gastrectomy (SG) (% 9,03) or gastric plication (GP) ( % 90,96) as an operation technique. 23 of these patients, had symptomatic cholelithiasis. We do laparoscopic bariatric surgery and cholecystectomy in the same session for those patients. All the patients had discharged without early complications. In 3 patients (13 %) after 6 months of operation, symptoms of gastroesophageal reflux (GER) cropped up. We made an endoscopy for these patients and diagnosed GER disease. After medical treatment, these patients have relieved. We have not seen any other complications. GER can be seen as a complication up to 47 % of patients undergoing laparoscopic bariatric surgery. Cholecystectomy in the same session did not increase the risk. Surgical treatment of additional pathology of abdomen in the same session is still controversial. We made cholecystectomy and bariatric surgery at the same time, because we rely on our experience in the surgery of obesity. We find non-objectionable to surgery of obesity and cholecystectomy in the same session

Background: Obesity is increasing globally. Weight loss surgery has been proved to be the most effective and sustainable weight control. Currently, Roux en Y gastric by pass and sleeve gastrectomy are the most common procedures. We compare results of both operations in our center. Methods: Patients who have undergone bariatric surgery by Chula Minimally Invasive Surgery Center, Chulalongkorn University were reviewed. Patients that have more than 6 months follow up were analyzed. Results: From July 2007 to December 2013. Two hundred and fifty consecutive Thai patients underwent 255 bariatric surgeries by Chula Minimally Invasive Surgery Center, Chulalongkorn University. There were 119 (46.6 %) Roux en Y Gastric bypass, 120 (47.1 %) sleeve gastrectomy, 9 (3.6 %) gastric bands, 2 (0.8 %) gastric plication and 5 (1.9 %) redo operation (3 sleeve gastrectomy to bypass, 1 pouch resizing and 1 plication to sleeve gastrectomy) Of these, 233 cases had more than 6 months follow up. The mean age was 35.1 (9–63) years. One hundred and twenty four of 233 (53.2 %) were women. Average pre-op BMI was 51.2(30.5–84.5) kg/m2 Pre-op BMI was significantly different between RYGB (48.8 kg/m2) and Sleeve gastrectomy (53.3 kg/m2) (p = 0.006). Gastric bypass resulted in mean EWL of 55.6 % and 71.8 % at 6 months and 12 months respectively whereas sleeve gastrectomy had mean EWL of 42.5 % and 53.1 % at 6 months, 1 year respectively (p \ 0.001). After excluding super morbidly obese (BMI [ 60 kg/m2) there were no different in pre-op BMI (46.7 kg/m2 for bypass vs. 49.1 kg/m2 for sleeve group (p = 0.093)) Gastric bypass was given EWL of 56.6 % and 72.5 % at 6 and 12 months versus 44.5 % and 54.9 % in sleeve gastrectomy (p \ 0.001) Fifty nine of 79 (74.6 %) who had diabetes were in remission and the left were able to decrease dosage of hypoglycemic drugs. Conclusion: Roux en y gastric bypass gives a better weight loss result comparing to sleeve gastrectomy. Randomize control trial has been initiated and necessary to address this difference. Post-operative management and follow up are also key factors to be effect the choice of operation.



Effects of Laparoscopic Gastric Plication in Metabolic Surgery

A Novel Method for Treating Gastric Fistula Complicating Laparoscopic Sleeve Gastrectomy: Biological Glue Application in a Combined Percutaneous and Endoscopic Approach

H. Yigitbas, H. Bilge, R. Kutanis, S. Arici, M. Tokocin, C. Ercetin, O. Gulcicek, E. Yavuz, A. Solmaz, A. Celik1, F. Celeb1 Bagcilar Training and Education Hospital, Istanbul, Turkey Obesity constitutes a serious health problem, which takes second place after smoking among preventable mortality. It impacts on health of the body by causing several diseases and by aggravating the progress of the diseases. Insufficient medical treatment and lack of patient’s adaption to the diet and physical activities leads to the development of surgical treatment. We aimed to evaluate the efficacy of recently used technique: ‘laparoscopic gastric plication’. In Bagcilar Research and Training Hospital; General Surgery Department we performed bariatric surgery in 321 patients who diagnosed as morbidly obese between March 2011 and March 2013. We performed laparoscopic gastric plication in 258 patients. 43 of them were T2DM. We analysed preoperative, postoperative findings and compared postoperative follow-ups retrospectively in these 43 patients. In this group 25 (%58) patients were female, 18 (%42) were male. Mean age was 41,6 ± 8,9 (23–66), mean height was 163 (153–185) cm, mean weight was 125,12 ± 19,2 (85–167) kg and the mean BMI was 44,37 ± 5,2 (33–57) kg/m2, we compared preoperative and post operative 12th month levels of HbA1c, Insulin, HOMA-IR, triglyceride, cholesterol, HDL-C, LDL-C, loss of weight, BMI; it was statistically significant (p:0.000). When we compared the %EWL levels of the patients in their 1st, 3th, 6th and 12th follow-ups; it was statistically significant (p:0.000). In conclusion we found out that LGP procedure does not increase the morbidity or mortality and makes an improvement in BMI and lipid profile. In patients follow-ups we observed improvements in diabetic parameters and insulin resistance

A. Assalia, A. Suissa, A. Mahajna, K. Yassin, I. Kogan, M. Leiderman, A. Ofer Rambam Health Care Campus, Haifa, Israel Laparoscopic sleeve gastrectomy (LSG) for the treatment of morbid obesity is gaining momentum worldwide. Leakage and subsequent gastric fistula is the most dreadful complication which may lead to serious morbidity and even mortality. We present herein a novel approach for the management of this severe complication. Patients and Methods: Eight morbidly obese patients (mean age = 39.2 years, mean BMI = 43.5 kg/m2) developed gastric fistula following LSG. Six patients underwent percutaneous drainage, one underwent operative drainage and one patient still had the drain from the original procedure. The fistula was acute in one patient, subacute in 5 and chronic in 2. Five patients underwent previous failed endoscopic interventions including stents, clips and injection of synthetic glue. Fibrin glue (5 ml of EVICEL Ò) was applied percutaneously in the space adjacent to the fistula, thus occluding the proximal tract and the gastric orifice of the fistula, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and treat possible continuous leakage. Results: There were no complications except of abdominal pain in 2 patients associated with fever in one. Both resolved within 1–2 days. Fistula closure was achieved in all patients. After a single application in 4, 2 applications in 3 and 3 applications in one. The mean follow up period was 7 months (range = 1–12). All patients are asymptomatic. Conclusions: Our initial experience indicates that percutaneous application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, cheap and effective method for the treatment of gastric fistula following LSG.

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Biliopancretic Diversion - Final Solution OD Obesity and Diabetes?

Complication-Based Learning Curve in Laparoscopic Sleeve Gastrectomy

P. Holeczy1, M. Buzga2, M. Bolek3, J. Kristof3, L. Havrlentova1, J. Sevcikova1

P. Delivorias, K. Fortounis, K. Konstantinidis, D. Fahiridis, C. Makridis

1

Papageorgiou General Hospital, Thessaloniki, Greece

AGEL Research and Training Center, Ostrava, Czech Republic; Medical Faculty, Ostrava University, Ostrava, Czech Republic; 3 Surgical Department, Vı´tkovice Hospital, INC, Ostrava, Czech Republic 2

Aims: Results of bariatric procedures are the best 2–3 years after the operation. Afterwards there is increasing weight tendency in some patients. There is the need for another operation or operations. The risk of secondary procedures is connected with greater risk, but there I also real benefit. The authors refer about influence of biliopancreatic diversion on weight and comorbidity. Methods: Prospective collected date from the group of 46 patients scheduled for reoperations for complications or failure of primary or secondary procedure. Of them were 10 biliopancreatis diversions. There were 6 women and 4 men. Five of them were diabetics. Results: Follow up in the range from 3 to 12 month was 100 %, weight reduction in average was 28 kg, it means 43,22 % excess weight loss. Improvement in glycaemia, glycated hemoglobin, and reduction of medication was observed in all diabetics. Improvement of hypertension was not as good, as was expected. Conclusion: Reoperation in bariatric/metabolic surgery are challenging for surgeon. They are connected with greater risk, but the positive effect could be recorded. After silure of ‘restrictive’ methods there is a need to perform the most complicated procedures. The result is weight reduction and improvement of comorbidity and quality of life.

Aim: The aim of our study was to evaluate the learning curve for laparoscopic sleeve gastrectomy (LSG) in association with the incidence of its complications. Method: The first consecutive 200 patients (39 M/161F) who underwent LSG in our Department were analyzed in a retrospective basis. Patients were divided in 10 groups (G1–10) of 20 according to case sequence. Complications over time were compared between groups. Results: Mortality and conversion rates were zero. In total, 14 complications (7 %) were recorded, including 5 cases (2.5 %) of staple line leak, 2 cases (1 %) of hemorrhage, 4 cases (2 %) of nutrient deficiencies, 1 case (0.5 %) of sleeve stricture, 1 case (0.5 %) of superior mesenteric and portal vein thrombosis and 1 case (0.5 %) of intraabdominal abscess. In 4 cases (2 %) reoperations were performed. There were 5 complications, 2 cases of hemorrhage successfully managed with transfusion and 3 cases of nutrient deficiencies, in the initial phase of LSG performance (G1–3 [1–60pts]). The majority of serious complications were recorded in G4–6 (61–120pts) (5 cases of staple line leak - 3 of which required reoperation, 1 case of intraabdominal abscess, 1 case of sleeve stricture requiring reoperation and 1 case of superior mesenteric and portal vein thrombosis). Apart 1 case of nutrient deficiency, there were no postoperative complications in subsequent groups (G7–10 [121–200pts]). Conclusions: LSG can be safely performed with acceptable morbidity. According to our results, postoperative complications of LSG might be reduced dramatically after an experience of about 100 cases.



A 6-Year Experience with Laparoscopic Adjustable Gastric Banding: 285 Patients

V-LOC Suture is an Effective and Safe Method to Close Gastrojejunostomy and Jeunojejunostomy in Gastric By-Pass

H. Altun1, O. Banli2, H.K. Celik3, R. Karakoyun4, A.B. Karip3, M. Okuducu3, B. Kaya3, K. Memisoglu3

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

Liv Hospital, Istanbul, Turkey; 2Bozok University, Yozgat, Turkey; Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey; 4Antalya Education and Research Hospital, Antalya, Turkey

San Paolo Hospital, Savona, Italy

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Aims: Obesity is an increasing health problem worldwide and it is a preventable cause of death. Laparoscopic adjustable gastric banding is the most popular restrictive procedure for morbid obesity in Europe. The aim of this study is to report 6-year results for laparoscopic adjustable gastric banding. Methods: A total of 285 patients underwent laparoscopic adjustable gastric banding at our center between February 2006 and July 2012. All patients met minimal eligibility criteria for bariatric surgery according to the NIH Consensus Development Panel report of 1991. There were 223 women (78.2 %) and 62 men (21.8 %). Median age was 38.5 years and ranged between 18 and 60 years. One of the two laparoscopic bariatric surgeons performed all the operations. Results: The mean operative time was 50 min (range 35–215 min). Mean hospital stay was 1.2 days (range 1–12 days). The mean excess weight loss was 46.1 %, 69.1 % and 65 % at 1 year, 2 years and 3 years follow up, respectively. Excess weight loss was 63 % at = 5 years follow up. Early complications (up to 30 days after surgery) occurred in 12 patients, while late complications occurred in 18 patients. Twenty-eight patients (9.8 %) were reoperated because of LABG related complications. Conclusion: Laparoscopic adjustable gastric banding has gained a lot of popularity. Laparoscopic adjustable gastric banding is associated with decreased postoperative complications and a shorter learning curve compared to other bariatric procedures. In our study, patients achieved satisfactory excess weight loss and low complication rate at 5 years.

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Aims: to review the outcomes of closure of gastrojejunostomy and jejunojejunostomy in double loop gastric by-pass with a three 0 barbed polyglyconate suture, the 15 cm long V-loc 180. Methods: from January 2011 and December 2013 V-Loc 180 was used in 84 patients, submitted to a double loop gastric by-pass, to close the side to side stapled gastrojejunostomy and the side to side stapled jejunojejunostomy. Primary outcomes were anastomotic leakage and anastomotic bleeding. Secondary outcomes were anastomotic stenosis, and the need to re-operate the patients because of an anastomotic complication. Results: there were no leak and no bleeding both in the 84 gastrojejunostomy and 84 jejunojejunostomy. Moreover there were no stenosis and no need to re-operate patients for anastomotic complications in the follow-up (mean 12 months range 1–24 months). Conclusion: closure of gastrojejunostomy and jejunojejunostomy in double loop gastric bypass with the V-Loc barbed suture can be performed safely and efficiently. In 168 anastomosis there were no adverse events and equivalent functional outcomes with our previous technique.

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Complications of Laparoscopic Sleeve Gastrectomy

Retroperitoneal Abscess: A Rare Complication After Laparoscopic Gastric Bypass

K. Fortounis, P. Delivorias, D. Paralikoudi, A. Anastasiadou, C. Makridis Papageorgiou General Hospital, Thessaloniki, Greece

E. Baldini1, S. Albertario1, F.B. Cattadori1, F. Bilancio1, M. Negrati2, P. Capelli1 Ospedale ‘G. da Saliceto’, Piacenza, Italy; 2Az. Sanitaria Piacenza, Piacenza, Italy

1

Aim: The aim of our study was to examine the morbidity and mortality arising from laparoscopic sleeve gastrectomy (LSG) as a single-stage bariatric procedure. Method: 204 patients (F/M: 165/39) who underwent LSG as a single-stage bariatric procedure in our Department from 2009 to 2013 were retrospectively reviewed. Postoperative course, clinical presentation and treatment of complications were recorded. Results: Mortality rate was zero. No conversions to open operation occurred. A total complication rate of 7.3 % was recorded. Staple line leak was the most frequent postoperative complication, observed in 5 patients (2.4 %). Conservative treatment with total parenteral nutrition and antibiotics was successful in 2 cases. However, 3 patients required a combination of percutaneous drainage under CT guidance, stenting and reoperation including abdominal washout, drainage and establishment of a feeding jejunostomy. There were also 3 cases (1.5 %) of hemorrhage (2 from the staple line and 1 from a port site) that needed transfusion, 4 cases (2 %) of nutrient deficiencies (2 of vitamin B12, 1 of vitamin B1 and 1 of folic acid) presented with peripheral neuropathy symptoms and managed with proper supplementation, 1 case (0.5 %) of sleeve stricture presented 6 months after LSG with dysphagia and vomiting that required open repair with Roux-en-Y gastrojejunostomy, 1 case (0.5 %) of superior mesenteric and portal vein thrombosis managed with therapeutic anticoagulation and 1 case (0.5 %) of intraabdominal abscess, in a patient under immunosuppressive therapy for rheumatoid arthritis, conservatively managed with antibiotics. Conclusion: LSG is a safe surgical option as a single-stage bariatric procedure, with relatively low complication rates. Early diagnosis and adequate multidisciplinary management of its major complications is the key for further reduction of LSG-related morbidity and mortality.

This video shows a case of a retroperitoneal abscess complicating a laparoscopic gastric bypass. A 43 years old man, 124,1 kg weight, BMI 43,6 kg/sm, was operated of a laparoscopic gastric bypass. Comorbidities were hypertension, hypercholesterolemia and metabolic syndrome. Five ports were placed. Gastric pouch was calibrated on a 36 F bougie, mesuring 6 cm fron the His angle. Fashioning the gastric pouch was difficult because of strong adhesions behind the small gastric curve and posterior gastric wall. Antecolic alimentary limb and bilio-pancreatic limb measured 150 and 80 cm, respectively. Termino-lateral anastomosis was hand-sewn with 3/0 PDS running sutures. A blue methilene test was performed and a naso-gastric tube was inserted through the anastomosis. A paraanastomotic drain was left in place. Patient had abdominal pain, irradiated to the back, with fever on postoperative day 1. A blue methylene test, orally administered, was positive (blue in the drain). An abdominal CT scan showed a gastric pouch fistula with a retrogastric collection, mimicking an lesser omental sac abscess. Patient received antibiotic and fluids and was reoperated. At explorative laparoscopy, peritoneal cavity was clean, with only a few fibrine membranes. An intraoperative blue test showed integrity if anastomosis. After dissection, a perforation of posterior gastric pouch wall was found, with a vertical staple line that was uncomplicated. The small omental sac was clean. A retroperitoneal suprapancreatic abscess was found, that was drained putting a drain directly into the fistula. Patient improved under parenteral nutrition and antibiotics. A postoperative CT scan showed the good drainage of the abscess cavity. An esophagogram showed the absence of leak 10 days after reoperation. An endoscopic prothesis was applicated 7 days after reoperation but it migrated 2 days after. CT scan and X-Ray controls showed the complete resolution of fistula and abscess 20 days after. Retroperitoneal abscess after gastric bypass are rare, and they mime a lesser omentum collection on radiological images. A possible etiology is misusing the calibration tube, that can cause contusion of the posterior gastric wall with a subsequent perforation. Prompt laparoscopic lavage and drainage is an efficacious way to treat this complication.



Postprandial Alterations of Ghrelin and GLP-1, 3 Years After Laparoscopic Sleeve Gastrectomy

The Role of Routine Blood Tests in the Evaluation of Postoperative Bleeding in Bariatric Patients

S. Kapiris1, P. Patrikakos1, D. Perrea2, T. Mavromatis1

C. Neophytou, N. Menon, J. Ahmed

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2

Evangelismos General Hospital of Athens, Greece; Laboratory of Experimental Surgery, Medical School, University of Athens, Greece Introduction: Metabolic surgery is the evolution of bariatric surgery. Laparoscopic Sleeve Gastrectomy (LSG) is an operation with encouraging results in long term weight loss. The aim of our study is to present the postprandial alterations of Ghrelin and GLP-1, preoperatively and 3 years after LSG. Method: Ten randomly selected morbidly obese patients underwent LSG. Blood samples were taken preoperatively (after overnight fasting) and after a standardized meal, consisting of bread carbohydrates, egg protein, and margarine fat. The samples were taken before the meal, 30’ and 90’ after. The same protocol of blood sampling was repeated 3 years after the initial surgery. The samples were analyzed for GLP-1, acylated ghrelin, and unacylated ghrelin. Results: Mean BMI decreased from 45.36 kg/m2 to 30.05 kg/m2. There was no significant change in the levels of GLP-1 preoperatively and 3 years after LSG, but a rapid decline of postprandial GLP-1 was observed between 30 and 90 min. The levels of unacylated ghrelin were significantly reduced 3 years after the operation, but the levels of the biological active aylated ghrelin presented no significant difference. The levels of total ghrelin (acylated plus unacylated) were reduced. Conclusion: Although total ghrelin is reduced 3 years after LSG (reflecting the absence of gastric fundus), the levels of the biological active acylated ghrelin remain unchanged possibly due to a compensation by an increase of production of extragastric acylated ghrelin.

Royal Derby Hospital, Derby, United Kingdom Aims: The aim of this study is to investigate the role of routine blood tests in evaluating and identifying post-operative haemorrhage in patients undergoing bariatric procedures. Methods: This was a retrospective study covering a period between 01/03/2009 to 31/05/ 2013. Data were obtained from the bariatric database maintained by one of the Royal Derby Hospital Bariatric surgeon. Epidemiological data, type of procedure and pre- and day one postoperative blood test results were recorded. There were no exclusion criteria. Statistical analysis was done using chi-square test. Results: A total of 367 consecutive patients (258 female) were included. 298 gastric bypasses, 53 sleeve gastrectomies and 16 revisions were performed. A total of 83 patients had 101 complications in the post-operative period ranging from six months to two years. Four patients had significant post-operative bleeding that required further surgical intervention. These were identified with a combination of observations (tachycardia and hypotension), physical examination, blood test results and imaging (in 3 cases). Analysis of pre and post-operative blood tests revealed a statistically significant relationship between haemorrhage and a drop in haemoglobin of more than 20 g/L (p \ 0.001), an increase in white cell count by 4x109/L (p \ 0.05), an increase in the haematocrit by a factor of 15 % (p \ 0.05) - which cannot be explained by the infusion of routine intravenous fluids alone and an increase in the creatine by 10 lmol/L (p \ 0.05). Conclusions: Physical signs and examination are valuable when assessing patients in order to establish any post-operative complications. Para-clinical investigations (routine bloods and imaging investigations) offer a more holistic approach and can sometimes reveal a significant complication that might otherwise not be obvious at first instance. The cut-off points proposed above can hopefully offer a useful guide and alert to the physicians that perform the initial assessment in such patients.

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Revisional Surgery: Routine One-Step Transforming Failed Gastric Band (LGB), Vertical Banded Gastroplasty (VBG), and Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Is it Significant To Reinforce Staple-Line During Laparoscopic Sleeve Gastrectomy? An Early Egyptian Experience

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2

2

2

R. Zorron , C. Bothe , E. Junghans , T. Junghans 1

Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany; 2 Division Innovative Surgery, Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Gefa¨s, Bremerhaven, Germany Objectives: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the most performed primary bariatric procedure for morbid obese patients, with good postoperative results and achieving adequate excess weight loss (EWL). Purely restrictive techniques as laparoscopic gastric banding (LGB) and vertical banded gastroplasty (VBG) have a higher failure rate in achieving adequate weight loss, and conversion to LRYGB can potentially be beneficial also for previous Sleeve Gastrectomy (SG) in patients with inadequate results. Methods: The video shows fundamental surgical steps in transforming LGBs VGBs, and SGs to LRYGB, in morbidly obese patients (BMI 45.3 to 57 kg/m2 submitted to restrictive procedure more than 2 years before and inadequate weight loss. Technical steps included: 1. Fully adhesiolysis and dissection of the small curvature including hiatus; 2. Liberation of the hiatus and upper greater curvature with ultrassonis energy; 3. Resection of the band and fibrous tissue and creating a small stapled gastric pouch over a 32Fr Bougie. 4. Handsewn gastrojejunal anastomosis PDS 3.0 at 70 cm, stapled jejuno-jejunal anastomosis at 150 cm; and 5. Leak testing with methylene blue and drainage. Results: Mean operative time was 266 min. Operative blood loss was less than 50 ml. There were no intraoperative complications. As postoperative complication, one patient was reoperated due to partial rupture and perforation of the Roux-en-Y anastomosis at 3 months after massive volume meal and recovered well. One patient received nontherapeutic relaparoscopy in the 2nd postoperative day. Follow-up showed adequate excess weight loss by 6 months and ameliorating of co-morbidities. Conclusions: One-step revision to LRYGB of failed restrictive bariatric procedures represents the state of the art in achieving optimal results in weight loss and controlling comorbidities. Careful identification of the altered anatomy and handsewing skills are important preconditions for the surgeon in performing advanced revisional procedures in bariatric surgery.

A.I. Talha1, K. Katry Md, Frcs2 1 Medical Research Institute, Alexandria University, Alexandria, Egypt; 2Faculty of Medicine, Alexandria University, Alexandria, Egypt

Background: Laparoscopic sleeve gastrectomy (LSG) is an easy and safe technique with a shorter learning curve. The risk of staple-line bleeding, leakage, and dehiscence are much higher because of long staple-line. This study was carried out to detect the importance of staple-line reinforcement. Methods: Between March 2010 and October 2012, we retrospectively reviewed the medical records of 168 consecutive patients with a diagnosis of morbid obesity based on the guidelines issued by IFSO who underwent LSG and completed their follow-up for a minimum one year; 102 with (group A) and 66 without (group B) staple-line reinforcement at Alexandria University hospitals. Outcome parameters including; leakage, bleeding, operative time, surgical complications, hospital stay, follow-up details, and quality of life were collected. Results: The demographic parameters were comparable in the two groups. No conversion to open surgery was detected. There was no case of staple line bleeding, leakage or stricture in either group. The mean operative time in Group A (139 ± 10 minutes) was significantly greater than in Group B (117 ± 19 minutes) (P = 0.01). No significant difference regarding the other outcome parameters. Conclusions: LSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience. Oversewing of the staple line did not have any additional benefit, although a larger study is required to reach a definitive conclusion.



Intragastric Single Port Surgery (IGS): New Technique for Endoluminal Sleeve Gastrectomy for Morbid Obesity- First Human Case Report

Single-Port Sleeve Gastrectomy in Adolescents with Severe Obesity

1

2

2

R. Zorron , H.N. Phillips , A.L. Oliveira , R.A.K. Fiorelli

2

1

Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany; Hospital Universitario Gafree Guinle UNIRIO, Rio de Janeiro, Brazil

G. Pourcher1, G. de Philippo2, P. Bougneres2, I. Dagher1 APHP/Antoine Beclere Hospital, Clamart, France; 2APHP/Biceˆtre hospital, Le kremlin-biceˆtre, France 1

2

Objectives: Laparoscopic sleeve gastrectomy has gained popularity and acceptance among bariatric surgeons, mainly as a result of its low morbidity and mortality. However, leak complications of sleeve gastrectomy happen due to inadequate blood supply at the His angle, and as a consequence of stenosis at the incisura angularis. To have optimal view control of the gastric sleeve, a new technique of Intragastric Sleeve Gastrectomy was tested in an experimental survival animal study, resulting in the first human case report. Methods: IRB approval and informed consent was obtained for percutaneous intragastric sleeve gastrectomy (IGS) in a 56-year-old female patient with a BMI of 43.2 Kg/m2 with comorbidities with indication for bariatric surgery. A 2.5 cm incision was made in the epigastrium and allowed exteriorization of the gastric wall, and a Single Port device was introduced intraluminally under direct view. Intragastric sleeve resection with endoscopic control of the resulting lumen was performed using consecutive charges of 60 mm intragastric stapling. The specimen was extracted through the single port without extraction bag. The gastrotomy was closed percutaneously with conventional single layer absorbable suture. Animal Ethic Comitee approval was obtained for a survival study with 5 swine. Results: The procedure time was 48 min. There were no intraoperative complications. Postoperative the patient underwent regular diet on the next day, and was dismissed on the 6th postoperative day. There were no postoperative complications, and the control swallow study revealed an adequate sleeve. Early follow up showed adequate weight loss. In the animal study, all survived 14 days with no complications. Conclusions: The new concept of intragastric percutaneous Single Port partial gastrectomy (IGS) allows the performing of sleeve gastrectomy and may represent a promising alternative therapy for selected patients. Further clinical series are needed to evaluate the role of this technique in clinical use.

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Background: The treatment approaches commonly used in overweight or obese youth are poorly effective in those with severe obesity. Published experience with bariatric procedures in obese adolescents suggests that weight loss, reversal of comorbidity, and safety are comparable or better than those seen in adults. Laparoscopic sleeve gastrectomy is commonly performed using multiple ports. Objectives: We aimed to be test single port laparoscopy (SPSG) as a minimally invasive surgery in severely obese adolescents. Methods: Prospective clinical and biochemical data were collected from 16 young massively obese patients followed in the Pediatric Obesity Center of Paris Sud University who underwent SPSG. Results: Mean age was 17.5 years, 12 were girls. Mean weight was 119.2 kg, and mean BMI 43.9. None of the patients had hypertension or diabetes. All patients were insulinresistant and 6 presented hypertriglyceridemia. Median operating time was 66 minutes. There were no intraoperative complications. No conversion to open surgery was required. No patient required additional trocars. No patient had postoperative complications. The median hospital stay was 3 days. During a median follow-up of 12.4 months, we observed a significative weight loss (41.7 ± 23.4 kgs after 12 months, 32.5 ± 7.7 % Weight Loss and 59.9 ± 11.9 of % Excess Weight Loss after 12 months (p \ 0.05 12 vs 6 months for both). Improvement of insulin-resistance was observed in all patients and all but one patient recovered from hypertriglyceridemia. Conclusions: SPSG seems at least as safe and effective in the short term in adolescents as it is in adults.

Surg Endosc

P572 - Morbid Obesity Which Reflects More Significant Ghrelin Profiles for Morbid Obese Patients, Ghrelin Cell Counts or Serum Ghrelin Level? Y. Miyazaki1, S. Takiguchi1, Y. Seki2, K. Kasama2, T. Takahashi1, Y. Kurokawa1, M. Yamasaki1, H. Miyata1, K. Nakajima1, M. Mori1, Y. Doki1 1

Graduate School of Medicine, Osaka University, Suita, Japan; 2 Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan Aims: The aims of this study was to estimate the number of ghrelin cells at the gastric mucosa and its clinical significance and compare it with serum ghrelin level in obese patients. Methods: Fifty-eight obese patients who underwent sleeve gastrectomy with or without duodenojejunal bypass were enrolled in the study. The number of ghrelin cells (GPCs) was counted using immunohistochemistry of the gastric mucosa at the fundus of all patients. Serum desacyl ghrelin level was evaluated with enzyme linked immuno solvent assay, which data was available for 25 patients. Results: The obese patients were divided into two groups with high and low ghrelin levels based on the number of GPCs and serum desacyl ghrelin level. The percent excess body weight loss (%EBWL) was almost significantly greater in the high GPCs group without differences in the patient backgrounds between the two groups (p = 0.054). Contrary to the number of GPCs, serum desacyl ghrelin level was not correlated with %EBWL (p = 0.43). Conclusions: The number of ghrelin cells at the stomach reflected more significant ghrelin profile as to excellent body weight reduction after sleeve gastrectomy rather than serum ghrelin level.

P574 - Oesophageal and Oesophagogastric Junction Disorder Laparoscopic Surgery for Submucosal Tumours Located Near the Esophagogastric Junction T. Soma1, M. Sugano2, C. Kawasaki1, M. Tsuji1, I. Fukui2 1

Moriyama Municipal Hospital, Moriyama, Shiga Prefecture, Japan; Obama Municipal Hospital, Obama City, Fukui Prefecture, Japan

2

Aims: Laparoscopic treatment is widely accepted for gastric submucosal tumours (SMTs). However, it is sometimes difficult to identify the line of resection. In particular, SMTs located near the esophagogastric junction tend to manage by proxymal or total gastrectomy, because there is possibility to develop postoperative stenosis or deformity. This study was conducted to evaluate surgical techniques for management of SMTs located near the esophagogastric junction. Methods: We retrospectively reviewed about three patients with gastric SMTs located near the esophagogastric junction at Obama Municipal Hospital between 1 October 2008 and 30 September 2011. Results: Laparoscopic surgical treatments were successfully performed on all patients. We performed proximal gastrectomy, intragastric surgery and wedge resection, respectively. In these cases, we confirmed esophagogastric junction by endoscopy. Endoscopist performed transoral endoscopy to identify distal margin of the lesion and direct visualization of esophagogastric junction. Accordingly we can be safely performed with adequate cutting lines. Moreover we minimizes the surgical specimen while still providing sufficient surgical margins to successfully cure gastric SMTs. Conclusions: Endoscopy-assisted gastric resection is a safe and reliable procedure for SMTs located near the esophagogastric junction, because it made produced less stenosis or deformity of the esophagogastric junction.

P573 - Oesophageal and Oesophagogastric Junction Disorder


Successful Medical Management of Gastric Fistula After Minimally Invasive Three Fields Esofagectomy by Megaesophagus Secundary to Achalasia

Management of Boerhaave’s Syndrome - A 10-Year SingleCentre Experience

E. Dorado, A. Romero Fundacion valle del lili, Cali, Colombia Introduction: Achalasia is a disease that affects men and women equally, although it is not yet clear etiology, progression to a megaesophagus is evident in the terminal stages of the disease. In advanced cases esophagectomy is the best option for these patients. Methods and Procedures: 50 year old patient with progressive dysphagia during six years of evolution with endoscopy, intestinal transit and manometry indicating megaesophagus for achalasia. He lost 6 kg in 2 months, nutritional recovery starts before surgery per 10 days and is scheduled for three fields minimally invasive esophagectomy. Procedure starts with a prone thoracoscopy, followed laparoscopy and finally ascent of the stomach and cervical with blue cartridge laterolateral anastomosis of the esophagus with the stomach. The patient had an incidental finding of Zenker diverticulum was resected with mechanical suture. we left a right thoracostomy and nasoantral feeding tube and 6 hours after procedure started nutrition. Results: 4 days left we ordered esophagogram showing no leaks and delayed gastric transit. per routine we dont perform pyloromyotomy. At seven postoperative day the patient shows change in the characteristics of thorax drainage and elevated acute phase reactants. we schedule an emergency thoracoscopy with evidence of empyema handled successfully with drainage and leave anterior and posterior thoracostomy, we didnt see a perforation, by accident nasoantral tube was move for nurse and we need a endoscopy for pass a new tube, During the passage of tube, air insufflation permit dehiscence of the suture line 1 cm the patient was managed with thoracostomy, enteral nutrition and New Whey protein. No infectious complications occurred 60 days after the first surgery decreased production of intrathoracic tube, methylene blue test and negative esophagogram filtration test we started diet. level of Albumin at time of dehiscence was 1.7 and 3.0 at discharge, Conclusion: Esophagectomy for minimal invasion is a safe and well tolerated procedure. 11 % may have leaks, especially in the cervical anastomosis. Conservative management with drainage of fistula and optimizing the nutritional requirements allowed rapid recovery and sealing of the fistula on a record time of 60 days.

Y.W. Leung, W.F. Wong, K.F. Wong, S.K. Leung Tuen Mun Hospital, Tuen mun, Hong Kong Aims: Boerhaave’s Syndrome is an uncommon but lethal condition. Despite various treatment modalities advocated, mortality may still reach 30–40 %. There are controversies over the management strategy, especially the choice of operative versus endoscopic treatment. We present our experience in the management of Boerhaave’s Syndrome, and explore the optimal management for this difficult condition. Methods: Patient records with diagnosis of spontaneous rupture of lower oesophagus (Boerhaave’s Syndrome) were reviewed from 2003 to 2013. There were 11 patients, 10 men and 1 woman. The mean age was 59 years. Demographic data, presentation, diagnosis, management and outcome were retrospectively analyzed. Results: 91 % of the patients had history of vomiting and 60 % presented with shock on admission. Mackler’s triad (chest pain, vomiting and surgical emphysema) was present in 30 % of cases only. In 80 % of cases, both chest X-ray and computed tomography revealed pneumo-mediastinum and pleural effusion. Nine patients received primary repair of oesophagus, with or without reinforcement flap. Two patients received endoscopic stenting. The mean age was 57.1 years in the operative group and 69.5 years in the endoscopic group. The overall mortality rate was 27 % (33 % in the operative group and 0 % in the endoscopic group). All patients were admitted to the intensive care unit (ICU). The mean ICU stay was 14.2 days in the operative group and 12 days in the endoscopic group. No statistically significant risk factors (sex, age, smoking and drinking habits, American Society of Anesthesiologists grading, albumin level, creatinine level, white cell count, contamination, management options, ICU stay) were identified that would predict morbidity or mortality. Conclusion: Boerhaave’s Syndrome is associated with high mortality. Endoscopic stenting can successfully manage Boerhaave’s Syndrome in selected cases as illustrated in two of our patients. It is an alternative to operative management and has the potential benefit of avoiding the operative risks.

