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

Surg Endosc (2014) 28:S1–S53 DOI 10.1007/s00464-014-3483-0

and Other Interventional Techniques

21st International Congress of the European Association for Endoscopic Surgery (EAES) Vienna, Austria, 19–22 June 2013 Oral Presentations

Ó Springer Science+Business Media New York 2014 KARL STORZ - EAES AWARD SESSION

O001 - Oesophageal Malignancies

O002 - Abdominal Cavity and Abdominal Wall

One Year Follow-Up of a Randomized Trial Comparing Minimally Invasive Versus Open Oesophagectomy for Oesophageal Cancer: The Time Trial K.W. Maas1, S.S. Biere1, M.I. Van Berge Henegouwen2, K.J. Hartemink1, S.S. Gisbertz2, M.A. Cuesta1, D.L. Van der Peet1 1 VU University Medical Center, AMSTERDAM, The Netherlands; 2 Academic Medical Center, AMSTERDAM, The Netherlands

Abdominal Wall Hernias—In Search of Consensus ˚ smietaski M. Pawlak, A. Lehmann, M. A Ceynowa Hospital, WEJHEROWO, Poland

Background: Oesophageal resection for patients with oesophageal cancer has a high morbidity, especially pulmonary infections. To reduce these complications the minimally invasive approach has been widely implemented. The TIME trial, comparing the minimally invasive oesophageal resection by thoracoscopy in prone and laparoscopy with the conventional approach by right thoracotomy, has shown a significant low pulmonary infection rate and a better quality of life postoperatively after minimally invasive oesophagectomy. Follow up at one year will add important information to this trial. Methods: All included patients in the multicentre, open-label, randomised controlled study, the TIME trial have been analyzed one year postoperatively, concerning survival, quality of life questionnaires and late complications. Results: Overall survival and disease free survival one year post-surgery are 72% respectively 65% with no significant differences between the two groups. Quality of life was still significantly better after minimally invasive oesophagectomy for global health (EORTC C30: 79 (10; 76–83) vs 67 (21; 60–75) p 0.004), physical activity (SF36: 50 (6; 48–53) vs 45 (9; 42–48) p 0.003) and pain score (OES18: 6 (9; 2–8) p 0.001 vs 16 (16; 10–22). Late complications were equal for both groups. Conclusions: At one year after oesophagectomy for oesophageal cancer there is no difference in survival, disease free survival or late complications between the open oesophagectomy and minimally invasive oesophagectomy. However, at one year after surgery, some quality of life questionnaires are still significantly better for patients who underwent the minimally invasive procedure than for patients who underwent the open oesophagectomy.

Background: Laparoscopic repair is becoming increasingly popular alternative in the treatment of abdominal wall hernias. In spite of numerous studies evaluating this technique, indications for laparoscopic surgery has not been established. Similarly, implant selection and fixation techniques have not been unified and are the subject of scientific discussion. The aim of this study was to assess whether there is a consensus on the management of the most common ventral abdominal wall hernias among recognized experts. Methods: Fourteen specialists representing the boards of the European Hernia Society, the European Association for Endoscopic Surgery and the European Registry of Abdominal Wall Hernias were surveyed in order to determine their choice of surgical technique for nine typical primary ventral and incisional hernias. The access method, type of operation, mesh prosthesis and fixation method were evaluated. Among the laparoscopic procedures the tackers number and its arrangement were assessed as well. Results: In none of the cases presented was the consensus of experts obtained. Laparoscopic and open techniques were used equally often. Especially in the group of large hernias decisions on repair methods were characterized by high volatility. The technique of laparoscopic mesh fixation was a subject of great variability both in terms of method selection and the number of tackers and sutures used. Conclusions: The consensus on management of abdominal wall hernias among recognized experts has not been achieved. Survey results indicate the need for further research and inclusion of large cohort groups of patients in the dedicated registries to evaluate the results of different surgical methods. This may help in the development of treatment algorithms in the future.

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Surg Endosc (2014) 28:S1–S53

O003 - Intestinal, Colorectal and Anal Disorders

O005 - Emergency Surgery

Surgical Site Infections After Colorectal Surgery—Prevalence And Risk Factors: A Population-Based Cohort Study F.A. Haggar, M.S. Rashid, IR Raiche, J. Moloo, J. Mamazza The Ottawa Hospital, University of Ottawa, OTTAWA, Canada

Laparoscopic Repair of Perforated Peptic Ulcer: Single Centre Results I. Cengeli, S. Guadagni, C. Galatioto, P.V. Lippolis, G. Zocco, N. Furbetta, M. Seccia Chirurgia D’Urgenza, Azienda Ospedaliera Universitaria Pisana, PISA, Italy

Background: Surgical site infections (SSIs) are a common and potentially serious complication of abdominal surgery. SSIs can significantly impact length of hospital of stay, post-operative morbidity and mortality, health-related quality of life and the cost of health care. The objective of this study is to investigate the prevalence and risk factors for SSIs after open and laparoscopic colorectal resections. Methods: All hospital admissions data of patients undergoing elective laparoscopic or open colorectal resections performed in Australia between January 1, 2001 and December 31, 2010 were obtained from the National Hospital Morbidity Database. Patients who underwent resections for malignant disease, diverticular disease and inflammatory bowel disease were included. Demographics, co-morbidities and postoperative complications were compared between patients with SSIs and without SSIs. A multivariate logistic regression model was fitted to identify independent risk factors associated with SSIs after index colorectal resections. Results: A total of 115, 572 colorectal resections were included. Of these, 79.9% (n = 93575) were open procedures and 20.1% (n = 21997) were laparoscopic procedures. Patients with SSIs had a significantly higher overall co-morbidity burden (p \ 0.001), higher perioperative complication rates (p \ 0.001) and longer length of stay (p \ 0.001). Based on logistic regression, surgical technique was found to be an independent risk factor for SSIs, with patients in the open group having a significantly higher risk (Odds ratio (OR): 1.59; confidence interval (CI): 1.32–1.94, p \ 0.001). Other significant independent risk factors for SSI included advanced age, male gender, indigenous status, diagnosis for cancer, ulcerative colitis or Crohn’s disease and co-morbidities such as liver disease, coagulopathy, fluid and electrolyte disorders, congestive heart failure, and pulmonary circulatory disease and renal failure. The strongest risk factors for SSIs were postoperative hemorrhage and hematoma (OR: 4.68; CI: 3.53–6.26, p \ 0.001) and wound dehiscence (OR: 5.37; CI: 4.84–5.97, p \ 0.001). Conclusions: In this population-based study, patients undergoing open colorectal resections had a significantly higher risk of SSIs than patients undergoing laparoscopic resections. Irrespective of surgical technique, perioperative complications such as hemorrhage, hematoma and wound dehiscence conferred a high risk of SSIs.

Aims: Perforated peptic ulcer (PPU) is the most common indication for emergency gastric surgery and it is associated with high morbidity and mortality. The outcome of a continuous series of patients with PPU treated laparoscopically is examined in this study. Material and Methods: From January 2002 to December 2012, 111 patients were operated for perforated ulcer. A ‘laparoscopy first’ policy was attempted and then applied in 56 patients (50.4%). Exclusion criteria for laparoscopic treatment included shock at admission, severe cardiorespiratory comorbidities and previous history of supramesocolic surgery. The aim of the study is a retrospective analysis of 56 patients laparoscopically treated (56/111; 50.4%). Demographics’ characteristics, operative time (OT), rate of conversion, incidence of complications and hospital stay were evaluated. Results: The patients distribution showed: 30 male and 26 female; mean age was 59 years (19 to 95 years). Mean ulcer size was 10 mm (range 3–40 mm) whereas Mannheim Peritonitis index (MPI) was 21 (range 10–32). Laparoscopic repair (LR) was carried out in 39 of 56 cases (69.6%) and included peritoneal lavage, suture of the perforation and omental patching. A conversion to laparotomy was necessary in 17 cases (30.4%): 4 gastric resection and 13 Graham repair. The ‘conversion group’ of patients was characterized by a significant difference in ulcer size (1.9 mm versus 0.7 mm; p \ 0.01), in ulcer site location (higher incidence of posterior ulcers; 5 versus 0; p \ 0.01) and higher MPI score (24 versus 20; p \ 0.05). The LR group showed: mean OT of 86 min (range 50–125 min); in-hospital morbidity and mortality rates of 7.6% (n = 3) and 2.5% (n = 1) respectively; mean hospital stay of 6.7 days (range 5–12 days). None of these patients required re-intervention. Conclusions: The results of our study show that LR for PPU is feasible with acceptable mortality and morbidity rates. A particular skill in laparoscopic abdominal emergencies is required. Perforation larger [1.5 cm, inadequate ulcer identification and MPI [ 25 should be considered as main risk factors for conversion.


O006 - Liver and Biliary Tract Surgery

Trend Setters? A Comparative Review of Results of Trans-Anal Endoscopic Microsurgery (TEMS) in a Single Centre S. Flexer, A. Durham-Hall, M. Steward, J. Robinson Bradford Teaching Hospitals, BRADFORD, United Kingdom

Bile Duct Injury Following Laparoscopic Cholecystectomy in England Y. El-Dhuwaib1, J.P. Slavin2, D. Durkin3, I. Begaj4, D.J. Corless2, M. Deakin3 1 Keele University, STAFFORDSHIRE, United Kingdom; 2Mid Cheshire Hospitals NHS Foundation Trust, CREWE, United Kingdom; 3University Hospital of North Staffordshire, STOKE ON TRENT, United Kingdom; 4University Hospitals Birmingham NHS Foundation Trust, BIRMINGHAM, United Kingdom

Introduction: The Dutch TREND study compared the efficacy of TEMS (trans-anal endoscopic microsurgery) and EMR (endoscopic mucosal resection) of rectal adenomas. This study highlighted a high rate of peri-operative and post operative complications in both groups, with polyp recurrence rates between 10 & 24% depending upon the method of excision. Methods: Bradford Royal Infirmary is a tertiary referral centre for TEMS and early rectal cancer. Data for all trans-anal endoscopic operations was entered in to a prospective data base over a 5 year period. Demographic data, complications and recurrence rates were recorded. Both benign adenomas and malignant lesions were included. Results: 164 patients (65% male) with a mean age of 68 were included. 114 (70%) lesions resected were benign adenomas with 50 (30%) malignant lesions. Median polyp size was 4 cm (range 0.6–14.5 cm). Mean length of operation was 55 min (range 10–120 min) There were no recurrences from any patients having a benign adenoma resected, 2 patients with malignant lesions developed recurrences. 3 intra-operative complications were recorded, 2 rectal perforations (repaired primarily, 1 requiring defunctioning stoma), a further patient suffered a blood loss of [ 300 ml requiring transfusion. 6 patients developed strictures requiring dilation either endoscopically or under anaesthetic in the post-operative period. Conclusions: We have demonstrated that TEMS procedures performed in a specialist centre confers significantly better results with regard to recurrence rates and complication rates when compared to the Dutch TREND study. Within a specialist centre, TEMS surgery should be offered to all patients over EMR for the treatment of rectal neoplasms.

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Aim: To investigate the incidence of bile duct injury (BDI) following laparoscopic cholecystectomy (LC), identify risk factors and to examine institutional variation. Methods: Hospital Episode Statistics data were obtained from the National Health Service Information Centre and imported into Access for analysis. All patients undergoing LC for conditions other than cancer between April 2004 and April 2009 were identified. This cohort of patients was followed using HESID to identify patients who underwent bile duct reconstruction (indicator for bile duct injury (BDI)) within a year of the index operation. Patient related factors studied included age, gender, acute pancreatitis and acute cholecystitis. Non-patient related factors included hospital volume, consultant caseload and consultant conversion rate. A funnel plot was used to examine institutional variation. Results: Some 238438 patients underwent LC and 415 (1.7 per 1000) underwent bile duct reconstruction during the study period. Multivariate analysis (binary logistic regression) showed that acute cholecystitis (odds ratio 1.448 (95% CI 1.024–2.047) p = 0.036); male gender (odds ratio 1.591 (95% CI 1.259–2.012) p \ 0.001) and increasing age (odds ratio 1.010 (95% CI 1.003–1.017) p = 0.006) were associated with an increased risk of bile duct reconstruction. All non-patient related factors were insignificant in both univariate and multivariate analysis. A funnel plot showed 5 hospitals had a significantly higher incidence of major BDI requiring reconstruction. Conclusion: analysis of hospital episode statistics suggests that the incidence of bile duct injury requiring biliary reconstruction in England is low and is consistent with the reported literature. A number of patient related factors are associated with increased incidence of bile duct injury. Five trusts appear to have a significantly increased rate of BDI requiring reconstruction.


S3

O007 - Morbid Obesity

O009 - Technology

The Actual Rate of Hypoglycemia R. Kefurt, C. Reiler, A. Bohdjalian, F. Langer, K. Schindler, P. Markus, A. Hofer, A. Tu¨rkcan, B. Ludvik, G. Prager Medical University of Vienna, VIENNA, Austria

Laparoscopic Near-Infrared Fluorescence Imaging of Uveal Melanoma Liver Metastases Using Indocyanine Green: A Technical Note Q.R.J.G. Tummers, F.P.R. Verbeek, A.E. Braat, C.I.M. Baeten, C.J.H. Van de Velde, A.L. Vahrmeijer Leiden University Medical Center, LEIDEN, The Netherlands

Introduction: The actual incidence of hypoglycaemia following Gastric Bypass (RYGB) remains a matter of controversy. The aim of this study was to determine the rate of hypoglycaemia after gastric bypass. Methods: 30 morbidly obese patients (26f/4 m; mean age 45a; mean BMI 48.2 kg/m2) were screened for hypoglycaemia (\ 65 mg/dl) 4 years after RYGB. Continuous Glucose monitoring (CGM) was performed for 5 days. Blood glucose (BG) was additionally measured 49/day by the patient along with detailed nutrition recording. A Mixed Meal Tolerance test (MMT) was used to detect postprandial hyperinsulinemic hypoglycaemia. BG, C-Peptide, Insulin were sampled at -10, 0, 15, 30, 60, 90, 120, 180, 240 min. Results: One patient was excluded due to incompliance, 4 patients due to invalid CGM-data. In a total of 29 MMTs, hypoglycaemia occurred in 13 patients (44%). The mean peak level of insulin during MMT was 71.2 (52.8) lU/ml (p = 0.33) and of C-peptide 9.7 (6.0) ng/ml (p = 0.003) for patients with and without hypoglycaemia, respectively. In 25 patients with valid CGM measurements, hypoglycaemia was detected in 20 patients (80%) with 1–9 hypoglycaemic episodes within 5 days. Postprandial hypoglycaemic episodes were recorded in 14 patients (56%), of which 4 had normal MMT. Patients without hypoglycaemic episodes during CGM and on MMT showed a mean peak level of 22 lU/ml of Insulin and 4 ng/ml of C-peptide in MMT. Conclusion: Hypoglycaemia after gastric bypass occurred in 80% of patients as assessed CGM and in 44% after MMT (with BG-measurements) and appears to occur more often than usually reported in the literature. Applying only the MMT might underestimate the rate of hypoglycaemia.

Aim: Uveal melanoma is the most common primary intraocular tumor in adults and up to 50% of patients will develop liver metastases. Complete surgical resection of these metastases improves survival, but only few patients are eligible for a radical surgical treatment. The aim of this study was to introduce near-infrared (NIR) fluorescence imaging during minimal invasive surgery for intraoperative identification of uveal melanoma liver metastases and provide guidance during resection. Methods: Two patients previously treated for uveal melanoma, both diagnosed with one solitary liver metastasis are presented. Patients received 10 mg indocyanine green (ICG) intravenously 24 h before surgery (optimal timing based on a dose-finding study performed in 40 patients with colorectal liver metastases and an open imaging system). A high definition NIR fluorescence laparoscope (Karl Storz, Germany) was used to detect malignant liver lesions. Results: In both patients, laparoscopic NIR fluorescence imaging using ICG successfully identified uveal melanoma liver metastases. A clear fluorescent rim around the tumor was observed. In patient 1, seven additional lesions in both left and right liver lobe, not seen with computer tomography (CT), were identified with inspection and NIR fluorescence imaging. In patient 2, one additional lesion, not identified by CT, magnetic resonance imaging, laparoscopic ultrasonography and inspection, was seen with NIR fluorescence imaging. Besides, NIR fluorescence imaging provided guidance during resection of metastases. Conclusions: We describe the successful use of laparoscopic identification and resection of uveal melanoma liver metastasis using NIR fluorescence imaging and ICG. This procedure is minimal invasive, and can be used complementary to conventional techniques for the detection of liver metastases.

TECHNOLOGY AWARD SESSION

O008 - Technology

O010 - Robotics, Telesurgery and Virtual Reality

Feasibility and Reliability of Pancreatic Cancer Staging Using A New Confocal Non Fluorescence Microscopy Probe: A Double Blind Study in Rats V.E. De Ruijter, S. Perretta, B. Dallemagne, M. Aprahamian, M. Ignat, V. Lindner, M. Diana, J. Marescaux IRCAD-IHU, University Hospital of Strasbourg, STRASBOURG, France

Pipeline Inspection Gauge (Pig) Device for Negotiation of Flexures for Robotic Hydro-Colonoscopy C. Tapia-Siles, S. Coleman, A. Cuschieri IMSAT, DUNDEE, United Kingdom

Introduction: Surgical management of pancreatic cancer depends on tumor resectability and staging. LN metastases are an important decision-making factor when it comes to the surgical treatment. Aims: To evaluate a new in vivo, endoscopic confocal microscopy (CFM) system not requiring fluorescence markers, for detection and staging of pancreatic cancer in rats. Methods: A confocal system consisting of a scanner (HRT II module Heidelberg Engineering, Heidelberg, Germany) and a dedicated rigid Hopkins rod-lens endoscope (KARL STORZ, Tuttlingen, Germany) were used for in vivo imaging of solid organs (40 frames/sec, lateral resolution 2 microns, scanning field 400 x 400 microns) in a rat model of pancreatic ductal adenocarcinoma. The scanner works in the reflexion mode and no fluorescence markers are necessary. A doubleblind study compared CFM to standard histology in (1) detection of tumors in rat models of cancer (n = 11) and controls (n = 6), and (2) in the detection of nodal involvement (splenic, celiac, mesenteric, and colic) at 3 and 6 weeks after tumor induction and in controls. Results: CFM detected tumors with 100% sensitivity and specificity, and identified 14 metastatic LNs with an average adenocarcinoma nodule diameter of 2.3 mm (range of 1–4.2 mm) out of the 65 examined. CFM analysis resulted in 2 false negatives and 1 false positive LNs detection compared to standard histology. CFM demonstrated a negative predictive value of 96.1% and positive predictive value of 92.9% in the detection of LN’s. Conclusions: CFM detected all the pancreatic tumors and has demonstrated a sensitivity of 86.7% and specificity of 98% in LN detection. Interpretation of the confocal images has a high concurrence rate with histopathology examination for primary tumor and lymphatic involvement detection (Spearman’s rho correlation of 0.87), making it a promising technique for in vivo real-time detection and staging of pancreatic cancer. Larger studies are warranted to confirm these preliminary results.

Background and Aims: Colonoscopy is used for the diagnosis of colorectal cancer. It remains a difficult procedure requiring significant expertise by fully trained endoscopists to orientate and control the colonoscope and negotiate the problematic colonic flexures to reach the caecum. Twenty % of patients undergoing colonoscopy need to repeat the procedure because the caecum is not reached or because of poor bowel preparation. The CODIR joint Dundee/Leeds ERC project is concerned with development of robotic device for the recently introduced hydro-colonoscopy (warm saline irrigation instead of CO2 insufflation). This paper reports on development and evaluation of a device capable of efficient negotiation of the flexures, thereby facilitating the advancement of a semi-autonomous device. Methods: The prototype developed is one of the robotic platform options for the CODIR project. It uses the Pipeline-Inspection-Gauge principle adapted for hydro-colonoscopy. Though similar to the Aer-O-Scope (colonoscope using a balloon propelled by CO2 insufflation) the device is different as it uses fluid to propel two independently controlled balloons for propulsion. The method used to control the balloons is a State Machine which adapts the thresholds required for balloon’s sealing volume/pressure specifically for the PIG device, determined from data on the initial movements detected by a magnetic motion tracking system. The CODIR PIG is able to inflate and deflate the two balloons enabling the device to adapt to the shape and configuration of the flexures. The pig colon preserved in embalming fluid was used to test the CODIR PIG device. Colonic segments were attached to a board by pinning the mesocolon in such a way as to reproduce the flexures encountered in the human colon. Results: The tests demonstrated successful negotiation of flexures in the porcine colon. An average velocity of 4 mm/s was obtained in straight segments, with driving pressure of 2–4 kPa. A complete halt of the device was observed in some cases at acute flexures before the control system could negotiate the bend in 10–20 s. Conclusions: The results obtained by the PIG device confirm that simple control strategies like adaptive State Machines are feasible and easy to implement for adaptive colonoscope navigation.

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O011 - Basic and Technical Research

O013 - Technology

Understanding the Role of Staple Height Variation on Tissue Oxygenation M. Godek1, J. Diederich1, A. Miesse1, D. Bronson1, U. Klinge2, R. Tolba2 1 Covidien Surgical Devices, NORTH HAVEN, United States of America; 2Universita¨tsklinikum Aachen, AACHEN, Germany

The Vitom: The New Video Telescopic Operating Microscope V.G. Menon, N.N. Nissen, A.N. Mamelak, P.K. Frykman, G. Berci, J.A. Williams Cedars-Sinai Medical Center, LOS ANGELES, United States of America

Aims: The objective of this study was to assess tissue oxygenation levels immediately following surgical stapling to determine the effect(s) of different staple heights on acute tissue response. Methods: Three prototype powered circular staplers (staple height: 3, 4 or 5 mm) were utilized for this acute in vivo study. A minimum of three firings for each staple height and hand sewn anastomoses were compared. Tissue thicknesses were measured, and a moor instruments laser Doppler blood (VMS-LDFTM) flow or an O2C system (Sonotechnik Austria) was used to collect tissue oxygenation measurements. Baseline and test measurements were taken at pre-determined intervals (0–60 min) in proximity to the selected anastomotic sites, at the staple line and approximately 0.5 cm from the staple line. Representative samples were excised and sent for histopathological evaluation. Results: Successful firings were achieved with all of the staple sizes in all tissues except porcine stomach, where only the 5 mm staple height accommodated the thick ([ 0.30 inch) tissue. Tissue oxygenation baseline results indicated an average value of 86% for colon, 81% for stomach and 72% for small bowel. Results indicate that the staple size applied to the tissue did have an effect on tissue oxygenation in some instances. In stomach, the tissue oxygenation level remained constant following stapling with the 5 mm staple height, a trend also observed for all three staple sizes in the bowel and all sizes except for the 3 mm staple height in the colon. Initially, the majority of stapled samples showed a slight decrease in oxygenation, but rebounded quickly (= 25 min). Tissue oxygenation and blood flow tracked. Conclusions: This novel study provided a first look at the effect of staple height on tissue oxygenation following stapling in stomach, bowel and colon with specific staple heights of 3, 4 and 5 mm. Notably, tissue oxygenation levels remained high and fairly constant following surgical stapling regardless of the staple size. However, some differences in tissue oxygenation were observed based on the staple size and tissue combination. Future work will expand on the role of staple height as it relates to tissue thickness and/or disease conditions.