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Value of HR-Manometry, Endoscopy and Barium Swallow in Diagnosing Hiatal Hernia in Patients with Symptoms of GERD

Surgical Management of Epiphrenic Esophageal Diverticulum

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

Introduction: Assessment of hiatal hernia is typically done with upper endoscopy, radiographic barium swallow or recently high resolution (HR) esophageal manometry. Comparison data between the methods concerning the detection of hiatal hernia and correlation to gastroesophageal reflux disease (GERD) is limited. Patients and Methods: Retrospective analysis of patients with subjective symptoms of GERD who underwent upper gastrointestinal endoscopy, HR manometry, barium swallow, and ambulatory multichannel intraluminal impedance monitoring (MII) between August 2012 and October 2013 at our institution. During endoscopy the gastroesophageal junction was graded I through IV using Hill’s classification. Hill grade III and IV were defined as hernia. Manometrically and radiologically hernia was defined as separation of the gastroesophageal junction [2 cm from the crural diaphragm. Statistically comparative analysis between hernia sizes, Hill grading, demographic data, and presence of reflux disease was performed. Results: 112 patients were analysed. With HR- manometry a hiatus hernia was diagnosed in 35 patients, radiologically in 86 patients and endoscopically in 54 patients. A significant accordance regarding the detection rate of hiatus hernia was proved between HR manometry and endoscopy (p = 0.001). GERD was diagnosed with MII in 77 patients (68.8 %). Hiatal hernia size detected with HR Manometry and HILL grading showed a significant correlation with GERD (p = 0.031 and p = 0.027). Radiographic barium swallow examination showed no accordance to HR manometry and endoscopically detected hernias, furthermore no correlation to GERD could be found. Increasing values of BMI significantly correlated with GERD (p = 0.018) Conclusion: Endoscopically and manometrically detected hernias correlated with each other and with objective GERD. Radiographic barium swallow should no longer be recommended for preoperative assessment of hiatal hernias and GERD patients.

´ braha´m, L. Andra´si, Gy. La´za´r J. Tajti Jr, A. Paszt, Zs. Simonka, Sz. A University of Szeged, Szeged, Hungary Introduction: The incidence of esophageal diverticula is very rare. Symptoms like dysphagia, regurgitation or foetor ex ore can be observed. Epiphrenic diverticula occur in the distal part of the esophagus near the diaphragm, usually projecting from the right posterior wall. The conventional exploration of the esophagus involves considerable morbidity, while nowadays the minimally invasive technique is the first choice for the treatment of the functional and benign esophageal disorders. Aims: The objective of the present study was the examination of the outcome of the minimally invasive surgical treatment of the epiphrenic esophageal diverticula. Methods: Between 1 January 2002 and 12 December 2011, a total of 6 patients (4 women, 2 men) underwent laparoscopic transhiatal resection of epiphrenic diverticulum in our institution. The mean age of the patients was 61.5 (52–76) years. In all cases preoperative examinations (swallow test, esophagogastroscopy, esophageal manometry and pH testing) were carried out. The mean size of the diverticula was 7.14 (3–12) cm. They occurred 3.7 (1–8) cm from the esophagogastric junction. Achalasia and hiatal hernia were observed in 2–2 cases. Results: During laparoscopic transhiatal exploration, controlled by intraoperative endoscopy, the resection of the diverticulum with endostapler, Heller’s esophago-cardiomyotomy and anterior Dor fundoplication were performed. In 1 case merely diverticulectomy was required. The duration of surgery was 150 (120–180) minutes. There were no intraoperative complications and conversion. The mean length of hospital stay was 10 (6–15) days. In 1 case mild extraluminal leakage of the contrast medium was detected by control postoperative contrast swallow test, which was resolved through conservative treatment. There was no death. During the follow-up the postoperative complaints of the patients were diminished and ceased. Conclusion: The minimally invasive surgical technique can be used safely with low rate of complications and fast recovery for the surgical treatment of epiphrenic esophageal diverticula.



Does Achalasia Always Make Patient Thin? A Very Rare Case of Achalasia Combined with Obesity Who Received Successful Single Incision Laparoscopic Surgery for Both Disorders

Our Standard Procedure in Anti-reflux Surgery for GERD Patients

H.C. Huang, H.C. Yeh, C.C. Luo, R.J. Chen

T. Suwa, S. Inose, K. Kitamura, T. Matsumura, K. Karikomi, E. Totsuka, N. Nakamura, K. Okada

Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan

Kashiwa Kousei General Hospital, Kashiwa, Chiba, Japan

Aims: Achalasia is an uncommon primary esophageal motor disorder and is characterized by ineffective relaxation of the lower esophageal sphincter (LES), leading to difficult emptying and gradual esophageal dilation. Most patients complained of dysphagia, aspiration, and pain. Reasonably, almost all patients with achalasia suffered from weight loss. We present a rare case of achalasia combined with obesity, who received laparoscopic Heller myotomy, Dor fundoplication and lapsroscopic sleeve gastrectomy (LSG) with single incision laparoscopic surgery (SILS) method at the same time. Patient and Methods: A 37 years old female suffered from dysphasia for 3 years. She received panendoscopy and upper gastrointestinal (UGI) series and achalasia was confirmed. For overcoming difficult swallowing, she always drank a lot of water to ‘flush’ food into stomach. Although dysphagia attacked, she never experienced body weight loss; quite the contrary, she became more and more fat. Some attempts for reducing weight were tried but failed at all. While visiting our hospital, her body weight was about 80 kg and the body mass index (BMI) was about 33 kg/m2. We performed UGI series and panendoscopy again for pre-operative survey. LES pressure could not be obtained because patient refused esophageal manometry study. The SILS operation of Heller myotomy with Dor fundoplication and sleeve gastrectomy was performed successfully. Outcome: This lady discharged from our hospital smoothly on the 6th day after operation. Although mild epigastric pain attacked sometimes, dysphagia was released obviously. UGI series and abdomen CT were performed for follow-up about one month after surgery and great improvement in esophageal empty without complication was confirmed. Gradual body weight reduction persisted during the first 6 months. The final effect of LSG should be followed in the future. Summary: Although very rare, achalasia combined with obesity may happen still. The surgical interventions for both disorders might be performed safely at the same time, even with SILS method.

Introduction: Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated. We have simplified it and established a simple procedure. Surgical Procedure: Setting Our 5-trocar setting with patients in the reverse Trendelenburg’s position for laparoscopic Nissen fundoplication is as follows. A 5 mm trocar was inserted just below the navel for a laparoscope (A). A 5 mm trocar was inserted in the upper right abdomen for a snake-retractor to pull up lateral segment of the liver. A 5 mm trocar was inserted in the upper right abdomen for operator’s right hand. A 5 mm trocar was inserted in the upper left abdomen (B). A 5 mm trocar was inserted in the middle left abdomen (C). Step 1 Under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus has been dissected free, and the esophagus is being recognized. The soft tissue at the posterior side of the abdominal esophagus was carefully dissected. Then the left crus of the diaphragma was recognized from the right side. Step 2 The branches of left gastroepiploic vessels and the short gastric vessels were divided with LCS. The left crus of the diaphargma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. Step 3 The right and left crura are sutured with interrupted stitches to reduce the hiatus. From the right side, the stomach is grasped from behind the esophagus. Then the fornix of the stomach is pulled to obtain a 360 degree ‘stomach-wrap’ around the esophagus (fundoplication). Using nonabsorbable braided suture, stitches are placed between both gastric flaps. THE CHARACTERISTIC FEATURES OF OUR PROCEDURE 1. Floppy Nissen fundoplication 2. No use of bougie device or taping technique for esophagus 3. Rotation of scope site Results: This procedure needs 2 surgeons (the operator and the assistant (scopist)). The mean operation time was about 60 min. A favorable outcome was assessed by radiograms performed during hospital stay. Resolution of the symptoms was noted at follow-up 1 month postoperatively in mostly all cases.

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Laparoscopic Fundoplication in Large Hiatal Hernia and Upside Down Stomach, a Case Report and Retrospective Review

Long-Term Results of Laparoscopic Antireflux Operations Performed by a Single Surgeon Without Mesh Prosthesis: EightYear Follow-Up

Y. Tsukumo, Y. Nagahisa, Y. Kawamoto, Y. Uchida, T. Ito Kurashiki Central Hospital, Kurashiki City, Okayama, Japan Aims: Laparoscopic surgery for upside down stomach is difficult and reported cases in Japan are few. We describe a rare case of massive incarcerated type IV hiatal hernia and upside down stomach successfully treated by laparoscopic surgery. To clarify the effectiveness of laparoscopic surgery, we also retrospectively reviewed cases of upside down stomach treated by laparoscopic repair in Japan. Methods: An 87-year old female was admitted with frequent vomiting. Abdominal CT scan revealed a large hiatal hernia and upside down stomach, and she underwent a laparoscopic fundoplication. Intraoperatively, it was difficult to pull both the incarcerated stomach and greater omentum, and strip off the adhesions around the stomach. A crural closure and composite mesh implantation was undertaken, followed by Toupet fundoplication. The postoperative course was good, and she was able to eat without vomiting six days postoperatively, resulting in hospital discharge. Results: Our retrospective investigation found 16 cases of of upside down stomach treated by laparoscopic repair in Japan. Fifteen patients (93.8 %) were female, and the mean age was 80 years (range = 49–100). The most common symptoms on presentation were postprandial, epigastric, or retrosternal pain (n = 6, 38 %) vomiting (n = 5, 31 %), and heartburn or stomach discomfort (n = 3, 18.8 %). Nine patients (56 %) presented with acute symptoms and 15 cases (93.8 %) were elective surgery. Median operating time was 235 min (range = 144–386) and mesh was used in six cases (38 %). Fundoplication was performed in 13 cases (81 %), consisting of Toupet in six (38 %), Nissen in six (38 %), and Dor in one case (6 %), respectively. Postoperative complications occurred in three patients (19 %), pleural effusion, delayed gastroduodenal emptying and deep vein thrombosis. Median postoperative hospital stay was 13.8 days (range = 6–44). There was no mortality or symptomatic recurrence. Conclusions: Laparoscopic surgery for upside down stomach was effective, and the rate of postoperative complication was satisfactory.

O.B. Ospanov, A.M. Orekesheva, R.E. Khassenov, M.N. Samatov Astana Medical University, Astana, Kazakhstan Background: This retrospective study reports the long-term results of laparoscopic antireflux surgery after primary and redo fundoplication. Methods: From 2005 to 2013, 477 patients underwent laparoscopic total fundoplication with cruroraphy for gastroesophageal reflux disease (GERD) with hiatal hernia (HH). Primary and redo operations were performed by a single surgeon. We excluded patients undergoing surgery at other hospitals or by other surgeons. All operations involved a posterior cruroraphy with wide stitching of crural muscle tissue using nonabsorbable sutures. An optional anterior cruroraphy was performed for rare cases of large HH. Mesh prostheses to reduce and strengthen the esophageal hiatus were not used, even with large HHs. An average of 3 (range, 2–5) crural stitches were used. The results were evaluated using the GERD-HRQL questionnaire. Results: All primary and redo operations were completed laparoscopically. There were no deaths. The mean primary operation duration was 68 ± 17.4 minutes, and the mean redo operation duration was 37 ± 7.4 minutes. The mean time between primary and re-operation was 3 months. The mean perioperative hospital stay was 3 days (range, 2–7). The median follow-up time was 60 months (range, 6–108). For patients undergoing primary laparoscopic fundoplication with cruroraphy, the mean GERD-HRQL was 6.5 (range, 0–41). Complete satisfaction with the operation for several years was reported by 395 patients (82.8 %). Irregular drug intake after surgery, with no evidence of recurrence, was reported in 77 patients (16.1 %). Only 5 patients (1 %) required reoperation. For these patients, the mean GERD-HRQL was 26.5 (range, 19–32) before reoperation and 2 after reoperation. At reoperation, fibrosis was noted around the nonabsorbable suture material on the crural diaphragm, which was similar to but less extensive than that found after mesh-hiatoplasty. Conclusions: In more than 82.8 % of our patients, the surgical results were regarded as excellent or good. Wide suturing of the crural diaphragm without the use of mesh prosthesis did not increase the likelihood of HH recurrence.



Reasons for Reoperation After Laparoscopic Fundoplication and Choice of Treatment for Complications Requiring Reoperation

First Experience of Thoracolaparoscopic Esophagectomy

O.B. Ospanov, A.M. Orekesheva, R.E. Khassenov Astana Medical University, Astana, Kazakhstan Purpose: This retrospective study reports the reasons for reoperation after laparoscopic fundoplication and the choice of treatment for the complications requiring reoperation. Methods: From 2005 to 2013, 477 patients underwent laparoscopic total fundoplication with cruroraphy for gastroesophageal reflux disease with hiatal hernia. Five of these operations (1 %) were reoperations. Results: All reoperations were completed laparoscopically, despite varying degrees of adhesions in the area of the previous surgery. The mean duration of reoperation was 37 ± 7.4 minutes. The mean time between primary and redo operations was 3 months. The reasons for the late complications requiring reoperation were as follows: Stenosis of the esophagus due to tightly-stitched diaphragmatic crura: 3 patients. This was presumably caused by using a thin (\34 Fr) esophageal-gastric tube. It was treated by laparoscopic expanding diaphragmo-crurotomy. Stenosis of the esophagus due to a tight fundoplication wrap: 1 patient. This was presumably caused by not dividing the upper short gastric vessels at the bottom of a small stomach and/or by using a thin esophageal-gastric tube. It was treated by laparoscopic separation of the tight fundoplication wrap, division of the short gastric vessels, and performing a ‘Floppy Nissen’ fundoplication. Stenosis of the esophagogastric transition due to malposition during the initial operation (malformation): 1 patient. This was presumably caused by capturing and holding the anterior wall of the body of the stomach (not the posterior wall of the fundus) through the retroesophageal orifice. It was treated by laparoscopic separation of the incorrectly superimposed fundoplication wrap, eliminating the malformation, and performing a ‘Floppy Nissen’ fundoplication. With compulsory intraoperative transhiatal dissection of the esophagus for small shortening, we never encountered relapse of the hiatal hernia or migration of the fundoplication wrap. Conclusions: The main reasons for poor results after laparoscopic antireflux operations appeared to be the use of a thin esophageal-gastric tube; preservation of the upper short gastric vessels in the presence of a small fundus; and incorrectly positioning of the fundoplication wrap during the first operation, by capturing and holding the anterior wall body of the stomach through the retroesophageal orifice.

M.A. Koshkin1, E. Khatkov1, E. Izrailov1, A. Domrachev2, S. Vasnev1, V. Kononets3, J. Feidorov2 1

Moscow Clinical Scientific Centre, Moscow, Russia; 2Moscow State University of Medicine and Dentistry Named After A.I. Evdokimov, Moscow, Russia; 3Russian Scientific Center of Surgery Named After B.V. Petrovskii, Moscow, Russia Despite the existing experience in minimally esophageal surgery in the world, there are small of this practice in Russia. Because there are no specific strategy of management and development minimally invasive method in major esophageal surgery. Aims: To perform a principles of introducing safety technique for thoracolaparoscopic major esophageal surgery. Methods: Since 09.2011 till 11.2013 10 patients (8 male and 2 female) were successfully operated by the thoracolaparoscopic method. Middle age was 52 years (27 to 67). Indications for surgery: middle and lower esophageal cancer: n = 2; burn stricture n = 4; other benign stricture n = 4. For patients with cancer 2 procedures were performed after neoadjuvant chemotherapy. Gastric pull-up were performed in 8 cases, one case minimally invasive Ivor Lewis procedure with circular stapler anastomosis and one case of colonic interposition. In all cases surgery team includes the experts of major esophageal surgery and major minimally invasive surgery. For all manipulations traditional instruments were used (ultrasound scalpel, monopolar coagulation, linear and circular staplers and 5–12 mm trocars). Results: Middle operating time was 600 minutes (435–765); middle blood loss about 200 ml. No mortality rate. There were two major complications: cervical anastomotic leaks in cases of gastric pull-up and colonic interposition. For treatment tube feeding diet were used and wide drainage of the cervical wound. One later complication: cervical anastomotic stricture after gastric pull-up, which was treated by dilatation. Middle postoperative duration of stay was 16 days. Conclusion: Minimally invasive esophagectomy is a technically feasible and safe procedure requiring advanced laparoscopic and esophageal surgical skilled team.

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Surgical Treatment of Patients with Short Esophagus

Comparative Evaluation of the Biomechanical Properties of Different Biomaterials in an Experimental Model of Hiatal Hernia Repair

F.P. Vetshev, A.F. Chernousov, T.V. Horobryh, S.V. Osminin First Moscow State Medical University, Moscow, Russia Failures of antireflux surgery are often results from undiagnosed short esophagus, causing postoperative complications (wrap migration, wrap slipping or wrap turning) in 20–35 % of cases. Basing on decades of experience with open antireflux procedures ([ 1000) were established certain principles and surgical techniques for successful outcomes. In clinical practice we use classification of hiatal hernias and short esophagus published in 1962 by B.V. Petrovsky and N.N. Kanshin. Patients undergoing surgical treatment for reflux-esophagitis often have short esophagus, severe clinical symptoms and drug therapy with PPI is not effective. We define two grades of short esophagus: grade I - cardia is situated not over than 4 cm below diaphragm; grade II - over 4 cm. It is important to diagnose grade of shortening preoperatively, because of different surgical technics for each condition. In case of esophageal shortening grade I we perform 360° fully symmetrical fundoplication wrap in our modification. We perform stomach dissection along curvature gastrica minor with mobilization of 6–7 cm of esophagus, legation of 2–3 short gastric vessels and arteria gastrica posterior. Starting from the curvature gastrica minor we form 4 cm length 360° fully symmetrical wrap by separately interrupted stitches taking muscle layer of the esophagus within. The wrap top got to be fixed at the right and left sides with 4 stitches. Since 1962 in case of shortening grade II we have performed valve gastroplication. We form 360° fully symmetrical wrap around cardia, previously performed as a tube with equal to esophagus diameter using transversal contracting stitches. Wrap migration or forming it in mediastinum doesn’t influence on functional results of procedure, as was also described by R. Nissen in 1959. In this report we analysed 105 patients with reflux-esophagitis and short esophagus (age 16 to 83) who underwent laparascopic antireflux procedures. Esophageal shortening grade I was diagnosed in 49 (47 %) cases; grade II in 56 (53 %), erosive-esophagitis 49 (47 %), Barrett’s esophagus 11 (10,5 %). Bouginage of the esophagus performed for 5 (4,7 %) patients with esophageal strictures. In all cases no postoperative complications detected. Due to the total clinical symptoms of refluxesophagitis elimination excellent distant postoperative outcomes were reached.

C. Markakis1, D.E. Mouzakis2, A.E. Papalois3, P. Dikeakos1, E. Spartalis1, D. Perrea1, M. Safioleas1, P. Tomos1 1 University of Athens, Greece; 2Laboratory of Advanced Materials, Technological Educational Institute, Larissa, Greece; 3ELPEN, Experimental Research Centre, Pikermi, Athens, Greece

Aims: Recurrence is common after laparoscopic hiatal hernia repair and reinforcement of the cruroplasty with prosthetic material has been advocated as a result. However, although Level 1 evidence of the efficacy of materials such as polypropylene exists, safety concerns have prevented their widespread use. For this reason, use of alternative materials with a better safety profile has been proposed. The aim of this study is to comparatively evaluate the biomechanical properties of different prosthetic materials in a porcine model of prosthetic cruroplasty. 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 acidTrimethylene 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 reoperated upon. The crural region was dissected free and the prosthetic material was harvested en block with all surrounding tissue. Strips of the native diaphragm and fascia lata were also harvested and used as controls. The implanted materials were divided into strips and tensiometry was performed. Results: The operation was completed successfully on 22/24 animals, while two animals died, both in the immediate postoperative period. All absorbable materials showed adequate tensile strength which was equivalent to the polypropylene mesh, but less than that of the native diaphragm. However, polypropylene and autologous fascia showed greater stiffness than the biological and autologous materials. Conclusions: The results of this study suggest that absorbable biological or synthetic materials as well as autologous fascia produced an equivalent result to polypropylene when used to reinforce the diaphragmatic crura. These data support the ongoing trend to replace conventional synthetic with bioabsorbable materials in the management of large hiatal or paraesophageal hernias.



Electrical Stimulation of the Les in GE-Reflux Disease - Endostim Treatment

Postoperative Reflux in the Treatment of Complicated Duodenal Ulcer

E. Eypasch1, H. Schulz2

I.V. Komarchuk

1

2

Heilig Geist-Krankenhaus Ko¨ln, Ko¨ln, Germany; EVK Castrop Rauxel, Castrop rauxel, Germany

Kharkiv Medical Academy of Postgraduate Education, Kharkov, Ukraine

Background: Innovative treatment options recently have become available for GERD. One of the treatments is electrical stimulation of the LES to improve sphincter function and decrease acid exposure (EndoStim Treatment) (Rodriguez Surgical Endoscopy 2013). The purpose of this study was to investigate this innovative treatment in selected reflux patients. Material and Methods: In 2 primary care hospitals in Northrhine Westfalia, Germany 7 patients with GERD underwent functional esophageal testing and were selected for implantation of the pacemaker device. All patients had proven defects of the LES on manometry and pathologically increased acid exposure during distal esophageal pH-monitoring. The 2 Sphincter stimulation electrodes were implanted in the cardiac region by laparoscopy and under endoscopic control. Hiatal hernia defects were closed by crural stichtes if necessary. The impuls generating device was implanted subcutaneously in the left lower quadrant of the abdomen. Results: 6 weeks postoperatively 6 patients showed a clear decrease in symptom-scores for heartburn and regurgitation from 20 to 12 an 4 points. In 2 patients the GLQI-score for quality of life rose to normal values as in patient with after fundoplication. One patient developed moderate gastroparesis for 2 weeks postoperatively. Apart from minimal skin irritation near the pacemaker pocket surgical complications did not occur. Conclusion: Electrical stimulation of the LES by the EndoStim device may become a very useful adjunct for highly selected patients with reflux disease since it has the potential to reduce acid exposure to the esophagus with minimal changes of the cardiac an fundic anatomy. The differential indication to fundoplication has to be explored carefully.

Background: Damage of topographic and anatomical relations in cardio esophageal zone after the selective or stem vagotomy can decrease muscle tonus of the upper third of the stomach, increase its angle, provoke cardiac socket relaxation and lead to gastroesophageal reflux (GER). Patients with GER symptoms observed preoperatively may develop their deterioration after surgery Methods: GER was diagnosed using 24-hour aesophageal pH monitoring and multichannel esophago-impedance-pH monitoring. Results were assessed according to Porto GERD classification 2002 (pH \ 4 - acid; 4 \ 7 - slightly acid, pH [ 7 - mild alkaline). Results: GERD was diagnosed in 46 patients aged from 22 to 46 years in 3 years after excision or suturing of the perforated ulcer in combination with selective or stem vagotomy, without restoration of antireflux procedures after vagotomy. No recurrence of peptic ulcer disease was observed. Preoperatively GERD symptoms were present in 12 patients. Due to Likert scale GER symptoms were rated from mild to moderate severe. No endoscopic evidence of reflux esophagitis was found before surgery in these patients. Reflux could be caused by motility disorders associated with the severity of peptic ulcer course. GER symptoms preserved and even increased in 3 out of 12 patients in 3 years after surgery. As per Likert scale symptoms assessed as moderate. 24-hour pH and impedance monitoring confirmed esophageal reflux. 34 patients had no GERD symptoms before surgery. No inflammatory changes were registered in the protocols of esophageal endoscopy before surgery. 3 years after surgery 9 patients developed moderately severe symptoms of GERD. Endoscopically they had first grade reflux esophagitis, which was not found before the operation. Against a normal gastric acidity or hypoacidity there was mildly acidic and alkaline GERD. DeMeester index ranged from 17.5 to 38.5. H.pylori test was negative in all patients. Patients with GERD symptoms were followed up by gastroenterologist. Conclusions: Tissues dissection for allocation of the vagus nerves trunks and vagotomy in cardiosophageal zone may contribute to the development or aggravation of GERD in some patients. To prevent postoperative reflux is necessary to restore the integrity of the destroyed tissues in combination with angle of His correction.

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Complications of Laparoscopic Gastroesophageal Reflux and Hiatal Hernia: Clinical Experience

Surgical Management of Esophageal Perforation: A 10 Year Experience

H. Yigitbas, A. Solmaz, O. Gulcicek, E. Yavuz, C. Ercetin, M. Tokocin, K. Ozdogan, F. Celebi, A. Celik, R. Kutanis

E. Folaranmi1, B. Alkhaffaf2, A. Shrestha1, S. Green1, B. Darmas1, B. Decadt1

1

1


Stockport NHS Foundation Trust, Salford, United Kingdom; Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom

2

Gastroesophageal reflux disorder (GERD), a common disorder upper gastrointestinal tract, which can lead to complications that include esophagitis, esophageal stricture and esophageal carcinoma. Despite the medical treatment, such complications of the disease are still increasing worldwide. Laparoscopic nissen fundoplication and hiatal hernia repair are still best choice of the treatment for hiatal hernia and GERD. Between October 2010 and October 2012, 152 patients (mean age was 45,8 (20–78), 94 men, 58 women) underwent surgical treatment for GERD. We did laparoscopic floppy Nissen fundoplication, fundoplication plus mesh repair and open Nissen fundoplication as technique. In 19 operations we used drain. Complications were; 3 dysphagia, 4 surgical site infection, 2 nonspecific abdominal pain, 1 malnutrition, 6 incisional hernia, 3 peptic ulcer, 6 anemia, 1 pneumomediastinum, 1 enterocutaneous fistula and 1 sepsis. Although hiatal hernia repair and Nissen fundoplication are surgical choice of treatment and we surgeons routinely do these operations more and more, we still see such complications more than expected. Minimal access approach to treat GERD seems to be easy and simple operation, but is not; we must be aware of these complications and manage as early as possible.

Introduction: The diagnosis and management of esophageal perforation and mediastinal sepsis is challenging and treatment strategy is controversial and varies widely. We present our 10-year experience of esophageal perforation and evolving treatment strategy for this condition. Methods: We reviewed all esophageal perforations admitted from January 2004–January 2014. All cases of esophageal perforation were included; those patients with a spontaneous or iatrogenic perforated oesophagus and cases of mediastinal sepsis due to complications following a cardio-esophagectomy. Results: 41 patients were treated (26 males) with a mean age of 54 (range 21–80). Five patients presented following instrumentation of the oesophagus for dilatation (3 patients) and removal of a food bolus (2 patients). Other causes included diagnostic endoscopy (2 patients), spontaneous perforation (14 patients), benign oesophageal ulcer (1 patient), locally advanced oesophageal carcinoma (1 patient), perforation secondary to an obstructing gastric tumour (1 patient) and perforation following laparoscopic Heller’s myotomy (1 patient). Sixteen patients developed sepsis following elective cardio-oesophagectomy. 22 patients underwent primary repair of the perforation over a T-tube with a gastrostomy, feeding jejunostomy and drainage of the thoracic, abdominal and mediastinal cavities, one patient had a distal gastrectomy and formation of a Roux-en-Y gastro-jejunostomy in addition to closing the oesophageal perforation over a T-tube and fashioning a feeding jejunostomy. Five patients underwent emergency oesophagectomy. Three patients underwent thoracoscopy and drainage. Three patients received an oesophageal stent and seven patients were treated conservatively. Median hospital and intensive care stay were respectively 74 (range 9–170) and 33 (range 4–84) days. Seven patients died (mortality 17 %), Six from respiratory complications and one patient from stent erosion. One of the 23 patients undergoing emergency thoracotomy died (mortality 4.3 %). Conclusion: This series accounts the favourable outcome in a cohort of patients with a potentially dismal prognosis. After confirmation of the leak by contrast studies, CT or endoscopy, urgent thoracotomy with repair of the perforation over a T-tube with a gastrostomy, feeding jejunostomy and drainage of the involved anatomical spaces, appears a safe policy and our preferred technique for more recent leaks. Patients with existing oesophageal pathology may be considered for emergency cardio-esophagectomy.



Laparoscopic Transhiatal Approach for Large Epiphrenic Diverticula

Long Term Patient Satisfaction and Medication Use After Nissen Fundoplication

V. Surlin1, D.N. Margaritescu1, D. Cartu1, E.F. Georgescu1, S.D. Patrascu2, I. Georgescu3, D. Ulmeanu4

S. Morelli, K.H. Haraldsdottir, G. Birgisson, S. Blo¨ndal

1

UMF of Craiova, Craiova, Romania; 2Clinical County Emergency Hospital, Craiova, Romania; 3University of Medicine and Pharmacy of Craiova, Romania; 4Sf Maria Hospital, Bucharest, Romania Authors present the case of a 64 years old patient diagnosed by upper digestive tract endoscopy with large epiphrenic esophageal diverticula. The patient’s complaints were of severe retrosternal pain and regurgitations, combined with mild dysphagia. The patient had no medical or surgical history, physical general examination was normal and the BMI was 29. Laboratory data were in the normal range. Upper digestive barium contrast x-ray indicated a dilated and sigmoid-like esophagus with epiphrenic diverticula of 8 cm on the right side. Data from endoscopy excluded esophagitis and located the diverticula 3–4 cm proximal to the cardia. The patient was scheduled for laparoscopic abdominal transhiatal approach in French position. The diverticula was dissected free of mediastinal pleura, isolated and resected with EndoGIA after calibration of esophagus with two 34 French bougies. A distal esocardiomyotomy was then performed followed by an anterior Dor fundoplication to prevent postoperative gastroesophageal reflux. There were no intraoperative incidents. Postoperative barium swallow at 48 hours showed normal esophageal transit and no leak of the staple line. Then the patient was allowed an oral liquid diet and was discharged after 5 days. Technical key points and a review of the literature are presented. Conclusion: Laparoscopic transhiatal approach for esophageal epiphrenic diverticula is feasible and safe for the patient

Landspitali - LSH, Reykjavı´k, Iceland Background: Laparoscopic anti reflux surgery is well established treatment for gastroesophageal reflux disease (GERD), but long term efficacy is still a matter of debate. The aim of this study was to evaluate long term patient outcome and medication use after antireflux surgery. Study Design: Between September 2003 and November 2005 115 consecutive patients who underwent Nissen fundoplication were evaluated before surgery and 8 to 10 years after surgery with the Gastrointestinal Quality of Life Index (GIQLI) with regards to overall satisfaction and medication use results. Results were availabe from 85 patients (follow-up period 97 to 123 months). Results: from thirty patients were included for following reasons, twenty patients did not return the questionnaire, eight had re-operation for recurrent symptoms two developed tumor in the upper gastrointestinal tract (esophageal melanoma and gastrointestinal stromal tumor of the stomach). Eleven incomplete follow up questionnaire were excluded from calculation of the satisfaction index. Fifty-two patients (61,2 %) were not taking any antireflux medications and 23 (27,1 %) were taking antireflux medications daily. Among the 74 complete questionnaires the average satisfaction index was 80 % (0,8 ± 0,13), compared to pre-operative value of 70 % (0,7 ± 0,1). Conclusions: Laparoscopic Nissen fundoplication for GERD is associated with sustained longterm patient satisfaction and acceptable antireflux medication use.

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P594 - Oesophageal Malignancies

Our Experience in Laparoscopic Nissen Fundoplication

Thoracoscopic Esophagectomy in Prone Position: Advantages of Five Ports Over Four Ports

A. Ioannidis1, Ch. Efthimiadis2, Ch. Kosmidis2, M. Grigoriou2, G. Georgios2, G. Basdanis1

K. Kawasaki1, T. Oshikiri2, S. Kanaji2, S. Nakayama2, H. Kominami2, K. Tanaka2, Y. Fijino2, M. Tominaga2

1

Kobe Rosai Hospital, Kobe, Japan; 2Hyogo Cancer Center, Akashi, Japan

Ahepa University Hospital Thessaloniki, Thessaloniki, Greece; Interbalkan Medical Center, Thessaloniki, Greece

2

1

Introduction: Recent inventions in endoscopic techniques brought out advancements in treatment of gastroesophageal reflux disease (GERD). We analysed our laparoscopic nissen fundoplication (LNF) procedures that we performed in our clinic. Methods: LNF was performed between January 2008–December 2013 in interbalkan medical center in Thessaloniki for 32 patients having GERD symptoms, osephagitis with/ without Barrett, hiatal hernia. Patients were reanalysed after 1 month postoperatively endoscopy and pH monitorization were held out for ones having reflux symptoms and dysphagia. Results: Twelve 12 female (37,5 %) and 20 (62,5 %) male patients with diagnosis of GERD were operated. Their mean age was 42 ± 9 (28–64) and their mean body mass index was 26.15 ± 2.90 (19–32). According to duration of GERD symptoms patients had complaints for 1–20 years in avarage. Preoperative endoscopic examination revealed that 20 (62,5 %) patient had esophagitis and 8 (25 %) patient had hiatal hernia. When the operative choices were interpreted, 8 (25 %) patient had Nissen fundoplication-cruroplasty-mesh repair, and 24 (75 %) had Nissen fundoplication procedures. Mean operation time was 55 ± 15 (35–120) minutes. Laparotomy was done for 3 (9,37 %) patients due to operative adversities. Mean hospital stay was 2.5 ± 1.5 (2–7) days and drains were kept for 2 ± 1 (1–4) days in avarage. None of the patients revealed any complications postoperatively. We observed no peroperative morbity and mortality. Conclusion: LNF became gold standard in treatment of GERD. For operative decision there must be a single objective sign concomitant with typical reflux symptoms. Our results correspond with recent literature and observed that the process LNF by an experienced surgical team is always for the benefit of the patient

Background: Thoracoscopic esophagectomy in the prone position (ThE-PP) is usually performed with four ports, which makes the operation almost solo surgery. We now perform ThE-PP with five ports, with the advantage of having the assistant able to provide additional help. Aims: The aim of this study was to elucidate the benefits of ThE with five ports over ThE with four ports. Methods: We retrospectively reviewed the clinical charts of 47 patients with esophageal cancer who underwent ThE-PP. A total of 14 patients underwent ThE-PP with four ports and 33 with five ports. We compared the number of dissected lymph nodes (LNs)-total; upper left, middle, and lower mediastinum-between the four-port and five-port groups. Results: The number of LNs dissected, including the total, the upper left and middle mediastinum, were not significantly different between the two operations. The number of LNs dissected from the lower mediastinum, however, was significantly higher in the fiveport group (median number and interquartile range: 5 and 2–7, respectively) than in the four-port group (0.5 and 0–3, respectively) (P \ 0.01). Conclusions: ThE-PP performed with five ports has an advantage over the same operation done with four ports in terms of lymphadenectomy in the lower mediastinum.



Laparoscopic Repair of Large and Recurrent Hiatus Hernia with Absorbable Mesh: An Update on Results from a Single Centre C. Hammer, C. Jukes, A. Conway, A. James, P. Jethwa Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom Aims: Despite the increasing popularity of laparoscopic repair of hiatus herniae there remains no consensus as to the best technique, especially with large or recurrent herniae. There are varied success rates in the literature, with recurrence reported as high as 42 %. We present our latest data on our use of a bio-absorbable mesh (Gore Bio-A) in the laparoscopic repair of large and recurrent hiatus herniae to evaluate the safety and efficacy of this technique. Methods: A retrospective analysis of a prospective database was performed. Patients with defects over 6 cm were deemed to have large defects. At surgery, the hiatal defect was repaired by primary cruroplasty with additional crural reinforcement using a ‘U’ shaped Gore Bio-A synthetic mesh, after which fundoplication was performed. Patients were assessed postoperatively with contrast swallow(s) and for functional outcomes, and as necessary with endoscopy and pH testing. Results: Twenty seven patients were identified from the database. 20 patients had large hiatal defects and 7 had recurrent hiatal defects. The mean age of the patients was 67.7 yrs (42–84 yrs), with M:F ratio of 1:2. BMI 28.2 (19.2–35.5). Mean length of stay 3 days (1–11 days). Mean follow up was 15 months (1–48 months). Ten patients report no further symptoms. Three recurrent hiatus hernia were detected on contrast swallowing all presenting with recurrent gastro-oesophageal reflux disease (GORD). Four further patients reported GORD without recurrent herniation. Nine patients reported gastrointestinal disturbances including bloating, nausea and bread intolerance. There were no mesh associated dysphagia or morbidity. Conclusions: In our experience, repair of both large and recurrent hiatus herniae with Gore Bio-A mesh is safe, effective and well tolerated. Despite being a bio-absorbable product the medium to long term outcomes are good with a low recurrence rate. This bio-absorbable product appears to be well tolerated and effective, however further randomised study is necessary to assess long-term outcomes.

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Thoracoscopic Esophagectomy in the Prone Position for Esophageal Cancer After Preoperative Neoadjuvant Chemotherapy H. Fujii, Y. Kawakmi, T. Aotake, Y. Hirose Japanese Red Cross Fukui Hospital, Fukui, Japan Introduction: Clinical trials revealed the efficacy of preoperative neoadjuvant chemotherapy for esophageal cancer. Aims and Methods: The outcomes of surgery and postoperative complications of thoracoscopic subtotal esophagectomy in the prone position were compared in 23 cases with the following preoperative neoadjuvant chemotherapy: 5 cases, 5FU-CDDP (the FP group); 5, docetaxcel-CDDP-5FU (the DCF group); and 13, no chemotherapy (the OP group). Operative Procedure: Patients were laid in a semi-prone position trocars were inserted into the 3rd, 5th, 7th, and 9th intercostal spaces and pneumoperitoneum was created at 6 mmHg. The esophagus was intrathoracically dissected with lymphadenectomy at the level of the upper esophagus in the chest. After intrathoracic maneuvers, the patient was laid with the lower extremities opened and the stomach was mobilized while attention was paid to preservation of blood vessels during the laparoscopic maneuver of five trocars. A small incision about 4 cm in length was made and the esophagus and stomach were pulled out to the outside of the body and a gastric tube was reconstructed. The reconstructed gastric tube was returned to the posterior mediastinum and anastomosed with the oral side at the neck incision. Results: Leukopenia at grade 2 or severer was observed in 1 case in the FP group and 4 in the DCF group, while fever at grade 1 or severer was observed in 3 in the DCF group. The average thoracoscopic operation time was 449 min in the FP group, 288 min in the DCF group, and 323 min in the OP group. The average blood loss was 255 gr in the FP group, 89 gr in the DCF group, and 152 gr in the OP group. The average number of extracted lymph nodes was 26 in the FP group, 29 in the DCF group, and 35 in the OP group. Treatment response was better but adverse effect at grade 2 or severer was more frequently observed in the DCF group than in the FP group. DCF therapy had no increase in postoperative and perioperative complications. Conclusions: Preoperative neoadjuvant chemotherapy plus thoracoscopic esophagectomy in the prone position was found effective treatment for esophageal cancer.

Surg Endosc



The Procedure of the Thoracic Duct Preserving Thoracoscopic Esophagectomy in the Left Lateral Decubitus Position

Endoscopic Mucosal Resection and Ablation for High Grade Dysplasia and Early Oesophageal Adenocarcinoma: Disease Progression and Regression

K. Shigemitsu, A. Urakami Kawasaki Medical School, Okayama, Japan The advantages of the left lateral decubitus position are that the good viewing in dissection of the upper mediastinal lymph nodes as well as open-thorasic surgery is obtained and that it is easy to support unexpected conditions, such as bleeding, and the like. At our institution, in introducing thoracoscopic esophagectomy in May 2012, the first to ensure the safety, we adopt the left lateral decubitus position with pneumothorax which does not require a mastery of assistant. Using 2 monitors reversing, both surgeon and assistant can obtain the eye-hand coordination simultaneously As carbon dioxide is introduced into the intrathoracic space, we can obtain good surgical view. Since metastatic lymphnode may be around the thoracic duct, thoracic duct preservation was not standard. But the fall of a postoperative nutrient state or immunity may be caused by excision of thoracic duct, and critical complications may be excited especially in cases with liver cirrhosis. The propriety of the thoracic duct preservation in thoracoscopic radical esophagectomy is still contraversial. With this institution, as long as there is no permeation of the thoracic duct by a tumor directly, a thoracic duct is preserved in principle. We show the point of the procedure of thracoscopic esophagectomy with lymphadenectomy, such as dissection of recurrent nerve lymph nodes and lower mediastinal lymph nodes, in the left lateral decubitus position with pneumothorax. We performed thoracoscopic esophagectomy for 11 patients with esophageal cancer from May 2012 to January 2014 with no major intraoperative complications such as chylothorax. Postoperative hospital stay was shorter in the patients treated with thoracoscopic esophagectomy in comparison with those treated with open esophagectomy.

Z.C. Oliphant, A. Snow, L.M. Almond, H. Barr Gloucestershire Hospitals NHS Trust, Gloucester, United Kingdom Aims: Endoscopic resection (ER) is emerging as a curative technique in patients with high grade dysplasia (HGD), intramucosal cancer (IMC), and early submucosal cancer (T1sm1) within Barrett’s oesophagus. This consecutive case series reports outcomes of ER, with or without mucosal ablation, in a single institution over a 7 year period. The primary outcome measure was the proportion of patients undergoing ER with or without ablative therapy that progressed to submucosal invasion or beyond. Secondary outcomes included the proportion that underwent disease regression, the effect of ER on staging compared to biopsy and the number of new referrals undergoing endoscopic therapy each year. Methods: Long-term follow-up of 72 patients with HGD or IMC treated by endoscopic resection (with therapeutic intent) between 2004 and 2011 is presented. Endotherapy with ER was performed for HGD (88 %) and IMC (12 %) in patients that were unsuitable for radical surgical intervention. ER was used alone, or in combination with mucosal ablation. Resection and ablation techniques varied throughout the study period reflecting changes in practice. Results: 72 patients were treated by ER +/- ablative therapy with curative intent for HGD or IMC between 2004 and 2011. The mean age of patients was 73.0 (52.0–93.0) years. Of these patients 38 % had a severe systemic co-morbidity. A median of 4 (1–11) procedures were undertaken per patient. In addition to ER, 43 % of patients were treated with argon plasma coagulation, 17 % with radiofrequency ablation, and 11 % with photodynamic therapy. A total of 13 (17 %) patients progressed to invasive carcinoma. The median time to progression from index biopsy was 26.3 (8.3–76.1) months and 12.6 (1.1–59.3) months respectively. Disease staging was upgraded by ER in 27 % of patients with a previous pinch biopsy. Conclusions: ER with endoablation is an effective and potentially curative option for patients with HGD or IMC although a proportion of patients will experience disease progression. This large UK series supports endoscopic resection for disease staging over pinch biopsy.



The Therapeutic Strategy and Management of Esophageal GIST

Management of Upper Gastrointestinal Cancer: Clinical Significance of Routine Diagnostic Laparoscopy

M. Stasek, C. Neoral, R. Aujesky´, R. Vrba, J. Chudaćek, J. Ikarda, M.J. Janı´kova´, Z. Zezulova´, B. Melichar University Hospital Olomouc, Olomouc, Czech Republic Aims: Due to the extremely low incidence, there is lack of evidence based data on the therapeutic strategy and outcome of patients with oesophageal GIST. Methods: We present a single centre retrospective study of 9 consecutive patients with oesophageal GIST with follow-up for 5–10 years. The surgical therapeutic strategy, histology including immunohistochemistry and mutation analysis, and imatinib treatment, including neoadjuvant indication, were analysed. Results: The surgical therapy included 6 thoracoscopic and 2 laparoscopic transhiatal enucleations with endoscopic navigation and 1 transmural excision of the tumor with oesophageal suture. 1 patient died 7 years after operation, 8 patients are alive without evidence of recurring disease. The mutation analysis revealed 2 mutations of E9 c-KIT and one in E11 c-KIT. Two patients were treated with imatinib mesylate, including 1 in neoadjuvant setting. Conclusion: Based on this experience, minimally invasive enucleation with endoscopic navigation seems to be efficient therapy of oesophageal GIST 50 mm and less in width. Oesophagectomy or transmural excision and possibility of neoadjuvant therapy with imatinib should be considered in tumors 50 mm and more in diameter. The histology and mutation analysis can guide selection of systemic treatment strategy.

A. Mirza1, I. Welch2 1

Monklands District General Hospital, Cheadle, United Kingdom; The University Hospital of South Manchester, Manchester, United Kingdom

2

Aims: The diagnostic laparoscopy has been used in the accurate staging of gastrointestinal cancers. The aim of this study was to evaluate the role of laparoscopy in comparison with computed tomography (CT) scan in staging patients with gastro-oesophageal junction (GOJ) and gastric cancer. Methods: The data were collected for patients between 1996 and 2011 for patients undergoing investigation and treatment for GOJ and gastric cancer at a single institute. The pre-operative data (staging data), intra-operative details, post-operative course and outpatient follow-up were analysed for individual cases. Results: Staging laparoscopy changed treatment plan in 52 (17 %) of 287 patients. Patients with negative staging CT scan, 10 % (Grade I GOJ) were identified with pathological intraperitoeal nodes, metastatic intraperitoneal deposits (5 %), ascitic fluid (ascitic tap positive for cancer cells, 3 %). Patients with metastatic disease were referred for palliative chemotherapy. Conclusions: Diagnostic laparoscopy is useful for detecting and confirming nodal involvement and distant metastatic disease not evident on the staging CT scan, that potentially could alter treatment and prognosis in patients with upper gastrointestinal cancer. Diagnostic laparoscopy should be performed as part of investigation and treatment planning for patients suffering from GOJ and gastric cancers. This can potentially avoid surgery in patients with advanced disease.

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Factors Relating to Long Term Quality of Life After Ivor Lewis Oesophagectomy for Oesophageal Cancer

Assistant-Based Standardization of Prone Position Thoracoscopic Esophagectomy

B. Ivanov, V. Shatkar, W. Alrawasdeh, T. Amalesh

Y. Shirakawa, T. Koujima, N. Maeda, S. Tanabe, T. Ohara, K. Sakurama, K. Noma, T. Fujiwara

Queens Hospital, Romford, United Kingdom

Okayama University, Okayama, Japan

The aim of this study was to assess the factors that influence the long term quality of life (QoL) after Ivor Lewis oesophagectomy for oesophageal cancer. Method: The study included the patients that underwent Ivor Lewis oesophagectomy for oesophageal or gastro-oesophageal cancer (Type 1 and 2) between 2008 and 2011 in BHR Hospitals and were still alive when the data was retrospectively collected-an interval between 18 and 57 months after surgery. Patients completed validated HRQL questionnaires (QLQ-30 and QLQ-OES18). Mean scores were calculated and compared between the different groups: laparoscopic gastric mobilization vs open approach; neoadjuvant/adjuvant chemotherapy vs no-chemotherapy; postoperative complication vs no complication; comorbidity vs no comorbidity. Results: Questionnaires response rates were 67 per cent. 37 patients were included in the study. Out of these 11 patients underwent a laparoscopic approach, 20 had adjuvant or neoadjuvant chemotherapy, 19 had at least one postoperative complication and 23 had at least one comorbidity. A difference of 10 or more between the mean scores was noted in favor of laparoscopic approach and no chemotherapy group for role, emotional and cognitive functioning. A higher level of symptomatology was noted in the chemotherapy and postoperative complication group with a mean score difference above 10 points for eating disorder, problem with coughing and taste and diarrhoea in the chemotherapy group and fatigue, pain, dysphagia, reflux, choking, dry mouth, trouble with coughing and talking in the postoperative complication group respectively. Patients from the laparoscopic approach group had a lower level of symptomatology overall. No significant differences were noted when comparing the comorbidity vs no comorbidity groups. Conclusion: Laparoscopic approach seems to have a positive effect on the long term QoL after Ivor Lewis oesophagectomy while chemotherapy and postoperative complications have a detrimental effect.

Background: The popularity of thoracoscopic esophagectomy in the prone position has increased due to the associated advantages of good exposure of the surgical field and ergonomic considerations for the surgeon. Solo-surgery is also possible in most cases requiring resection of the esophagus and the surrounding lymph nodes. However, no one approach could be used for all cases of patients requiring extensive lymphadenectomy. In April 2012, we developed an assistant-based procedure to standardize exposure of the surgical field. The purpose of the present study was to describe and evaluate this technique. Methods: We performed thoracoscopic esophagectomy for 65 patients (62 males, three females) in the prone position at our facility from June 2011 to September 2012. Patients were divided into one of two groups: a pre-standardization group (n = 37) that underwent surgery before April 2012 and a post-standardization group (n = 28) that underwent surgery after April 2012. The thoracoscopic operative time and the clinical outcomes were compared between these two groups. Results: The thoracoscopic operative time was significantly shorter (P = 0.0037) in the post-standardization group (n = 28; 266.8 ± 31.3 min) than in the pre-standardization group (n = 37; 301.0 ± 52.5 min). Learning curve analysis using the moving average method showed stabilization of the thoracoscopic operative time after the technique was standardized. No significant differences were found in the number of mediastinal lymph nodes dissected or intraoperative blood loss when comparing the two groups. Further, there were no significant differences in the overall complication rate and the incidence of pneumonia or recurrent nerve palsy when comparing the two groups. Conclusions: Assistant-based surgery and standardization of procedure resulted in an excellent and safe surgical field. Thoracoscopic esophagectomy in the prone position decreased the operative time, even in patients requiring extensive lymphadenectomy.


P603 - Paediatric Surgery

Outcomes of Minimally Invasive Oesophagectomy for Cancer

Laparoscopic Suprarenalectomy

A. Menon, P. Ireland, K. Akhtar


Salford Royal Hospital, Salford, United Kingdom


1

Aims: Minimally invasive oesophagectomy (MIO) has become increasingly popular in recent years, but has not yet widely adopted due to concerns regarding safety and oncological efficacy. The study aims to describe our experience with MIO with emphasis on these issues. Methods: A retrospective review was carried out on patients undergoing MIO (utilizing laparoscopic gastric mobilisation and thoracoscopic oesophageal resection) for cancer or high grade dysplasia between September 2009 and November 2013. Outcomemeasures were: length of hospital stay, indexcomplication rates, 30 day mortality, margin status, and numbers of lymph nodes retrieved. Results: 24 patients underwent two-phase oesophagectomy with LGM during the study period. There were no conversions to laparotomy (0 %) and eight conversions to thoracotomy (33 %). Rates of postoperative anastomotic leak, chylothorax, and conduit ischaemia were 8 %, 8 %, and 0 % respectively. Circumferential and longitudinal resection margin positivity was 25 %, and 0 % respectively. The median number of lymph nodes retrieved was 21 (IQR 17–28). There was no in-patient mortality during the index admission or at 30 days postoperatively. Median length of hospital stay was 11 days (IQR 7–37). Conclusions: MIO appears to be a safe procedure as the results in our series compare favorably with national audit figures both open and minimally invasive oesophagectomy. The high numbers of retrieved lymph nodes appear to be in line with recent meta-analytic evidence favoring MIO over the open approach in this regard. However further work is required to fully determine oncological efficacy in terms of survival.

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Introduction: The Ganglioneuroma, like neuroblastoma, and ganglioneuroblastoma belongs to a group of tumors which are formed from ganglion cells of the neural crest known as neuroblastic tumors. These are the second most common solid tumors in childhood representing 15 % of neoplasms, overcome only by the central nervous system tumors1. The ganglioneuroma is often asymptomatic, slow-growing and most of the time the diagnosis is made? as an incidental finding after a radiology study ordered for another reason. The presence of the tumor must be confirmed on imaging studies such as ultrasound (US), CT scan or MRI3, 6. A report by the ‘Children’s Cancer group’ says ganglioneuromas patients have a disease-free survival of 90.8 % and 90.0 % total survival3, 6, 10. Materials and Methods: A 15 years old male presented with lower left quadrant pain of 12 hours evolution. The pain irradiated to left flank and ipsilateral anterior thigh and exacerbated after voiding. Results: Diagnostic laparoscopy was performed and core needle intraoperative biopsy was sent to pathology reporting a tumor consistent to a ganglioneuroma benign tumor. Complete resection was achieved. The final pathology report was: Left adrenal gland tumor of 10 cm consistent with a Ganglioneuroma, the capsule was complete. Conclusion: Renal laparoscopic adrenalectomy in pediatric patients compared to traditional open surgery gives better results, minimal invasion to the cavity, better postoperative analgesia, less blood loss, shorter hospital stay, better aesthetics and a return to normal activities in a short time. Laparoscopic adrenalectomy is a safe and effective surgical technique for the treatment of adrenal gland pathology. In our experience, we agree that the transperitoneal approach is a safe procedure with good functional results. Keywords: Transperitoneal laparoscopy; Suprarenalectomy; Ganglioneuroma; Childhood.

Surg Endosc



Lymphatic Sparing Laparoscopic Varicocelectomy With or Without Artery Sparing is There a Difference?

Transumbilical Endoscopy Assisted Surgery in Children

A. Yehya, R. Shalaby, M. Ismail

T. Tanimizu, A. Hinoki, D. Kitagawa, K. Koiwai, H. Tsujimoto, K. Hatsuse, K. Hase, J. Yamamoto

Al-Azhar University, Cairo, Egypt

National Defense Medical College, Tokorozawa, Japan

Background: The ideal surgical treatment for varicocele is still a matter of controversy because of the frequency of postoperative complications. We aiming to evaluate the difference between artery and non-artery lymphatic sparing laparoscopic varicocelectomy. Patients and Methods: 64 boys presented with primary varicocele were diagnosed by clinical examination and confirmed by colored Doppler ultrasonography. The mean age 12.25 ± 1.6 years (ranged 9–16 years). The patients were divided into two groups. Group A; 34 cases underwent non-artery lymphatic sparing laparoscopic varicocelectomy (NALSLV) using methylene blue dye. Group B; includes 30 boys underwent lymphatic and artery sparing laparoscopic varicocelectomy (ASLSLV) using MB. The main outcome measurements of this study includes hydrocele formation, varicocele recurrence, testicular size, hospital stay and operative time. Results: All procedures were completed laparoscopically without conversions or complications. All patients achieved full recovery and were discharged within 24 hours. The mean follow-up period was 18 ± 4.3 months (10–36 months). In group A; all patients underwent (NALSLV) with no hydrocele, one case of recurrence, two cases of testicular atrophy. In group B; 30 boys underwent (ALSLV) with no hydrocele, two cases of recurrence and no testicular atrophy. No significant difference in hospital stay and operative time in both groups. Conclusion: Low incidence of complications with LSLV with artery sparing. Also there no significant difference between artery and non-artery sparing using MB so we recommend (A LSLV) as a skill for treatment of varicoceles in children and adolescents.

Purpose: Transumbilical endoscopy assisted surgery (TUEAS) is a new procedure for surgery with necessity of extract the resected specimen, and subsequent extracorporeal suture or anastomosis after endoscopic incision or atherectomy. We report our experience of TUEAS in children. Materials and Methods: TUEAS cases that were performed in children from 2012 to the present were retrospectively evaluated. Under general anesthesia and ultrasound guided rectus sheath block, a 5 mm trocar for 30 degree scope was inserted on the farthest umbilical ring from the working site. a nearly semicircular skin incision was made at the contralateral side of the first trocar on the umbilical ring; the subcutaneous region was dissected extensively; and the 5 mm trocars were inserted at both ends of skin incision for working trocar. After intraperitoneal procedure, a small laparotomy was created followed by a dissection between each working trocars. For prophylaxis of wound infection, surgical wounds were closed using subcutaneous suture with 5-0 PDS Results: The subjects were 13 children (male:female = 8:5) aged 4 days to 16 years who underwent TUEAS during the study period. The surgeries included 7 appendectomies for peritonitis more than 48 hours from onset, 2 splenectomies, one ovarian cystectomy, 2 Meckel’s diverticulectomies. No additional laparotomy or serious complication was found. Postoperative appearances of the surgical wounds were extremely inconspicuous. Conclusion: Many procedures were reported in transumbilical surgery, however, these are not well suited for complicated surgery or necessity of extract the resected specimen. Our procedure is more appropriate for these cases than conventional umbilical surgery, and TUEAS provides superior cosmetic results.



A Solid Pseudopapillary Tumor of the Distal Pancreas Treated with Laparoscopic Distal Pancreatectomy and Splenectomy: A Case Report

Laparoscopic Repair of a Late Presenting Bochdalek Hernia

J.W. Park1, D.J. Kim2

Instituto Tecnolo´gico de Estudios Superiores de Monterey, Monterrey, Mexico

Chungbuk National University, Cheongju, Korea; 2Chungbuk National University Hospital, Cheongju, Korea

A. Franco, D. Reyes-Salas, E. Silva-Aguirre

1

Introduction: Pancreatic tumors are very rare in children. Only small numbers of cases were reported even from large referral centers over several decades. Solid pseudopapillary tumor is a unique pancreatic tumor of low malignant potential, which commonly affects females of reproductive age. It was first described by Franz in 1959 and was recognized as a distinct tumor of the exocrine pancreas by the World Health Organization in 1996. Its cellular origin is unclear. Case Presentation: A 9-year-old female child suddenly presented abdominal pain with nausea and vomiting. She was previously healthy. Physical examination revealed a palpable mass in RUQ, which was hard, fixed, non-tender and well-demarcated. Abdominal CT scan showed a 10.5 cm lobulating contoured, heterogenous enhancing mass between pancreatic tail and splenic hilum. Differential diagnoses were solid pseudopapillary tumor of the pancreas, most likely, and neurogenic tumor of splenic origin or lymphoma. There was no evidence of regional lymph node enlargement. All results of preoperative laboratory tests including tumor markers such as alpha-fetoprotein, beta HCG, carbohydrate antigen -125 and -19–9 were within normal limits. Chest X-ray and echocardiography were normal. She underwent a laparoscopic distal pancreatectomy and splenectomy. The histopathologic examination finally revealed a solid-pseudopapillary tumor of the pancreas. She was recovered uneventfully and is being followed up without any evidence of recurrence until 9 month after operation. Conclusion: We herein report a rare case of a solid pseudopapillary tumor of the pancreas in a 9-year-old female child who was treated successfully by a laparoscopic distal pancreatectomy and splenectomy. Considering benign characteristic of this tumor, laparoscopic excision might be an ideal, safe and feasible treatment option.

Aims: The aim of this study is to present a laparoscopic repair of a late presenting Bochdalek hernia through a 3-port technique using an abdominal approach. Methods: Case report. Results: We report a 4-year-old male admitted to the emergency room presenting abdominal pain and dyspnea. The mother referred previous events of hospitalization during the last year due to chronic constipation, abdominal pain and emesis, followed by gastroenterology consultation that treated him with a short course of prokinetics. He had presented to the emergency room one week previous due to abdominal pain, exacerbated on the upper left quadrant. He was currently treated with antispasmodics and laxatives. Initial clinical examination revealed a normal mental status. Polypnea with 97 % oxygen saturation. Peristalsis was present on auscultation of the left hemithorax. Abdomen was soft and untender. Laboratories revealed mild leukocytosis. A chest radiograph revealed loops of bowel in the thoracic cavity. A chest CT scan revealed a left posterior hemidiaphragmatic defect. The left thorax was occupied by small bowel loops, transverse and ascending colon and spleen. The patient was admitted for a laparoscopic hernia repair. A 3-port technique was used, returning the viscera to the abdominal cavity and repairing the defect with 3/0 ethibond. Postoperative period was uneventful. The patient was discharged on the sixth day postop. Conclusions: Surgical management of congenital diaphragmatic hernias includes abdominal or thoracic approach. Abdominal approach for congenital diaphragmatic hernia is best when intestinal malrotation or bilateral hernia is associated. The thoracic approach allows a better exposition and is the preferred approach in obese patients. Laparoscopic approach for Bochaldeck hernia has different benefits such as early recovery, short hospital stay, excellent cosmetic results, good visualization of the defect and less complications. Repair must be tension-free, preserving the diaphragm’s natural shape for an ideal respiratory function.

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Surg Endosc

P608 - Pancreas

P610 - Pancreas

Laparoscopic Pancreaticoduodenectomy with Posterior Approach and Pancreaticogastrostomy

Audit to Evaluate Adherence to the Management of Acute Pancreatitis Guidelines

A.R. Elgeidie

S.P.B. Vincent, A. Ali, K. Khatri

Mansoura University, Mansoura, Egypt

Inverclyde Royal Hospital, Greenock, United Kingdom

Despite the fact that laparoscopic pancreaticoduodenectomy (LPD) remains one of the most advanced laparoscopic procedures it is beginning to gain wider acceptance due to the evolution in laparoscopic technology and instrumentation within the past decade. Total mesopancreas excision was recently highlighted as a key point in curative-intent surgery for pancreatic head adenocarcinoma and it was confirmed by further studies that have shown a significantly increased rate of R0 resections. Total mesopancreas excision in pancreatic head cancer has been proved to be facilitated by the posterior approach in duodenopancreatectomy. Regarding the impact of the posterior approach technique on long-term outcome of patients with pancreatic head cancer, a recent study has shown a significant improvement of the survival as compared to the standard pancreatico-duodenectomy). Current RCTs suggest that pancreaticogastrostomy (PG) is better than pancreaticojejunostomy (PJ) for pancreatic reconstruction after PD. In the combined results of PG versus PJ, a significant difference in the morbidity of intra-abdominal complications was found. In this video presentation we demonstrate the technique of LPD using the posterior approach for resection and PG for anastomosis.

Sarah Vincent, Ahmed Ali, Kamran Khatri InverclydeRoyalHospital, Greenock, UK Aims: The aims of this audit were to evaluate how well the principles of the UK Guidelines for the management of acute pancreatitis were adhered to within the last six months of practice. Method: All patients with a coded diagnosis of acute pancreatitis from January 2013 to July 2013 were included. All data was obtained from clinical notes, Trakcare and Clinical Portal and stored on a secured Microsoft Excel file. Results: There were 24 patients, 10 women, 14 men with an average age of 58. It was found that 17 out of 24 of patients had the cause of pancreatitis identified. In 21 of 24 patients diagnosis was made within 48 hours of admission. Documentation for severity assessment took place in 50 % of cases. 3 out of 3 patients who were documented to have severe pancreatitis were admitted to HDU, altogether 5 patients were admitted to HDU. No patients were given antibiotics for more than 14 days. Four patients with confirmed gallstone pancreatitis, 3 out of these patients received definitive management. Conclusion: The audit achieved its objective to establish both good and bad clinical practices occurring within the general surgical department and highlighted the need for improvement within clinical practice.

P609 - Pancreas

P611 - Pancreas

Laparoscopic Distal Pancreatectomy: First Experience

Cases of Pancreatoduodenectomy Laparoscopic in Cali Colombia

O.M. Gulko, V.V. Chornyi, M.E. Nytchytaylo, O.M. Lytvynenko, O.A. Lavryk, V.P. Serdjuk, O.M. Simonov

Zuluaga Zuluaga1, J.O. Zorrilla Lara1, E. Bolanõs Quintero2, A. Mejia Prado2, I. Siljic Bilicic1, A. Osorio2

National Institute of Surgery and Transplantology, Kyiv, Ukraine

1

Introduction: Laparoscopic distal pancreatectomy (LDP) has become the gold standard for benign tumors. Laparoscopic pancreatic surgery is becoming an acceptable alternative to open resection of selective pancreatic lesions. It has become an increasingly used technique in the surgical treatment of several pancreatic diseases. The aim of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery. Methods: From January 2010 to November 2013 fifteen laparoscopic distal pancreatectomy were performed. The patients (mean age 45.9 years) had final diagnoses of chronic pancreatitis pseudocyst (n = 2), benign cystadenoma (n = 8), neuroendocrine tumour (n = 3), primary pancreatic carcinoma (n = 2). Results: All of them underwent successfully laparoscopic distal pancreatectomy. The operative duration was 190 min (range, 140 to 230), volume of blood loss (256 ± 188) ml, mean time of oral food taking (1.5 ± 0.9) days and mean postoperative hospital stay (7.1 ± 1.9) days. Two patients were diagnosed of post-LDP pancreatic fistula (1 B level) and all of them became cured after conservative treatment. There was no mortality. Conclusion: Our little experience supports the idea that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and may not require specialized training. Further data are required to make more definitive conclusions.

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Hispital universitario del valle, Cali, Colombia; 2Clinica de occidente, Cali, Colombia

Cancer of the pancreas and periampullary region offer a challenge in handling due to the low rate of resectability at the time of diagnosis. Group experience gastrointestinal surgery with this type of pathology are commented, making a review of the literature of experience in minimally invasive surgery in this type of procedure.

Surg Endosc

P612 - Pancreas

P614 - Pancreas

Usefulness of the Three Steps Approach on Laparoscopic Pancreaticoduodenectomy

Laparoscopy Assisted Central Pancreatectomy and Pancreaticogastrostomy for the Pancreatic Schwannnoma

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

R. Morimura1, H. Ikoma1, Y. Yamamoto1, H. Konishi1, Y. Murayama1, S. Komatsu1, A. Shiozaki1, Y. Kuriu1, T. Kubota1, M. Nakanishi1, D. Ichikawa1, H. Fujiwara1, K. Okamoto1, C. Sakakura1, E. Otsuji1, T. Ochiai2

Sugita Genpaku Memorial Obama Municipal Hospital, Obama, Japan Minimally invasive surgical techniques for pancreatic or duodenal disease are being applied with increasing frequency. We modified previously described several surgical approaches on right colectomy and applied to laparoscopic pancreaticoduodenectomy (LPD) for the safe procedure. The step 1 (inferior approach) is to access inferior side of pancreas and superior mesenteric vessels, similarly to the inferior approach on right colectomy. The transverse colon and the small intestine are lifted upward, and the posterior side of the duodenum is dissected from the inferior vena cava (IVC) and the aorta. The step 2 (medial approach) is to access to the front side of the superior mesenteric vein (SMV), similarly to the medial approach on right colectomy. The small intestine is placed downward and the ileocecal vessels are pulled toward right caudal side. This approach is continued until the root of the gastro-colic trunk (GCT) from the SMV is identified. The step 3 (superior approach) is to access the pancreas over the transverse mesocolon. The step2 helps identification of SMV and GCT in this approach from the caudal side of the pancreas neck. After division of the pancreas, the root of in the inferior pancreaticoduodenal artery (IPDA) and the first jejunal artery (FJA) can be easily identified and divided under a clear view. After pulling through the terminal duodenum on the right side of mesenteric vessels, the neural plexus behind pancreas head is dissected using the hanging method for the pancreas head, which use a cotton tape hanged over pancreas. This method allows to make a moderate countertraction and to prevent congestion and bleeding from the specimen side tissues. 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.

1

Kyoto Prefectural University of Medicine, Kyoto, Japan; 2North Medical Center Kyoto Prefectural University of Medicine, Kyoto, Japan

A case of Report: A 71-year-old female patients with an asymptomatic pancreatic mass that was found in the course of the evaluation of her pulmonary disease. The computed tomography (CT) scan demonstrated a 4.3 ± 3.7 cm well-encapsulated tumor, which was composed of cystic area and located pancreatic body. Laparoscopy assisted central pancreatectomy and pancreaticogastrostomy was performed and pathologic examination revealed a benign schwannoma. Pancreatic schwannomas are particular rare neoplasms. Despite using sophisticated imaging modalities such as CT and magnetic resonance imaging, the preoperative diagnosis of a pancreatic schwannoma is difficult and imageguided biopsy is also discouraged because of the high risk of tumor hemorrhage and dissemination. Complete surgical resection is the treatment of choice, but the surgical approach remains debatable. With recent advances in the field of minimally invasive surgery, few laparoscopic approaches to pancreatic schwannomas have been reported. We summarized the literature on cases regarding the laparoscopic management of the pancreatic schwannoma.