Aims: Surgeons have routinely utilized surgical loupes and stand-alone operating microscopes for complex microsurgical procedures. Surgical loupes have limited magnification and depth of field and the operating microscope occupies valuable operating room (OR) space. Critically both result in surgeon fatigue, due to the neck strain of looking down for hours through small pupils. We have utilized a high definition (HD) video telescope in neurosurgical, hepatobiliary and pediatric microsurgeries in place of loupes and microscopes. Methods: The ViTOM system consists of a pre-sterilized high definition camera, attached to a camera holder (mechanical or pneumatic arm). The horizontal ViTOM, consisting of a prism with integrated light cables (illumination and a perpendicular field of view), is attached to the camera with the entire field displayed on HD video monitors. The ViTOM is positioned 25–35 cm above the operative field with a 12–169 magnification factor without interference of manipulation in the field beneath. Results: The ViTOM system is versatile and has been utilized in over twenty neurosurgical, fifty hepatobiliary, and ten pediatric cases. All sets of surgeons noted an initial learning curve for the Endo-Eye coordination but there is a depth of field of 12 mm without the need for re-focusing. Limitations have been overcome and compensated by multiple benefits of the system; 1) excellent video quality (perception) and 2) a reduction in surgeon fatigue. In neurosurgery, difficult pineal tumor dissections have been made easier and in hepatobiliary surgery, the use of the ViTOM during pancreaticoduodenectomy for the pancreatic-enteric anastomosis has been a factor in reduced rates of pancreatic fistula. In pediatric surgery, the congenital abnormality, non-amenable to a laparoscopic approach, can be managed with the utilization of the ViTOM. Conclusions: The system described here provides better magnification and vision than surgical loupes. Magnification is equal to the operating microscope. The ViTOM, however has the benefit of reduced surgical fatigue and easier set-up compared to the operating microscope, saving OR time. Another benefit is the ability to document cases in HD quality for educational purposes, not achievable by either surgical loupes or microscopes.


O014 - Technology

Comparing Hardware on 1st and 2nd Generation Lapmentortm C. Va˚penstad1, R. Ma˚rvik2, J.J. Jakimowicz3, S.N. Buzink4 1 SINTEF, TRONDHEIM, Norway; 2National Centre for Advanced Laparoscopic Surgery, Trondheim University Hospital, TRONDHEIM, Norway; 3Faculty of Industrial Design, Delft University of Technology, DELFT, Nederland; 4Catharina Hospital, EINDHOVEN, The Netherlands

Use of Self-Retaining Barbed Suture for Rectal Wall Closure in Transanal Endoscopic Microsurgery—An Experimental Study A. Kirschniak, P. Wilhelm, S. Axt, U. Niwa, C Falch, S. Mu¨ller ¨ BINGEN, Germany University hospital Tu¨bingen, TU

Aims: The use of virtual reality (VR) simulators has the potential to reduce adverse events by moving skills training out of the operating room. An important aspect of VR simulation is realistic haptic feedback, which it has been difficult to achieve. We conducted a study to assess the influence of different haptic feedback systems on psychomotor performance by comparing the 1st with the recent 2nd generation haptic system of the LapMentorTM VR simulator (SimbionixTM Ltd). Methods: Surgeons with different levels of experience in laparoscopy were asked to test the two different VR simulators. The order by which the systems were tested was random. They performed the tasks peg transfer and clipping and cutting. After having tested the systems they answered 34 questions on how they perceived the hardware on the two simulators. Their actual performances were compared. Results: Fourteen surgeons participated in the study (5 experts, 7 residents). Ten surgeons thought the 2nd generation system succeeds best in simulating tissue resistance for the peg transfer task, four surgeons did not notice a difference. The surgeons performed the peg transfer task faster on the 2nd generation system with an average of 145 s on the 1st generation system and 117 s on the 2nd generation system. For the clipping and cutting task two surgeons found that the 1st generation system succeeds best in simulating tissue resistance, six the 2nd generation system and six did not notice a difference. The surgeons performed the clipping and cutting task faster on the 2nd generation system with an average of 128 s on the 1st generation system and 109 s on the 2nd generation system. On a scale from one (disagree) till five (agree) the surgeons gave the 1st generation system a median score of 3 and the 2nd generation system a median score of 4 when asked if the system can be used to train tissue manipulation like push and pull. Conclusions: Haptic feedback on VR simulators seems to influence performance score and the way surgeons perceive simulators. The surgeons found the haptic feedback system on the 2nd generation system to be more realistic.

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Aims: To investigate the efficacy of self-retaining barbed sutures in comparison with monofilament clip fixated sutures for rectal wall closure in transanal endoscopic microsurgery. Methods: Full thickness wall defects of cattle rectal specimens were closed via transanal endoscopic microsurgery using a monofilament suture with clips at the end (, n = 26) or a self retaining barbed suture (v-locTM, Covidien, n = 26). Primary end point is the maximum burst pressure of the suture line. Secondary end points are suture time and stitch accuracy. Results: Bursting pressure median of 45.5 mbar [median 17–106] for barbed sutures and 33.5 [19–106] for monofilament sutures (p = 0.582). A critical bursting pressure below 25 mbar occurred in 5 cases with barbed sutures and in 7 cases with monofilament sutures (p = 0.740). Suturing time and stitch accuracy of the suture lines did not differ between the two groups. Conclusion: Barbed sutures display equal bursting pressure compared with monofilament sutures. An additional time gain compared with monofilament clip fixated sutures is not achieved.


S5

OLYMPUS - EAES AWARD SESSION


O017 - Technology

Single Incision Laparoscopic Cholecystectomy: Some Remarks About Safety G. Celona, N. Romano, D. Pietrasanta, M. Blois, S. Sergiampietri Health Unit 5 - Pisa, PISA, Italy

Does the Single Port Access Increase The Morbidity Related to the Incision in the Early and Late Postoperative Period? M. Socas-Macias1, S. Morales-Conde1, I. Alarcon del Agua1, A. Navas Cuellar1, G. Jimenez1, J. Garcia1, C. Mendez1, H. Cadet1, J. Padillo Ruiz1, A Barranco Moreno2 1 HUVirgen del Rocio, SEVILLE, Spain; 2Virgen del Rocio Hospital, SEVILLA, Spain

Currently, laparoscopic cholecystectomy is the gold standard for the treatment of benign gallbladder-related disease. Recently, single incision laparoscopic surgery has been proposed in order to obtain better cosmetic results and, perhaps, reduced postoperative pain. When a new surgical procedure is introduced into clinical practice, concerns may arise about safety. All randomized controlled trials, among those available in literature, compare the rate of postoperative complication between single incision laparoscopic cholecystectomy (SILC) and conventional one, without finding any statistically significant difference. Yet, wound-related complications were reported as higher in SILC, though in a not statically significant way. A recently published review showed an increase in the rate of bile ducts injuries during SILC. Finally, all these results about morbility should be reconsidered in complicated (acute cholecystitis, common bile duct stones) and obese patients. Here we report our series of patients, considering mainly the occurrence of complications. From June 2009 to December 2012, we have performed 62 SILC for benign gallbladder disease. In all patients diagnosis was cholelithiasis; 4 patients showed common bile duct stones after intraoperative cholangiography. The median Body Mass Index was 25.1 (range 18–41). Mean operative time was 83.4 min. The overall postoperative complication rate was 4.96 % (8 patients). We accounted 2 hemorrhagic complications (one acute bleeding from the incision, which needed urgent reoperation and one hematoma of the umbilical wound). The biliary complications (1.86 %) were represented by one choleperitoneum from iatrogenic injury of an anomalous right posterior sectional duct, which finally requested a reconstruction by double hepaticojejunostomy and 2 cases of residual common bile duct stones, treated endoscopically. The incidence of incisional hernia was 1.86 % (3 patients). According to other authors, we think that the future of SILC depends on the long term safety, especially in regards to biliary injuries and hernia formation. Moreover, we need to demonstrate the feasibility and safety of SILC in more complex circumstances.

Introduction: Single-port access (SPA) reduces postoperative pain and improves cosmetic results. However, the umbilicus is considered to be a physiologic weak, wet and sometimes unclean area which could lead to an increased early morbidity, or an increased rate of incisional hernias, due to an inadequate closure. Aim: To analyze the morbidity related to SPA, as well as the risk of development an incisional hernia after applying a ‘Protocol to close the SPA’, based on patient’s characteristics and the technical difficulty of closing the fascial defect. Method: Prospective study of patients operated on through a SPA approach. With a transumbilical incision between 1.5–3 cm. We have applied the Protocol to close the SPA fascial incision shown in Table 1, with posterior closure of the skin with single stitches of vicryl-rapidÒ 2/0. In all the patients, where we could not perform a suitable fascial closure under direct vision, due to obesity or lateral placement of the SPA, we proceed to place a ventral patchÒ mesh fixed to both sides of the defect. We have analyzed the morbidity rate in the early and late postoperative period (infections, seromas, hematomas, incisional hernias). Results: In our series of 211 patients, operated on through a SPA approach (52 cholecystectomies, 25 incisional/groin hernia repairs, 69 colectomies, 4 splenectomy, 41 bariatric surgeries, 20 miscellaneous). Medium follow up 20 months. We have only had 6 seromas (2.8% of the series), solved after medical treatment, and 5 surgical wound infection (2.4%), which needed to be drained, all of them after colonic surgery. We have had 3 cases of incisional hernias, in patients where we did not used prophylactic mesh. There wasn’t a higher rate of complications in those patients where we placed a mesh. Conclusion: Neither transumbilical incision nor mesh placement seems to increase the morbidity related with the SPA in the early postoperative period. A tailored approach to close the fascial defect in the SPA seems to eliminate the risk of incisional hernia.



Single-Port Laparoscopic Hepatectomy M. Asakuma, Y. Inoue, K. Komeda, T. Shimizu, F. Hirokawa, Y. Miyamoto, M. Hayashi, K. Uchiyama Osaka medical college, OSAKA, Japan

Single Incision Laparoscopic Colectomy for Colorectal Diseases: An Early Experiences from Thailand T. Akaraviputh, A. Trankarnsanga, C. Phalanusitthepa, A. Methasate, V. Taweeruchana, V. Chinswangwatanakul Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Aims: Since the first report of single-port laparoscopic liver resection has published, the reports in this field are hardly seen. We provide an initial report of the indications and procedures for singleport laparoscopic hepatectomy in 15 cases of human patients. Methods: Laparoscopic hepatectomy and single port laparoscopic surgery has been performed in 81 patients and 220 patients respectively at our institution. Among them, we experienced 15 cases of single port hepatectomy. Ten cases of partial resection and 5 cases of lateral sectionectomy were performed. A surgical glove port was used and the patient was placed in the French position with the surgeon between the legs in all the cases. 2.0 cm long incision for the port was made on the umbilicus. Parenchyma without significant structure was divided using laparoscopic coagulating shears (LCS) while an Echelon FlexTM was used for significant vessels such as Glisson’s sheath or root of hepatic vein. Specimens were retrieved through the umbilical incision. The incisions were extended until the size of specimen. Results: All the procedures were successfully done by single port fashion, without any additional port. The mean operation time was 116 min and the mean bleeding was 41 ml. The patient was able to resume an oral diet and full mobility free of opioid analgesia on the first postoperative day. The resection margin was clear. Conclusions: Single port surgery is a new method of laparoscopic surgery which does not establish yet. It is important that resection surface should be a simple flat plane which can be straightly approached from the umbilicus. Or tumor located peripheral of the normal liver, though estimated plane is curved, could be also good candidate for this approach. Because safety is primly important factor to be assured, we have kept these criteria for single port hepatectomy. From the result of our series, all the operations have performed without blood transfusion and mean operative time was 116 min. The problem of this approach might be uncleanness of the benefit over the conventional method except cosmetic benefit. Time is too fast to define the conclusion, while some RCT is ongoing to answer this question.