P613 - Pancreas

P615 - Pancreas

Experience of Using Minimally Invasive Techniques for the Management of Patients with Severe Acute Pancreatitis

Laparoscopic Distal Pancreatectomy; Focused on the Transection Line of the Pancreas

A.Y. Berdinskikh, V.A. Bombizo, P.N. Buldakov

T. Goto

Regional Clinical Hospital of Emergency Medical Care, Barnaul, Russia


Introduction: Severe acute pancreatitis is a disease taken the leading positions in emergency surgery. Absence of a unified international standard of surgical treatment. Consistently high mortality rate. Aims: Surgical treatment efficiency evaluation of patients with severe acute pancreatitis using minimally invasive techniques. Materials and Methods: Treatment results of 32 patients admitted to Regional Clinical Hospital of Emergency Medical Care from April 2013 to January 2014. Patients were divided into two identical groups (age, severity at admission on the APACHE-II Score). The age of patients ranged from 35 to 78 years. Group A (n = 17). Patients underwent surgeries using minimally invasive techniques. Group B (n = 15). Patients underwent surgeries using traditional (open surgery) techniques. All patients underwent emergency surgery after the minimum required tests including ultrasound and CT-scan. Patients’ severity before surgery was from 10 to 26 points on the APACHE-II Score. In group A minimally invasive approaches included laparoscopy (10 mm and 5,5 mm ports), laparoscopic debridement, retroperitoneoscopy, left retroperitoneal debridement, endoscopic drainage and left retroperitoneal drainage. Patients in group B underwent open surgery (midline incision), open debridement, lumbotomy and retroperitoneal drainage. Results: Minimally invasive surgeries were performed successfully to all patients of group A. Six patients were needed repeated surgeries (necrosectomy). 14 patients were needed repeated surgeries in group B. Performing retroperitoneoscopy allowed evaluating the degree of tissues damage, and dissection could help delimit the spread of inflammatory process in retroperitoneal fat. A significant decrease in the severity of the postoperative period and pain reduction (VAS) were noticed in group A. Decrease in length of hospitalization was marked in group A, which is important for patients of working age. There were no deaths in group A. Two patients died in group B. Conclusion: Benefits of using minimally invasive techniques are represented among the patients in group A and expressed in the severity of the postoperative period reduction, a decrease in pain (VAS), the hospitalization length and mortality reduction.

Background: We gradually improved and standardized the surgical procedure in laparoscopic pancreatic surgery after it was introduced in our institute in March 2007. Pancreatic parenchyma thickness and relative position of the vessels will change by transect line of the pancreas in the laparoscopic distal pancreatectomy (LDP). Object: To standardize our procedure of LDP focused on the transect line of the pancreas. Material and Methods: We reviewed the findings in a consecutive series of 32 patients who underwent LDP from March 2007 to October 2013 out of which transection of pancreas neck 6 cases, transection of the left side of pancreas 12 cases. Surgical procedure: We usually use stapler when the pancreas is divided. When the pancreatic parenchyma was too thick, we fluttered a few minutes using intestinal forceps. We keep in mind to have transect line of the pancreas to be perpendicular to the major axis of the pancreas. Point of Caution: (1) Transection of pancreas neck: We can recognize the root of the splenic artery from the back side after mobilizing the pancreas body and tail but the splenic artery from the upper edge of the pancreas side must also be examined. The superior mesenteric vein (SMV) was identified at the inferior edge of the pancreas at the junction of the pancreatic head and body. The SMV was detached from the posterior surface of the pancreas toward its superior edge and branching of the SMV and splenic vein (SPV) was widely exposed. The common hepatic artery at the upper edge of pancreas need to be isolated to prevent involvement during the transection of the pancreas with stapler. (2) Transection of the left side of pancreas: When the SPV is difficult to be isolated from the pancreatic parenchyma, we can transect both SPV and pancreatic parenchyma together. Conclusion: It is important to grasp the precise anatomical findings using MDCT before operation. The focal point is the excision line of the pancreas, with which the safety of the LDP can be improved.

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Surg Endosc

P616 - Pancreas

P618 - Pancreas

A Novel and Safe Method for Retraction of the Liver and the Stomach During Laparoscopic Distal Pancreatectomy

Rational Medical and Economical Approach to the Patients with Acute Pancreatitis Surgical Treatment

M. Shinzeki, I. Matsumoto, S. Asari, T. Goto, J. Ishida, A. Ueta, Y. Nanno, T. Matsumoto, A. Takebe, M. Kido, T. Ajiki, T. Fukumoto, Y. Ku

V.M. Demidov1, S.M. Demidov2

Kobe University School of Medicine, Kobe, Japan It’s important to achieve and maintain an optimal surgical field during laparoscopic surgery. Various liver retraction methods during laparoscopic gastrectomy were reported but the necessity of additional laparoscopic port for the hand of the assistant and post operative liver dysfunction with some types of liver retractor were unresolved issues. During laparoscopic distal pancreatectomy, the lateral segment of the liver and the stomach should be retracted to expose pancreas and handle splenic vessels in safety. We introduce a new technique to retract the liver and the stomach during laparoscopic distal pancreatectomy using a silicon disk. This method is simple and safe to achieve an adequate surgical field by retraction of the lateral segment of the liver and the stomach without liver damage. The silicon disk is an oval shaped silicone rubber membrane with a flexible frame around the membrane and has small holes at the four corner on the membrane. At the first step of the operation, we fixed a silicon dick to the right crus of the diaphragm through the dorsal space of the stomach with a 2-0 monofilament polypropylene suture. The opposite side of the suture passed through the holes on the silicon disk was pulled and fixed on the abdominal wall. Then the lateral segment of the liver and the stomach is lifted up by the silicon disk and the anterior aspect of the pancreas is clearly exposed. Furthermore the silicon disk works as a shield wall to protect stomach, liver and other tissues from injury by the autosuture device in a setting of transection of the pancreas. We herein report the usefulness of a new method to retract the liver and the stomach using the silicon disk during laparoscopic distal pancreatectomy.

1 National Medical University, Odessa, Ukraine; 2Municipal City Hospital N10, Odessa, Ukraine

Aims: To evaluate the comparative cost of the patients with acute pancreatitis (AP) miniinvasive treatment. Methods: The retrospective randomized controlled clinical trial study lasted for 8 years and includes 178 patients with AP that were treated in the surgical departments of the Odessa Municipal Hospitals N9 and N10. The AP patients were retrospectively divided on two groups: the 1st - those patients who were undergone traditional abdominal surgery with wide open access, The 2nd group - those patients who were undergone miniinvasive surgical procedures. Results: The data we received showed no difference in the efficacy of the performed surgical interventions in two groups of patients with the tendency to its increasing in the patients with the intraarterial drugs administration. The lethality constituted 4 cases in the 1st group and 0 - in the 2nd. The clinical success rate with respect to clinical and laboratory symptoms improvement was 81 ± 7 % in the 1st group and up to 99 % in the 2nd group. Complications and side-effects throughout 1–2 years of the follow up were registered in 7–11 % of patients of the 1st group and less than in 2 % of the 2nd group patients. Lifethreatening events were observed in 4 cases in the 1st group and were absent in the 2nd group. The costs for patients were significantly lower for those in the 2nd group despite the high price of the microcatheters for intravascular interventions. The high cost of medical treatment for the 1st group patients was mainly due to prolonged stay-in the hospital and included nursing costs, hospitalization costs, prices for remedies as well as readmission rate. Conclusions: These additional financial calculations showed evident advantage of miniinvasive surgical technology versus traditional way of AP treatment for every patient that may allow to them to make his own preference of AP treatment.

P617 - Pancreas

P619 - Pancreas

Acute Pancreatitis Surgical Treatment Efficacy Improvement

Laparoscopic Distal Pancreatectomy with Splenectomy for Neuroendocrine Carcinoma: Case Report

V.M. Demidov1, S.M. Demidov2 National Medical University, Odessa, Ukraine; 2Municipal City Hospital N10, Odessa, Ukraine 1

Aims: To increase the efficacy of the surgical treatment of patients with acute pancreatitis (AP). The idea of these clinical observations has the following Background: we started pre-operative miniinvazive treatment from the 5th day from the moment of the disease onset. Methods: 33 patients with acute destructive pancreatitis were treated. The treatment was aimed to pancreatic gland edema diminishing, extrahepatic bile tracts decompression, traditional desintoxicative and pancreatoprotective pharmacons administration etc. Abdominal cavity laparoscopic drainage was performed to 25 patients. Eleven patients were treated traditionally with the very first days of the input to the department. Fourteen patients constituted the group of the patients to whom we injected the Dalargin (SP ‘Vector’, Novosibirsk, Russia) and Deltaran (Russia) using catheter inserted into bursa omentalis. Results: Traditional AP treatment resulted in the certain improvement of the disease manifestation. Besides, the patients with the additional intrabursal Dalargin and Deltaran administration started after the 5th day of the disease onset showed more progressive clinical condition improvement. There were no cases of the pancreonecrosis development in this group of patients (2 patients out of 10 with the traditional AP treatment had pancreonecrosis). We didn’t observe any cases of complication among the 14 patients treated with Dalargin and Deltaran (2 complications were in 10 patients with the traditional AP treatment). The average time of patients treated traditionally days-in the hospital equal to 9–14 days. The average time of patients who received Dalargin and Deltaran days-in the hospital was 4–7 days shorter comparing with the same index in the traditionally treated patients. Conclusions: Intrabursal drugs with the potent pancreatoprotective properties administration in patients with destructive AP has some important advantages - less cases of disease progression, of complications and the quicker patients rehabilitation.

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S. Stipancic, J. Bakovic, M. Knezevic, G. Aralica Clinical Hospital Dubrava, Zagreb, Croatia Aims: Aims of this summary is to report a case of. first laparoscopic distal pancreatectomy with splenectomy in our hospital due to neuroendocrine cancer Despite the relatively slow start of laparoscopic pancreatic procedure to other laparoscopic resections, an increasing number of these procedures are being performed. Methods: We present laparoscopic distal pancreatectomy with splenectomy in our hospital due to neuroendocrine cancer in a form of the case report. Results: A 66-y-old man reported to clinic due to a tumor in a pancreatic tail, size 27 9 25 mm in close contact with spleenic vein, revealed on abdominal MSCT during surveillance of left kidney cyst. A EUS guided cytopunction was performed and analysis showed neuroendocrine tumor, chromogranin positive and Ki67 7 %. The tumor marker were normal, CEA 4.1 ad Ca 19–9 0.6. We planned a laparoscopic distal pancreatectomy with splenectomy. During the procedure, we faced only with difficulty transection of the pancreas. After surgery patient was well, he had faster recovery and he was discharged on the seventh day after surgery. The pathology report revealed neuroendocrine carcinoma (T3 N0 11/0 l.n.G1 R0), CKAE1/AE3, NSE, chromogranin A and CD 56 positive, no. of mitosis 2/10 and Ki67 more than 20 %). Due to pathology report patient was sent to oncology on adjuvant therapy. One year after the end of treatment, the patient continues to be followed-up and does not show any sign of recurrence. Conclusions: The pancreatic location of the tumor remains the most critical factor in the use of laparoscopy as the standard procedure. Lesions in the body and tail should be performed laparoscopically unless there is contraindication. However, the technical skills and a ability of training are the limiting factors to widespread use.

Surg Endosc

P620 - Pancreas

P622 - Pancreas

Endoscopic Main Pancreatic Duct Stenting for Diagnosis and Treatment of a Retention Cyst in a Patient with Chronic Pancreatitis and Wirsung Lithiasis

Copper Absorption in Chronic Pancreatitis

M. Garancini1, E. Bolzonaro1, A. Delitala1, F. Pugliese2, M. Scotti1, A. Giani1, P. Riva1, V. Giardini1

Manchester Royal Infirmary, Swansea, United Kingdom

1

2

San Gerardo Hospital, Monza, Italy; Department of Digestive Endoscopy, Niguarda Ca’ Granda Hospital, Milano, Italy

Introduction: Few topics in medicine are as controversial as the evaluation and management of patients with cystic neoplasms of the pancreas. Case Report: A 54 years old woman with no significant medical history came to our attention for an asymptomatic pancreatic cystic diagnosed with ultrasound. Computed tomography, magnetic resonance imaging (MRI) and endoscopic ultrasound plus fine needle aspiration were performed and found a 40 mm cystic lesion of the pancreatic tail communicating with main pancreatic duct without adjacent mass, septations or thickened cystic wall; signs of chronic pancreatitis were also detected. A dilatation up to 9 mm of the main pancreatic duct due to a 7 mm lithiasis of the head of pancreas was found. Cystic fluid showed increased viscosity and the analysis revealed no malignant cells, amylases: 21615 U/L, Carcino Embryonic Antigen (CEA): 30.6 ng/ml and CA 19.9: 37561 U/ml. The patient underwent lithotrypsia and Endoscopic Retrograde Cholangiopancreatography (ERCP), but endoscopic stone removal failed. A second ERCP was performed with successful placing of a stent draining the main pancreatic duct; post procedure course was regular. The abdominal MRI performed 30 days after treatment showed complete cyst disappearance. Discussion: The differential diagnoses for such lesion was: retention cyst due to the pancreatic head lithiasis with indication to conservative treatment or intraductal papillary mucinous neoplasia main duct type with indication to surgical resection. Retention cyst was considered the most suitable diagnosis because of the presence of hyper-pressure in the main pancreatic duct due to the stone and the CEA fluid level lower than 192 ng/ml (nonmucinous lesion). Nevertheless, many authors reported that a high CA 19.9 fluid value should be considered suspicious for a malignant lesion. The communication between the cyst and the main duct can be considered common in both the diagnostic options. ERCP plus stenting of the main pancreatic duct allowed the correct diagnosis and management of the cystic lesion. Conclusion: In presence of pancreatic obstruction due to lithiasis of the Wirsung together with a cystic lesion of uncertain nature, ERCP plus stenting of the main pancreatic duct could be considered a valuable both diagnostic and therapeutic option.

P.R.S. Tasker, J.M. Braganza, H. Sharma

Aims: The purpose of the study was to determine the influence of exocrine pancreatic insufficiency (EPI) on copper absorption in man. Method: 64Cu absorption was measured by a computerised deconvolution program after separating 64Cu in serial blood samples from that bound to caeruloplasmin by elution through charcoal columns. The method was previously designed, validated, and tested for reproducibility using healthy volunteers. Results: 10-h absorption from 350-ml water for twelve healthy volunteers was 43.7 (±10.2) % (Mean ± SD) [1.94 ± 0.49 % (10 h absorption/BMI)]. Excluding three on oral contraceptives (OC+), 64Cu absorption was 42.3 (± 9.7) % (n = 9) [or 1.84 ± 0.43 %/ BMI]; 6 male, 3 female), and serum copper, caeruloplasmin, and 64Cu-caeruloplasmin and urinary 64Cu were all similar suggesting equivalent copper status on their habitual diet. In nine patients with CP, 10-h absorption was 35.9 (± 12.8) % [1.71 ± 0.52]; 6 male and three female. Variation increased due to the inclusion of clinical pancreatic insufficiency (CPI) patients, who had pancreatic steatorrhoea. Lower absorption 26.9 (± 7.5) % (n = 5) [1.33 (± 0.33)] associated more with CPI (t = 4.078, P2 P \ 0.01) than with vagal transection (VT +) (n = 3) (t = 3.588, P2 \ 0.01). Non-CPI patients absorbed 47.2 (± 7.3) % (n = 4) [2.17 ± 0.18]. Without patients with achlorhydria (DM, DH), the CPI group 10 h absorption was still low at 32.1 (± 3.1) % (n = 3) [1.57 (± 0.11)]. In the CPI group, the three patients (DH, DM, and NK) had been on long-term supplements (LT +). VT + (DH, DM, BJ) had lowest absorption; two (DH, DM) with achlorhydria absorbed least. When Nutrizym was combined with oral 64Cu dose in two, DM (total pancreaticoduodenectomy patient) increased his per cent absorption from 18.2 to 40.9 % reversing the CPI trend, whereas a non-CPI patient, absorption remained unaltered (42.8 to 40.8 %). Conclusion: The greater decrease in 64Cu absorption in CP with casein was due to both increased Cu status and reduced release of Cu from casein binding. Whereas 64Cu absorption from 350 ml water reflected inversely only copper status. There was no evidence of direct inhibition of copper absorption by normal pancreatic secretion in man, but severe EPI appeared to result in decreased 64Cu absorption.

P623 - Pancreas P621 - Pancreas Limited Value of Staging Laparoscopy in Patients with Pancreas Head and Peri-ampullary Cancer N. Alexakis1, S. Sbarounis2, K. Toutouzas1, M. Skalistira2, S. Katsaragakis1, M.M. Konstandoulakis1 1

Department of Surgery, University of Athens, Athens, Greece; 2 Hippocratio Hospital, Athens, Greece Background: Pre-operative staging laparoscopy for suspected peri-pancreatic tumours is not widely accepted due to its low yield (4–13 %) and its usefulness has been questioned. Methods: Data from a prospectively collected database (2005–2012) with 117 patients who had preoperative computed tomography and/ or MRI were analyzed. Detailed preoperative imaging, staging, and operative data were collected for each patient. Results: 117 patients were evaluated and 110 patients were deemed radiological resectable and underwent laparotomy. There were 99 patients with resection (Kausch-Whipple operation) and 11 without resection (8 due to extensive vascular involvement and 3 due to peritoneal/ liver metastases). There were 7 patients who were deemed radiological unrespectable (6 due to vascular involvement and 1 due to peritoneal/ liver metastases). There were no patients with false positive results. The sensitivity, specificity, PPV and NPV of preoperative radiological imaging in determining unrepeatability due to liver/ peritoneal metastases were 25 %, 100 %, 100 % and 97.4 % respectively. Conclusion: Only 2.6 % of patients in the present series would have benefited from staging laparoscopy. However the low sensitivity suggests the use of laparoscopy in a few selected patients.

Raised 64Cu-Caeruloplasmin and Urinary 64Cu Excretion; Indicators of Altered Copper Status in Chronic Pancreatitis P.R.S. Tasker, J.M. Braganza, H. Sharma Manchester Royal Infirmary, Swansea, United Kingdom Aims: The aim was to confirm the increased copper status suggested in the rat with pancreatic insufficiency (PI) in man, and to determine the influence of pancreatic extract. Methods: These results from venous and urinary sampling were taken as the part of the study on absorption in chronic pancreatitis (CP) using computerised deconvolution, which provided a direct measure of copper absorption. Results: In CP 64Cu transfer to caeruloplasmin increased relative to the dose absorbed. Although mean 64Cu absorption in patients with chronic pancreatitis, after a water-based test, was similar to normal subjects, serum 64Cu-caeruloplasmin by 3 hours and 64Cu excretion in urine by 4 hours showed a significant rise in patients with CP compared to controls after both oral and intravenous 64Cu. Furthermore, in keeping with dose dependency after oral dose, the difference in the rise of 64Cu-caeruloplasmin in CP and controls was enhanced by expressing the counts as a proportion of the 10-h percentage absorption derived by deconvolution (P2 P \ 0.001). Clinical pancreatic insufficiency (CPI) were patients with pancreatic steatorrhoea. Dividing 64Cu-caeruloplasmin by the 10 h absorption percentage reversed the relationship between CPI and non-CPI groups in oral tests. 64Cucaeruloplasmin became more elevated in CPI subjects with greater divergence from controls but dose-related 64Cu-caeruloplasmin in the non-CPI group was still above controls. A similar trend was seen after injected 64Cu. In two CPI IV tests in the presence of oral supplements 64Cu-caeruloplasmin showed a nearly quadruple increase. Conclusion: Because these changes were enhanced by division with time-related and 10 h absorption, block in rate of tissue utilisation of 64Cu-caeruloplasmin was not proposed. Serum 64Cu-caeruplasmin was recently absorbed copper; any increase compared to controls may reflect increased 64Cu absorption in CP. Those with CPI absorb even more copper relative to the oral dose of 64Cu applied. This was apparent even though 64Cu absorption on testing was reduced. Previous rat studies emphasised increased liver copper retention in the presence of PI, so the implication of raised copper status in CP may be attributable to reduced exocrine secretion. Pancreatic extracts on limited data appears to return 64Cu absorption to normal but enhance 64Cu-caeruloplasmin synthesis.

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P624 - Pancreas

P626 - Pancreas

Reduced Port Surgery for Laparoscopic Pancreaticoduodenectomy

Diagnostic Laparoscopy for Staging Gastric and Pancreatic Cancer

S. Tyutyunnik1, I.E. Khatkov1, V.V. Tsvirkun1, R.E. Izrailov1, S.A. Domrachev2, A.O. Atroshchenko1, I.Y. Feydorov1

M. Beuran, S. Paun, B. Gaspar, B. Stoica, I. Tanase, I. Negoi Emergency Hospital Bucharest, Romania

1

Moscow Clinical Scientific Center. MSUMD, Moscow, Russia; 2 Moscow State University of Medicine and Dentistry, Moscow, Russia Purpose: Several techniques have been introduced in laparoscopic pancreatic cancer surgery, but most of them use more than five ports. and the use of reduced port surgery (RPS)has gradually become widespread. To assess the safety and usefulness of five port total laparoscopic pancreaticoduodenectomy. Patients and Methods: From January 2007 to July 2013, 60 patients with tumors of pancreatic head and periampullar area underwent total laparoscopic pancreaticoduodenectomy with 5 ports: 1 12-mm, 3 10-mm and 1 5-mm trocars. Results: The mean operation time was 444 ± 120,8 minutes. The mean postoperative hospital stay was 22,0 ± 1,4 days. Postoperative mortality was 5.1 %. The complication rate was 43,3 %. Most common complications were delayed gastric emptying n-10 (14,3 %); bleeding n-1 (1,4 %); BDA insufficiency n - 4 (5,7 %); PJA insufficiency n-4. Resected margins were positive in three cases. Conclusion: Five ports total laparoscopic pancreaticoduodenectomy is a safe and feasible procedure for patients with benign and malignant tumors of pancreatic head and periampullar area.

Introduction: Surgical resection is the only potentially curative treatment for different digestive cancers like gastric or pancreatic. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). Method: We studied retrospectively all digestive cancers who underwent diagnostic laparoscopy for staging in a period of 2 years admitted in Emergency Hospital of Bucharest. Results: A total of 19 patients underwent laparoscopy for staging the cancer and for knowing the possibility of curative resection. We had in 2 years 7 laparoscopy for staging gastric cancer and 12 patients with pancreatic tumor. The CT scan was performed in majority of the cases. For gastric cancer male/female ratio was 6/1 and for pancreatic cancer 5/7 and the overall median hospital stay was 8 days. Conclusion: CT is not sufficiently sensitive to detect or exclude peritoneal disease and diagnostic laparoscopy may decrease the rate of unnecessary laparotomy.

P625 - Pancreas

P627 - Pancreas

Less Common Laparoscopic Surgery for Pancreatic Diseases

Laparoscopic Distal Pancreatectomy and Splenectomy for Disconnected Pancreatic Tail Syndrome Following Previous Open Pancreatic Necrosectomy

M. Vrany, M. Man Hospital Jablonec nad Nisou, Jablonec nad nisou, Czech Republic Aims: There is a wide range of surgery and endoscopic interventions for different pancreatic diseases. In our video we would like to present our experience with less common laparoscopic operation of pancreas, our technique. Method: The first video presentation shows the resection of the uncinatums of pancreas for Grawitz tumor metastasis. The second video shows the central pancreatectomy and construction of the gastropancreatic anastomosis performed laparoscopically. Results: We will review the results obtained on patients who underwent this kind of operation. We considered the early postoperative outcome, duration of the operation and postoperative follow up. Conclusion: Even though laparoscopic resection of pancreas is demanding, this operation can be done safely with low morbidity.

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A.V. Ariyarathenam1, A.V. Cota2, S. Aroori1 Plymouth Hospitals NHS Trust, Plymouth, United Kingdom; 2Royal Cornwall Hospital NHS Trust, Truro, United Kingdom 1

Aims: This case demonstrates the technique of Laparoscopic Distal Pancrearectomy and splenectomy (Lap-DPS) in a patient who previously had undergone open pancreatic necrosectomy and cholecystectomy for severe pancreatitis. Patient Details: A 48 year old male patient with recurrent left upper abdominal pain for over 12 months and was referred to our tertiary Hepato-Pancreatico-Biliary centre. The patient had undergone an open pancreatic necreosectomy and cholecystectomy for severe gallstone pancreatitis, 2 year previously. Computerized Tomography confirmed the presence of a small remnant of tail of pancreas with a dilated pancreatic duct and an associated large pancreatic cyst and splenic vein thrombosis. There was no connection between the tail of pancreas and pancreatic head remnant, in keeping with his symptoms of a disconnected pancreatic tail syndrome. Procedure: At laparoscopy, there was a cyst in the tail of pancreas with extensive adhesions between pancreatic cyst, omentum, stomach, transverse colon, spleen and diagphram. Splenic vessels were densely adherent to the pancreatic cyst. Following adhesiolysis, distal pancreatectomy and splenectomy was performed. During surgery, a serosal tear was made in the transverse colon and this was successfully repaired laparosocpically. Patient recovered well and was discharged home 5-days following surgery. The histology confirmed chronic pancreatitis with increased stromal fibrosis. At six months follow up, he is well with no further abdominal pain. Conclusion: Laparoscopic distal pancreatectomy and splenectomy is feasible and safe in patients with previous history of open pancreatic necrosectomy. Disconnected pancreatic tail syndrome should be considered in patients with upper abdominal pain following pancreatic necrosectomy.

Surg Endosc

P628 - Physiology, Pathophysiology, Immunology

P631 - Radiology/Imaging

Impact of Analgesic Modality on Stress Response Following Laparoscopic Colorectal Surgery: Data from a Randomised Controlled Trial

Region Specific CT Scan: Could it be the Future of the Imagining in Acute Abdomen

D.E. Barr1, J. Foster1, P. Ewings2, C. Boulind1, J. Reid1, J. Jenkins3, B. Williams-Yesson1, N. Francis1

A. Hammad, L. Chiwanda, M. Biddle, A. Mukherjee Hairmyres Hospital, Glasgow, United Kingdom

Aims: Routine use of thoracic epidural anaesthesia (TEA) after laparoscopic colorectal surgery has been questioned. Single centre studies have found alternative methods of analgesia to be equally efficacious following laparoscopic surgery. It is however, widely perceived that epidural analgesia modulates the stress response after open surgery, and this may be important in reducing cardio-pulmonary and infectious morbidities. TEA may also modulate the neuro-endocrine stress response to laparoscopic surgery, facilitating enhanced recovery. The aim of this study was to evaluate the impact that post-operative analgesia has on the stress response following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) post-operative care protocol. Methods: Data was collected as part of a double blinded randomised controlled trial at two UK sites. Patients undergoing elective laparoscopic resection for benign or malignant tumours of the colon or upper rectum were randomised to receive either TEA or continuous local anaesthetic infusion to the extraction site wound via wound infusion catheter (WIC) for 48 hours post operatively. Peripheral venous blood samples were taken prior to induction of anaesthesia, and then at 3, 6, 12 and 24 hours after the start of operation. Samples were analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 as markers of the of neuroendocrine, metabolic and inflammatory cascades after surgery. Results: Twenty five patients consented to blood sample collection; distributed between TEA and WIC arms of the trial in a ratio of 11:14. No significant differences were observed for cortisol, insulin or interleukin-6 at any of the time points. However, there was a trend towards reduced serum concentrations of epinephrine in the epidural arm at 3 hours (p = 0.06) when compared to the WIC arm of the trial. This difference was not present at other time points. Complications were equally distributed between trial arms. There were no mortalities. Conclusions: This limited randomised control trial indicates that the impact of epidural analgesia on stress modulation is minimal following laparoscopic colorectal surgery within an ERAS programme. Larger studies are required to validate these findings within the context of identifying the optimum analgesic modality following laparoscopic colorectal surgery.

Aims: This study aims at analysing the diagnostic role of CT in the management of patients presenting with acute abdomen. Emphasis is on identifying the usefulness of CT in avoiding unnecessary surgery and defining its accuracy over clinical diagnosis in different anatomical regions. Method: A retrospective observational study was undertaken on 85 patients over a period of nine months who had CT abdomen after having presented to the surgical receiving ward with acute abdomen. Results: Average time from admission to scanning was 1.43 days. Pain was the most common indication for CT with 73 patients (85.88 %) (n = 85). 12 patients had additional features including abdominal distension, jaundice, acute weight loss, features suggestive of upper GI/pancreatic ca, gas under diaphragm on CXR, pulsatile abdominal mass and abdominal wall swelling. 12 patients (14.12 %) had a normal scan. Out of the total 85 patients, 25 patients proceeded to general surgical intervention after CT (29.41 %) 8 patients were transferred to urology for further intervention. Eight patients had radiological intervention. The remaining 44 patients (51.76 %) were treated conservatively. 12 patients presented with right iliac fossa (RIF) pain. CT findings confirmed clinical diagnosis to be correct in 58.33 % of these (7/12). Flank pain (FP) with a clinical diagnosis of urolithiasis was only correct in 28.57 % (4/14). The remaining 10 patients with flank pain however a wide array of diagnosis was shown on CT including ovarian mass, faecal loading, perforated duodenal ulcer, acute pancreatitis and diaphragmatic hernia Clinical diagnosis was proven to be correct after CT in 100 % of patients (n = 59) presenting with LIF, RUQ, generalised and central abdominal tenderness. The matching of the clinical diagnosis and CT scan findings is statistically significant of RIF and flank pain (P = 0.001). Conclusion: CT scanning is a useful diagnostic tool for most acute abdominal surgical presentations. Its role is most pronounced in the diagnosis of RIF and FP as compared to other regions. More importantly, CT findings had contributed towards planning an effective conservative management in more than 50 % of cases obviating the need for active surgical or radiological intervention. A larger prospective multicentre study is needed to validate this results.

P630 - Radiology/Imaging

P632 - Robotics, Telesurgery and Virtual Reality

Splenic Artery Embolization is Safe and Effective in Polytrauma Patients with High Grade Splenic Injuries

Robotic Single-Port Laparoscopy Versus Single-Port Laparoscopy on a Dry Platform: Does Robotic Surgery Facilitates Single-Port Laparoscopy?

1

Yeovil District Hospital, Yeovil, United Kingdom; 2University of Exeter Medical School, Exeter, United Kingdom; 3St Marks Hospital, Harrow, United Kingdom

J.H. Murphy, A. Bhalla, P. Thurley, J. Lund Nottingham University Hospitals, Loughborough, United Kingdom

A. Fransen1, N.D. Bouvy2, J. Vandenbos2, L.P.S. Stassen2 Laurentius Hospital, Roermond, The Netherlands; 2MUMC+, Maastricht, The Netherlands 1

Aims: Splenic artery embolization (SAE) is increasingly used to treat splenic rupture (SR). We aimed to find whether SAE was safe to use for high-grade splenic injuries in the context of acutely unwell and polytrauma patients. Secondary outcomes were relation between prophylactic antibiotics and outcome, and the impact of radiological follow up. Methods: A retrospective review of patients undergoing SAE for SR within our centre between 2009 and 2013. Study end points were 30-day mortality, complication rate and need for salvage splenectomy. Results: 14 patients underwent SAE (P-possum scores 4–23 %, median = 14 %). Median age was 59 years (7–93). Charlson co-morbidity Index of 1-year survival was 67–97 % (median 92.5 %). Grade of splenic injuries were Grade II (n = 1), Grade III (n = 9), Grade IV (n = 3) and Grade V (n = 1). 10 patients suffered polytrauma with associated truncal and orthopaedic injuries (injury severity scores 17–48, median = 32). Coils were successfully deployed in all cases. Median length of stay was 13 days. All patients were vaccinated, 5 commenced prophylactic antibiotics, one of whom developed hospital acquired pneumonia. Those without antibiotics did not suffer infective complications. Five were followed up radiologically without significant findings. One patient without radiological follow up re-presented clinically with intra-abdominal collection requiring drainage. Conclusions: High-grade splenic injuries in a polytrauma setting can be safely treated with SAE. The withholding of prophylactic antibiotics does not adversely affect outcome. Radiological follow up may not be necessary however our case series may be too small to detect significance.

Introduction: Single-port laparoscopy is one step further towards nearly scar less surgery. Laparoscopy through a single port causes lack of triangulation and clashing of instruments. It is postulated that robotic single-port laparoscopy might overcome this problem due to the use of articulating instruments and chopstick setting of instruments. This study will evaluate two validated tasks of the Fundamentals of Laparoscopy. These tasks will be performed by experienced laparoscopists on a dry platform with a single-port in a robotic setting (da Vinci ÒSiTM Surgical System with EndoWristÒ instruments) versus a non-robotic setting. Method: Two tasks of the Fundamentals of laparoscopy, peg transfer and knotting, will be performed by 10 experienced laparoscopists. Each task will be conducted 10 times in each setting. Participants will be randomized to start in either the robotic or the non-robotic group. Participants can familiarize with robotic laparoscopy beforehand. Each task will be scored for time and errors. Statistical analysis will be conducted with paired T-test and ANOVA. In the robotic setting the da VinciÒSi Surgical System with da Vinci SingleSiteTM instruments will be used. Results: The complete results will be presented on the EAES congress, june 2014. The authors hypothesize that robotic single-port laparoscopy shows a steeper learning curve regarding time and errors compared to non-robotic single port laparoscopy. Additionally the authors assume that the learning curve will be steeper in the robotic setting, for complex tasks, such as knotting compared to basic tasks as peg transfer. Conclusion: We will compare the learning curve of two tasks of the Fundamentals of laparoscopy in a robotic versus a non-robotic single port setting.

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Laparoscopic Surgery in Sitting Position is Better Than Robotic and Standard Laparoscopic Surgery

Revisional Surgery in Gastrojejunal Margin Ulcer After Roux-enY Gastric Bypass

M.K. Hussein

R. Gonzalez-Heredia


University of Illinois Hospital and Health Sciences System, Chicago, United States of America

Aims: The advantages of Robotic surgery in comparison to standard laparoscopic surgery is the ability to do surgery in sitting position and 3D view and the ergonomic of movement and third hand assistance but the disadvantages is one field surgery, the presence of a second surgeon in the field, extra expenses, the elongated time and absence of tactile sensation and the disadvantages of standard laparoscopic surgery is increased musculoskeletal complaint which is reduced by laparoscopic sitting position. Method: I report my experience in the field of Laparoscopic surgery at the American University of Beirut Medical Center and affiliated hospitals where I shifted all laparoscopic procedures including Bariatric procedures to sitting position with 100 % completion of the procedures in the first 194 cases. Results: Laparoscopic sitting position will allow you to do long list surgery with decreased muscle fatigue, back and knee pain. Conclusion: Therefore, laparoscopic surgery is feasible in the sitting position and can maintain all the advantages of standard laparoscopy and avoid the disadvantages of Robotic surgery.

Background/Hypothesis: Marginal ulcer after Roux-en-Y gastric bypass (RYGB) is a challenging situation that bariatric surgeons face. A revisional procedure is indicated when medical treatments fail to improve symptoms. A minimally invasive approach is always worthy to attempt. We present a video of a robot-assisted revisional surgery of a gastrojejunal margin ulcer after RYGB. Materials and Methods: A 37 years-old woman with a body mass index of 32 was found to have a chronic margin ulcer near the gastrojejunal asatomoses associated to severe epigastric pain. The patient was treated with PPI for a year without resolution. decision was made to perform a robot-assisted approach. An excision of the previous gastrojejunostomy an redo-gastrojejunostomy was successfully performed. Results: Procedure started with a diagnostic laparoscopy that showed some adhesions of the liver to the small bowel and the alimentary limb. It was also noted that the patient had a medium-size hiatal hernia. Dissection was carried out in between gastric pouch and remnat. An intra-operative EGD was performed showing a 3 cm ulcer with a prolene suture in the ulcer bed. A transection of the gastric pouch over the anastomoses including part of the alimentary limb was performed. Then the hiatus and hernia sac were dissected, an crus were repaired. A new double layer han sewn gastrojejunostomy was performed. There were no intr- or pot-operative complications. Patient was discharged POD3. Conclusions: This video highlights the technical details of a robotic revisional surgery on a margin gastrojejunostomy ulcer in a previous RYGB. The robotic system allows for an accurate and fine dissection, with precise reconstruction of a gastrojejunostomy after a margin ulcer on RYGB



Robotic Right Colectomy for Hemorrhagic Right Colon Cancer

Robotic Assisted Reversal of Hartmann’s Procedure for Diverticulitis

E. Felli, N. de’ Angelis, C. Salloum, M. Nencioni, M. Disabato, D. Azoulay, F. Brunetti

E. Felli, N. de’ Angelis, D. Azoulay, F. Brunetti

Hospital Henri Mondor, Creteil, France

Hopital Henri Mondor, Creteil, France

Aims: right colon cancer rarely presents as an emergency. Affected patients are mostly aged and have frequent co-morbidities and malnutrition. When presenting as an emergency, the most common clinical presentation associated with right colon cancer is bowel occlusion and massive bleeding. For massive right colon cancer bleeding, there are no definite guidelines at present. Minimally invasive surgical procedures for right colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergency and semi-urgent surgery, minimally invasive techniques are rarely performed. Methods: we report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in a semi-urgent setting by robotic surgery. At admission, the patient had severe anaemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon neoplasia with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesions, while a constant bleeding from the right colon mass was temporarily arrested by endoscopic argon coagulation. Results: a robotic right colectomy in a semi-urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient’s poor nutritional status, an ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. Conclusions: right colon cancer may present as an emergency, although this occurs in a minority of patients. A minimally invasive approach can be used if the general conditions of the patient are adequate and the vital prognosis is not affected by a longer procedure or a delayed operation. Robotic surgery still does not have a definite role in colorectal surgery, but its indication is growing constantly. Usually performed for specific sub-groups of elective patients, robotic surgery may also be successfully used in a semi-urgent setting with good postoperative and oncologic outcomes

Aims: Minimally invasive technique, such as laparoscopy, for the reversal of Hartmann’s procedure has been frequently described as a safe and feasible approach associated with low morbidity and fast recovery. Robotic surgery has not yet been described for the reversal of Hartmann’s procedure. Methods: We report the case of an 84-year-old man originally operated in emergency setting by conventional Hartmann’s procedure for complicated diverticulitis, who underwent robotic reversal of Hartmann’s procedure. Results: The surgical procedure and the post-operative follow-up were uneventful, with low post-operative pain, early return to bowel function, and discharge at day 3. Conclusions: The robotic surgery appears to be a safe, feasible and valuable approach for the reversal of Hartmann’s procedure.

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Delta-Shaped Anastomosis in Totally Robotic Billroth I Gastrectomy

Robotic Low Anterior Resection for Rectal Cancer

K. Kikuchi, K. Suda, T. Tanaka, S. Furuta, K. Ishikawa, Y. Ishida, S. Satoh, I. Uyama Fujita Health University, Toyoake, Japan

J. Rejholec1, R. Malecek2, J. Moravı´k1, F. Galgoczyova´1 1

Krajska´ zdravotnı´ a.s.-Nemocnice Decıń o.z., Decıń, Czech ´ stı´ nad labem, Czech Republic; 2Krajska´ Zdravotnı´ as. - CRCH, U Republic

Background: Since 2007, we have applied the technique of delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy, which could be easily performed only with endoscopic linear staplers. To date, we have experienced over 150 cases using this technique with sufficient outcomes. The objective of this study was to determine if this method could be used in totally robotic Billroth I gastrectomy. Materials and Methods: A single institutional non-randomized prospective study was performed from 2010.1 to 2013.12. Consecutive 35 operable patients with resectable distal gastric adenocarcinoma who agreed to uninsured use of the surgical robot were enrolled. Under general anesthesia, a longitudinal 12 mm incision is created on the umbilicus and a camera trocar was put in place. Robotic 3rd, 1st, and 2nd arms were docked on the 8-mm left upper, left lower and right upper trocars, respectively. The 8-mm left lower trocar was placed through the 12-mm trocar (trocar-in-trocar technique). The assistant surgeon used the 12-mm right lower trocar. After mobilization of the gastroduodenum, the duodenal bulb was transected in the dorsoventral direction using the linear stapler through the 12-mm left lower trocar. Sufficient lymphadenectomy was performed and the stomach was transected through the 12-mm left lower trocar. A small incision was created on the greater curvature side of the remnant stomach and the posterior side of the duodenum. Then, the camera and the 1st arms were moved to the right lower and the camera trocars respectively, and the 45-mm stapler was inserted through the left lower trocar, with one jaw in each incision. The posterior wall of the stomach and that of the duodenum were put together, and the stapler was closed and fired. A V-shaped anastomosis was made on the posterior wall. The common stab incision was temporarily sutured with three stitches and closed with an application of the 60-mm stapler. Results: Median time for anastomosis was 969sec (479–2135 sec). Median of total operation time was 340 min (255–464 min). Anastomotic leakage, anastomotic bleeding and remnant gastric stasis did not occurred in this series. Conclusions: Delta-shaped anastomosis in totally robotic Billroth I gastrectomy was feasible and safe.

Aims: Robotic surgery, so entrenched in urology and gynecology, even now, despite 13 years of clinical practice raise contradictory, and often very negative attitudes in the surgical community. In our center we deal with robotic surgery since the second half of 2008. At the operational expertise to participate is urology, surgery, gynecology and otorhinolaryngology. We performed ?1371 robotic operations in total. Methods: Retrospective chart review of robotic surgical patients with diagnosis of rectal cancer. In total, we performed 150 robotic surgical interventions, 147 of them for colorectal cancer of which 136 were low anterior resections for rectal cancer. From the file were excluded patients with palliative procedures. Standard diagnostics - colonoscopy, Magnetic resonance, Endoscopic ultrasound, ultrasound of the liver, X-ray, histology and laboratory. In patients with T3 or N1 or higher staging preoperative chemo-radiotherapy was done. Results: The surgery involved two surgeons. The slope of the patients is approximately 300,000 inhabitants. The surgery is, except from the laparoscopic revision, a fully robotical procedure without undocking. Standard protective ileostomy is performed, except from some performances for tumors in the upper third of the rectum. The average distance of the tumor from the anus was 8.6 cm. 59.7 % of the patients have received preoperative neoadjuvant therapy. Median operation time was 189 minutes. Protective ileostomy was performed in 64.8 % of the patients. The number of conversions was 6.8 %. The average number of lymph nodes collected was 18.7. Percentage leak was 8.86. Late mortality 15.83 % Conclusion: Implementation of robot-assisted resection of the rectum is possible and oncologically comparable with laparoscopic or open procedures. It does not affect the number of leaks, neither the complications. The main advantage is easier access to the distal rectum (manipulation, visualization). Number of conversions is given by a learning curve (second surgeon - low laparoscopic experience) and technical problems with stapling.


P640 - Spleen

Single-Center 7-Year Experience with Robotics in General Surgery: Do Benefits Outgain the Costs?

‘Two Step Mini-Invasive Approach’ in Multiple Aneurysms of the Splenic Artery: Proximal Embolization with Vascular Plug Followed by Laparoscopic Splenectomy

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

F. Ceriani, F. Caravati, S. Cutaia, E. Galfrascoli, M. Canziani

Athens Medical Center, Athens, Greece

Multimedica Santa Maria, Castellanza, Italy

Introduction: Since the introduction of robotics in surgery, many surgeons around the world believed that the digital era would enhance human capability in performing complex and challenging surgical operations. Although existing literature is rather extensive, wide use of robotic surgery remains a topic of doubtfulness and controversy, mainly regarding the net costs of the technology. Material: From September 2006 till December 2013 we have performed 915 roboticallyassisted procedures in 755 patients (including double procedures). Since 2006, we have been recording all data concerning our robotic surgery program in a specially-designed database application. All patients were informed on the benefits of the technology prior to their procedures and gave their written consent. Results: Our database yields 75 different types of procedures. We have categorized this large number into 10 classes according to the frequency of procedures and calculated mean days of stay (mLOS). Our experience includes 332 cases of cholecystectomy (multiport and single-site) with LOS of stay 1,77 days (1,33 for the single-site subgroup) which is less than the corresponding LOS for our laparoscopic group of 3304 patients (LOS = 1,79). Our series of gastroesophageal junction surgery includes 107 fundoplications and 16 Heller cardiomyotomies (LOS 2,29). Corresponding laparoscopic LOS (195 cases) is 2,45. Results from the rest of the classes are presented (42 ventral hernia repairs (LOS 2), 114 colorectal cases (LOS 7,20), 87 gynecological cases (LOS 2,05), 25 bariatric cases (LOS 2,2), 25 gastric cases (LOS 8,61), 16 spleen surgery cases (LOS 4,78), 12 pancreas surgery cases (LOS 9,87), 31 obstructive ileus/adhesiolysis cases (LOS 3,14). Conclusions: Use of the robotic system may be justified if total hospital costs are included in financial comparisons to laparoscopic surgery, especially for procedures requiring ICU stay. Cost benefit in such complex procedures would outweigh the extra costs of robotics used in simpler cases, and justify the use of robotics with positive budget for the hospitals. Large meta-analyses are expected to provide these results in order to keep robotics in action.

The advancement of diagnostic imaging has increased the frequency of detecting splenic artery aneurysms. With an incidence of 3 % to 25 % SAA rupture has been associated with aneurysm size and comorbid factors including pregnancy, past history of liver cirrhosis or transplantation, and alfa-1-antitripypsin deficiency. Various therapeutic options for SAA include endovascular management, laparoscopic surgery, and open surgery, although their indications and applications as standard therapy remain controversial. Laparoscopic splenectomy has become a safe and feasible procedure for spleens of normal size. Only a few publications report the outcome of laparoscopic splenectomy with pre-operative splenic artery embolization for massive splenomegaly. Proximal splenic artery embolization is performed for splenic salvage in the setting of trauma or before splenectomy in patient with splenomegaly. Typically, this has been done with the use of metallic coils, but precise placement of the first deposited coil may be limited. The amplatzer vascular plug met be used to accomplish precise proximal splenic artery embolization We present a case of multiple aneurism of the splenic artery in a young woman. We decide to associate two miniinvasive techniques instead of a laparotomic treatment. The two step treatment (embolization with amplatzer vascular plug followed after 24 hours by standard laparoscopic splenectomy in right side position) is a feasible and safe procedure which allows to avoid a laparotomic intervention. The two steps procedure permit also to observe vitality of the tail of the pancreas after 24 hour of de-vascularization and eventually decide to do a distal pancreatectomy in association with the splenectomy.

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Surg Endosc

P641 - Spleen

P643 - Spleen

Laparoscopic Splenectomy in Thalasaemia Major Teenager: Case Presentation

Bleeding Encountered During Laparoscopic De-roofing of Large Splenic Cyst and the Various Haemostasis Techniques

P.R. Sookha1, H. Charitar-Sookha2, S.S. Seewoosungkur3

C.H. Tan1, J. Rao2

1 Apollo Bramwell hospital, Clinique du Nord, Riviere du rempart, Mauritius; 2Apollo Bramwell Hospital, Moka, Mauritius; 3Clinique du nord, Baie du tombeau, Mauritius

1

A 16 years old patient suffering from major thalassaemia came to our clinic with a request for laparoscopic splenectomy. He was refused laparoscopic splenectomy in multiple centers in Mauritius due to the size of the spleen. Indeed no cases of laparoscopic splenectomy was registered in Mauritius prior to this case. Using my knowhow after my training in Pelican hospital, Oradea, Romania, I performed a laparoscopic splenectomy in this boy. My main trouble during the surgery was removal of the specimen through a 3 cms minilaparotomy in piecemeal, which took more time than the resection of the spleen. The patient was discharged 24 hours postsurgery, with fast recovery and returning to normal activity after few days. Conclusion: Size of the spleen is not an absolute contra-indication for laparoscopic splenectomy.

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

Indication for Surgery: Symptomatic large splenic cyst Disgnostic Study: CT abdomen and pelvis Position: Supine Trocar Placement: Infraumbilical, RHC and LIF Summary: A 19-year-old Malay girl was admitted for 3 weeks history of abdominal bloatedness and was found to have splenomegaly. Commuted tomography of the abdomen and pelvis showed a large 13 9 11 9 9 cm exophytic cystic lesion arising from the lower pole of the spleen. She was admitted electively a week later for laparoscopic de-roofing of the splenic cyst. Intraoperatively, bleeding occurred during the de-roofing and haemostasis was achieved using a combination of direct pressure with gauze, Enseal tissue sealer, Surgical haemostat, Diathermy and Argon plasma coagulation. Results: The patient was discharged well on post-operative day 3. There was no postoperative complication. Conclusion: Laparoscopic de-roofing of the spleen can be done safely. Surgical haemostat, Enseal tissue sealer, Diathermy, Argon plasma coagulation and direct pressure with gauze may be used successfully to achieve haemostasis in the event of bleeding. These are an array of haemostatic techniques a laparoscopic surgeon needs to familiar with if bleeding is encountered in a laparoscopic surgery. Learning Points: What to do when encountering bleeding in laparoscopic spleen surgery. Various haemostatic techniques in laparoscopic spleen surgery

P642 - Spleen

P644 - Spleen

Laparoscopic Splenectomy, is Sutures and Staplers Mandatory?

Diferrent Modalities for Laparoscopic Splenectomy: A 10 Years Experience

A. Ghasoup1, O. Sadieh2, T. al Qurashi1 1

Security Force Hospital-Makkah, Makkah, Saudi Arabia; 2Saad Specialty Hospital, Al khobar, Saudi Arabia

Background: Laparoscopic splenectomy is widely adopted world wide since the first laparoscopic splenectomy (LS) was reported in 1992, especially for haematological disorder. Methods: Lateral approach through a four trocars in the upper abdomen in a steep fowler position with left sided elevation was used. The major part of the dissection was conducted from behind, thus allowing a safer vascular control with the aid of 30 degree scope. The short gastric vessels, lower pole vessels and the main vascular pedicle successfully secured using ligature (high radiofrequency current) without the need for vascular stapler or ligatures. Results: 52 patients laparoscopic splenectomy, 34 patients for ITP, 10 haemolytic anaemia, 7 for spherocytosis and one for abnormal position left iliac fossa wandering spleen, average blood loss was about 200 ml, the mean operative time was 120 minutes, and mean hospital stay is 4 days, there was no mortality and minimal morbidity. Conclusion: Laparoscopic splenectomy successfully accomplished without the need for stapler or sutures and it is safe with a rapid recovery using the high radio-frequency current (Ligasure). And found to prevent electric hazards, eliminating frequent instrument interchange, thus saving time; they reduce the risk of injury to the pancreas, by dividing the splenic attachments as close as possible to the splenic parenchyma.

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W.N. Abdel Salam, E. Elkayal, M.M. Gamal, H.M. Elkomy, M.I. Gaber Alexandria University, Faculty of Medicine, Alexandria, Egypt Background: Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas remain controversial. Recently, efficacy and safety of vascular sealing devices for sealing vessels and reducing intraoperative blood loss has been reported with various laparoscopic procedures. LS remains a challenging procedure to be performed by experienced laparoscopic surgeons. Aims: to assess safety and feasibility of LS for different pathologies and with different size of the spleen and also to assess different methods to control the splenic hilar vessels. Patients and Methods: The study retrospectively analyzed 120 laparoscopic splenectomies performed for a variety of indications over 10 years. Different approaches and methods of dissection were used, including the anterior approach, lateral approach, monopolar coagulation, clips, endostaplers and vascular sealing devices. The perioperative data were compared including patient characteristics, diagnosis, operative details, complication rate and post-operative hospital stay. Results: Laparoscopic splenectomy was completed for 118 patients. Conversion to open surgery was necessary for 2 patients due to hilar bleeding. 8 patients underwent combined laparoscopic splenectomy and cholecystectomy. According to diagnosis, patients were divided into 58 patients presented with idiopathic thrombocytopenic purpura, benign splenic tumor in 3 cases, lymphoma in 4 cases, hereditary spherocytosis in 5 cases, liver cirrhosis and portal hypertension in 20 cases (of which, 4 cases were hand assisted) and 30 cases of primary hypersplenism. Diameter of spleen was 13–25 cm. Anterior approach used in 15 patients while semi lateral approach used in 105 patients. To control hilar vessels, clips with vascular sealing device were used in 10 cases, endostaplers in 7 cases, endo-loop with vascular sealing device in 2 cases and vascular sealing device alone in 101 cases. Intraoperative blood loss was 50–500 ml. No blood transfusion was needed. Operative time was 60–240 minutes. Postoperative hospital stay was 2–5 days. There were 14 cases with postoperative complications: portal thrombosis in 12 cases, hemoperitoneum in 1 case, surgical wound infection in 1 case. There was no mortality. Conclusion: Laparoscopic splenectomy is a feasible, effective, and safe surgical procedure for patients who require splenectomy. Massive splenomegaly and portal hypertension should not be considered contra-indication for LS.

Surg Endosc

P645 - Spleen

P647 - Spleen

Laparoscopic Treatment of Posttraumatic Splenic Cyst

Laparascopic Surgery for Giant Splenic Cyst: Early Return to Work and Retaining of Job for Contract Employees

S. Stabina, A. Kaminskis, G. Pupelis Riga East University hospital Gailezers, Riga, Latvia Introduction: Splenic cysts are not particularly common and may be primary or secondary. In 1958 Martin defined parasitic and nonparasitic cysts as primary and false cysts (posttraumatic) as secondary. We present laparoscopic fenestration of a symptomatic splenic cyst diagnosed in a young man who experienced road accident as a kid. Materials and Metods: Case report Result: A 27 year old male was first delivered to the hospital with left upper quadrant pain after physical exertion. Abdominal ultrasound detected large localised fluid collection in the upper part of the spleen. A CT examination revealed a large cyst of the upper part of the spleen (12 9 13 cm) with focal calcification of the wall and extension of the cyst to the spleen hilum. The carbohydrate antigen 19–9 (CA 19–9) was elevated reaching 353.27 U/ ml. Laboratory test for Echinococcus was negative. Laparoscopic splenic cyst fenestration was performed and patient was discharged on 4th postoperative day for outpatient management. The histological diagnosis was false cyst with wall hialinosis. Conclusion: The splenic cyst is relatively rare pathology highlighted in rather few studies mainly published as a case reports. Minimally invasive approach with preservation of the spleen is justified when nonparasitic cause of cyst is verified.

M. Ozer1, Z. Kilbas1, M. Saydam2, O. Kozak1 1 Gulhane Military Medical Academy, Ankara, Turkey; 2Mevki Asker Hastanesi, Ankara, Turkey

A patient who had complaints about abdominal pain and bloating after meals admitted another medical center and 15 cm diameter cyst located in the upper pole of the spleen had been identified at ultrasound and computed tomography. He had a history of twice percutaneous intervention also. But cyst has relapsed. The patient admitted to our clinic and declared that if he had not surgery within 15 days for receiving for bill of health, he could lose his job. A simple thick-walled cyst has been verified and then the surgeons decided for laparoscopic surgery. Laparoscopic partial cystectomy and splenic cyst drainage operation within protecting of spleen was performed. Patient was discharged 3 days later without any postoperative complication and 10 days later bill of health report was issued. His career has been retained with the clean bill of health report. Beside many advantages of the laparascopy like better cosmesis, and less pain, we wanted to present this case which emphasized of early return to job accompanied with the literature.

P646 - Spleen

P648 - Spleen

Splenic Injury After Colonoscopy Rare But Warrants Urgent Attention

Laparoscopic Splenectomy: Correlation Between Spleen Size and Clinical Outcome

M. Salama, B. Meshkat, I. Ahmed, A. Elsayed

S. Stipancic, J. Bakovic, M. Knezevic, R. Klicek, I. Runjic

Our Lady of Lourdes Hospital, Drogheda, co. louth, Ireland

Clinical Hospital Dubrava, Zagreb, Croatia

Introduction: Splenic injury after colonoscopy is very rare but serious and may be lethal With increasing use of colonoscopy, surgeons are more likely to encounter this unusual complication It is under recognised, under reported and few cases remain undetected Diagnosis as delayed due to lack of awareness of this complication CT is very sensitive, but awareness and knowledge of this complication is the best tool to aid early diagnosis Case Report: we present a case of 62 years old male who complained of abdominal pain for 2 days post colonoscopy and polypectomy. He had background history of hyper-tension and right inguinal hernia repair. On examination Temp 36.8 B.P-108/70 P- 88/m Abdomen-tender with left side guarding Lab.Hb-7.8 WBC-8.5 Platelets-289 INR-0.9 U&E - LFTS normal CXR-no free air under diaphragm PFA-unremarkable CT-splenic injury (spleen is enlarged 16/7.5 cm in axial plane with haematoma. Free fluid surrounding the spleen liver and pelvis). The patient treated conservatively for 2 days in ICU and discharged 8 days post admission Conclusion: Splenic injury during colonoscopy is rare, associated with significant morbidity and mortality. It warrants a high degree of clinical suspicious critical to prompt diagnosis. early surgical consultation is warranted.

Aims: The aim of this study is to describe a 10-year experience with laparoscopic splenectomy in Clinical Hospital ‘Dubrava’ Zagreb, Croatia. Methods: All patients submitted to LS from 2003 to 2013 performed by a single surgeon. All data were prospectively recorded. Results: LS was done for 50 patients. The indications for surgery included benign (40/50, 80 %) and malignant (10/50, 20 %) disease. Mean spleen craniocaudal length was 15.79 cm. Normal spleen size was determined in 26/50, 52 % with mean size 11.41 cm. and splenomegaly was found in 14/50, 28 % patients with mean size 18.21 cm. Ten patients (20 %) met criteria for massive splenomegaly with mean size 23.80 cm. ITP was the most common benign disease and non Hodgkin’s lymphoma was the commonest malignant disease The median operative time was 120 minutes (60 to 210). Operative time was longer for enlarged spleens (P \ 0.001) and in malignant cases (P = 0.018). Conversion rate was 12 % with no statistical differences between normal and enlarged spleens (P = 0.917) and benign and malignant disease (P = 0.384). Complications occurred in 5 (10 %) patients. Complications were more frequent in normal spleen size group (4/26, 15.38 % vs 1/24, 4.17 %). Complications included: postoperative bleeding in splenic bed requiring reoperation (1 case), iatrogenic lesion of colonic splenic flexure during specimen retrieval and perforation of retrieval bag (1 case) and portal vein thrombosis (3 cases). Blood transfusion was necessary in nine patients (18 %). The lowest blood transfusion requirement was in patients with normal spleen size (P = 0.009). Mean hospital stay for all patients was 5.49 days with no differences between groups. Conclusion: LS can be successfully performed for most benign and malignant splenic diseases independently of patients’ age and body weight. The size of the spleen does not preclude laparoscopic dissection. In case of massive splenomegaly, LS can be technically demanding but nevertheless feasible in experienced hands.

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Surg Endosc

P649 - Spleen

P651 - Spleen

Single Incision Laparoscopic Splenectomy for an Extremely Rare Pathology: A Splenic Hamartoma

Is Laparoscopic Splenectomy Safe in Patients with Immune Thrombocytopenic Purpura and Very Low Platelet Count

R. Aktimur, G.O. Kucuk, E. Colak, N. Ozlem, I. Kececi

N. Aksakal, U. Barbaros, O. Agcaoglu, M. Tukenmez, B. Kilic, O. Cucuk, R. Seven, A. Dinccag, S. Mercan

Samsun Research and Education Hospital, Samsun, Turkey Splenic hamartoma is a very rare benign vascular proliferative neoplasm, which composed of an anomalous mixture of normal splenic elements, such as red and white pulp. To date more than 150 cases have been reported. Estimated incidence is 0.024 %–0.13 % in autopsy series. Most cases discovered incidentally while evaluating other medical problems or in autopsies. Advanced imaging techniques has led to increase in the detection rate of incidental masses in the spleen. On the other hand, the diagnosis of a solitary splenic tumor may require splenectomy to assure a definitive histological diagnosis. Laparoscopic surgery for splenic pathologies becoming the standart technique both benign and malignant disease, enclosing hamartoma. Literature have had a few reports on laparoscopic splenectomy for hamartoma, but there are no published case on single incision laparoscopic surgery for splenic hamartoma. In this video presentation we describe a case of splenic hamartoma treated with intraumblical single incision laparoscopic splenectomy. A 24-year-old man admitted for further evaluation of a solitary solid splenic mass. Abdominal MRI showed, 42 9 42 mm regularly contoured solid mass in the posterior central aspect of the spleen. This images considered to suggestive for diagnosis a splenic hamartoma. Although the diagnosis of malignant tumor was not excluded completely, an intraumbilical single incision laparoscopic splenectomy was performed. The patient was placed on the operating table in a right semilateral decubitus position. An intraumbilical incision measuring 4 cm was made and a special port, designed for single incision laparoscopic surgery that contains a wound protector and removable four trocars plate with two 5 mm, one 10 mm and one 5–12 mm trocars was used. With the use of curved laparoscopic retractor and monopolar hook/5 mm blunt tip ligasure vessel sealing device, spleen resected and the specimen extracted intactly through the incision in a plastic bag. The total operation time and estimated intraoperative blood loss were 60 minute and 20 mL respectively. The patient postoperative course was uneventful and he was discharged on the second postoperative day. The resected spleen was pathologically diagnosed as splenic hamartoma.

Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey Aims: Minimal invasive procedures has become increasingly popular during the last decades. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic splenectomy in patients with immune thrombocytopenic purpura who has very low platelet counts. Methods: Between March 28, 2005 and June 08, 2013, a total of 132 patients with the diagnosis of immune thrombocytopenic purpura were included to study. The patients who underwent laparoscopic splenectomy were alienated into two groups according to their platelet counts lower than 10000 (group 1) and higher than 10000 (group 2) Results: There were 16 patients in group 1 with very low platelet counts, and 116 in group 2. One patient in group 1 had converted to laparotomy due to peroperative bleeding, and there were 5 conversion to open in group 2. There were also 2 patients in group 2 who underwent laparatomy on post operative day 1 due to delayed intra-abdominal bleeding. Moreover, one patient in each group had pancreatic fistula. Conclusion: Laparoscopic splenectomy is a safe technique in patients with ITP even the patients have very low platelet counts.

P650 - Spleen

P652 - Spleen

The Laparoscopic Splenectomy and Complications in the Setting of Massive Splenomegaly

A New Minimally Invasive Method: For Splenic Hytatid Cyst

S. Stipancic1, R. Klicek1, M. Knezevic1, J. Bakovic1, M. Milosevic2, I. Runjic1 1

Clinical Hospital Dubrava, Zagreb, Croatia; 2School of Public Health Andrija Stampar, Zagreb, Croatia

Aims: To report our experience and outcomes of laparoscopic splenectomy in the setting of splenomegaly and massive splenomegaly. Methods: We performed analysis of 50 patients underwent to laparoscopic splenectomy (LS) whose data were prospectively recorded. Data collection included age, gender, the nature of splenic disease, ASA classification, BMI, spleen size, number of ports used, operative time, concomitant operation, perioperative or postoperative requirements for transfusion, conversion to open surgery, mode of splenic hilum ligation, length of hospital stay, postoperative morbidity and mortality According to spleen size the patients were classified in three groups: normal spleen size group in whom the longest axis of the spleen did not exceed 15 cm (26/50, 52 %), splenomegaly group (14/50, 28 % cases) and massive splenomegaly group (10/50, 20 %cases). We analyzed whether the massive splenomegaly (splenic size = 20 cm) increases the risk for LS in comparison to data in patients with normal spleen size or splenomegaly up to 20 cm in diameter. Results: Majority of our 50 patients submitted to LS had benign splenic disease (40/50, 80 %), and almost half of them had enlarged spleens (24/50, 48 %). In normal spleen size group significantly the lowest proportion of patients, had diagnoses of malignancy (3.85 %vs 28.6 % in splenomegaly and 50 % in massive splenomegaly, P = 0.005), and the duration of operation was shorter (92.50 min vs 142.80 min and 145.00 min respectively, P = 0.001). Operative time was longer in malignant cases (147.50 min vs 110.00 min, P = 0.018). Overall conversion rate was 12 % (6 cases) with no statistical differences between three groups according to spleen size as well as no difference between benign and malignant splenic disease cases. Complications that occurred in 5 (10 %) patients were more frequent in normal spleen size group (4/26, 15.38 % vs 1/24, 4.17 %). Portal vein thrombosis was detected in 3 (6 %) of all cases and all patients suffered from benign splenic disease. Mean hospital stay for all patients was 5.49 days with no differences between groups. Conclusion: Despite of longer operative time LS in the setting of massive splenomegaly is safe with no higher complication rate or morbidity.

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A. Uzunkoy Harran University School of Medicine, Sanliurfa, Turkey Background and Aim: Disease of hydatid cysts is one of the most common health problems on the World. It is seen rarely at the spleen. Treatment of splenic hydatid cysts includes open or laparoscopic surgery. In selected cases, percutaneous drainage methods may be safe and some advantages as minimally invasive methods. In this study, it was presented a patient with splenic hydatid cyst underwent percutaneous drainage method. Material and Methods: Forty-two years old female patients with splenic hydatid cyst was treated percutaneous treatment. Percutaneous Aspiration Injection and Respiration (PAIR) were performed under ultrasonography. A drainage catheter was placed in the cyst cavity with Seldinger method. After aspiration of the cyst cavity, hypertonic saline solution is injected into cyst cavity. After fifteen minutes, this solution respirated. Albendazole were given preoperatively for 4 days and postoperatively during 3 months. The patient followed up 4 years with ultrasonography and computed tomography. There was no complication and recurrence following period. Conclusion: Percutaneous treatment of hydatid cysts has many advantages. This technique has cosmetic advantages, confirm diagnosis, reduces risk of surgery, hospitalisation time and hospitalisation costs. But this technique has some risks such as anaphylactic shock, secondary echinococcosis caused by spillage. Therefore medical treatment (albendazole or mebendazole) should be given before and after percutaneous interventions. In conclusions, percutaneous treatment of splenic hydatid cysts may be safe and effective procedure for selected cases.

Surg Endosc

P653 - Technology

P655 - Technology

Twenty Years’ Experience of Gasless Laparoscopic Surgery in Japan. An Analysis of Its Clinical and Commercial Decline

Transanal Minimal Invasive Surgery with the Endorec Trocar: a Low Cost But Effective Technique

K. Shinohara

V. Bridoux, L.S Schwarz, M. Dazza, L. Lacaze, F. Michot, J.J. Tuech

Tokyo University of Technology, Tokyo, Japan

Rouen University Hospital, Rouen, France

Background: Gasless laparoscopic surgery (‘Gasless’) methods and devices were developed in the mid-1990s by several surgeons in Japan. Advantages of Gasless over standard laparoscopic surgery that creates a pneumoperitoneum (‘Pneumo’) exist. However, Gasless will soon be abolished in Japan. Here the background and possible reasons for the decline of Gasless in Japan are analyzed by examining the 20-year history of Gasless use in Japan. Material and Methods: Gasless and Pneumo were compared in terms of safety, technical difficulties, economy, and sales network of the devices. The reasons behind Gasless’s commercial decline were also analyzed. Results: Advantages of Gasless over Pneumo were as follows: absence of complications such as gas embolism and cardiorespiratory collapse due to pneumoperitoneum, and the feasibility of combining Gasless with hand-assisted procedure and mini-laparotomy. The disadvantages of Gasless were as follows: subcutaneous wiring for abdominal wall lifting is technically difficult and time-consuming; the devices for abdominal wall lifting interfere with movement of the forceps and creation of an unequal intra-abdominal working space. Discussion: The nationwide survey on the status of endoscopic surgery in 2011 conducted by the Japan Society for Endoscopic Surgery showed that the percentages of Gasless use were 9 % of 433 departments of abdominal surgery, 26 % of 167 departments of gynecology, and 2 % of 197 departments of urology. Indications for Gasless use were poor cardiopulmonary function, laparoscopic hepatectomy, advanced age, pregnancy, and pheochromocytoma. Although Gasless is a novel technique with several advantages, it failed commercially because of its poor maneuverability and poor supply network of devices. The disadvantages of Pneumo such as gas embolism and cardiopulmonary suppression have been reduced because of standardization and advances in procedures and instruments. The main reasons for Pneumo’s commercial success in Japan were quality of disposable devices, good ergonomics, usability, and worldwide supply network.

Aims: Transanal endoscopic microsurgery (TEM) is a well-established surgical approach for local excision of benign adenomas and early-stage rectal cancer. This technique is expensive and associated with a long learning curve. To avoid these obstacles, we have developed an alternative approach using the EndorecTM trocar (Aspide, France), which combines the advantages of local transanal excision and single-port access. The aim of this study was to evaluate the feasibility of this technique. Methods: Fourteen consecutive patients underwent transanal resection using Endorec trocar and standard laparoscopic instruments. A retrospective evaluation of the outcome of this technique was performed. Results: Fourteen patients were successfully operated. Rectal lesions included adenoma in ten patients, T1 adenocarcinoma in three and one T2 adenocarcinoma not amenable for abdominal surgery. The average distal margin from the anal verge was 10 cm (range 5–17 cm), and the mean diameter was 3.5 cm (range 1–5 cm). Negative margins were obtained in 13 patients (92,8 %). Median operating time was 60 min (range 20–100). The excisional area was sutured in nine patients. Median postoperative stay was 4 days (range 1–13). Postoperative complications (21 %) included postoperative fever in one patient and two patients were readmitted with rectal blood loss 6 and 15 days postoperatively and were treated with conservative measures. Conclusions: Our current data show that transanal surgery using Endorec trocar is feasible and safe. Although long-term outcomes and definite indications should be yet evaluated, we believe that this new technique offers a promising alternative to TEM.