Aims: Single incision laparoscopic colectomy (SILC) has been developed recently using various types of special curved instruments with the benefits of reducing the number of incision and better cosmetic outcome. This study presents early results of the patients underwent SILC using standard instruments. Methods: A retrospective analysis of the patient who underwent SILC at Minimally Invasive Surgery Unit, the Department of Surgery, Faculty of Medicine Siriraj hospital between May and December 2011 was performed. Patient’s demographic data, perioperative outcomes, early postoperative complications and pathological data were recorded. Results: There were 33 patients underwent SILC without need special curved instruments. The man age of the patients was 63 years (range = 23–90). The operations were right hemicolectomy (n = 9), left hemicolectomy (n = 3), sigmoidectomy (n = 19), anterior resection (n = 1), and total colectomy (n = 1). The technique for trocars insertion was multifascial incision (n = 30) (Fig. 1) or GelPOINT (n = 3). The operative time was 145 min (range = 60–600) and the blood loss was 44.8 mL (range = 10–100). One patient needs a conversion to open technique because of a very large tumor. Anastomotic technique was created using stapler (n = 24) or hand sewn (n = 9). The pathological result revealed colorectal cancer (n = 29), colonic diverticulosis (n = 2), B-cell lymphoma (n = 1) and FAP (n = 1). The median number of lymph nodes examined was 17.2 nodes (range = 0–34). The length of hospital stay was 8.6 days (range = 5–20). There was no perioperative mortality. Conclusions: SILC using standard instruments is a feasible and safe procedure. This technique may be an alternative to conventional laparoscopic colectomy with shorter hospital stay, quicker recovery period and comparable oncologic outcomes.

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O019 - Gastroduodenal Diseases

O021 - Different Endoscopic Approaches

Reduced Port Surgery for Gastric Malignancies H. Kashiwagi, K. Kumagai, E. Monma, M. Nozue Shonai Amarume Hospital, YAMAGATA, Japan

Single Port Surgery with Pretumoral Approach of Trans-Axillary Video-Assisted Breast Surgery Aimed at Low-Invasion and HighAesthetics K. Yamashita, S. Haga, K. Shimizu Nippon Medical School, TOKYO, Japan

Aim: Despite the rapid development of laparoscopic surgery in last decade, laparoscopic gastrectomy for gastric malignancy is still controversial in the world. One of the reasons is the complexity of this procedure. Although recent trend of laparoscopic procedure has been toward minimizing the number of incisions, 4 or 5 ports are normally required to complete this operation. Multi-channel port such as SILS-port (Covidien Japan) is now available and it is a crucial tool to perform Single Incision Laparoscopic Surgery (SILS) or reduced port surgery. We report the laparoscopic distal gastrectomy (LADG) using dual ports method with SILS port. Method: Ten patients who were diagnosed with the early stage of gastric cancer were offered the LADG using dual ports method. Mean age and Body Mass Index (BMI) were 68.1 and 21.4, respectively. Distant metastasis or regional lymph node swelling was not shown in all cases by the preoperative series of graphical studies. For the specific surgical instruments, a 5 mm flexible scope (Olympus, JAPAN) and SILS-port were used. Nylon ligature with a straight needle was also available to lift up the gastric wall, instead of lifting instrument. The 12 mm-port (Ethicon, Japan) was inserted into left lower abdomen for the usage of the surgical instrument by the right hand of an operator. Results: Mean operation time and blood loss were 266.9 ± 38.3 min. and 37.8 ± 56.8 g, respectively. All patients were transferred to the general unit from the high care unit on day 1 after surgery and started to take soft meals. Mean hospital stay after surgery was 8.1 ± 1.5 days. No major complications occurred in the post-surgery period. No difference between dual ports methods and conventional multi-ports method we performed previously was shown in mean operative time and operative blood loss. Conclusion: Although benefits of reduced port surgery, compared to conventional laparoscopic surgery have not been established, this type of surgery is safe and expected some advantages. Cosmetic benefit is the definitive advantage and less postoperative pain may be an advantage. In addition, tissue trauma and port-related complications such as organ damage, adhesions, bleeding, wound infection and hernias can be decreased.

Aims: Endoscopic surgery for the early breast cancer is outstanding in native aesthetics without harming the breast skin. We called it as video-assisted breast surgery (VABS). However, the skin incision at the edge of the areola is the perils of deformation and dislocation of the nipple and the areola, and also of disturbance of the sensory nerve in the breast skin. We devised the trans-axillary retro-mammary (TRAM) approach of VABS. It needs only one skin incision in the axilla and can treat any tumor even in the medial or lower side of the breast without making any injuries on the breast skin. And it can preserve skin touch sensation. We improved this technique easier to be performed by the pre-tumoral approach. Methods: We made axillary skin incision long to 2.5 cm. We dissected major pectoral muscle fascia to detach retromammary tissue. We cut the mammary gland vertically to the skin at the proximal cut margin, and dissect the subcutaneous tissue above the tumor. Then we cut the gland with clear surgical margin, and removed it through the axillary port. In the pretumoral TARM, the resection area behind the tumor was not dissected before dissecting above the gland. Results: We have performed VABS on 300 patients since December, 2001. And we performed TARM on 120 patients of early breast cancer, stage I and II, and the new pretumoral approach on 20 patients. The tumor size was 2.2 cm. The average patient age was 50.2 years old. Surgical margins were all negative. There was no serious complication after surgery. The original shapes of the breast were preserved well. 5-year survival rate is 100%. The skin incision only in the axilla made better looks and shapes of the breast. It could shorten the operation time and minimize the resection volume. The postoperative esthetic results were excellent and better. The sensory disturbance was minimal. All patients expressed great satisfaction. Conclusions: Pretumoral TARM is better to facilitate VABS for the popular benefit.



Objective and Subjective Evaluation for Surgical Wounds of Reduced Port Surgery for Colorectal Neoplasm A. Hamabe, I. Takemasa, M. Uemura, N. Haraguchi, J. Nishimura, T. Hata, T. Mizushima, H. Yamamoto, Y. Doki, M. Mori Osaka University, SUITA, OSAKA, Japan

Laparoscopic Ventral Hernia Repair with Different Types of Mesh V.V. Grubnik, N. Parfentieva, K.O. Vorotyntseva Odessa national medical university, ODESSA, Ukraine

Aims: Reduced port surgery (RPS) or single-port laparoscopic surgery (SPLS) have gradually gained acceptance also in the field of colorectal surgery. To date, however, the benefits that can be obtained from these surgeries have yet to be revealed. We considered RPS, including SPLS, might be associated with higher cosmetic satisfaction, and therefore investigated postoperative wounds evaluation from the viewpoints of both medical experts and patients themselves. Methods: From 2009 to 2011, a total of 232 patients underwent RPS for colorectal diseases in our hospital. As subjective evaluation, we scored fineness of surgical wounds on a 4-point scale (fair, average, good, excellent) at a month, 3 to 6 months, and a year after surgery. In addition, we are conducting a survey in the form of a questionnaire for analyzing objective evaluation. Results: SPLS were performed for 178 patients, and on the other hand, 54 cases were inserted additional trocars. Subjective evaluation was performed for 92 patients, and scores improved gradually as time passed after surgery (fair/average/good/excellent: 14/26/32/29% at a month, 18/15/35/48% at 6 months, and 9/9/11/45% at a year after surgery). Subjective evaluation was significantly correlated with the length of wound incision at 6 months and a year after surgery (p = 0.0409 and 0.0142, respectively). Conclusion: Minimizing the length of wound incisions seemed to be of importance to improve wound fineness. At the moment, the results of questionnaires are under analysis, and we are going to disclose the relation between objective and subjective evaluation for surgical incision, thereby revealing the significance and benefits of RPS.

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Introduction: Results and rate of complications after laparoscopic hernia repair strongly depends on type of mesh and methods of mesh fixation. The aim was to compare different types of mesh for laparoscopic ventral hernia repair. Methods: Prospective randomized study was conducted from 2009 to 2012. Study group consisted of 92 patients (men—31, women—61) with a mean age 56.4 ± 11.5 years (range, 28–79 years). Umbilical hernias were in 27 patients, paraumbilical hernias were in 15 patients and ventral postoperative hernias were in 51 patients. For operations we used two types of mesh: lightweight PTFEe meshes (MMDI) and PTFEe mesh (Gore-Tex). In group I (49 patients) lightweight PTFEe meshes with nitinol framework were adequately fixed to the abdominal wall using only 3–4 transfascial sutures. In group II (44 patients) PTFEe mesh Gore—Tex were fixed to the abdominal wall with double row of spiral tackers. Results: Two groups were statistically comparable. Mean surgery duration was 72 min for the patients of the group I and 117 min for group II (p \ 0.05). There was one conversion in group I, and one in group II. The pain score was significantly less at 24 and 48 h in the patients of group I (mean visual analog scale score, 2.74 vs. 3.82, p \ 0.01). There were fewer complications among the patients of group I (7.5% vs. 37%, p \ 0.01). Recurrence at mean follow-up of 30 months was in 2 patients (4.5%) of group II, and in 1 patient (2.0%) of group I, (p [ 0.05). Conclusions: Meshes of new generation with nitinol framework can significantly improve laparoscopic ventral hernia repair. The fixation of these meshes is very simple using 3–4 transfascial sutures. The absence of shrinkage of these meshes makes the probability of recurrence minimal. Absences of takers allow avoiding the postoperative pain. We consider that these new meshes can significantly improve laparoscopic ventral hernia repair.


O024 - Abdominal Cavity and Abdominal Wall Laparoscopic Versus Open Repair of Ventral (Non-Inguinal) Abdominal Wall Hernias. An Ongoing Debate A. Malik1, A. Alkadi2, A. Talpur3, J.N. Qureshi3 1 College of Medicine, Qassim University, BURAYDAH, Saudi Arabia; 2College of medicine, UNAIZAH, Saudi Arabia; 3Liaquat University of Medical and Health Sciences, JAMSHORO, Pakistan Introduction: The optimal repair technique for ventral hernias is still under debate. This study is performed to compare the results of open mesh repair of ventral hernias with laparoscopic ventral hernia repair in terms of outcome, morbidity and mortality. Methods: Two hundred and seventy two (272) patients were admitted with ventral hernias of different variety during study period extending from January 2007 to June 2010 in a public sector university and various private hospitals. Ventral hernias like epigastric, paraumbilical, umbilical and incisional hernias were included while huge and complicated hernias were excluded. The study population was divided into two groups, Group A (Laparoscopic group) & Group B (Open surgery group). Group A comprised 140 patients who opted for laparoscopic ventral hernia repair while group B comprised 132 patients who were willing for open mesh repair. The patients’ demographic characteristics, operative details and outcomes were recorded, compared and statistically analyzed on SPSS version 17. Results: A total of 272 patients were included as study subjects during study period of two and a half years. The study population comprised 64 males (23.52%) and 208 (76.47%) females. The Para-umbilical hernia was the most common variety (n = 174, 63.97%) followed by incisional hernia. One hundred and forty (51.47%) patients were operated by laparoscopic technique and were designated as group A, while 132 (48.52%) patients were operated by open mesh technique and were designated as group B. The operative time was comparatively longer in group A compared to open repair (p \ 0.001) especially in the first 20 operations. The overall outcome in group A patients is encouraging in this series compared to open mesh repair in terms of complications, morbidity, cosmesis and mortality. Conclusion: Laparoscopic ventral hernia, although a new technique, has a number of advantages over open mesh repair. A substantial amount of work has to be done before a concrete conclusion can be drawn.