P654 - Technology

P656 - Technology

Surgical Treatment by External Drainage of Cystic Transformation of Bile Ducts Method

Transrectal Hybrid-Notes Anterior Resection Using an Articulating HD 3D Laparoscopic Surgical Video System

D.V. Fokin, I.V. Kirgizov, V.A. Dudarev

D.C. Steinemann, A. Zerz, S.H. Lamm

GCB 20, Kresnoyarsk, Russia

Cantonal Hospital Baselland, Bruderholz, Switzerland

The Aim of the Study: Assessment of changes of morphological structure of the liver in an echinococcosis in children depending on the tissue pressure. In a consequence of that it was possible to establish that at cysts in diameter from 4,5 to 5 sm: pressure in perycysts to a zone to 2 sm makes 834 Pa, in bioptatis taken away in this area the raised maintenance of fibrous elements and fatty infiltration in 1,7 times became perceptible. The volume of periportal tracts is enlarged in 1,5 times. Depression of the maintenance of a glycogen and volume of hepatocytes in 1,2 times that speaks about sclerotic changes in a liver parenchyma was thus taped. At measurement of fabric pressure in a zone, from 2,5 to 5 sm fabric pressure is on the top borders of norm and made 825 Pa, and the morphological picture wears admissible changes, at measurement of fabric pressure and a morphological picture in kept away refocal zone, more than 5 sm of changes aren’t taped. Conclusions: Thus, value of fabric pressure as factor reflecting morphological changes in a liver tissue is confirmed. And in the subsequent defines resection volume at cystically-focal liver lesions, with possibility of the subsequent control of its normalization at a resection and to take in a residual cavity.

Aims: Although, in standard laparoscopy anterior resection can usually be performed using two five millimetres 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 rectum 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 laparoscopic assisted operations into totally laparoscopic procedures. Methods: In this instructive HD 3D video we present our technique of transrectal laparoscopic anterior resection in diverticular disease. 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 with the energy device. The mobilization is completed from lateral. Afterwards the proximal rectum is preparated and the anterior resection is performed. The specimen is extracted transrectally, followed by an intracorporeal purse-string suture after insertion of the anvil in the oral colon. A circular stapler is inserted transanally and the end-to-end anastomosis is performed. Conclusion: In our experience on 27 patients the transrectal 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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Surg Endosc

P657 - Technology

P659 - Technology

Short-Term Outcomes of Reduced Port Laparoscopic Low Anterior Resection for Rectal Cancer

Surgeons Prefer Seeing Three Dimensions When Suturing Laparoscopically

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

E. Caruana, J.H. Robertson, B. Tang, I.S. Tait, K.L. Campbell

Samsung Medical Center, Seoul, Korea Background: Single incision laparoscopic low anterior resection (LAR) for rectal cancer is challenging technique and only allowed for selected patients. To overcome several limitations, we suggest single incision laparoscopic port plus additional port at right low quadrant (RLQ) in abdomen. The aim of this study is to evaluate the feasibility and shortterm outcomes of reduced port laparoscopic low anterior resection for rectal cancer Methods: Between 2009 and 2013, 176 consecutive patients underwent reduced port laparoscopic LAR for rectal cancer were reviewed. Median age was 57 (28–84). The low and mid rectal cancers were 36 (20.5 %) and 79 (44.9 %) respectively. The patients underwent neoadjuvant chemoradiotherapy were 43 (24.4 %). 3 channel-hand made port was inserted through a 3.5 cm transumbilical incision or protective ileostomy site, and 12 mm additional port was inserted at RLQ of abdomen. All the procedures were performed as usual laparoscopic LAR technique. Results: The patients with TNM stage 3 were 58 (33.0 %), median length of distal resection margin was 2.0 cm (0.2–8.0), and median harvested number of lymph nodes was 14 (3–73). The patients of right ileostomy site approaches were 60 (34.1 %) and left side approach were 29 (16.5 %). The median operation time was 165.5 (91–357) minutes, blood loss was 141.7 (20–700) ml and average 1.8 (1–5) linear stapler for transection of distal rectum was used. The cases of ileostomy formation were 89 (50.6 %). There was no postoperative mortality, and the postoperative complication rate was 18.8 %. There was no above grade IV of Clavien-Dindo complication classification, leakage rate of anastomosis was 4.5 %, and conversion cases were 2(1.1 %). Conclusions: The reduced port LAR for advanced mid or low rectal cancer was safe and feasible approach. However, further studies are needed to prove the advantages of this procedure.

Cuschieri Skills Centre, Dundee, United Kingdom Aims: To assess whether surgeons express any preference between two dimensional (2D) and three dimensional (3D) systems for laparoscopic suturing. Methods: Surgical trainees and consultants were each asked to perform a standardised laparoscopic suturing task of seven minutes’ duration twice in succession, using the 3D and 2D mode of a Karl Storz 3D TIPCAM in random order. The scope remained attached to a Karl Storz Endoskope HD stack and a standard training box. Candidates’ overall subjective preference was recorded; with a rating of various elements of the experience with each system being noted by each candidate on a Likert scale. Paired Student’s t-tests were used to test for significance in difference between ratings given to each modality. Results: 27 surgeons, 81.5 % male (n = 22) were recruited. Users rated their 3D experience to be superior in terms of depth perception (mean rating 8.56 ± 1.09 vs 5.00 ± 1.92, p \ 0.0001), contrast (mean rating 7.89 ± 1.25 vs 7.04 ± 1.34, p \ 0.01) and sharpness (mean rating 8.11 ± 1.45 vs 7.26 ± 1.51, p \ 0.05). There was no significant difference noted in ghosting (mean rating 6.33 ± 2.60 vs 6.00 ± 3.00, p = 0.59). Our study fails to identify a significant difference for commonly cited adverse effects of 3D systems, including headache (mean rating 1.67 ± 1.94 vs 1.63 ± 1.55, p = 0.93) and visual strain (mean rating 4.00 ± 2.83 vs 3.74 ± 2.38, p = 0.57). The majority (88.9 % n = 24) expressed an overall preference for the 3D interface. There was no difference between trainees and consultants. Conclusions: This study demonstrates that both experienced surgeons and those in training share a preference for using a 3D versus a 2D setup for performing laparoscopic suturing. Better depth perception, and an overall improved visual and general user experience is found when using a 3D setup. Additional adverse effects were not observed.

P658 - Technology

P660 - Technology

Development of a Slender (Needle Type) Flexible Device to Control Organs to Obtain a Good Surgical Field

Automatic Registration of Activation and Power Settings of Electrosurgical Devices

I. Hisashi, Y. Yamamoto, R. Morimura, H. Konishi, Y. Murayama, S. Komatsu, A. Shiozaki, Y. Kuriu, M. Nakanishi, D. Ichikawa, H. Fujiwara, K. Okamot, C. Sakakura, T. Ochai, E. Otsuji

A.C.P. Guedon1, L.S.G.L. Wauben1, J. Blok2, M. van der Elst2, J. Dankelman1, J.J. van den Dobbelsteen1

Kyoto Prefectural University of Medicine, Kyoto, Japan Objective: In laparoscopic surgery, it is important to secure a sufficient surgical field. Various tips have been made for devices to control organs more easily and safely. However, since the size of the tip of a device is limited by the diameter of the lumen of the trocar use during the intraabdominal approach, the devices have not been effective. I recently developed a new device to control organs. Method: The product was made from stainless steel, with the flexible tip coated with silicon, and had a slender body, like a needle (1.5 mm–3.5 mm) (Patent pending in Japan). The tip can be transformed to make it suitable for organ control using maniphalanxes, and can hold the selected form. The transformation of the tip is therefore performed manually outside of the abdomen, and is inserted and retracted via an umbilicus wound. Result: Adjusting the tip to various shapes by hand was easy. The performance of this new device for retracting organs was good in the animal experiments and in the initial human cases examined. Discussion: This device has an a traumatic shape due to the flexibility, in opposition to the fine, needle-like, body of the tip. Because of the small size of the tip, there is little parietal damage, so a supplemental of a device is easy. This device will therefore be useful for laparoscopic surgery.

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1 TU Delft, Delft, The Netherlands; 2Reinier de Graaf Gasthuis, Delft, The Netherlands

Aims: Electrosurgical devices are critical pieces of equipment and one of the most routinely used instruments during surgery. The large amount of functionalities and handling methods of electrosurgical devices has made the evaluation of different surgical approaches difficult. Data on the actual use of electrosurgical devices would provide more insight in the way of performing electrosurgery by different individuals, the amount of energy transmitted to patients and the effect on clinical outcomes. This study aims to develop methods to measure the amount of current used and to automatically register the activation and the power settings of electrosurgical devices during the procedure. Methods: A current measurement device was developed and tested in a lab setting on an electrosurgical device (Valleylab, Force FX) with a resistance of 12 Ohm to simulate the resistance of patient’s tissue. The current levels as a function of time were recorded for different settings in monopolar and bipolar modes. Current measurements were also performed during actual surgery in three laparoscopic procedures and were compared with data on the activation and power settings gathered through observations. Results: Preliminary results show that the detection of the activation of the device was 100 % reliable in lab and surgery settings. Variations in power settings were detected as well although the exact power level could not be determined precisely because of the difference in energy absorption between patients. Conclusion: The developed current measurement device can reliably detect the activation of electrosurgical devices during laparoscopic procedures. It offers the possibility to gather data about the frequency and duration of use of the devices for different individual surgeons, for different surgical approaches, or for patients with distinctive characteristics (i.e. obesity). More measurements are needed to determine the reliability of the detection of the power settings. We conclude that current measurement to monitor the use of electrosurgical devices has the potential to provide valuable information for the evaluation of the performance of different surgeons or approaches in surgery.

Surg Endosc

P661 - Technology

P663 - Thoracoscopic Surgery

Gastric Electrical Stimulation for Medically Refractory Gastroparesis with a Robotically Controlled Needle Holder

Video-Assisted Thoracoscopic Chest Wall Tumor Resection With or Without Reconstruction

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

D.L. Tsai, J.Y. Lee, L.C. Chen, J.S. Hsieh, Y.T. Chang, S.H. Chou

University Hospital of Grenoble, La tronche, France

Kaohsiung Medical University Hospital, Kaohsiung city, Taiwan

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 electrical stimulation 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 diabetic nephropathy and a gastric emptying data of 1143 minutes. The instrument was used to place the electrodes during a laparoscopic gastric electrical stimulation. Results: For this procedure, it is important that the ski needles attached to the electrodes are tunneled and parallel into the seromuscular anterior gastric wall for approximately 2 cm. The combination of distal shaft bending and rotation of the end effector of the robotic instrument enable an ideal positioning of the electrodes. Furthermore, the robotic needle holder facilitates the sutures performed to anchor electrodes in the gastric wall by passing the ski needles through the anchoring disc. Conclusion: The use of this robotic instrument for the positioning and the fixation of the electrodes during gastric electrical stimulation facilitates and improves surgeon gesture.

Aims: When resections for primary soft tissue mass of the chest wall or locally advanced non-small cell lung carcinoma with chest wall invasion, a large chest wall defect will be expected. So we consider minimally invasive options for better post-operative recovery effects Methods: From August 2010 through November 2013, 6 patients with chest wall tumor were managed by video-assisted thoracoscopic surgery. The patients underwent general anesthesia, decubitus position and intubation with double- lumen endotracheal tube in place to allow selective lung ventilation. 2 incisions were made, 1 for 10 mm thoracoscope with 30 degree lens, and another for endoscopic instruments. Results: Division of the ribs, and chest wall soft tissue via video-assisted thoracoscopic surgery with endoscopic instruments was satisfactory. No patient required conversion to thoracotomy, and no intra-operative complications occurred. During the entire procedure for all patients, values of mean blood loss is 104 ml (range, 35–155 ml), operation time: 252.5 (150–300) min, largest diameter of specimen size: 10.6 (9.3–12.1) cm, and chest wall tumor size: 6.0 (4–8.2) cm. No patient required intensive care unit stay, and the mean length of hospital stay is 10.2 (6–16) days. 2 patients required delayed chest tube removal due to prolonged air leak and increased pleural effusion amount. There were no deaths, no major complication occurred, all patients had uneventful post-operative course. Conclusions: As minimally invasive surgical instrumentation has evolved, and thoracoscopic surgical techniques have improved, thoracoscopic resection for primary chest wall malignancies or locally advanced non-small cell lung carcinoma, including those tumors with chest wall invasion, is now possible. Our cases demonstrate that video-assisted thoracoscopic resection for patient with chest wall tumor is safe and feasible. We also found that it is just as efficient to approach the rib resection from an internal vantage point, and in fact, the view may be enhanced. It is difficult to conceive of any theoretic advantage to divide overlying muscles to achieve a safe rib resection, so we believe it is reasonable to expand minimally invasive approaches for less common complex operations-particularly for frail patient.



Uniportal Thoracoscopic Lobectomy with Special Reference to the Method: Ology: An Initial Report in Japan

Surgical Treatment of the Relaxation of the Diaphragm by the Biological Tissue Welding

M. Kamiyoshihara1, H. Igai1, T. Ibe1, N. Kawatani1, K. Shimizu2, I. Takeyoshi2

E.N. Maietnyi, Y.V. Ivashko

Maebashi Red Cross Hospital, Maebashi, Japan; 2Gunma University Graduate School of Medicine, Maebashi, Japan

1

Introduction: Totally thoracoscopic pulmonary lobectomy for lung cancer is a wellestablished procedure. Most authors have described the video-assisted thoracoscopic surgery (VATS) approach to lobectomy using three to four incisions. Our institute has performed uniportal thoracoscopic surgery for pneumothorax based on a fundamental belief in concepts such as ‘reduced port surgery.’ We herein present a successful case of uniportal thoracoscopic lobectomy through 3.5-cm incision, with special reference to the methodological differences between uniportal and conventional VATS. Case: An 84-year-old female patient had primary lung cancer in the right lower lobe. We performed uniportal VATS as follows. A 3.5-cm access incision was made in the sixth intercostal space on the anterior axillary line. The access incision was protected with a polyurethane wound retractor. After collapse of the lung, the interlobar fissures, pulmonary vessels, bronchi, and pulmonary parenchyma to the affected bronchus were divided and sectioned with an endoscopic stapling device. The resected lung was removed in an organ retrieval bag through the utility incision. After the operation, a 19-F silicone chest drain was placed. The operating time was 150 min, and the blood loss volume was less than 30 ml. Analgesics were administered on postoperative day (POD) 0 (one 25-mg ampule of pentazocine hydrochloride and one 600-mg tablet of loxoprofen sodium hydrate). The patient was able to walk around her bed on POD 1. The chest tube was removed and she walked around the hospital ward on POD 2. We permitted her discharge on POD 5. Discusssion: We generally do not use special instrumentation even when uniportal VATS is introduced. Instruments should preferably be long and curved to allow for simultaneous insertion of two or three instruments. In addition, we always use a flexible thoracoscope and an energy device during totally endoscopic thoracic surgery. The use of conventional instruments for retraction and dissection during uniportal VATS major lung resection is possible; however, we prefer to use the following innovative techniques: the shaft-on-shaft technique, the pulley method, one-hand encircling, one-hand exposure, extra vessel exposure, stapler bending, and ‘move the ground.’

Department of Thoracic Surgery, Kiev, Ukraine Results of treatment of 17 patients with diaphragm relaxation aged 26–65 years who were treated at the Clinic in the period from 2002 to 2014. 11 patients were operated in the classical way. In 6 patients with vistseroliz formation and duplicates the aperture used welding coagulator. Formation dublications of the diaphragm was performed of welding complex. Analysis of the application when performing welding coagulator dissection tissues showed a decrease intraoperative blood loss by 2.5 times and reduce interference. In forming dublikatury diaphragm in 6 patients were welding coagulator used to enhance graft and fixation dublikatury. Welding seam was formed in chess order based on vascular pattern. Analysis of the postoperative period in patients operated with the use of welding set coagulator subjective decrease in pain. In the early postoperative period was marked reduction in the need for analgesic drugs. Local inflammation of the pleural leaves in place the plastic was noted in 4 patients and groups who need extra pleural puncture and evacuation of fluid. The use of welding seam thus avoiding local pleurisy. Additional pleural puncture in group II patients were not enforced. Follow-up for 6, 12 and 24 months has established stability diaphragmatic dome formed by means of welding coagulator to load and physiological mobility of the diaphragm. The use of welding technology in surgical interventions to improve the quality of the diaphragm intervention reduce the number of complications and length of treatment. Needs further improvement method of forming joint and strengthening the diaphragm.

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Video-Assisted Thoracoscopic Surgery Versus Sternotomy for Treating Mediastinal Tumors

Application of Z-Plasty for Wound Enlargement in Thoracoscopic Lobectomy

S. Sugiyama, M. Miyahara, Y. Naka, M. Aoki, M. Touge, K. Sugiyama, Y. Doki

K. Kishimoto, N. Miyamoto, A. Koyanagi, R. Nonomura

Tomei-Atsugi Hospital, Atsugi-shi, Japan Introduction: For several years, thoracoscopic resection has been a standard procedure for treating mediastinal tumors. We compared the advantages of the transsternal approach versus thoracoscopic resection for managing mediastinal tumors in terms of blood loss, operation time, morbidity, and mortality. Method: The study population comprised 28 patients with mediastinal tumors who were treated at our institute between 2003 and 2013. There were 18 men and 10 women, with a mean age of 55.1 years (range, 27–78 years). Of the 28 patients, 11 underwent sternotomy. Postoperative histological classification of these 11 tumors was as follows: thymoma in 5 patients, thymic cyst in one, neurinoma in 2, teratoma in 2, and bronchogenic cyst in one. The remaining 17 patients underwent thoracoscopic resection, and sternal lifting devices were used to access the working space during video-assisted thoracoscopic resection in 4 of these patients. With regard to the extent of resection, thymectomy was performed in 3 cases, thymic cyst in 7, paravertebral neurogenic tumor removal in 2, pleuropericardial cyst removal in 2, teratoma excision in 2, and bronchogenic cyst removal in 1. Results: No intraoperative complications or mortality was noted. The mean operative time (134.4 min vs. 182.8 min) and blood loss (42.1 ml vs. 234.8 ml, p \ 0.001) was significantly lower in the thoracoscopic resection group than in the sternotomy group. Pathologically, 3 thymomas were classified as Masaoka stage I, and 1, as Masaoka stage III in the thoracoscopic resection group, and 5 thymomas were classified as Masaoka stage I, and 1, as Masaoka stage III in the sternotomy group. Disease recurrence was not seen at a mean follow-up time of 15 months in both groups. Conclusion: Mediastinal tumors can be resected safely and with low morbidity by performing thoracoscopic resection.

Shimane University Faculty of Medicine, Izumo, Japan Aims: Thoracoscopic lobectomy has the benefit of decreased postoperative complications compared to lobectomy by thoracotomy. Thoracoscopic surgery also has a major cosmetic advantage, which is an important outcome for patients. To optimize the cosmetic outcome, the size of the incision for removal of the resected lung should be minimized. Here, we describe the use of Z-plasty, a common technique in plastic surgery, for this purpose. Methods: Thoracoscopic lobectomy is completed using 4 ports with external diameters of 5.5–11.5 mm. One of the port wounds is enlarged at the time of extirpation of the resected lung. The incision is elongated to 25–35 mm, depending on the lung volume. Then, 60° simple Z-plasty is performed at the median of the wound. Theoretically, in 60° Z-plasty, 175 % elongation is achieved. The resected specimen is put in a strong bag (Anchor Tissue Retrieval SystemTM) and pulled out. The wound is sutured with Z-design, which achieves a zigzag shape that almost disappears within several months. Thus, wound enlargement can be achieved without additional skin elongation in the long axis direction. Results: From April 2012 to December 2013, we have performed 108 consecutive Z-plasties in thoracoscopic lobectomy without wound problems such as infection or skin flap necrosis. Conclusion: Minimally invasive surgery has major advantages in reducing postoperative pain, shortening the hospital stay, facilitating convalescence, and improving the cosmetic outcome. Even greater benefits of minimally invasive surgery can be obtained by integration of techniques from plastic surgery into common practice. Here, we have illustrated the utilization of Z-plasty as a simple but useful technique for wound enlargement that confers improved cosmetic outcomes in thoracoscopic lobectomy.



Noble Covering Technique with Oxidized Cellulose Mesh in Video Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

Vats Sentinel Node Biopsy Reduces the Need for Systematic Mediastinal Lymphadenectomy in Early Stage NSCLC

H. Numanami, M. Yamaji, R. Taguti, M. Haniuda

N. Ilic1, J. Juricic1, V. Markovic2, N. Frleta Ilic3, D. Ilic1, Z. Covic1, J. Banovic1, D. Krnic1, Z. Pogorelic1

Aichi Medical University, Nagakute City, Japan

University Surgical Hospital, Split, Croatia; 2Clinical Hospital Centre, Nuclear Medicine Dept., Split, Croatia; 3Policlinic Cito, Oncology Dept., Split, Croatia 1

In video assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax, surgeons have numerous effort in order to prevent recurrence. From six years ago, we have performed ‘Jelly-Fish method’ devised by Masato Sasaki (Department of Surgery (II), University of Fukui, Faculty of Medical Sciences) to avoid recurrence. Jelly-Fish method, which we have applied in our department is as follows. 1) We make a slit in 20 9 20 cm oxidized cellulose mesh (SURGICELÒ mesh by ETHICON, Inc). 2) We start resection of the lung including bulla with endoscopic stapling device. 3) At the stage of the lung becoming resectable in the use of one more stapling, we interrupt the resection. A ‘pedunculated lung tissue’ is formed. 4) We pass the ‘pedunculated lung tissue’ through the slit in the mesh. 5) Then, we performed stapling and resection of the ‘pedunculated lung tissue’ with the mesh. Then the mesh is fixed at the stapled line. 6) The mesh is spread to cover over the lung including the stapling line. Since starting of Jelly-Fish method, postoperative recurrence of spontaneous pneumothorax was only one case. Thus, Jelly-Fish method is effective to prevent recurrences of spontaneous pneumothorax. However there are some problems in the method. First, when get wet with water and blood, the handling of SURGICEL Ò mesh is significantly worse to spread over the lung. Second, in the narrow thoracic cavity, it might be difficult to pass the ‘pedunculated lung tissue’ through the slit in the mesh (above 4). These manipulations might be the rate-determining step especially young surgeons. Instead, we have devised a new method to facilitate these. a) We made a plastic cylinder as an applicator of SURGICEL Ò mesh. b) We stitch SURGICEL Ò mesh onto a stapling device. By excising the ‘pedunculated lung tissue’ using the stapler, the mesh is fixed to the lung automatically. We will show these procedure with some images.

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Objective: Systematic mediastinal lymphadenectomy is still essential for an adequate postoperative staging of NSCLC. We tried to investigate the controversial role of sentinel node biopsy (SNB) in early stage non small cell lung cancer (NSCLC) surgery using videothoracoscopic approach (VATS). Methods: A total of 52 patients with clinical T1N0MO NSCLC underwent SN navigation VATS lobectomy using Tc-99 labeled tin colloid followed by systematic mediastinal lymphadenectomy (SML) in two years time period (2010–2012). Mapping of the mediastinal lymph nodes by their number and station followed by hystopathological evaluation was performed. Patients data were statistically analyzed. Results: Intraoperative SN was identified in 45 (87 %) of these patients with 92 % of accuracy. We found lobe specific skip nodal metastases in 5 (10 %) patients resulting in upstaging. The incidence of ML metastases seemed to be more often in adenocarcinoma patients (p \ 0.05), but skip nodal metastases showed higher rate in squamous cell carcinoma patients. Intraoperative frozen section was not confirmed accurate for detecting micrometastases in two (4 %) patients. Operative time was prolonged for 10 (8–25) minutes showing no difference in complication rate. Conclusion: Minimally invasive VATS procedure showed absolute safety and high accuracy. Our results indicated that SN identification could reduce mediastinal lymph node dissection in early stage NSCLC. Further clinical studies should be carried out in order to prove that minimally invasive surgical procedures could be curative for T1N0MO NSCLC.

Surg Endosc



The Importance of Variable Positioning of the Upper Horns Towards the Brachiocephalic Trunk in the Thoracoscopic Thymectomy

A Novel Fluorescence Marking Technique for Small Lung Nodules Using Photodynamic Diagnosis Endoscope System and Vitamin B2: Experimental Study

T. Patrascu, F. Bobirca, E. Catrina, O. Mihalache

R. Waseda, N. Tanaka, I. Matsumoto, M. Makoto, G. Watanabe

Dr. I.Cantacuzino Hospital, Bucharest, Romania

Kanazawa University, Kanazawa, Japan

The thoracoscopic thymectomy gives patients suffering from non-tumoral myasthenia gravis the advantages of surgery performed with minimal invasiveness, as well as long-term results which are similar to the classical technique. The anatomy of the thymus may provide the surgeon with surprises, due to the variable positioning of this gland, which may appear in as much as 18 % of cases. Among the most difficult, especially in the thoracoscopic approach, is the positioning of the upper horns towards the brachiocephalic trunk. An accurate dissection requires increased attention and good knowledge of the anatomic variations: the entire thymic gland is located behind the brachiocephalic trunk or just the superior horns, which can also be arranged in the variations at the front or at the back of blood vessels; adherent between the tymus and pleura, pericardium or aorta artery; positioning towards the pulmonary bilateral hills. Due to the relatively narrow working space and the vicinity of major blood vessels, the thoracoscopic thymectomy represents a challenge for each individual case, the experience of the surgeon being very important in recognizing the local anatomy variables but also in managing the work-intensive dissection and the potential complications which may occur. We are showing the case of a patient where it was discovered, during the course of the surgical intervention, that the well individualized superior horns were located behind the brachiocephalic trunk, which required a labour-intensive dissection; the thoracoscopic approach has offered better exposure of the space behind blood vessels and an increased dissection accuracy. The presence of anatomic anomalies of the thymic gland does not represent a contraindication to the minimal invasive surgery however it requires an increased attention, in order to attain the goal, which is to entirely remove the gland.

Objective: When performing sublobar resection for small lung nodules, accurate identification of the location and extent of target lesion is essential. Especially in thoracoscopic surgery, we have to visualize the target without palpation. We evolved a novel fluorescence marking technique using the photodynamic diagnosis endoscope system and vitamin B2. We examined the efficacy and safety of this technique in porcine experimental model. Methods: Pigs underwent general anesthesia and marking procedure in right lung. Before procedure, pseudolesions imitating small lung nodules were prepared in throughout right lung by painting small circle about 1 cm in diameter on parenchymal pleura. The photodynamic diagnosis endoscope system consisted of the D-Light system as the excitation light source and a TRICAM camera as the fluorescence sensing endoscope (Karl Storz GmbH & Co, Tuttlingen, Germany). Vitamin B2 was used as the fluorescence substance. The tip of very thin catheter was placed via a bronchoscopy close to the target, and the fluorescent substance was injected. 3 markings were performed for each lesion to visualize the extent of it. The fluorescent marking were identified using the photodynamic diagnosis endoscope system. Data collected were number of identifying the fluorescent marking site. The size, duration and light intensity of fluorescence of marking site were recorded. Light intensity of fluorescence was measured by ROI’s software (Hamamatsu, Japan). Perioperative complications were also recorded. Results: For a total of 12 target lesions, 36 fluorescence markings were performed. In all procedures, it was possible to identify the marking sites by its blight yellow-green fluorescence. The mean size (mm) of marking sites was 5.3 ± 0.9 just after injection, 5.5 ± 1.1 after 15 minutes, 5.5 ± 1.3 after 30 minutes, and 5.7 ± 1.2 after 1 hour. The mean light intensity of fluorescence was 136.2 ± 10.1, 145.5 ± 10.5, 157.1 ± 8.3, 163.3 ± 7.0 in each time. The intensity of non-marking site was 40.2 ± 5.3. At every measurement from injection until 1 hour later, the light intensity of the marking sites was significantly stronger than that from non-fluorescent sites. No perioperative complications were encountered. Conclusions: This fluorescence technique involving the photodynamic diagnosis endoscope system and vitamin B2 was useful to visualize the location and extent of small lung nodule in porcine lung.


P672 - Training

Thoracoscopic Left Splanchnicectomy - Two Trocars Tehnique. Case report

Stepwise Training Program for Residents: Using a Newly Developed Training Box, Needle Holder for Laparoscopic Surgery

V. Jinescu, G.H. Lica, P.M. Andrei, G. Chidiosan, M. Beuran Bucharest Clinical Emergency Hospital, Bucharest, Romania Background: The management of intractable abdominal pain caused by unresectable pancreatic cancer remains challenging, thoracoscopic left splanchnicectomy (TLS) being an ultimate solution. We evaluated the feasibility of performing the TLS with a two trocars technique for a patient diagnosed with unresectable pancreatic cancer. Patient and Method: A 59 year old patient diagnosed with irresectable pancreatic cancer [stage IV (T4N1M1)] with liver metastasis underwent a laparoscopic liver biopsy and a thoracoscopic left splanchnicectomy for pain control (pain degree - 8 on Wong-Baker scale) using a two trocars technique with optic trocar inserted in VIth intercostal space on mid axillary line and a 5 mm working trocar in IXth intercostal space on posterior axillary line. Results: Surgical procedure duration for the thoracoscopic splanchnicectomy was 30 minutes. Pleural drainage tube was removed 24 hours postoperatively. There were no complications. Pain relief was achieved after thoracoscopic left splanchnicectomy with no recurrence at one month check-up. Conclusions: Thoracoscopic unilateral left splanchnicectomy decreases substantial the pain and significantly improves the quality of life in patients with unrespectable pancreatic cancer and can be safely performed with a two trocar technique in selected patients. Keywords: Pancreatic cancer; Pain; Thoracoscopy; Splanchnicectomy.

H. Kawahira, H. Hayashi, R. Nakamura, N. Hanari, H. Gunji, H. Matsubara Chiba University, Chiba, Japan Introduction: The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific surgery. Two-hand coordination and suturing is the two most complex and technically challenging for residents under laparoscopic surgery. The goal of our stepwise program is aim to introduce residents to accomplish laparoscopic suturing, cholecystectomy and appendectomy. Methods and Procedures: We developed a stepwise training program with three-time lectures and practices. Each session is presented by a designated instructor and trainers and the trainee uses training box and needle holder. We have developed a new needle holder and training box with industries for this program. The trainees participates the evaluating the box and the needle holder. The trainee will take a termination test at last lecture. Trainees bring a mobile training box and needle holder that we developed and practice at home and their hospitals. The instructor is responsible for the accomplishment at each time lecture and practice. Results: This program will start in November this year and we are recruiting trainees. We will report the accomplished results. Conclusions: We developed a new training program with three sessions. We suggests that our training program is different from single suturing seminar but sustainable for practicing techniques for laparoscopic surgery.

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P673 - Training

P675 - Training

Evaluation of the Validity of the Lap-Mentor Laparoscopic Sigmoidectomy Module

Effective Implementation of Endoscopic Submucosal Dissection for Routine Practice in Poland - The Key to Success is in Japan

Y. Niwa

M. Spychalski1, A. Dziki1, S.E. Kudo2

Nagoya University Graduate School of Medicine, Nagoya, Japan, Aichi, Japan

1 Medical University of Lodz, Lodz, Poland; 2Showa University Northern Yokohama Hospital, Japan

Background: The sigmoidectomy module of LAP-MentorTM surgical simulator (Simbionix) is the first virtual reality (VR) simulation training program for colon cancer surgery. Although several recent studies have demonstrated the usefulness of VR surgical simulators for basic skills, few study of VR procedure modules have reported. Purpose: The purpose of this study was to evaluate the (face and construct) validity of the sigmoidectomy module of LAP-Mentor TM simulator. Methods: LAP-Mentor TM simulator automatically measures and records 40 parameters of trainee’s movement during the sigmoidectomy module. These parameters are considered to indicate various aspects of laparoscopic skills including total time, path length of both hand, and risk of injury to the rectal or colon wall, and so on. Eight surgeons who have various level of surgical experience (20–600 cases laparoscopic colectomy) participated in this study. They tried two tasks of this module (task 1: medial peritoneal incision to distal division; task 2: anastomosis using the circular stapling device) and subsequently were asked to fill in a questionnaire comprising 21 items about this module. Recorded all parameters of LAP-Mentor TM and the result of a questionnaire were analyzed. Results: All surgeons carried out this module. Average total time was 52 minutes (range: 31–90 minutes). Distance of IMA division from origin on the aorta (mm) was 11.3 mm (2–32 mm). Number of incidence implying risk of injury to the rectal or colon wall was 6.1 (1–11). Total path length of right instrument was 6989 ± 3262 cm, and total path length of left instrument was 5181 ± 2704 cm. Four parameters of all 40 parameters have a correlation with experience of laparoscopic colectomy; distance of IMA division from origin on the aorta (R = 0.86), average speed of right instrument movement (R = 0.83), untreated bleeding incidents (R = 0.74) and minor bleeding incidents (R = 0.66). The questionnaire showed participants thought it was preferable to learn gross anatomy, spatial perception, operative procedure and instruments, while unsatisfactory about haptic feedback and detailed anatomy. Conclusions: The parameters measured in this module might not have strong correlation with experience of actual laparoscopic colectomy. Nevertheless, the module was seemed to be useful for novice surgeons to preview the outline of the colectomy.

Aims: Endoscopic submucosal dissection (ESD) is a relatively new, but gradually utilized treatment modality for colorectal laterally spreading tumors (LST). Although the safety and effectiveness of the method have already been shown in Japan, it has not yet been widely adopted in Western practice. The successful transfer of skills, necessary to perform this method in Europe with results comparable to those in Japanese expert centers, remains a challenging process. The aim of the study was to analyze the efficacy of training in the Japanese endoscopy center on performing ESD in our institution. Methods: Commencement of ESD service in the Department of General and Colorectal Surgery, Medical University of Lodz was preceded by the training at the Showa University, Digestive Disease Center, Yokohama, Japan. Following factors critical for effectively performed ESD, based on skills enhanced during the training were assessed: the percentage of accurate Kudo scale classifications, the proportion of curative resection and en-block resection, the ability to treat potential complications i.e perforation or bleeding associated with ESD. Results: 36 ESD were performed within six months after finishing the training. The percentage of accurate Kudo scale qualifications reached 88.8 % (n = 31). In four cases a discrepancy between Kudo qualification and the results of histological examination were observed. In three cases ESD was withdrawn because of suspicion of invasive cancer (Kudo - Vn), later confirmed in the operative pathology report (adenocarcinoma pT2). The proportion of curative resections and en bloc resections was 97 % and 61 % respectively. Perforation occurred in three cases (n = 3, 8.3 %). Immediate perforations (2 cases) were successfully managed endoscopically (in one case using the Tulip method). Significant bleeding during ESD occurred in two cases (n = 2, 5 %) and was successfully managed during the procedure. Conclusions: The presented results confirm the effectiveness of training in the Japanese endoscopic center before ESD implementation in our institution. The skills acquired during the training in Japan, enabled to make the learning curve for colonic ESD possibly the safest for the patients.

P674 - Training

P676 - Training

Effect of Augmented Reality Simulator for Basic Laparoscopic Skills Training Comparing with Virtual Reality Simulator

Surgical Team Progress in Colorectal Laparoscopic Skills in TwoYear Period

M. Fujiwara, R. Fukumoto, C. Tanaka, Y. Niwa, N. Iwata, M. Kanda, S. Yamada, T. Fujii, Y. Kodera

A. Karachun, A. Petrov, Y.u.V. Pelipas, P.A. Sapronov, E.A. Petrova

Nagoya University, Nagoya, Japan Aims: Virtual reality (VR) surgical simulators have been more widely introduced to surgical training additionally to the conventional box trainers. VR simulator can provide objective assessment of performance of trainees but its virtual haptic feedback is inferior to that of actual instruments in box trainers. Augumented reality (AR) simulator such as ProMISTM (Haptica) provides realistic haptic feedback in addition to the ability to provide objective assessment of performance. AR simulator has been reported to be useful especially for relative complex task like suturing, while few studies have shown concerning basic tasks. In this study, the effect of ProMISTM AR simulator on the training of basic laparoscopic tasks is evaluated comparing with VR simulator. Methods: Twenty-six novice participants were divided to two groups: AR group using ProMISTM AR simulator and VR group using LAP-MentorTM VR simulator (Simbionix) group. The participants initially underwent a pretest including capsule transfer task, clipping task using another VR simulator: LapVRTM (Immersion). They were subsequently allocated to either AR group or VR group. Each participant underwent a 3-hour training in which they challenged peg transfer task and cutting task based on the Fundamentals of Laparoscopic Surgery (FLS) modules using each device. The participants then went back to the LapVRTM and repeated the same tasks as the pretest. Performances of the tests before and after the 3-hour training were compared in each group. Moreover the ratios of the score of posttest/pretest were calculated to reveal the degree of improvements. Results: No difference between AR and VR group was found in the mean age and experiences. Comparison of the scores before and after the 3-hour training session of both group revealed significant reduction of the time to complete in all tasks. Path lengths of dominant hand in the clipping task reduced in VR simulator training group. No significant improvement was found in other parameters. There were no significant differences in the ratios of post/pre improvement for most parameters. Conclusions: Effect of the training of basic laparoscopic skills with AR simulator was confirmed, but its superiority over VR simulator was not clarified in the current study.

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Scientific-Research Institute of Oncology Named After Professor Petrov N.N., Saint-Petersburg, Russia Background: Spreading popularity of mini-invasive approach in colorectal cancer treatment revealed certain questions concerning training of surgeons for such operations. Method: A retrospective study was conducted to evaluate the progress of laparoscopic skills in a single center in two-year period (2012 vs 2013). Operating time, mean blood loss and some patient selection criteria were estimated. All surgical procedures were performed by the same two surgeons. Surgeon A had had an experience of laparoscopic surgeries prior to study, but was trained unsupervised, while surgeon B had no experience, but had been surgeon’s A first assistant. Results: Mean operating time decreased from 178,9 to 153,7 min for the whole team (p = 0,04) and from 170,9 to 144,5 min for surgeon A (p = 0,02). Difference in mean time between surgeons A and B - was 144,5 min vs 190,5 (p \ 0,01). There was no difference in mean blood loss between surgeons (p = 0,4). No significant difference was found in patient selection criteria like age and gender, tumors preoperatively staged as T4 (5 % vs 4 %). For rectal cancer cases there were more patients after chemoradiotherapy in 2013 (62,5 % vs 33,3 % in 2012), though this difference was not significant (p = 0,3). The amount of men was the same for rectal cancer cases in 2012 and 2013 - 55,6 % vs 50,0 % (p = 0,5). Discussion: Surgeon B managed to achieve the same mean blood loss and was only 45 min slower, than surgeon A - appropriate training allowed surgeon B to shorten his learning curve. Patient selection strategy for laparoscopy didn’t change significantly during this year with a slight trend to operate more rectal cancer cases after chemoradiation therapy. Conclusion: Spreading of laparoscopic technique in colorectal cancer lead to increasing amount of such surgeries in our center. Appropriate training allows laparoscopic surgeons to achieve good results from the very beginning of their learning curve.

Surg Endosc

P677 - Training

P679 - Training

The Learning Curve for the Catheterisation of the External Jugular and the Femoral Vein in Rats in Obesity Related Research

An Analysis of Advanced Laparoscopic Skills Acquisition in an Intensive Laparoscopic Colorectal Training Program

I. Christakis, V. Constantinides, P. Georgiou, T. Tan, F. Palazzo, S. Bloom Imperial College London, United Kingdom

F.M. Sanchez Margallo1, M.A. Sanchez Hurtado1, A.M. Matos Azevedo1, J.A. Fata´s Cabeza2, I. Dıáz-Guemes1 Minimally Invasive Surgery Centre, Caćeres, Spain; 2Hospital Royo Villanova, Zaragoza, Spain 1

Background: Intravascular access for the short or long term administration of experimental agents and access to multiple blood samples are frequently used in rodents. Such vessel cannulation in rats is a technically challenging procedure with numerous potential problems. The aim of the present study was to assess a surgeon’s learning curve in the cannulation of the jugular and femoral vein in rats. Methods: A single researcher performed 200 micro-surgical operations between September 2012 and September 2013. Animals (male Wistar rats) were anesthetised with isoflurane and the right jugular vein the left femoral vein were catheterised. The procedure time and adverse intra-operative events were recorded prospectively and analysed. Animals were allocated to 4 groups of 50 based on chronology (Group 1: first 50 animals, Group 2:50–100, etc). Results: The operating time required for cannulation of the jugular vein for groups 1–4 was 24.6 min, 15.9 min, 15.2 min and 15.7 min respectively. Group 1’s operating time was significantly longer than all the other groups (p \ 0.001 for all groups). Groups 2, 3 and 4 did not differ significantly between them (p [ 0.05). The cannulation of the femoral vein required a mean of 32.6 min for group 1, 24.9 min group 2, 18.4 min for group 3 and 17.2 min for group 4. The operating time of group 1 was significantly longer when compared to all groups (p \ 0.001 for all groups). Group 2 also had a longer operating time when compared to groups 3 and 4 (p \ 0.001 for both groups). Finally, groups 3 and 4 did not show any statistical significant difference when their operating time was compared (p [ 0.05). The adverse effects included two unexpected deaths, both of which occurred in group 1 (0.5 % in total). Conclusions: There is a learning curve for the experimental cannulation of the femoral and jugular vein in rats. The plateau is reached by approximately 50 and 100 procedures in jugular and femoral vein cannulation respectively. This should be taken into account in the design of rodent model studies and highlights the importance of training and adequate supervision. To our knowledge, this is the first report on the learning curve on this type of micro-surgical procedure.

Objective: We present the usefulness of this novel training program and validation of the five editions of the Advanced Laparoscopic Colorectal Course organised by the Jesus Uson Minimally Invasive Surgery center and certified by the EAES. Methods: This course is based on the practice of sigmoidectomy (SG) and ileocecal resection (IR) in the porcine model. In addition, there is emphasis on the objective assessment of laparoscopic intracorporeal suturing (LIS) skills, required for the resolution of complications, or the improvement of the anastomosis manoeuvres. It consists of 2.5 days long with 2/3 parts of practice. Remaining time is spent on theoretical-audiovisual contents. During the first morning theoretical concepts of ergonomics in laparoscopy are taught to subsequently practice LIS in box-trainer on inorganic and organic tissues. At this point both techniques of SG and IR in porcine model will be performed by each attendant until the end of the course; participants are assisted by the expert faculty at any time. In addition, both the first day in box-trainer (P1), as the last day in animal model (P2), attendants’ LIS skills are objectively assessed through a level test by performing a simple stitch. Also, at the end of the training course, the 68 trainees subjectively ranked various educational and organizational topics of the training program by means of a questionnaire. Results: average participants’ opinions regarding the ‘theoretical-audiovisual part’, ‘practice in animal model’ and ‘level test’ exceeded 9 points in a range of 0–10. In addition, 81.9 % and 95 % of the subjects considered ‘duration of the course’ and ‘theory-practice distribution’ as appropriate, respectively. 86.8 % considered themselves to be ready to perform the techniques in human patients. And 81.9 % of them considered they had improved ‘much’ at the end of the 2.5 days. With regard to the level test, there was a significant improvement of the average completion time (P1 3.87 ± 1.53 min vs P3 2.22 ± 0.86 min, p \ 0.001). Conclusion: (s): our novel training program for advanced colorectal laparoscopy showed a very high evaluation. Also, the level test proved to be a simple and useful method to evaluate the participants LIS skills evolution.

P678 - Training

P680 - Training

How Music Affects Surgeons in the Operating Room and in Learning Laparoscopic Skills

Comparative Evaluation of Two Training Models in Laparoscopic Surgery

K.D. Nguyen, J. Bingener-Casey

B.D. Dumbrava1, F. Turcu1, D. Gheorghe2, A. Meius2, D. Ulmeanu3, C. Copaescu4

Mayo Clinic, Rochester, United States of America

Spitalul Clinic de Urgenta ,,Sf. Ioan,,, Bucharest, Romania; 2UMF Carol Davila, Bucharest, Romania; 3Regina Maria Hospital, Bucharest, Romania; 4Ponderas Hospital, Bucharest, Romania 1

Aims: The presence of music in surgery is still a debated topic. This study aims to focus on the effect that music has on surgeons while they are in the operating room and compare it to the effect that music has on surgeons while they learn laparoscopic skills. Methods: The literature search was done in three databases. In SCOPUS and PubMED, the searches were titled ‘music AND operating room’ and ‘music AND surgical skills.’ In OVID, the Medical Subject Headings (MeSH) were ‘Music’ and ‘Operating Room’ for the OR search, and ‘Music,’ ‘Learning,’ and ‘Laparoscopy’ for the skills search. Relevant articles were included by checking the References section of papers found in the search. Out of the numerous articles reviewed, 17 of them were suitable and incorporated in this study. Results: The majority of the studies in the OR search used the survey method. Two studies raised concerns about music being a distraction and a barrier to communication. Most found beneficial effects for the surgeon, such as decreasing autonomic reactivity and anxiety, and increasing task speed and accuracy. Self-selecting music has better outcomes than standard classical music. Many surgeons prefer music in the OR; some say it is as essential as the instruments used in surgery. All studies found in the laparoscopic skills search were randomized control trials. A couple found there was no significant difference in learning a new laparoscopic task with or without music. Interns’ surgical skills were adversely affected in an environment that included music as one of the distractors. Three RCT’s found that the ‘Mozart effect’ exists and can improve surgical performance. Listening to classical music decreased time of task completion in laparoscopic skills while more upbeat music increased speed and decreased muscle fatigue when mastering a robotic surgical technique. Conclusion: Music has many positive effects on surgeons while they learn new surgical skills and do routine work in the operating room, but it is important to account for the detrimental consequences it may have on distracting inexperienced surgeons and communicating with other OR staff.

Modern surgery has to find balance between surgical ethics, patient safety, cost effectiveness and proficient training. Novel methods of teaching must be researched, reviewed and published. Laparoscopic suturing is the borderline between basic and advanced minimally invasive surgery and has a high grade of difficulty compared to open surgery and microsurgery’. The aim of the study was to appraise two ‘hands-on’ training models for learning laparoscopic suturing techniques. Working Hypothesis: Recurring practice of each gesture which constitutes the laparoscopic surgical knot would lead to acquisition of proper routine action and a faster technique learning. Methodology: Two study groups were assembled by randomization from within a group of voluntary students (n = 36) which we recruited online. None of them had any exposure to laparoscopic teaching programs. A support group was built from students with some hands on surgical training. For each study cohort the same theoretical presentation with pictures and videos with the laparoscopic knots was displayed. Then Group A reproduced at the pelvitrainer each nodal point separately, while the control cohort (Group B) repeated uninterrupted the nodal points of the surgical knot. A 10 minute test was given to each volunteer, to make as many sutures as possible. The test was video recorded, saved with a random number, and assessed by a surgeon who was blinded regarding the affiliation with the study group. Results: The study participants of the step by step group (n = 18) scored within the test time of 10 minutes 2,6 knots, and the video loop-mode group (n = 18) 3,5 knots. The student t-test value is 0,06 and so the differences are not statistically significant. The feedback quiz indicated us some interesting facts which would help us in impending research. Conclusions: The absence of any result (validation or invalidation of the working hypothesis) proves some deficiencies in the study design. There were several bias factors which we have to take in account for further research.

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P681 - Training

P683 - Urology

An Experience of Laparoscopic Surgery Simulation for General Surgery and Gynecology Residents in a Developing Country

Single Port Intravesical Laparoscopic Repair of Vesicovaginal Fistula

L. Caruso1, D. Esposito2, M. Meinero3, A. Mottola4, E. Pavesi3, G.P. Ferulano1

A.A. Moharram Cairo University Hospital, Giza, Egypt

1

University of Naples - Policlinic ,,Federico II,,, Naples, Italy; 2 Second University of Naples, Italy; 3University of Modena and Reggio Emilia, Modena, Italy; 4Ospedale Evangelico Villa Betania, Naples, Italy Aims: to start a program of laparoscopic surgery simulation to be included in the general surgery and gynecology residency program of Ministry of Health of Palestine. The course ‘Laparoscopic Skills and Tasks: not anatomical procedures’ provided a not anatomical approach to laparoscopic surgery to improve trainee’s psychomotor abilities and practical skills eluding direct approach with the operating room, ethical issues and the risk of damage for surgical patients. Methods: during October and November, 2013 an intensive course of 57 hours was held by 3 italian experts in laparoscopic simulation for 9 residents in both surgery and gynecology (7 males, 2 females - 5 general surgeons, 4 gynecologists) attending the second and fourth residency year in 3 hospitals of the MoH of Palestine (Jenin, Beit Jala, Jericho). The trainees attended 12 hours of frontal lessons about laparoscopy in general, virtual reality and physical reality laparoscopic simulation and laparoscopic equipment and instruments. Thus, participants were divided in 3 groups of 3 and each trainee attended separately a 15 hours practical course in which he was fully guided by a personal tutor in completing 7 different surgical tasks using three different types of surgical simulators: LapMentor, iSim Laparoscopic Trainer and Endobox. Both pre and post training 5 items questions surveys were submitted to assess satisfaction grade about the course and confidence in mini invasive techniques. The tutors graded each task performed with a score from 1 to 5 to verify the achievement of predetermined goals. Results: after the training 100 % of the trainees obtained at least the minimum predetermined required score for each task. The 72 % of participants was able to perform not anatomical laparoscopic surgical tasks like simple knot or running sutures without the help of the tutor. An increase in satisfaction grade and in confidence with the technique was found in 72 % and 100 % of the trainees, respectively. Conclusions: laparoscopic surgery simulation training in a developing country seems to be a good instrument to give surgical residents without any experience in laparoscopic surgery a cost-effective first approach to mini invasive techniques avoiding risks for patients and ethical issues.

Objective: to report a new technique for repair of small sized (less than 5 fr.), supratrigonal vesicovaginal fistula using a minimally invasive single port laparoscopic approach to the fistula. Patients and Methods: In all 10 women with vesicovaginal fistula were operated upon in the period between 2010 and 2012 in El Galaa teaching hospital using a single port intravesical laparoscopic approach of the fistula where a 2 cm suprapubic incision was done, an anterior bladder wall incision was done in which the port was placed and fixed in the urinary bladder. Complete dissection of the fistulous tract, and complete separation of the urinary bladder from the underneath vaginal wall was done. The urinary bladder was sutured in 2 continuous layers using 000 vicryl. Results: Follow up for 8 cases was for one year, and 5 months for 2 patients. Follow up was for: urine leakage, any lower urinary symptoms such as burning micturition, frequency, urgency or urge incontinence. Urine analysis was done every 3 months to ensure absence of urinary tract infection. None of the 10 cases had any leakage after the repair. Only one case showed UTI, urgency from the group operated upon for the first time which was treated medically for 3 weeks. No other complications were reported Conclusion: This approach is a new minimally invasive technique where the fistula was exposed directly and has the advantages of short operative time, essay technique, no or very few intra and post-operative complications and short hospital stay.

P682 - Training

P684 - Urology

Does Non Surgical Dexterity Correlate with Laparoscopic Skills on a Simulator?

Single-Site Retroperitoneoscopic Donor Nephrectomy

E.A. Williams, T. Reid, A. Woodward

M. Maruyama, N. Akutsu, K. Otsuki, I. Matsumoto, H. Aoyama, M. Hasegawa, K. Saigo, T. Asano

Royal Glamorgan Hospital, Wales, United Kingdom

NHO Chiba-East National Hospital, Chiba, Japan

Aims: The relationship between non-surgical dexterity and surgical skill is not well understood, with limited, conflicting data in the literature. It is very likely that an assessment of practical skills will form part of the selection process for surgical training in the future, and therefore factors that may advantage or disadvantage individuals practically must be appreciated. The aim of this study was to assess laparoscopic skill using a simulator, in a cohort of surgically naive individuals, and determine if this correlates with non-surgical dexterity. Method: 60 GCSE level students completed a questionnaire to collect information on their level of computer game use, musical ability and surgical interest. Following a demonstration, each student had the opportunity to complete a single run through basic task on the ‘MIST-VR’ virtual reality laparoscopic simulator. Objective performance data was logged based on time taken, economy of movement and number of errors made, and from this an overall score recorded. Results: Regular computer game players had better scores than non-game players (p \ 0.05). This improved performance was based on significantly better economy of movement (p \ 0.05), and not number of errors made. Conversely playing a musical instrument to at least a grade examination level was not associated with any significant difference in laparoscopic performance. Similarly an interest in a surgical career did not correlate with difference in overall performance, but there was significantly improved economy of movement in this group (p \ 0.05) Conclusion: This study suggests that certain measures of non-surgical dexterity correlate with surgical skills on a laparoscopic simulator. Some individuals may therfore have an advantage if skills assessments become part of the selection process for surgical training. Further work is necessary to evaluate the dexterity factors affecting surgical skills, and to establish if an initial advantage gained is maintained throughout training.

Aims: We have performed retroperitoneoscopic nephrectomy for living kidney donor surgery since 2000. Recently, we introduced single-site retroperitoneoscopic donor nephrectomy (SSRDN) as a less invasive donor surgery. In this study we elucidate the efficacy of SSRDN. Method: Between May 2012 and March 2013, the procedure was performed in 7 donors (5 women and 2 men) by a single surgeon. All potential donors met the usual criteria for kidney donation. The mean age and body mass index of the donors were 62.6 years (range, 53–74 years) and 24.3 kg/m2 (range, 22.3–29.0 kg/m2), respectively. Left-sided nephrectomy was performed in all the donors. The donors were positioned in the right lateral position, and a 7-cm-long incision was made in the left flank. The incision was extended to the retroperitoneal space using the muscle-splitting technique. The retroperitoneal space was then expanded using an inflation balloon. A GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA) was placed in the incision. The subsequent technique and equipment were the same as those used in conventional 3-port retroperitoneoscopic donor nephrectomy (RDN). The renal artery and vein were dissected using a vascular stapler, and the kidney graft was directly extracted through the incision. Data from 14 consecutive left-side RDN procedures (from 10 women and 4 men) were obtained and compared with the SSRDN data. Results: SSRDN was successfully completed in all the donors. The mean operative time was 197 ± 28 minutes, warm ischemic time was 4.1 ± 1.2 minutes, and blood loss was 75 ± 113 mL. No statistical differences were found between the present method and conventional 3-port RDN. Intraoperative and postoperative complications were not observed in any of the donors. Graft function after transplantation was good, and delayed graft function was not observed in any of the recipients. Conclusions: This technique can be easily introduced in the clinical setting by surgeons experienced in RDN.

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Surg Endosc

P685 - Urology

P687 - Urology

Seven Cases of Laparoscopic Surgery for an Umbilical Urachal Remnant

Initial Experience in the Laparoscopic Treatment of Total UteroVaginal Prolapse

K. Yokomizo

G.E. Dejeu, T.T. Maghiar, A.M. Maghiar

Showa University Fujigaoka Hospital, Yokohama, Japan


Background: The urachus is an embryonic remnant that results from the involution of the allantonic duct and the ventral cloaca. The obliterated urachus, also known as the median umbilical ligament, extends from the anterior dome of the bladder towards the umbilicus. An infected urachal remnant is an uncommon benign condition that usually recurs and has the potential to become malignant. We reported our experience in laparoscopic surgery for urachal remnants. Patients and Methods: Between January 2010 and December 2013, seven patients with urachal remnants were experienced at our hospital. The clinical data and surgical treatments of all patients were retrospectively reviewed. Laparoscopic surgery for all cases was performed using three ports. The urachal remnant was excised by electrocautery, and the stump on the bladder was ligated with ENDOLOOP Ligature and some absorbable sutures. Results: Seven patients (4 males, 3 females) with a mean age of 33.2 years underwent laparoscopic surgery successfully. The median operation time was 97.8 minutes. The average postoperative hospital stay was 4.1 days. No intraoperative or postoperative complications were reported. Conclusion: Laparoscopic resection of urachal remnant allows for better anatomical visualization and may be considered as a safer, more effective, and more cosmetically beneficial alternative to open surgery.

In the Surgery-Urology clinic of Pelican Hospital in Oradea, Romania, we examined a number of 160 female patients with pelvic floor defects. Out of the 160 examined patients 26 had utero-vaginal prolapse of varying degrees. 12 patients we diagnosed with 3rd degree genital utero-vaginal prolapse, and we proposed surgical treatment for all these 12 patients. One patient was excluded due to other pathologies from the surgery group. We operated on all 11 remaining patients, and we performed colpo-sacro-pexy with polypropylene mesh in all of them, one case had to be converted to the open procedure due to adhesions caused by previous pelvic surgery. The surgery was finalized laparoscopically in all other 10 cases. The mean operation duration was of 3 hours, ranging from 6 hours for the first case to 2 hours and 15 minutes for the last case. Only one patient out of the 11 operated exhibited postoperative urinary incontinence at effort and it was necessary to perform a suburethral mesh banding using the TOT method.

P686 - Urology

P688 - Urology

Successful Living-Related Kidney Transplantation in a Donor with Duplicated Inferior Vena Cava

Laparoscopic Left Nephrectomy for a Voluminous Cystic Tumor

H. Chen, M. Huang, Y. Su

A. Delitala, M. Garancini, A. Giani, M. Scotti, E. Bolzonaro, A. Acquati, R. Perego, A. Mariani, M. Ratti, P. Riva, V. Giardini

Shuang-Ho Hospital, New Taipei City, Taiwan

HSGererado, Monza, Italy

The 20 year-old female is a living donor for kidney donation to her father, end-stage renal disease under hemodialysis. After series pre-operative examinations, she received totally laparoscopic donor left side nephrectomy. The splenic flexure was taken down and the ureter and godanal vessels were isolated. Left side inferior vena cava with short common channel of renal vein were found during hilar dissection. The left gonadal vessel drained into left side inferior vena cava directly. The graft renal vein was divided nearby the inferior vena cava with endo-GIA 30’ 3.5 and the graft renal artery was also divided with endoclip and hemolock. After operation, a JP drain was left in the renal fossa and was removed 3 days after operation. The patient was discharged 5 days after operation and the recipient was also discharged with functional graft 10 days after operation.

A 47 years old man came to our attention after the finding of a voluminous cystic neoplasm during an abdominal Ultrasound. His medical history was notable for tonsillectomy in the childhood and irritable bowel syndrome. Abdomen MRI was performed and showed a large cystic lesion of 55 9 35 mms occupying the medial part of the left kidney with mixed fluid and solid aspect and multiple sepimentations and irregular edges. Hematochemical tests including neoplastic markers revealed no pathological findings. The patient underwent contrast enhanced ultrasound study which detected large and irregular calcifications and hypervascularity; the lesion was suspected for cystic neoplasm and was diagnosed as type IV following Bosniak classification. Total body scintigraphy and brain and chest CT were performed and did not recognize any abnormalities. Totally laparoscopic left nephrectomy was performed. The hystological analysis described a clear cell renal carcinoma with cystic aspect, focal infiltration of the capsule and negative resection margins (pT3a, R0). Post operative course was uneventful, the drenage tube was removed on 3 th post-operative day, the patient was discharged on 5th postoperative day.

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Surg Endosc

P689 - Urology

P691 - Vascular Surgery

Horseshoe Kidney Mass in a Morbidly Obese Male

Ultrasound Evaluation Severity Carotid Atherosclerosis in Correlation with Coronary Artery Disease

A. Hariri, S. Agrawal, N. Gibbons, D. Hrouda Charing Cross Hospital, London, United Kingdom Aims: Surgery on horseshoe kidneys presents a technical challenge due to abnormal kidney location, aberrant vasculature, and presence of renal isthmus. Furthermore, when occurring in the markedly obese, this poses additional risks due to difficulties in exposure, prolonged operative times and existing co-morbidities. We present our case of a morbidly obese male (BMI = 58.2 kg m-2) with a mass in a horseshoe kidney, successfully managed with laparoscopic assisted hemi-nephrectomy. We highlight the challenges faced, as well as the techniques used to overcome them. Methods: Retrospective review of case notes for a patient with horseshoe kidney mass confirmed on contrast-enhanced computed tomography (CT). Results: The patient underwent a laparoscopic assisted left hemi-nephrectomy via a transperitoneal approach open Hassan technique using long bariatric ports. Histopathology specimen confirmed the diagnosis of Furman grade 2 and 3 metastatic clear cell renal carcinoma. The post-operative period was uneventful and the patient was discharged home at day 5. At review after three months, the patient had made a complete recovery with good wound healing. Conclusion: We highlight the importance of detailed pre-operative planning, adherence to laparoscopic surgical principles and the use of a multidisciplinary approach in the management of complex surgical patients.

N. Kadric, J. Jahic, B. Banjanovic, R. Rajkovic Center for the Heart BH, Tuzla, Bosnia-Herzegovina Increased carotid intima media thickness (CIMT) is simple noninvasive markers in evaluation atherosclerotic disease. Carotid disease is common finding in patient with coronary artery disease (CAD). The presence of carotid plaques is associated with increased risk of cardiovascular events in patients with CAD. The aim of this study was early detection of atherosclerotic disease processes and best treatment strategy. There were 200 patients who underwent carotid ultrasound, coronary angiography and echocardiography. Results: Collected data, morbidity and mortality will be presented. The presence of carotid plaques is associated with increased risk of cardiovascular events regardless of treatment strategy.

P690 - Vascular Surgery


Usefulness of Multi-port System Subfascial Endoscopic Perforating Vein Surgery

Fibrolaparoscopy in Diagnosis and Treatment of Postoperative Peritonitis

H. Sugawara, M. Ichiki, K. Sai, K. Kamata, M. Anzai, Y. Nakano

U. Riskiev, A.M. Khadjibaev, K. Asomov

Sendai Hospital of East Japan Railway Company, Sendai City, Japan

Republican Research Centre for Emergency Medicine, Tashkent, Uzbekistan

Objective: The usefulness of a multi-port system was evaluated by comparing surgical outcomes with a two-port system SEPS with those with multi-port system SEPS. Methods: SEPS was performed using a high-vision camera system (Karl Storz) while carbon dioxide (8 to 12 mmHg) was insufflated through a rigid endoscope with 30-dgree viewing angle type L lite-guide. EndoTIPÒ (Karl Storz, Tuttlingen, Germany) was used as the first port. Multi-port system SEPS was defined as a surgical technique which started with two-port system SEPS and it was replaced with three-port system SEPS (UIP2011, Prague)using an additional flexible trocar (AesculapÒ, B. Braun Melsungen AG) and curved forceps (AesculapÒ) during surgery aiming to have better visualization and make it easier to detach or preserve the accompanying artery. Results: Between March 2004 and March 2013, we performed SEPS on a total of 106 legs (in 102 patients) consisting of 53 legs in male patients (50 %) and 53 legs in female patients (50 %). The mean age of patients was 61.9 ± 11.6 years old. Clinical classification was C4b for 42 legs (39.6 %), C5 for 11 legs (10.4 %), and C6 for 53 legs (50 %). The disease treated was primary leg varicose veins in all the legs except for four legs with postthrombotic syndrome. SEPS systems used were one-port systems in 18 legs, two-port systems in 69 legs, and multi-port systems in 19 legs. The mean number of IPVs per leg dissected endoscopically was 2.3 veins (range: 1 to 4) and 2.9 veins (range: 1 to 4) for twoport systems and multi-port systems, respectively. SEPS success rates for two-port systems and multi-port systems were 93.2 % and 100 %, respectively, for Cockett perforating veins, and 93.3 % and 100 %, respectively, for paratibial perforating veins (p \ 0.01). The ulcer healing rate was 90.9 % for both two-port systems and multi-port systems. Accompanying artery preservation rates were 61.5 % (32/52, n = 37) and 96.7 % (29/30, n = 19) for twoport systems and multi-port systems, respectively (p \ 0.01). No serious complications occurred in two-port system SEPS or multi-port system SEPS. Conclusions: Compared with two-port systems, multi-port systems provided significantly higher accompanying artery preservation rates and SEPS success rates (Cockett perforating veins) (p \ 0.01).

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Our study was aimed at analysis of results of surgical treatment of patients with intraabdominal complications resulting after using a method of fibrolaparoscopy in an early postoperative period. Methods: Fibrolaparoscopy was accomplished with a flexible endoscope Olympus CHFT20 that was introduced into abdominal cavity through silicone drainage tubes (laparoport) kept after the first operation. Research included 230 patients with postoperative peritonitis (POP) within a period since 2005 to 2013. In all were 141 (61,3 %) males and 89 (38,7 %) females, aged 16–86, median age was 49,00. All the patients were divided into two groups subject to postoperative period after fibrolaparoscopy carried out in complex treatment. The 1st group (main) consisted of 82 (35,6 %) patients with POP that were underwent fibrolaparoscopy with diagnostic and therapeutic goal in postoperative period. The 2nd group (control) included 148 (64,4 %) patients that were not underwent fibrolaparoscopy in postoperative period. A median duration of fibrolaparoscopy in a group of patients with postoperative peritonitis was 10 ± 2,4 minutes. Results: Fibrolaparoscopy was performed on days 1-, 3-, 5- and 7. Failure of sutures was excluded in 9 patients after anastomosis surgery in different areas of GIT because laboratory and instrumental findings exhibited accomplishment of re-operation. Continued thrombosis was excluded in 8 patients after operations for mesenterial thrombosis by a method of fibrolaparoscopy, and in 5 patients on days 1-and 2 after operation was revealed continued thrombosis with necrosis of small intestine. The patients were underwent reoperation. Sanitization of abdominal cavity by fibrolaparoscopy was conducted in patients of main group. Quantitative determination of microbial colonization of peritoneal exudate revealed decrease on microbial concentration as result of repeated sanitizations from 4,84 + 0,32 ?/ml up to 0,92 + 0,11 ?/ml. Patients from control group with POP were underwent repeated sanitization operative interventions 1,7 times more than patients of main group. Conclusions: Introduction of fibrolaparoscopy into clinical practice gives causes for substantial progression for improvement of diagnosis and treatment while arising intraabdominal complications in an early postoperative period.

Surg Endosc



Single Incision and One Port Laparoscopy Surgery: A Latin American Experience

The First Clinical Experience of Targetted Full-Thickness Laparo-Endoscopic Excision for Benign Colonic Polyps

G. Gonza´lez Uribe1, F. Da´vila Avila2, D.A. Tsin3, L. Gutierrez Rodriguez4, M.G. Dominguez.5, F. Zamora6, M.R. Da´vila Centeno7, U. Da´vila Avila2, J. Lemus Allende8

A. Currie, A Brigic, C.D. Fraser, N.S. Suzuki, S. Thomas-Gibson, O.D. Faiz, R.H. Kennedy St Mark’s Hospital, Harrow, United Kingdom

1

Issstecali, Tijuana, Mexico; 2Hospital Fausta Da´vila Solı´s, Pozarica, Veracruz, Mexico; 3Mount Sinai Hospital of Queens, Long Island City New York, United States of America; 4Ex presidente Asociacioń Mexicana de Cirugıá Endosco´pica, Distrito Federal, Mexico; 5 Fundacion Hospitalaria, Buenos Aires, Argentina; 6Excelap, Caracas, Venezuela; 7Hosp. Gral. Dr. M. Gea Gonza´lez, Distrito Federal, Mexico; 8Hosp. Regional Pemex, Pozarica, Veracruz, Mexico Background: To evaluate different single incision laparoscopy including One Port Laparoscopy Surgery (1PLS) also known as (CL1P) that uses percutaneous needle assistance. We focus on the geographical area or country according to the affordability, availability of instruments, technology, and results. Aim: To identify, in the current literature, and in our own Surgical Technique One Port Laparoscopy Surgery (1PLS) (CL1P) experience, the best feasible single incision laparoscopy that better serves patients and surgeons in Latin America. Project Description: This study compares different publications, oppose our own surgical technique experience on single incision laparoscopic procedures focusing on cost, availability, learning curve and results Results: One port Laparoscopy surgery is the best cost containment single incision laparoscopy with less tissue trauma, better cosmetic and good results. The study compares different single incision laparoscopy and one port laparoscopy surgery (1PLS) focusing on cost containment, tissue damage, and accessibility in Latin America.

Background: The current treatment for endoscopically irresectable colonic polyps is hemicolectomy, with accompanying morbidity in 40 % of patients. To date laparo-endoscopic colonic excision has been imprecise. To address this, following extensive experimental surgery, we have described (Brigic et al, BJS:2013) targeted, full thickness laparo-endoscopic excision (FLEX). Aim: To report the first clinical experience of the FLEX procedure for a colonic polyp. Project Description: After research governance approval and informed consent, a 56 yearold patient with a 3.5 cm endoscopically unresectable benign caecal polyp underwent the FLEX procedure. Endoscopically placed plication sutures precisely localized and everted the polyp, which was excised using a laparoscopic stapler. The terminal ileum was intubated to demonstrate patency. The caecal suture line was oversewn and specimen removed laparoscopically. Preliminary Results: Excellent postoperative recovery occurred with discharge\48 hours. The technique has the potential to reduce the need for colectomy in benign polyps and early colonic malignancy.