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O026 - Oesophageal and Oesophagogastric Junction Disorder Hiatal Hernias with Paraesophageal Involvement—Mesh Reinforcement With or Without Additional Fundoplication? A Randomized Controlled Study B.P. Mu¨ller-Stich1, G.R. Linke1, V. Hogg1, J. Senft1, M. Gondan1, F. Marra2, T. Simon1, A. Zerz2, C. Gutt2 1 University of Heidelberg, HEIDELBERG, Germany; 2 ST. GALLEN, Switzerland Aims: For large hiatal hernias with paraesophageal involvement (PEH), mesh reinforcement and addition of a fundoplication represents the surgical standard technique. Due to potential fundoplication related side-effects, the question arises, as to whether routine addition of a fundoplication is needed after mesh reinforced PEH repair. Aim of the present randomized controlled study was to evaluate the outcome of PEH repair by laparoscopic mesh-augmented hiatoplasty without fundoplication (LMAH) compared to laparoscopic mesh-augmented hiatoplasty with fundoplication (LMAH-F). Methods: Forty PEH patients were randomly allocated to LMAH (n = 20) or LMAH-F (n = 20). Symptomatic and objective outcome was assessed one year postoperatively by validated symptom scores (Gastrointestinal Symptom Rating Score; Gastrointestinal Quality of Life Index) and uppergastrointestinal endoscopy. Results: At one year follow-up, no mesh-related complications were documented in both groups. Endoscopy revealed a recurrent hiatal hernia in 33.3% patients following LMAH and in 16.7% patients following LMAH-F (p = 0.266). A re-intervention was necessary in 5.9% of LMAH patients and in 30% of LMAH-F patients (p = 0.062). Reflux syndrome score improved significantly within both groups with a higher reflux score at one year in LMAH patients (1.9 ± 1.2 vs 1.1 ± 0.4; p = 0.02). Complaints of dysphagia (2.1 ± 1.6 vs 1.9 ± 1.4; p = 0.74) and gas bloating (2.6 ± 1.4 vs 2.8 ± 1.4) did not differ between LMAH and LMAH-F patients. Quality of life score improved significantly within both groups with no difference between groups at one year (116.0 ± 16.2 vs 115.9 ± 15.8; p = 0.99). Conclusions: PEH repair by LMAH-F seems to have a more efficient antireflux effect without an increased risk of side-effects compared to LMAH. However, re-interventions are more often needed when a fundoplication is added, and both techniques result in a comparable, good quality of life.

O025 - Education


Delivering the Next Generation of Innovators: Introducing the Business Engineering Surgical Technologies (Best) Educational Method V.E. De Ruijter, S. Perretta, T. Katsichtis, A. Collinson, J. Collinson, B. Dallemagne, L. Swanstro¨m, J. Marescaux IRCAD-IHU, University Hospital of Strasbourg, STRASBOURG, France

Outcomes of Laparoscopic and Open Surgical Treatment of Colitis Ulcerosa ´ braha´m, J. Tajti G. La´za´r, Zs. Simonka, A. Paszt, Sz. A University of Szeged, SZEGED, Hungary

Introduction: Technological innovation in surgical science and healthcare is vital and calls for close collaboration between engineering and surgery. Platforms that facilitate effective and directed communication between young professionals from both worlds would serve this purpose. To satisfy such an educational need in the storm of the current economic crisis is particularly challenging. Aims: This pilot study explores an innovative teaching method free of charge combining surgery, engineering and business in a multidisciplinary, high-quality, low-cost and learning-by-doing philosophy. Methods: From November 2011 till December 2012, the BEST educational method was initiated in two parts: the first component delivered 40 online lectures and corresponding evaluations by worldrenowned faculty, streamed live or pre-recorded, with an interdisciplinary profile focused on surgery, engineering, and business. The second component was a 5-day intensive onsite course, organized at IRCAD in Strasbourg, France. The program included workshops in engineering, entrepreneurship team projects, and in-depth hands-on experience in laparoscopy, robotic surgery and flexible endoscopy on experimental animal models with special emphasis on the interdisciplinary aspect of the training. A 1-to-5 Likert scale satisfaction survey was administered to all students. A panel of expert surgeons, engineers and entrepreneurs assessed the team projects for potential patent application. Results: 633 individual and institutional users from 50 different countries attended the online course (mean age 27.1; SD 13.2) and participated to a total of 4141 lectures. Seventy-six young professionals (71% medical, 25% engineering, 4% business background) from 25 different countries applied to participate at the onsite course. Thirty participants were selected (15 medical, 13 engineering, 2 business students) based on the results of the online course evaluation, curriculum vitae and a letter of intent. A satisfaction rate of 4.5 (SD 0.5) was awarded to the onsite course by the participants. Six provisional patents were filed for the most promising projects. Conclusion: BEST proved to be a global talent incubator connecting students and faculty despite institutional and economical boundaries. Viable and innovative ideas arose from this revolutionary approach which is likely to spin off significant technology transfer and lead the way for future interdisciplinary surgical education programs.

Aims: Several reports from specialized centers have demonstrated the feasibility, safety, and good functional outcome of the minimally invasive procedures for ulcerative colitis (UC). This study was designed to evaluate the results of laparoscopic surgery and to compare to traditional open technique in the treatment for UC. Patient and Methods: Between 2005 and 2012 study period subjects consisted of 43 patients who had primary surgical treatment for CU, 20 through conventional laparotomy and 23 in whom surgery was via laparoscopic approach. 17 cases were emergency ones and 26 of them were planned surgical procedures. The short-term outcomes and cosmesis were evaluated in both groups. Mann–Whitney U test and Student’s t-test were used for statistical analysis. Results: There were no statistically significant differences between the two groups in the patient characteristics regarding BMI, age, gender, comorbidities, ASA classification. The average elapsed time from the appearance of CU to the operation was not significantly different in the two groups (lap vs open) (8.53 ± 5.72 vs. 7.94 ± 9.92 years). There were 14 planned restorative proctocolectomies with ileal pouch-anal anastomosis (IPAA) via laparoscopy and 4 open traditional operations. The mean operative time was significantly longer in the laparoscopic group (243.85 ± 49.42 vs 185 ± 17.8 min; p \ 0.001). There were 9 emergency subtotal colectomies with terminal ileostomy and mucus-fistula formation with LAP method, and 13 operations with traditional method. The mean operative time in LAP group was similarly longer (183.13 ± 29.99 vs. 143.33 ± 29.57 min). There was no significant difference between laparoscopic and open IPAA or subtotal colectomy with respect to estimated blood loss, blood transfusions, postoperative narcotic usage, return of bowel function, length of hospital/ICU stay, and hospital readmission rates. There was no death. Overall postoperative morbidity was similar between both groups [25% vs. 21.7 %, p = not significant (NS)], including major surgical postoperative complications indicated reoperation (20% vs. 13%). However, the minimal invasive technique associated less postoperative pain and resulted better cosmesis and patient satisfaction. Conclusion: A staged, minimally invasive approach for patients fulminant or not fulminant ulcerative colitis is technically feasible, safe, and reasonable operative strategy.

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Laparoscopic Approach to Abdominal Emergencies: Results from a Retrospective Series of Adult Population According to Eaes Guidelines M. Berselli, A. Mangano, L. Livraghi, L. Latham, L. Farassino, C. Cotronea, V. Bianchi, G. Pagano, B. Gambitta, E. Cocozza Azienda Ospedaliera Ospedale di Circolo e Fondazione Macchi, VARESE, Italy

Rectal Prolapse—Laparoscopic vs. Conventional Surgery. Our Experience I. Zhivkov1, G. Gurbev1, D. Banchev1, K. Vasilev2, E. Belokonski2 1 Firs MHAT, SOFIA, Bulgaria; 2Military Medical Academy, SOFIA, Bulgaria

Aims: To analyze the results of laparoscopic approach to acute abdomen in a high volume laparoscopic center according to EAES guidelines. Materials and Methods: A series of patients with diagnosis of acute abdomen between January 2008-December 2012 was analyzed. The correct surgical approach was identified case by case according to EAES specific pathology management guidelines, taking into consideration the laparoscopic expertise of the surgeon and patient’s conditions. The characteristics of the patients, operative time, conversion to laparotomy, postoperative hospital stay, peri-operative morbidity and mortality were analyzed. Results: 475 patients had a laparoscopic surgical approach. Thirteen groups of patients were analyzed: perforated gastroduodenal ulcer (GDU), acute cholecystitis (AC), acute pancreatitis (AP), acute appendicitis (AA), acute diverticulitis (AD), small bowel obstruction (SBO), incarcerated hernia (IH), ventral hernias (VH), mesenteric ischemia (MI), gynecologic disorders (GD), non specific abdominal pain (NSAP), abdominal trauma (AT), other interventions (OI). The more numerous group was the AC (228 patients) where the postoperative morbidity and mortality rate was 5.7%, 0% respectively. The higher median age and postoperative in-hospital stay was registered in the GDU group (74.5 years and 14.5 days respectively). The more long median operative time (120 min) was in the OI groups. The overall postoperative mortality rate was 1.05% (2 patients in the GDU, 1 patient in the AD, MI and AT group). The lower and higher conversion rate was registered in the AD (31.6%) and in the AC group (1.3%) respectively. The higher postoperative complication and mortality rate occurred in the IH (37.5%) and in the GDU (14.2%). In the OI group (54 patients) 17 left colectomy and 13 right colectomy for bleeding or stenotic neoplasms were performed (complication, conversion and mortality rate were 23.3, 6.7, 0% respectively). Conclusions: The guidelines GoRs can help the surgeon to decide the best surgical approach. A very low mortality rate can be achieved via an advanced surgical expertise and a correct patient selection. Conversion to open laparotomy has to be considered if necessary. The laparoscopic approach can minimize the surgical trauma and avoid unnecessary laparotomies; however, in several pathologies further study are necessary for its validation.

Background: Rectal prolapse is one of the most common benignant diseases of the modern time. Because of the delicacy of this kind of morbidity a great number of patients look for medical help when symptoms are extreme manifested. The rectal prolapse disease could be divided into two major groups—incomplete (prolapse of the rectal mucosa) and complete rectal prolapse (full thickness). There are three degrees of the complete form- internal, visible at the anal verge on straining and external. A different operative treatment with different preoperative approach is needed for all the different form of the rectal prolapse. Aim: To prove the advantages of the laparoscopic operative techniques in the treatment of rectal prolapse. Material: We are observing a group of patients including 124 persons with rectal prolapse. They were observed and passed operative treatment in 16 years period from the beginning of 1997 till present days. The gender distribution is approximately 4:1—96 female and 28 male patients. The exact number of patients with complete rectal prolapse is 75. Operation distribution 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—4; Laparoscopic anterior sling—10; Laparoscopic posterior sling- 7; Laparoscopic resection and rectopexy- 1 patient. Conclusions: The perineal operative techniques (not abdominal approach) are characterized by shorten operative time, low mortality, less postoperative pain, short hospital stay but increased recurrence. All kinds of open surgery rectopexy and rectopexy with resection are characterized by better postoperative result relative to low recurrence rate, improved continence, but longer and more painful postoperative period, slower recovery and higher operative risk of injuries to the pelvic organs. On the other site is the laparoscopic approach with all kind of operative techniques which are characterized with short hospital stay, relatively shorten operative time, low recurrence rate, improved continence.


O031 - Spleen

Systematic Review of Surgeon Credentialing and Quality Assurance of Laparoscopic Surgery for Colorectal Cancer in Multi-Centre Trials J.D. Foster1, G.B. Hanna2, N.K. Francis1 1 Yeovil District Hospital, YEOVIL, United Kingdom; 2Imperial College London, LONDON, United Kingdom

Building a New Paradigm: Lessons Learned from a Prospective Consecutive Series of 423 Laparoscopic Splenectomies S. Fernańdez-Ananıń, E.M. Targarona, C. Rodrı´guez-Otero, J.L. Pallare´s, C. Balague´, F. Marinello, M. Trias Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Background: Credentialing of surgeons and quality assurance of surgical technique are important considerations for multicentre clinical trials in surgery, especially when investigating new and evolving surgical procedures such as laparoscopic surgery. There is a need to demonstrate that technical proficiency of the surgeon is not acting as a confounding factor. We evaluate the methods that have been utilised for quality assurance of technical performance in multicentre trials investigating laparoscopic colorectal surgery. Methods: A Systematic review was undertaken using Ovid MEDLINE and EMBASE databases for the period 1991-December 2012. Inclusion criteria were large multicentre randomized controlled trials (= 3 sites and [ 50 patients) comparing laparoscopic surgery for the treatment of colorectal cancer with other approaches: including open, hand-assisted, and robotic methods. All publications relating to identified trials were retrieved, together with trial protocols where available online. Methods used for surgeon credentialing and quality assurance were extracted for review. Results: Searches identified 2637 unique citations. 49 articles reporting on 13 multi-centre trials met the inclusion criteria: 8 trials investigating laparoscopic colonic (+/- rectosigmoid) cancer surgery, 2 investigating colon and rectal TME surgery, and 3 investigating rectal TME surgery alone. Only 1 trial did not report methods employed for surgeon credentialing in published articles/ protocol. Methods used for credentialing were number of laparoscopic cases performed by a surgeon (12 trials), and submission of unedited video of laparoscopic technique (6 trials). Minimum numbers of cases required varied from 5–200 cases. None describes the use of objective tools to standardize the assessment of submitted videos. The degree to which a standardized surgical technique is described in the protocol varies amongst trials. 3 of the trials provided live or video presentations demonstrating preferred resection technique. Conclusions: Methods employed for quality assurance of surgeons’ competency prior to participating in multicentre randomized controlled trials in laparoscopic colorectal surgery are heterogeneous and somewhat arbitrary. There is a need to develop standardized and validated methods for surgical quality assurance to reduced bias in multicentre surgical trials.