Laparoscopic Treatment of Advanced Renal Cell Cancer with Single Spleen Metastasis: A Case Report

Strategies to Shorten the Learning Curve for Robotic Colorectal Resection: A Single Centre Experience of the First 44 Cases

F. Cabras1, S. Mijatovic2, U. Bracale3, J. Andreuccetti1, G. Pignata1

T. Singhal, L. Khan, J. Khan, A. Parvaiz

San Camillo Hospital, Trento, Italy; 2University Clinic of Serbia, Belgrade, Serbia; 3University Federico II, Naples, Italy

Portsmouth Hospitals NHS Trust, Orpington, United Kingdom

1

Background: In literature have been documented 5 cases of solitary splenic metastases from primitive renal cancer (RCC). Aim: Considering the risk of spontaneous spleen rupture, splenectomy is the ‘gold standard’. Laparoscopic radical nephrectomy, vs open, decrease blood loss, determine shorter hospital stay and less need for pain medication. Project Description: The video shows a case of an 80 y.o. woman presenting anemia and weight-loss. Abdominal examination described a left-sided mass. CT-scan confirmed a 70x150 mm mass, and splenic metastasis of 20 9 30 mm. Laparoscopic ‘en-bloc’ left nephrectomy and splenectomy were carried out in 138 min., without complications. Infiltration of hilum and dislocation of the renal artery were found. Postoperative uneventful. Stool canalization and free-diet on day 2. Discharging 6 days after surgery. Histology confirmed RCC and metastasis. Preliminary Results: We assess that laparoscopic ‘en-bloc’ splenectomy and left nephrectomy should be the ideal treatment for good prognosis and to reduce the incidence of anemia or spleen rupture.

Background: Few robotic colorectal resections have been performed compared to laparoscopy. Reasons include high operating costs, concerns regarding oncological efficacy, patient safety and difficulties in performing multi-quadrant abdominal procedures. Aim: Using a modular training framework coupled with standardised surgical technique and proficiency gained from performing laparoscopic colorectal resections we aimed to achieve comparable outcomes using a robotic platform. Project Description: Analysed data from first 44 patients undergoing robotic colorectal resections between May and December 2013. Preliminary Results: 44 patients underwent robotic colorectal resection. 38 (86 %) resections were for cancer (28 rectum, 7 sigmoid, 2 splenic flexure, 1 transverse colon) and 6 (14 %) for benign disease. The median lymph node yield was 18 (SD 10). One patient (2.3 %) had anastomotic leak. Median length of stay was 6.5 days (SD 8) and total operating time 255 minutes (SD 90.9). There were no conversions and no deaths within 30 days of operation.

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Surg Endosc



Short- and Medium-Term Results of Totally Laparoscopic Resection for Low Sigmoid and Rectal Cancer

Laparoscopic Repair of a Symptomatic Morgagni Hernia in an Adult

H. Shimizu, J. Matsumoto, H. Otsuka, I. Osaka, K. Takuma, K. Takanishi

M.D. Reyes-Salas, G. Gonzalez-Hernandez, H. Reyes-Sepulveda, J.A. Diaz-Elizondo

Tokyo Metropolitan Tama Medical Center, Tokyo, Japan

Technologico de Monterrey, Monterrey, Mexico

Background: As laparoscopic techniques and instrumentation have advanced, surgeons have been trying to complete laparoscopic procedures using fewer ports and incisions. Generally, a laparoscopically assisted colectomy (LAC) requires a mini-laparotomy for specimen extraction, which often causes postoperative pain, wound complications, and incisional hernia. However, we have successfully performed totally laparoscopic resections for low sigmoid and rectal cancer using a high anterior resection technique with transanal specimen extraction (HAR-TASE) and a low anterior resection technique with transanal pull-through (LAR-TAPT). Methods: A prospectively maintained database was reviewed to assess the short, mid, and long-term outcomes of surgery at our institution. Indications for surgery included clinical stage ? and ? carcinoma of the rectum and low sigmoid colon with tumor size smaller than 3 cm. HAR-TASE was selected for a patient with colorectal anastomosis above the peritoneal reflection. LAR-TAPT was selected for a patient with colorectal anastomosis below the peritoneal reflection. Results: From June 2008 to April 2013, 80 patients (40 HAR-TASE, 40 LAR-TAPT) underwent totally laparoscopic colorectal cancer resection. There were 35 females and 45 males with a mean age of 66.5 ± 10.5 and mean body mass index 23.0 ± 3.2 kg/m2. The mean operative times were 223.8 ± 36.7 min for HAR-TASE and 286.2 ± 62.9 min for LAR-TAPT. The rate of conversion to mini-laparotomy was 11 % (n = 9). Complications were observed in 10 % of patients (n = 8), including 5 anastomotic leaks and 2 anastomotic strictures. The mean length of hospital stay was 13.4 ± 11.0 days. The mean size of tumor was 17.8 ± 13.1 mm. Pathologic cancer stages included 53 stage?, 6 stage ?A, and 21 stage ?(A, B, and C). Urinary or sexual dysfunction was not observed. There was no mortality or cancer recurrence at 34 months’ follow up. Conclusions: Totally laparoscopic resection for low sigmoid and rectal cancer can be performed safely in carefully selected patients with acceptable oncologic outcomes at medium-term follow up. Further studies are necessary to assess the long term results.

Objective of the Study: Present a video demonstrating our laparoscopic approach for a Morgagni Hernia repair in an adult. Methods and Procedures: Video shows a 36 years old female with 2 year history of chest pain and shortness of breath treated as recurrent respiratory tract infections. Chest x-ray revealed herniation of bowel contents into right thoracic cavity. Computed tomography (CT) was indicated. Contrast enhanced CT showed a diaphragm defect and herniation of transverse colon and omentum to the right hemithorax. A laparoscopic repair was performed. The hernia content was gently reduced with blunt dissection. The sac was no resected. The defect was closed with non-absorbable sutures and a tissue excluding mesh (polypropylene mesh with a bioresorbable hydrogel coating) was fixed in the repaired place with tackers. Results of the Study: The patient had a good evolution during the follow up period. Was discharged home on the 3rd post operative day without complications. Respiratory symptoms and chestpain resolved. Conclusions: Laparoscopic Morgagni hernia repair is a viable and safe procedure including hernia reduction, suture closure of the defect and mesh implantation as in conventional approach but offering benefits of minimally invasive surgery.

P698 - Pancreas


A Novel Method of Stump Closure for the Laparoscopic Distal Pancreatectomy by a Fully-Powered Endostapler

Small Bowel Obstruction After Laparoscopic Gastric Bypass and Its Surgical Management: Experience in 10 Years

T. Kusano, M. Murakami, T. Aoki, K. Matsuda, T. Koizumi, K. Mitamura, S. Fujimori, M. Watanabe, K. Otsuka, T. Kato

M.D. Reyes-Salas, J.A. Diaz-Elizondo, R.A. Rumbaut-Diaz, H. Guajardo-Perez, S. Sherwell-Cabello

Showa University School of Medicine, Tokyo, Japan

Technologico de Monterrey, Monterrey, Mexico

Background: Laparoscopic approaches have been introduced to the many fields of abdominal surgery. Laparoscopic distal pancreatectomy (LDP) is one of the most accepted laparoscopic procedures in the field of pancreatic surgery. Although it has been reported various methods of pancreatic stump closure using some staplers, pancreatic fistula still remains significant as the major problem of pancreatic surgery. We demonstrate here that a novel method of stump closure by a fully-powered endostapler (iDriveTM Ultra powered stapling system; COVIDIEN Corporation), which may have an ability of less stress during a compression and clamping on tissue, allow the surgeon to perform a safer and simpler LDP. Purpose: The aim of this report is to assess the safety and operability of this new device, compared with the conventional devices, Endo GIATM Ultra Universal Staplers (Covidien) or ECHELON FLEXTM ENDOPATHÒ Staplers (Ethicon Endo-surgery). Patients and Methods: This retrospective study included 28 patients who underwent LDP between June, 2009 and December, 2013. The patients were divided into two groups based on the surgical procedure: the using iDriveTM Ultra (group I; n = 5) and the using conventional devices (group II; n = 23). In the group II, before the slow stapling for 2 min, the pancreas was kept 2 min to compress. In the group I, the same pre-compression and slower stapling technique for 5 min were performed. Patient’s characteristics, operative data, and postoperative outcome were evaluated. Results: All patients successfully underwent LDP. There were no significant differences in age, gender, diabetes mellitus and prior abdominal operation between two groups. There were no significant differences in operative time (175 min vs. 210 min) and intraoperative blood loss (102 ml vs. 220 ml). Incidence of clinical pancreatic fistula (defined by the International Study Group of Pancreatic Fistula (ISGPF)) was significantly lower in the group I than in the group II. Consistent with the results for pancreatic fistula, postoperative hospital stay were shorter in the group I. Conclusions: Our data shows that LDP by a fully-powered endostapler is a safer and simpler procedure to prevent pancreatic fistula compared with the conventional devices.

Background: An internal hernia is the most common cause of small bowel obstruction (SBO) in patients with a Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) with an incidence reported of 2–5 %. Objective: Present our incidence of small bowel obstruction and internal hernias after LRYGB and determine the causes. Methods and Procedures: A retrospective and descriptive study was carried out of 705 patients, reviewing charts between the years 2003 and 2012 that were operated of LRYGP and required hospitalization between those years because of an episode of small bowel obstruction. The tests and procedures used to diagnose the bowel obstruction included: physical examination, CT scan and diagnostic laparoscopy. Causes that lead to the episode of SBO were determined. Results: 18 patients with previous LRYGP presented with SBO requiring hospitalization. 9 were female and 4 males. Ages 16–79 years (Mean 52.4, DE 17.8). The leading cause for SBO was an Internal Hernia; 13 patients (72.2 %) sub-divided in transmesocolic hernia (2, 15 %), Petersen’s space hernia (3, 23 %) and jejunal mesentery space (8, 62 %) with a mean time for presenting SBO from surgery of 26 months. 2 patients were pregnant; required surgical intervention and had no complications post-op. Others etiologies for SBO were adhesions (3 patients, 16.6 %) and jejunal-jejunal anastomosis obstruction (hemobezoar and torsion). All the patients that required surgical intervention were approached laparoscopically. Conversion to open surgery was not required. The mortality rate was 0 %. Conclusion: SBO occurred with an overall incidence of 2.5 % in this series of patients with a previous LRYGP. We must consider the diagnosis of an Internal hernia as the first etiology for SBO because it represents 72.2 % of the causes. Our incidence of internal hernias is 1.8 %, which is low compared with other series probably because of the change of the technique from retrocolic to antecolic. When indicated, the laparoscopic approach for SBO can be achieved with minimal mortality risk.

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P703 - Flexible Surgery

Bochdalek Hernia Repair with Mesh Laparoscopic in a No Pediatric Male

Laparoscopy and Endoscopy Cooperative Surgery (LECS) for Gastric Submucosal Tumor


M. Kawai, L.S. Lee, K. Tashiro, S. Kawashima, R. Tanaka, K. Uchiyama


Osaka Medical College, Osaka, Japan

1

Introduction: Congenital diaphragmatic hernia of Bochdalek specifically it is a defect that usually posterolateral diaphragm and the left side is placed in 80 % of cases. The incidence is approximately 2.32 9 10,000 live births, with an exceptionally rare disease in adults. This condition may go unnoticed during childhood (asymptomatic) forming a true clinical entity in adulthood where the diagnosis can be established accidentally by chest X-ray or further complications to the passage of the abdominal viscera through pathological hole diaphragm. The patient may report significant chest pain, either by respiratory compromise (atelectasis, pneumonia) may be an early or complications such as volvulus, late complication character, with possible rupture of the abdominal viscera into the chest. Material and Methods: Male 25 years old without chronic degenerative diseases, surgery at 3 years and 11 years of transabdominal repair of Bochdalek hernia. However, for 4 years starts with repetitive boxes nausea, vomiting and colic type mesogastrio and epigastric pain associated with food. Physical examination evidenced hipoexpansibilidad thoracic dominance of the left hemithorax, abolition of breath sounds with pectoriloquia and presence of bowel sounds the same side; depressible soft abdomen with no signs of peritoneal irritation, and no evidence of organomegaly. Thoracoabdominal CT where diaphragmatic defect is reported with hernia sac containing transverse colon and stomach was performed. Results: Mesh plasty is performed laparoscopically Patient was operated successfully elective, laparoscopic abdominal approach with showing in left hemidiaphragm hernial process 20 cm diameter gastric and intestine (transverse) content. Plasty and diaphragmatic hernia repair with mesh placement is made. Conclusion: Accurate preoperative diagnosis of Bochdalek hernia is determined by imaging studies. As for the goals of treatment of this condition experience shows the importance of separating asymptomatic and symptomatic cases, help us through the history discarding the existence of trauma, diaphragmatic defect and correct the position the abdominal contents in place. So far transthoracic repair is the right choice for hernias while addressing the left hernias has been discussed, which raises and abdominal approach is used to have greater advantages for the recognition and treatment malrotations.

Aims: Local resection is generally selected for gastric submucosal tumor, however some cases such as tumor located near the esophagogastric junction (EGJ) or unidentified of tumor edge are difficult using laparoscopic approach. For these cases, the laparoscopic and endoscopic cooperative surgery (LECS) technique was designed by Hiki et al. We introduce two resected case of gastric submucosal tumor by LECS. Methods: First video case is 32 year old female, tumor size was approximately 2 cm and located posterior wall near the EGJ. She underwent endoscopic local resection of whole layer including safety margin from submucosal tumor. Then defect was closed under laparoscopic suture. (Total operating time: 300 min. Bleeding: 20 ml) Second video case is 64 year old male, tumor size was approximately 4 cm and located posterior wall near the EGJ. He underwent intragastric submucosal resection through the laparoscopic 3-trocar using by laparoscopic device. (Total operating time: 230 min. Bleeding: 10 ml) Results: No specific events after operative course were observed in both cases. Hospital stay was approximately 10 days. Conclusions: We introduced two cases of LECS, however the tumor resection by only endoscopically is sometimes difficult because of some limitation of endoscopic device. Therefore we believe that LECS including intragastric operation of laparoscopically contributes less invasive and facilitates for the resection of gastric submucosal tumor.


P703a - Amazing Technologies

Laparoscopic Surgery of Duodenal Tumors - Five Cases

A Randomised Controlled Clinical Trial Investigating 3D Laparoscopy - Pilot Study Results

´ . Botos, L. Sikorszki, A. Berencsi, R. Temesi, E. Kiss, J. Bezsilla, A S. Bende

K.E. Schwab, T. Rockall, I. Jourdan

B-A-Z County Hospital, Miskolc, Hungary

MATTU at RSCH, Guildford, United Kingdom

Duodenal tumors account for 1 % to 2 % of total gastrointestinal tract tumors. Endoscopic diagnosis and localisation are the key factors to determine the options for correct management. When the successful resection of the tumor requires full thickness excision of the duodenal wall, laparoscopic surgery reduces invasiveness. From January 2006 to December 2013, five duodenal tumors were operated on laparoscopically at our department. A total of five patients (two males and three females) with a median age of 58 years (ranging from 43 to 79 years) were treated. All of the patients underwent limited resection after duodenal mobilisation. There were four wedge resections with primary closures and one closed resection with endo-GIA. The median tumor size was 2,4 cm (ranging from 1 to 5 cm). There were no conversion and morbidity. The hospital stay was an average of 7 days (between 5 and 10 days). The histological findings had an interesting variety with lipoma, ectopic pancreas, pseudopyloric metaplasia, neuroendocrine and gastrointestinal stromal tumor. Laparoscopic surgery for benign and borderline duodenal lesions is a feasible alternative to open conventional therapies but it needs meticulous radiological and endoscopic assessment and laparoscopic skills.

Background: The benefits of 3D laparoscopy have been known for years, however, poor operator tolerance prevented adoption. The newest 3D passive polarising technology may offer a real option, as demonstrated by recent laboratory studies. This is the first randomised clinical trial using this technology. Aim: Our aim is assess this new 3D technology in a statistically powered RCT to see if lab based perceived benefits are transferable to the operating theatre. Project Description: Laparoscopic Cholecystectomy patients are randomised to surgery using a 2D or 3D system. All surgery is video recorded in 2D and analysed by independent blinded surgeons. Primary outcome is time and secondary outcome is precision of surgery, assessed using Human Reliability Assessment Tools. A Pilot study was performed using the first 20 patients. Preliminary results: The surgical time and error production appears reduced in comparable surgeries, using 3D laparoscopy.

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Surg Endosc



Tapp Hernia Repair with 3D Mesh and Fibrin-Glue

Laparoscopic Rectopexy; Is it Useful for Persistent Rectal Prolapse in Children?

D.E. Popa, A. Ilco, A. Belega, D. Vasile University of Medicine ‘‘Carol Davila,,, Bucharest, Romania

A. Abdelkader1, H. Fahmy1, M. Ismail2, M. Abdelrazik2 Royal Commission Medical Centre, Yanbu, Saudi Arabia; 2Faculty of Medicine, Al-Azhar University, Cairo, Egypt

1

Background: since the introduction of TAPP technique for laparoscopic hernia repair, there is a continuous concern about meshes that are easy to be applied and also decrease the incidence of reoccurrence. Fibrin-glue is proved to decrease postoperative chronic pain syndrome that can appear secondary to tacks, even the resorbable ones. Aims: to investigate the benefits of 3D mesh (both from the surgical technique point of view and reoccurrences) and fibrin-glue as fixation tool. Material and Method: we present the first part of a prospective ongoing study, started in 2012, containing 34 patients Results: out of the 34 operations, three were performed in emergency conditions, for incarcerated hernias. Bowel movements started after an average of 1,14 days (for gases) and 2,57 days for stool. GIQLI score (Gastro Intestinal Quality of Life Index) had a median value of 11,42 reported at a maximum value of 144. Duration of the operation was between 55–130 min with a median value of 85 min. Conclusion: anatomically shaped mesh allows an easier application making the surgical technique more facil. Fibrin glue, applied with its laparoscopic special device doesn’t seem to be at the origin of any postoperative chronic pain.

Rectal prolapse is a relatively common, usually self-limiting illness in children. Peak incidence is between 1 and 3 years [1, 2]. The intervention is required for the persistent rectal prolapse (PRP). Only scanty experience is available with laparoscopic rectopexy in children. There on available work using both mesh and suture laparoscopic rectopexy in literature. This work is unique in that it presents our clinical experience with both mesh and suture laparoscopic rectopexy in children. This is a prospective clinical study for the outcome of laparoscopic rectopexy (LRP) by both mesh and suture technique in children with persistent rectal prolapse (PRP). Materials and Methods: Fourteen cases of PRP were managed with LRP from February 2008 to August 2012. Results: Of the 14 children, 10 (71.42 %) were males and 4 (28.57 %) were females. Male to female ratio was 2:1. The mean age of presentation was 5 years (range 3–8 years). The presenting complaints were mass descending per rectum along with bleeding per rectum lasting from 1 to 3 years. All had rectal prolapse of 5–7 cm in length. 12 out of 14 child had recurrence even after sclerotherapy before referral to laparoscopic rectopexy. The mean duration of surgery was 30 minutes (range 20–60 minutes). No intraoperative complications were reported, only one case get constipation and managed conservatively and no recurrence. Conclusion: LRP is safe, feasible in children and gives satisfactory results after failure of all conservative even sclerotherapy injection. Keywords: Rectal prolapse; Laparoscopy; Rectopexy

P705 - Education


Goals Assessment of Three Key Steps in Laparoscopic Cholecystectomy

Mini-Laparoscopic Cholecystectomy: An Asian Hospital Experience

K.H. Kramp, M.J. van Det, J.P.E.N. Pierie

A. Wong, Y.L. Lin, J. Lee, C.S. Foo

Medical Center Leeuwarden, Leeuwarden, The Netherlands

Changi General Hospital Singapore, Singapore

Aims: GOALS (Global Operative Assessment of Laparoscopic Skills) assessment has been designed to evaluate surgical skills in minimal invasive surgery. A longitudinal blinded randomized study was conducted to compare GOALS video assessment of 3 procedural key steps with OSATS assessment after direct observation and to estimate the validity en reliability of GOALS in our medical center. Method: Video fragments of 1) opening of the peritoneum, 2) dissection of triangle of Callot and achievement of CVS and 3) dissection of the gallbladder from the livered were blinded, randomized and rated by two consultant surgeons with GOALS. A grade was given for overall competence for every fragment. Two direct observers, a supervising surgeon and an attending surgeon, rated the trainee after the procedure with OSATS. Concurrent validity with OSATS was calculated with the Spearman rho correlation coefficient. Construct validity was calculated with the Friedman two-way analysis of variance by ranks and the Wilcoxon signed-ranks test. The interrater reliability was calculated with the intra-class correlation coefficient. Results: Ten trainees performed 6 laparoscopic cholecystectomies. Sixty procedures were recorded on video and divided into 160 fragments for evaluation with GOALS. A high correlation was found between mean GOALS score (r = 0.943, p = 0.005) and mean OSATS score. Also a high correlation was found between mean GOALS score and caseload (r = 0.943, p = 0.005). A significant increase was found between the GOALS scores of the 6 procedures (p = 0.002). The trainees performed significantly better in the sixth cholecystectomy compared with the first (p = 0.004). Inter rater reliability was reasonable for the mean GOALS score (0.469; p = 0.008) and good for overall competence (0.707, p \ 0.001). The fragments containing the opening of the peritoneum and dissection of the triangle of Callot with achievement of CVS showed the largest improvement in GOALS scores. Discussion/Conclusion: This study indicates that blinded video assessment of three key steps provides a valid representation of the total performance in laparoscopic cholecystectomy. In addition, our results support the existing evidence that GOALS is a valid assessment tool. However, implementation of GOALS in surgical education should be done with care to retain the interrater reliability.

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Aims: Our general surgery unit in a tertiary teaching hospital in Singapore has been performing standard laparoscopic cholecystectomy (SLC) for almost 20 years. Here we review the technique and outcomes of our initial experience in mini-laparoscopic cholecystectomy (MLC). Methods: In routine practice, we used the 10 mm–5 mm–5 mm–10 mm port configuration, with 10 mm ports in the epigastrium and infraumbilical positions. This configuration was most suitable for teaching our surgical trainees and allowed us to use easily available Ligaclips with 10 mm applicators for clipping the cystic duct and artery. A 10 mm 30-degree optic was placed in the infraumbilical port. In introducing the new technique, we sought to minimise its technical difficulty by attempting to keep the steps of the operation fairly similar to our current practice. This included maintaining the use of ligaclips rather than teaching junior trainees laparoscopic knot tying early in their training. We placed 3 mm ports in all 3 subcostal positions, dissection was carried out using 3 mm instruments, ligaclips were applied through the 10 mm infraumbilical port guided by a 3 mm optic in the epigastric port. All other aspects of the operation was essentially similar to SLC. Results: For a period of 2 years ending December 2013, we performed 19 MLC, selecting mostly patients with symptomatic gallstones in our initial experience. The mean age was 52 with an even distribution between the genders. Indications for surgery were: 10 biliary colic; 2 each of gallbladder polyps, gallstone pancreatitis and choledocholithiasis; and 1 each of cholangitis, empyema gallbladder and resolved cholecystitis. Median operative time was 75 minutes, average length of stay 1.3 days and mean pain score (0–10) at 24 hours post surgery 0.5. There were no complications or conversions to either SLC or open surgery in our cohort. Conclusion: The immediate post-operative outcomes of our MLC cohort was similar to that of our SLC patients. The new technique is safe and easy to perform even by trainees under supervision. Although best suited for non-inflammed gallbladders, even complicated gallbladders can be attempted with this technique.

Surg Endosc



Endoscopic Surgery for Incarcerated Inguinal/Obturator Hernia

Stoma Site Hernia After Laparoscopic Reversal Procedure, is There a Prevention Way? Texas Endosurgery Institute Experience

H. Tsutsumida, M. Uto, M. Kamimura, T. Kamimura Kamimura Hospital, Kagoshima shi, Japan There is no consensus on the surgical method for incarcerated-inguinal/obturator -hernia. In our hospital, we have performed endoscopic surgery for all 276 patients with inguinal/ obturator-hernia who could undergo general anesthesia since March 2008. Here, we describe 8 of these cases with concomitant incarcerated-hernia of the intestinal-tract or appendix. The subjects were 1 male and 7 females (mean-age 80.4-years-old, range: 55–99 years-old) with femoral-hernia (4 patients, right/left: 2/2), right internal-inguinal-hernia (1 patient), and obturator-hernia (3 patients, right/left: 2/1). The incarcerated organ was the smallintestine in 7 patients, of whom 2 with obturator-hernia required resection of the smallintestine, and the appendix in 1 patient. The average operation time was 90.2 minutes (range: 59–129 minutes) in 6 patients who received mesh-shape reinforcement, including 1 case with surgery on both sides. This time is similar to that for the conventional transabdominal preperitoneal (TAPP) approach. There were no perioperative/postoperative early-stage complications. Incarcerated-femoral-hernia can be released without damage to the intestinal-tract and blood-vessels by incising the iliopubic-tract in the direction of 12 o’clock to secure an anatomically safe region after displacement/tugging of the incarcerated-intestinal -tract to the dorsal side. Placement of a Nelaton-catheter in the hernia sac with the incarceratedintestinal-tract, as in laparotomy, and hydraulic-pressure using physiological saline were useful for incarcerated-obturator-hernia. For 5 patients with femoral or internal-inguinal-hernia, standard TAPP with mesh was performed after release of incarceration. In cases of obturator-hernia in which small intestine resection could be avoided, trimmed mesh was fixed on the Cooper ligament and intrapelvic muscle layer. TAPP is often not performed for incarcerated-inguinal/obturator-hernia due to the difficult interperitoneal operation caused by an expanded intestinal-tract. However, we found that the operative field of view improved after release of incarceration. The incarcerated-intestinal-tract was identifiable in the laparoscopic field of view, permitting confirmation of the hernia characteristics, and resection and inosculation of the small intestine could be performed under direct vision at the wound of the umbilical port. This less invasive treatment is advantageous in cases requiring resection. Thus, aggressive endoscopic surgery for an incarcerated-hernia may be useful at medical facilities where TAPP is performed as first-line treatment for inguinal-hernia.

M.A. Hernandez, M.E. Franklin Jr Texas Endosurgery Institute, San antonio, United States of America Background and Objectives: Stomas represent an important cause of morbidity. Studies show that the incidence of incisional hernia at the site of the stoma closure is up to 30 % at a mean time of 7 months after stoma closure. Currently, there are no studies regarding the prevention of an incisional hernia after stoma closure. The aim of this study is to demonstrate that laparoscopic placement of mesh at the time of a stoma closure is feasible, safe and is associated with decreased incidence of hernia in the stoma site. Methods: We performed a prospective study at the Texas Endosurgery Institute between January 2007 and January 2014 of all the patients that underwent laparoscopic assisted stoma closure. Results: A total of 133 patients underwent elective laparoscopic assisted closure of a stoma with placement mesh at stoma site. Population included was 89 males and 44 females with a mean age 63.5 years (38–88 years) and a mean BMI of 28.2 kg/m2 (19.3–44.5). 82 of the patients had a loop ileostomy and 51 colostomy. Surgeries were performed with no conversions in a mean operative time of 102 minutes (35–260) and an estimated blood loss of 53 cc (10–300). Polyester, polypropylene and biologic meshes were place intraperitoneally. Mean length of hospital stay was 6 days. Conclusion: We have demonstrated that mesh can be safely and successfully placed to reinforce the stoma site after closure. We had no major full thickness wound issues, no mesh complications and zero occurrence rate at follow up of 30 months.

P709 - Basic and Technical Research Oncologic Safety in Usage of the Laparoscopic Coagulating Shears Y. Izumiya, K. Kubota, I. Ichikawa, S. Komatsu, K. Okamoto, H. Fujiwara, A. Shiozaki, H. Konishi, M. Nakanishi, Y. Kuriu, H. Ikoma, Y. Murayama, R. Morimura, C. Sakakura, E. Otsuji Kyoto Prefectural University Of Medicine, Kyoto, Japan Background: Use of energy devices, such as laparoscopic coagulating shears (LCS) and vessel ceiling system is essential for the laparoscopic gastrectomy (LG). Now, LG is adapted to advanced gastric cancer. However, when cutting deeply into the tumor tissue itself by the energy devices, it possibly makes tumor cells scattered to peritoneal cavity, which can be a cause of peritoneal dissemination. Objective: To clarify whether or not the tumor cells are alive in the mist when you cut the tumor tissue by the energy devices. Materials and Methods: We used Harmonic scalpel as a LCS and Enseal as a vessel ceiling system (Johnson and Johnson, Cincinnati, OH, USA). Eight weeks old female nude mice were used as an animal model. Experimental procedures were performed in accordance with ‘Guidelines for proper conduct of animal experiments,’ prepared by the Science Council of Japan. We developed peritoneal metastasis models by injecting gastric cancer cell lines into nude mice (HGC27, NUGC4, MKN28, MKN45, MKN74; 1 9 107 cells/ml). Two weeks later, we euthanized the mice and removed the peritoneal nodules. When cutting them by the energy devices, we collected and cultivated the mists for 2 weeks. We checked the existence of living tumor cells under the microscopy (NUGC4 and MKN45). Results: In both uses of Harmonic scalpel and Enseal, tumor cells were not observed in the mist. However, in the case the peritoneal tumor tissue was crushed and exposed by the devices before activation, tumor cells were alive. Conclusion: In gastric cancer surgery, we should pay carful attention not to cut into tumor tissues and suspected metastatic lymph nodes.

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Surg Endosc



Novel Method for Intraoperative Tumor Localization During Laparoscopic Gastric Local Resection: Endoscopic Submucosal Cutting and Light Transmission

Emergent Laparoscopic Covering Ileostomy for Ileal Stenosis Due to Direct Invasion of Rectosigmoid Cancer and for Sigmoid Colon Cancer Penetration to Retroperitoneal Cavity

Y.J. Lee1, J.H. Park2, S.H. Jeong2, C.Y. Ha2, J.Y. Kim2, T.J. Park2, C.Y. Jeong2, Y.T. Ju2, E.J. Jung2, S.C. Hong2, S.K. Choi2, W.S. Ha2

H. Urakami, Y. Nishihara, A. Matsunaga, Y. Kawaguchi, J. Tokuyama, K. Osumi, S. Seki, A. Shimada, T. Oishi, Y. Isobe, S. Matsumoto

1

Gyeongsang National University Hospital, Jinju, Korea; Gyenongsang National University, Jinju, Korea

2

National Hospital Organization Tokyo Medical Center, Tokyo, Japan

Backgrouds: Intraoperative tumor localization is prerequisite for deciding the proper extent of gastric resection during laparoscopic gastric local resection of early mucosal cancer and submucosal tumor. In this study, we introduce a novel method for precise intraoperative tumor localization and appropriate resection in porcine model: endoscopic submucosal cutting and light transmission. Methods: A series of 4 pigs (35–40 kg) were used for this study approved by an animal use committee. Total 10 cases of laparoscopic local resection were performed. The size of the target lesion was approximately 2 cm. The imaginary lesions were located in high body anterior wall (n = 2) and posterior wall (n = 2), lower body posterior wall (n = 2), angle (n = 2), and antrum anterior wall (n = 2) of the stomach. We sequentially performed mucosal marking around the lesion, precutting the mucosa surrounding the marking, and submucosal cutting along the precutting line using white light endoscopy. Then, endoscopic light source was directly placed in front of the lesion. We could identify exact oval shaped submucosal cutting margin in laparoscopic view. The laparoscopic local resection was done under direct endoscopic view after confirming minimal distance from the stapler line to submucosal cutting line. After extracting of the resected specimen, we removed linear stapler line and measured the size of mucosal marking, submucosal cutting, resected entire mucosa, and resected entire serosa. Results: The procedure was completed for all the pigs. The local resection of stomach was completed for the all lesion. We could identify the exact submucosal cutting line of the resected specimen in all cases. The mean size of the resected specimen are: (i) marking lesion, 21.8 9 19.6 cm; (ii) submucosal cutting, 25.8 9 22.6 cm; (iii) resected entire mucosa, 35.6 9 27.6 cm; and (iv) resected entire serosa, 41.4 9 30.2 cm, respectively. There was no intraoperative morbidity. Conclusion: Endoscopic submucosal cutting and light transmission provides an exact and useful method of intraoperative tumor localization during laparoscopic local resection of stomach in terms of minimal resection of normal stomach tissue and surefire guarantee of mucosal margin.

We experienced two cases undergoing emergent laparoscopic covering ileostomy for ileal stenosis and sigmoid colon cancer penetration. A 55-year-old female occasionally noticed melena and abdominal discomfort for three years without visiting any medical clinic, and was referred for vomiting, abdominal pain and severe anemia. CT showed rectal mass directly adhered to ileum resulting in small bowel distention, and moreover, showed multiple liver, lung masses and multiple paraaortic lymph nodes (LN). Small bowel obstruction due to rectosigmoid cancer directly invading ileum with multiple liver, lung and paraaortic LN metastases was suspected and emergent laparoscopic covering ileostomy was done. Ileus was recovered, however, melena continued. Hartmann’s procedure, partial resection of ileum and ileostomy closure was performed by open surgery one month later to control. Unfortunately bone metastasis was observed one year later, chemotherapy was initiated and continued with maintaining good performance status. A 54-year-old female who had a history of bilateral hip join replacement referred for left lower abdominal pain and low grade fever. Blood test showed leukocytosis and high inflammatory reaction. CT demonstrated a localized abdominal abscess formation containing air density of 6 cm in size which is closed to sigmoid colon, solitary liver mass of 3 cm in size and a hematoma of 7 cm in size around gluteus minimus muscle and iliopsoas muscle. Cause of abscess formation was unclear and abdominal pain was under control, therefore conservative therapy was chosen. However, abscess was enlarged to 9 cm in size and inflammatory reaction got worse. Abscess drainage and covering ileostomy were done laparoscopically three days after emergent admission. No malignant findings was histologically observed in abscess content, however, patient was finally diagnosed sigmoid colon cancer without distant metastases. Curative sigmoidectomy and ileostomy closure was done by open surgery four months following first surgery. Adjuvant chemotherapy was inducted and patient is now free of cancer. Laparoscopic intervention is widely used in the diagnosis and management of abdominal emergencies. However, emergent surgery is associated with high morbidity and mortality rates in patients with distended and unprepared bowel. Emergent laparoscopic ileostomy could be useful to cure ileus or digestive penetration.

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