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Background: Laparoscopic splenectomy (LS) has become a well-accepted technique. However, elective splenectomy currently is an infrequent procedure, and large clinical experience on LS are lacking. Hematological disease has a great impact on spleen anatomy and patient biology that may increase the complexity and risk of the procedure. Aim: To identify the risks and predictive factor of perioperative outcome from a consecutives series of 423 LS. Material and Methods: From Feb 1993 to Oct 2012, 423 LS were performed following an ‘all comer’ policy and prospectively recorded. 113 pts had a malignant condition and 310 benign. Data stored were clinical (age, sex, BMI, diagnosis, platelet count, preoperative treatment, splenomegaly), intraoperative (conversion, op. time, blood loss) and postoperative (length stay, reoperation, morbidity, mortality, spleen weight, final diagnosis) outcome parameters. Univariate and multivariate analyses were performed to determine the predictive significance of variables. Results: Conversion rate was 6.6 and 17% developed complications. Univariate analysis showed that conversion was related to sex (M = 16/139 vs F = 11/235; p = 0.02), age (56 ± 18 vs 47 ± 19; p = 0.031), spleen weight (1795 g ± 1708 vs 573 g ± 707; p = \0.001) and malignancy (p = 0.006). Op time was related to spleen weight (p = \0.001) and morbidity was related to sex (M = 36/119 vs F = 32/216; p = 0.006), age (52 ± 16 vs 47 ± 19; p = 0.043), spleen weight (1186 g ± 1369 vs 552 g ± 690; p = \0.001) and malignancy (p = 0.004). Hospital stay were significantly related to malignant diagnosis (p = 0.001), as age (p = \0.001) and spleen weight (p = \0.001). Multivariate analysis showed that spleen size is an independent predictor factor for longer op. time, conversion, stay and morbidity (p \ 0.05). Also, sex is a predictive factor of conversion and morbidity (p \ 0.05). Conclusion: LS is a feasible, reproducible and safe, but hematological diagnosis exerts a heavy impact on surgical outcomes. This information should be taken in account when evaluating possible candidates to LS according diagnosis and surgical experience.


S9


O034 - Technology

The Oslo Comet-Study: Randomized Controlled Study of Open And Laparoscopic Liver Resection for Colorectal Liver Metastases A.A. Fretland1, A. Kazaryan2, B. Røsok2, B.A. Bjørnbeth2, K. Flatmark2, A. Sokolov2, R. Kristiansen2, K. Øyri2, M.H. Andersen2, T.E. Mollnes2, B. Edwin2 1 The Intervention Centre, Oslo University Hospital, OSLO, Norway; 2 Oslo University Hospital, OSLO, Norway

Preliminary Evaluation of a Novel Handheld Articulating Laparoscopic Instrument Driven by Robotic Technology Used in Experimental Single-Site Surgery F.M. Sanchez Margallo, J.A. Sanchez Margallo, F. Pe´rez Duarte, A. Carrero Gutie´rrez Minimally Invasive Surgery Centre, CACERES, Spain

Background: Laparoscopic liver resection is becoming a standard procedure in many specialized centres. However, there are to date no RCT scrutinizing the surgical and oncological equivalence of laparoscopic and open liver resection. Aim: To conduct an open, randomized study with reduction in perioperative morbidity (30 d) as primary end point. Secondary end points will be assessment of 5-year survival, resection margins, recurrence pattern, postoperative pain, quality of life, evaluation of the surgical trauma and activation of the immune system. ERAS-principles are implemented. A bio bank is established and deep genome sequencing will be performed on blood cells, metastases and primary tumours. Novel, sophisticated software tools have been developed to facilitate comparison of clinical study data with the large data sets from immunology studies and genome sequencing. Patients and Methods: Patients with colorectal liver metastases resectable without formal liver resection, vessel/bile duct reconstruction or ablation are selection candidates. Exclusion criteria are unresectable extra hepatic disease or inability to give written consent. Power calculation shows that 340 patients are needed to evaluate the primary end point. Patients are recruited from South/East Norway (population ca. 3 million) where our institution is the referral centre for HPB surgery. The Regional Health Authority funds the study. Randomization is computer generated. Conclusion: Until January 14th 2013, 60 patients have been included. Genome and immunology data is being processed, and results will be presented at completion of each sub study. ClinicalTrals.gov: NCT01516710

Objectives: The aims of this study were to evaluate the therapeutic safety and feasibility of digestive and urological laparoscopic procedures combining a single-site approach and a new system handheld articulating laparoscopic instruments (KymeraxTM, Terumo Europe NV, Germany) in a porcine model. Material and Methods: This system consists of a generator, handles and interchangeable instruments (scissors, dissector and needle-holder). Three healthy female pigs underwent laparoscopic cholecystectomy and Nissen fundoplication using a laparoscopic single site approach (SILS, Covidien) placed in the upper abdominal midline through a 3 cm incision. Three female pigs were used to create a surgical model of kidney pseudotumor. A single-site laparoscopic partial nephrectomy was performed in these animals. In all cases the surgeons handled conventional laparoscopic instruments with the left hand and articulated laparoscopic instruments with the right hand. During surgery, the operative time and the presence of complications were recorded. The validation of the new device includes a questionnaire. Animals were euthanized after surgery, performing postmortem examinations. The quality of dissection and intracorporeal suturing and knotting were evaluated using a scoring system. Results: No complications were registered during the surgical procedures. In the subjective assessment of this device the surgeons indicate that the rotation of the tip facilitates the suture maneuvers in single-site approach. The importance of visualizing the end of the instruments and the need for previous training to get used to handling were also registered in the questionnaires. During the necropsy it was found that the quality of the suture was lower than that obtained by conventional laparoscopic approach of previous studies. Conclusions: Single-site laparoscopic gastrointestinal and urological surgeries are feasible and safe techniques using a novel handheld articulating laparoscopic instrument. This device allows functional results similar to traditional instruments but requires previous training and does not provide advantages in surgical time compared with conventional laparoscopy. More studies are needed to determine the exact scope of this new technology in the field of minimally invasive surgery.


O036 - Endocrine Surgery

Totally Laparoscopic Treatment for Perforated Sigmoid Diverticulitis (Hinchey Stages Iii and IV): Feasibility and Safety M.G. Spampinato, D. Cassini, S. Orlandi, F. Manoochehri, B. Gnocato, F. Selvaggi, T. Filosa, G. Baldazzi Policlinico di Abano Terme, ABANOTERME, Italy

Transoral Periosteal Thyroidectomy (TOPOT): From Cadaver to Human H.Y. Lee1, H.Y Kim2, J.W. Bae2 1 Korea University Anam Hospital, SEOUL, Korea; 2Korea University Medical Center, SEOUL, Korea

Background: A well-recognized treatment for patients with perforated sigmoid diverticulitis (Hinchey’s stage III-IV) is the Hartmann’s procedure (HP). Aim: to analyse feasibility and safety of a full laparoscopic approach to perform the HP and the following restoration of bowel continuity. Materials and Methods: From January 2008 to May 2012, 109 patients with acute diverticulitis were referred at our hospital. Patients were stratified according to Hinchey’s classification as following: 76 patients (69%) Hinchey stage I-II and 33 patients (31%) Hinchey stage III-IV; the latter received an emergency surgery by mean of HP and were divided in two groups according to the type of approach used; 21 (64%) patients (Group A) underwent a laparotomic HP while 12 (36%) patients (Group B) were approached with a full laparoscopic technique. A retrospective comparative analysis of prospective collected data was performed. Results: HP operative time was 160 min in group A and 90 min in group B. All 33 (100%) patients underwent a restorative bowel surgery (RBS) of which 29 (88%) were performed laparoscopically with a median operative time of 130 min. Median Blood loss was 300 ml (HP) and 250 ml (RBS) in group A and 150 ml (HP) and 100 ml (RBS) in group B. There was no differences between group A and B with regards to morbidity rate and median hospital stay. However group A had a higher number of wound infection while one patient in the laparoscopic group required a readmission and redo surgery due to a small bowel volvulus. Conclusions: In our experience the totally laparoscopic approach is a feasible and safe option to treat patients with acute complicated diverticulitis in need for an HP procedure and to restore the bowel continuity, even when the emergency surgery has been performed by laparotomy.

Background: Although endoscopic thyroid surgery is gaining wide acceptance, however, existing endoscopic methods for thyroidectomy also have been blamed for necessity of more flap dissection and longer operative time. More recently, transoral endoscopic thyroidectomy have been reported to overcome the limitations of previous approaches. Herein we present our initial experience of new transoral periosteal thyroidectomy (TOPOT) in cadaver and porcine models, which showed better operative view with lesser limitation of motions and new robotic TOPOT in humans, which, to our best knowledge, had not been reported yet. Method: TOPOTs were performed in seven human fresh cadavers and ten living pigs. Total thyroidectomies were performed in all cadavers and pig. In animal study, follow-up examinations were carried out for 7 days and followed by autopsy. After animal experiences, three patients underwent robotic thyroid surgery using TOPOT, with da VinciÒ surgical system, at the Korea University Anam Hospital. All patients were evaluated regarding recurrent laryngeal nerve function, intra- and postoperative complications, and postoperative outcome. Results: Through three trocars in mandibular periosteal area, it was possible to create a working space under the platysma muscle and to reach the pretracheal area. Total thyroidectomies were performed and all recurrent laryngeal nerves were preserved in all cadavers using TOPOT. Mean operative time was 89.8 (55–132) min. In ten orally intubated living pigs, total thyroidectomies were also performed via transoral, mandibular periosteal approach without complications. Postoperatively, white blood cell count remained normal in all cases. Both recurrent laryngeal nerves were intact in all cases. For humans, two lobectomy of thyroid for a follicular neoplasm and a nodular hyperplasia and a lobectomy of thyroid with central neck dissection for a papillary thyroid microcarcinoma were performed using a robotic transoral periosteal approach. In one case, the patient suffered from a paresthesia of the mental nerve, but it improved within 4 weeks. During postoperative course, there was no local infection at the incision site or within the anterior neck area. All patients had no temporary vocal cord palsy. Conclusion: TOPOT might be feasible, effective and safe method of natural orifice transluminal endoscopic surgery for thyroid gland.

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O037 - Oesophageal and Oesophagogastric Junction Disorder Initial Experience with Per Oral Endoscopic Myotomy (POEM) H. Rivas, K. Helling, B. Sung, E. Leroux, S. Ahmed, J.G. Gallo Korkowski Stanford University School of Medicine, STANFORD, United States of America Introduction: Per oral endoscopic myotomy (POEM) is a relatively new procedure for treatment of esophageal achalasia. We report our initial experience with the first ten POEM procedures performed at our institution. Methods and Procedures: Preparation to perform POEM procedure was undertaken by using a combination of didactic study, observation, and simulation on animal and fresh human cadaveric specimens. Then, an ethical committee approved this clinical protocol. Patients with esophageal achalasia were recruited from July–December, 2012. All patients underwent preoperative endoscopy, high resolution manometry, esophagram and had Eckardt scores[3. All patients underwent a 10 cm myotomy extending from 7–8 cm proximal to the GE junction to 2–3 cm into the cardia of the stomach. Endoscopic examination at the conclusion of each procedure was performed to evaluate for injury or perforation, as well as for adequacy of the myotomy in improving passage of the endoscope into the stomach. All patients were admitted to the hospital following the procedure. A gastrografin swallow study was performed for each patient on post-operative day #1. Results: Ten patients were recruited and underwent a successful POEM procedure. The average age was 74 years (48–90). 50 percent of patients had previous Botox. The average operative time was 112 min (80–190). The average hospital stay was 1.5 days (1–4 days). No major complications or mortality was present. All patients had Eckardt scores after POEM \ 2. All patients were highly satisfied and with objective relief of dysphagia. Conclusions: Per oral endoscopic myotomy is safe and effective for treatment of esophageal achalasia. With increased experience of the entire surgical team, case efficiency improved. Our patients each left the hospital reporting symptom relief and fast recovery times. POEM is an excellent alternative to other surgical treatments for esophageal achalasia as demonstrated by our initial ten cases.


O039 - Oesophageal Malignancies Intraoperative Assessment of Perfusion of the Gastric Pull-Up and Correlation with Anastomotic Leaks After Esophagectomy J. Zehetner, S.R. DeMeester, J.A. Hagen, A. Shahin, F. Augustin, D.S. Oh, J.C. Lipham, T.R. DeMeester USC, United States of America Background: Anastomotic complications are the leading cause of morbidity after esophagectomy with gastric pull-up (GPU). The aim of the study was to evaluate the use of laser-assisted fluorescent-dye angiography (LAA) to assess graft perfusion intraoperatively and to correlate perfusion with anastomotic leaks. Methods: A retrospective chart review was performed of 150 patients that had LAA during esophagectomy with GPU and cervical anastomosis from March 2008 until July 2011. LAA was performed after creating the gastric tube but prior to performing the anastomosis, and the transition from good to compromised perfusion was marked with a stitch. The location of the anastomosis relative to the stitch was noted. Results: The median age of the patients was 66.5 years. No anastomosis was performed in 6 patients who had a delayed reconstruction. Anastomotic leaks occurred in 24/144 patients (16.7%). Patients with compromised perfusion were significantly more likely to have a leak (49% vs. 2%, p \ 0.0001). On univariate analysis compromised perfusion (seen in 24% with no leak vs 92% with leak, p \ 0.0001) and hypertension (in 48% with no leak vs 75% with leak, p = 0.0149) were significantly associated with an anastomotic leak, but compromised perfusion was the only significant factor by multivariate analysis. Conclusion: Perfusion is the most important factor for anastomotic healing without leak after esophagectomy and gastric pull-up. Perfusion in the gastric tube can be assessed intra-operatively using LAA, and leaks were significantly reduced when the anastomosis was placed in an area identified by LAA as having good perfusion.



Patient-Specific Bio-Elastic Organ Manufacturing by MultiMaterial 3D Printer in Laparoscopic Surgery Simulation and Navigation M. Sugimoto Kobe University, KOBE HYOGO, Japan

Circumferential Resection Margin and Quality of Mesorectal Excision in Rectal Cancer: Open vs. Laparoscopic vs. Robotic R.C.M. Bergamaschi, M. Barnajian State University of New York, STONY BROOK, United States of America

Our new technology of Bio-Texture Modeling by multi-material 3D printing system enabled manufacturing patient-specific bio-elastic 3D organ models by simultaneous jetting of different types of model materials and compounding the PVA (polyvinyl alcohol), which is a water-soluble synthetic resin that was first industrially produced in Japan. Such organ models can be soaked in water to look and feel even closer to real organs. We evaluated its feasibility in therapeutic simulation and navigation for laparoscopic surgery to facilitate planning and execution of the therapeutic procedure. Based on MDCT images, after generating an STL-file out of the patient’s data set, the inkjet 3D printer created a 3D multimaterial organ model. This system enabled the simultaneous use of two different rigid materials, two flexible materials, one of each type, any combination with transparent material, or two jets of the same material to form 3D organ textures and structures. The patient individual 3D printed models were used to plan and guide the successful therapeutic procedure in laparoscopic surgery. The 3D objects using combination of transparent and soft materials allowed creation of translucent models that show visceral organs and other details, overcome the limitation of the conventional image-guided navigation. The actual size transparent organ model with vessels and tumor could be manufactured and be handled. The elastic GI tract, bile duct, and solid organs (liver, pancreas, etc.) and bony structure were useful for simulation and educational aspects. This enabled each composite material to provide specific values of organ bio-texture for tensile strength and elongation to break for training of pre-surgical dissection and suturing procedures. These technologies provided better anatomical reference tool as a tailor-made simulation and navigation including laparoscopic surgery, NOTES, and robotic surgery and contribute to medical safety/accuracy, less-invasiveness and improvement of the medical education for students and trainees. Its combines the advantages of conventional 3D modeling and precise virtual 3D planning and can be applied advantageously in personalized simulation and navigation. We believe that personalized bio-elastic organ manufacturing can take medicine and mankind to the next level.

Aims: Circumferential resection margin (CRM) width and mesorectal excision (TME) quality predict survival in rectal cancer patients. Concerns exist regarding impact of laparoscopic coning on CRM and impact of robotic surgery on TME quality. This study compares open and laparoscopic to robotic TME with regard to CRM and TME quality. Methods: Data on first 10 patients who underwent robotic TME were extracted from prospective IRB-approved database. Automated matching randomly selected open and laparoscopic TME patients who fulfilled matching criteria (gender, tumor size). Rectal cancer was defined as adenocarcinoma located within 12 cm from anal verge. TME was defined by Heald. TME quality was assessed as complete, nearly complete, and incomplete by Nagtegaal. CRM was evaluated according to Quirke. ANOVA was used for comparison. Values are median. Results: Propensity matching of 10 robotic TME patients yielded 10 open TME patients and 10 laparoscopic TME patients with similar gender (p = 0.873) and tumor size (p = 0.873). Distribution of age (p = 0.359), BMI (p = 0.372), ASA class (p = 0.999), distance from verge (p = 0.789), staging (p = NS), neoadjuvant chemoradiation (p = NS), prior abdominal surgery (p = NS), comorbidities (p = NS) were similar among matched pairs. No significant differences in operating time (p = 0.063), distal resection margin (p = 0.977), and lymph nodes harvested (p = 0.721). Although TME quality was similar (90:10:0 vs. 80:10:10 vs. 80:10:10% p = 0.677), CRM was improved in robotic TME patients (15.6 vs. 6.9 vs. 21.4 mm p = 0.041). Conclusions: CRM was improved by robotic TME when compared to open and laparoscopic TME despite inclusion of robotic learning curve. TME quality did not differ significantly.

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Multidimensional Analysis of the Learning Curve for Robotic Total Mesorectal Excision for Rectal Cancer: Lessons from a Single Surgeon’s Experience H.J. Kim, G.S. Choi, J.S. Park, S.Y. Park, J.P. Ryuk, S.H. Youn Kyungpook National University Medical Center, DAEGU, Korea

Fluorescence Imaging for Assessment of Perfusion During Robotic Left-Sided Colorectal Surgery: Preliminary Results of a Prospective Multicenter Study J.A. Lagares-Garcia1, G. Spinoglio2, M. Hellan3, A. Pigazzi4 1 Roper Hospital, CHARLESTON, United States of America; 2 Ospedale SS Antonio E Biagio E C. Arrigo, ALESSANDRIA, Italy; 3 Miami Valley Hospital, DAYTON, United States of America; 4 University of California Irvine, IRVINE, United States of America

Aims: The robotic approach in the treatment of rectal cancer was expected to overcome the long learning periods of the laparoscopic approach. However, there have been few studies of the learning curve of robotic total mesorectal excision (TME). We aimed to provide a multidimensional analysis of the learning process in robotic TME for rectal cancer. Methods: This is single surgeon’s experience from 167 patients undergoing robotic TME between December 2007 and August 2012. To evaluate a comprehensive learning process, operative time, conversion, perioperative morbidity, and circumferential margins were hypothesized as the most relevant factors of learning process, and a single hybrid variable indicative of the success of the procedure was generated based on these factors. A moving average method for operative time and risk-adjusted Cumulative Sum (CUSUM) model were used for evaluating the learning curve. Results: The overall conversion occurred in 2 cases (1.2%). Having adjusted for case-mix, the riskadjusted CUSUM plot demonstrated that the composite event was more frequent at the beginning of the series, and after 32 cases, the cut-off point, it began to decrease. The moving average of robotic console time was shown steady decreasing and a biphasic graph pattern, with the first plateau at 32 to 34 cases and the second plateau at 72 cases. Therefore, the operative experience was divided into 3 periods based on the significant change of these findings. The robotic console time significantly decreased with increasing of phases (phase 1 vs. 2 vs. 3, 112.3 min vs. 90.0 min vs. 68.4 min, respectively, p \ 0.001). Lower rectal cancer required coloanal anastomosis, and preoperative chemoradiation was more frequent over the phases. However, postoperative complications did not increase throughout the series (p = 0.818). Conclusions: Our study shows that the learning process for robotic TME affects the first 32 cases most heavily in terms of operative time and perioperative outcomes. The current study suggests that it is possible to perform more difficult robotic procedures with accumulation of experience without increasing postoperative morbidity. These results may impact on the settings of future trials and on basis for performance monitoring of robotic TME.

Aims: Anastomotic insufficiency is a relatively frequent and serious complication of colorectal resections. Suboptimal perfusion has been identified as an important risk factor of impaired anastomotic healing. Previous literature suggests that fluorescent imaging might help to assess perfusion and thus alter the transection location of bowel during colorectal surgery, resulting in a significant reduction of postoperative anastomotic leaks. A novel fluorescent imaging system has recently been developed for the use with the da Vinci Surgical System. The aim of this study is to evaluate the impact of fluorescence imaging on the selection of the optimal bowel transection point during left sided robotic colorectal surgery. Methods: Patients undergoing left-sided colorectal resections were included in this prospective, IRB-approved, multicenter trial. After complete mesenteric dissection, the proximal (colonic) transection location was determined and marked under conventional white light. The location was then re-evaluated using robotic fluorescent imaging. The same method was applied distally when potential alteration of transection location was possible. Changes in either transection point selection were recorded. Results: Twenty patients (8 male, 12 female) with an average BMI of 26.8 kg/m2 and an average ASA classification of 2.6 were enrolled. 70% of patients were diagnosed with a malignant pathology and 40% were treated with neo-adjuvant therapy. 60% of the procedures were performed on the rectum and 40% on the colon. During the proximal assessment, fluorescent imaging delivered additional information when compared to white light in 60% of the patients. 45% of proximal transection locations were changed to a further proximal location of on average 1.5 cm after fluorescent imaging. Additional information of the fluorescent imaging was reported in 45% of the patients during the distal assessment. None of the distal transection locations were altered. No intra-operative or device-related complications were observed; no postoperative leaks occurred. Conclusion(s): Fluorescence imaging seems to add value during the evaluation of perfusion of transection locations during left-sided robotic colorectal resections. Further studies will help determine if optimization of perfusion at the transection point results in fewer anastomotic leaks when compared to conventional assessment methods.



A Cost Effectiveness Analysis of Open and Robotic Surgery in the Treatment of Rectal Cancer W. Petz, B. Andreoni, E. Bertani, G. Bislenghi, F. Uccelli, P.P. Bianchi European Institute of Oncology, MILAN, Italy

Robotic Surgery Leads to Higher Trocar Site Hernia Incidence Compared to Standard Laparoscopy G. Scozzari, M. Zanini, R. Principato, F. Cravero, F. Rebecchi, M. Morino University of Torino, TORINO, Italy

Aims: Robotics is a promising new technology with increasing diffusion in pelvic surgery. Despite some technical advantages in comparison to standard laparoscopy, the main concern in the adoption of robotic technique is due to the elevated costs of the procedure. This retrospective study compares the costs of robotic and open rectal resection for cancer in a comprehensive cancer centre with a high volume of colorectal cancer surgery. Methods: One-hundred and twenty patients were retrospectively analyzed from a prospective database, 60 received an open rectal resection (ORR) and 60 a robotic rectal resection (RRR). Patients were well-matched for age, sex, BMI and AJCC stage of cancer. Costs calculated by procedure per patient were: pre and postoperative work-up, histopathological processing of surgical specimen, drugs and materials, disposable tools, duration of surgery, working time of surgeons, nurses and staff, hospital stay, complications and their management. Results: Costs of preoperative, postoperative work up and histopathologic processing were the same for ORR and RRR (410.94, 69.73, 610.2 € respectively). Cost of drugs, materials and disposable tools was higher in RRR (2923.8 vs 1742.3 €). Median surgical time was 195 min in ORR and 339 min in RRR, with a consequent higher cost for RRR (1447.4 vs 2497 €). For each robotic procedure a further amount of 779.26 € was calculated for the amortization of the equipment purchasing. Median hospital stay was eight days in ORR and six days in RRR (4000 vs 3000 €). Major complications were 15% in ORR and 5% in RRR (p: ns), incisional hernias 12% in ORR and 0% in RRR (p: 0.003) and surgical site infections 28% in ORR and 0% in RRR (p \ 0.0001). Only costs of surgical site infections were evaluated, and it was of 1950 euro for the whole group of ORR. Overall cost was 8280.5 € for ORR and 10291 € for RRR. Conclusions: In this analysis robotic rectal resection is almost 2000 euro more expensive than open surgery. The increased cost of robotic resection can be compensated by better clinical outcomes together with the increased patients turn-over, which can enhance cost efficacy of the procedure.

Aims: Trocar Site Hernia (TSH) represent a rare but probably understudied complication of laparoscopic surgery. Surgical robots for abdominal surgery are characterized by a strong mechanical power of the robotic arms, potentially leading to higher lateral stretch effect on muscular and fascial abdominal wall layers, ultimately resulting in TSH development. Nevertheless, to date no data are available with regards to postoperative TSH incidence rates in robotically-assisted laparoscopy. Aim of the study was to compare TSH incidence in robotic abdominal surgery compared with the same procedures performed by standard laparoscopy. Methods: Patients who underwent laparoscopic or robotic-assisted (da Vinci Surgical System) Roux-en-Y gastric bypass between November 2007 and June 2012 underwent a clinical assessment and an ultrasonography (US) study of the abdominal wall. Results: Globally, 111 patients entered the study, 72 in the laparoscopic and 39 in the robotic group. Mean preoperative age was not significantly different between groups (44.2 vs 45.3 years), while the robotic group showed a significantly lower preoperative BMI (43.4 vs 49.0 kg/m2, p \ 0.001). Preoperative incidence rates of diabetes, arterial hypertension, sleep apnea and smoking were not different between groups. The operative time was significantly longer in the robotic group (278.3 vs 186.8 min, p \ 0.001). The postoperative incidence of early wound infection and/or dehiscence was 12.5% in the laparoscopic and 7.7% in the robotic group (p = ns). At the follow-up evaluation, no TSH was evident at the clinical examination of the abdomen. Nevertheless, when US study of the abdominal wall was performed, 21 patients in the laparoscopic group showed one or more TSH (29.2%) compared to 18 in the robotic group (46.2%). Conclusions: The present study showed a clinically significant trend towards an higher incidence of TSH in obese patients who underwent bariatric surgery with the da Vinci robotic system compared with those operated by means of standard laparoscopy. Although not statistically significant, this results might reflect a stronger mechanical effect of robotic arms on abdominal wall structures and should be further studied by larger, prospective comparative studies.

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O047 - Technology

O049 - Technology

Utility of a Human-Type Robot as Humanoid Surgeon in Multi Piercing Surgery of Ultra-Minimally Invasive Laparoscopic Surgery O. Takeshi1, H. Kenji2, E. Nobutsuna2, T. Atsuo2 1 Kyushu University, FUKUOKA, Japan; 2 Waseda University, TOKYO, Japan

Evaluation of Clinical Usefulness of an Organic Electroluminescence Monitor in Laparoscopy-Assisted Gastrectomy for Gastric Cancer H. Hayashi, N. Hanari, M. Mori, D. Horibe, H. Gunji, H. Matsubara Chiba University, CHIBA, Japan

Purpose: The robot developed for clinical use such as da Vinci Surgical System allowed solo surgery, for example, prostatectomy within a restricted operative field. However, concerning gastrectomy or colectomy, which needs widely dynamic action such as overturning organs, it is difficult to operate at the same position. For its reason, surgeons frequently have to move the whole body of heavy robot. We successfully performed minimally invasive endoscopic surgery by using humanoid. The following four points are benefits of humanoid in compare with conventional commercialized surgical robots: (1) easy adaptation to conventional equipment of operation room as same as human surgeon; (2) prevention of instability caused by fatigue in robot hands; (3) quick transportation without help of commander surgeon; 4) possibility of storage in compact space. Methods: We carried out humanoid-assisted solo surgery by NOTES-assisted Needlescopic Surgery, what is defined as Multi Piercing Surgery (MPS). Partial gastrectomy and cholecystectomy were performed in two pigs. The utility of a humanoid was evaluated about 1) accuracy and 2) stability of posture. At first, instability and stability of endoscopic view were evaluated with the naked eye by observing the video recorded by the 3D camera in glassless 3D monitor. Furthermore, we clarified the instability of endoscope by the sensor coil of electromagnetic navigation system inserted through the channel of the endoscope. And then the time that required for move from storage position to surgery position for humanoid, was counted. Results: It turned out that flexible endoscope operation by humanoid did not cause any instability except for minor deviation that originated in the physical property of flexible endoscope. Center point of endoscopic view did not tremble in evaluation of both grassless 3D monitor and tracks of electromagnetic navigation system at all. Furthermore, unlike conventional robots, humanoid as same as surgeon of human-being was able to be quickly set at the surgery position. Conclusion: Humanoid in MPS possibly works as a useful tool to ensure safety and certainty without changing conventional equipment of operation room.

Aims: Organic electroluminescence (EL) monitors, which utilize organic materials that emit light in response to an electric current, offer high contrast and rapid motion responses. Their features also include fewer limitations on viewing angles, superior color representation at low brightness levels, and lower image lag in moving images. These features have raised expectations about their application in the medical field. Thus, we compared the usefulness of an organic EL monitor and a conventional liquid-crystal display (LCD) monitor employing images recorded during laparoscopic surgery. Methods: Images of laparoscopic lymph node dissection in gastric cancer were simultaneously displayed on one organic EL monitor and two LCD monitors, the three of which were indistinguishable in appearance. Six experienced surgeons evaluated the images. Each evaluator determined clinical usefulness indices (11 items) and image quality indices (11 items) on a 5-point scale (1, very good; 2, good; 3, average; 4, poor; and 5, very poor) for each of the images consisting of 20 scenes from 5 cases. Results: Scores for the organic EL monitor were statistically significantly superior to those obtained with the LCD monitors for the following items: all 11 clinical usefulness indices including organ distinguishability (mean scores for the organic EL monitor vs. LCD monitors were 2.3 vs. 3.2), stereoscopic images of organs (2.3 vs. 3.2), reproducibility of actual images (2.4 vs. 3.3), and general impression of picture quality (2.4 vs. 3.3); and 9 image quality indices including brightness and luminosity (2.0 vs. 3.7), contrast (2.2 vs. 3.4), and color reproducibility of dark areas (2.5 vs. 3.3). Conclusions: The organic EL monitor was considered to reduce restrictions on laparoscopic images, in which uniformly bright views are difficult to obtain, enhance organ distinguishability, and facilitate the acquisition of stereoscopic views of the operative field. Introduction of this monitor, which can faithfully reproduce the colors and textures of organs and tissues, into clinical practice is anticipated to enhance the safety and precision of laparoscopic surgery.

O048 - Technology


A Lactate Biosensor for Early Detection of Anastomotic Leak and Intra-Abdominal Sepsis in Peritoneal Fluid N.A. Hirst, P.A. Millner, D.G. Jayne St James’s University Hospital/University of Leeds, LEEDS, United Kingdom

Laparoscopic Sleeve Resection Versus Greater Curvature Plication for Morbid Obesity: 1-Year Results of Multicenter Prospective Randomized Trial V.V. Grubnik1, O.B. Ospanov2, K.A. Namaeva2, M.N. Samatov2, N.K. Kusmanov2, V.P. Gollyak1, M. Kresun1 1 Odessa national medical university, ODESSA, Ukraine; 2 Medical University, ASTANA, Kazakhstan

Aims: Anastomotic leak (AL) is a catastrophic surgical complication and a cause of considerable morbidity and mortality. Delay in diagnosis is associated with poorer prognosis. Current diagnostic tests are insensitive and costly, and timely intervention is often missed. Application of biosensor technology has the potential to offer ‘point of care’ detection of AL, aiding earlier diagnosis and improving survival. Methods: Lactate is a biomarker for early AL. Lactate biosensors were constructed using lactate oxidase enzyme immobilised to a carbon electrode transducer surface. Interrogation was by chronoamperometric electrochemical measurement. The biosensors were evaluated in spiked buffered solution, calf serum, and peritoneal fluid from patients after elective colorectal surgery suffering AL and with uneventful recovery. Results: We have successfully constructed and optimised a novel amperometric lactate biosensor capable of detecting lactate in patient peritoneal fluid. Lactate oxidase concentration and incubation times were optimised (1.25 U, 20 min), and testing with common interferents confirmed high selectivity, with only ascorbic acid generating a minor signal at 9.6% of the response to lactate. Biosensor results from post operative day 1 peritoneal samples were compared with those of a commercial colorimetric assay, and were found to be statistically similar for each patient using Spearman’s rank-order correlation, rs = 0.891, p = 0.001. This small patient cohort also demonstrated a trend to increased lactate levels in AL samples compared to non-AL. Conclusions: Biosensor technology can be used to measure lactate in abdominal fluid, and may provide ‘point-of-care’ diagnosis for anastomotic leak and intra-abdominal sepsis. Future work will focus on construction of other biosensors for AL and a multiplex platform for clinical application.

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Introduction: Laparoscopic sleeve gastrectomy (LSG) is feasible restrictive and appetite-suppressive procedure. One of the most serious complications of this operation is staple line leak. New modification of LSG, laparoscopic greater curvature plication (LGCP) has a similar restrictive mechanism without potential risk of leak. Aim of study was to compare effectiveness and safety of LSG and LGCP. Methods: Multicenter prospective randomized study was started in 2010. 50 patients with morbid obesity were initially enrolled. There were 38 women and 12 men. Main inclusion criteria was BMI [ 35 and \ 65 kg/m2. Main exclusion criteria were: ASA [ III, age [ 75. Mean age was 42.6 ± 6.8 years (range, 35–62) for both arms. 6 patients had diabetes mellitus. Time frame is 24 months. Patients were assessed 1 year after surgery. LSG arm included 21 patients with mean BMI 42.8 ± 5.3 kg/m2 (range, 37–61), LGCP arm included 23 patients with mean BMI 43.1 ± 4.9 kg/m2 (range, 36–63) (p [ 0.05). Results: Mean operative time was 92 min (range, 60–140) in LSG arm and 53 min (range, 36–98) in LGCP arm (p \ 0.05). There were no conversions in both arms. Morbidity was 9.5 % in LSG arm (staple line leak—1, spastic lower esophageal sphincter—1), and none in LGCP arm (p [ 0.05). Mean stay was 4.0 days (range, 3–14) in LSG arm and 2.8 days (range, 2–5 days) in LGCP arm (p [ 0.05). Mean % EWL was 49.5 in LSG arm and 45.2 in LGCP arm (p [ 0.05). There was an improvement in diabetes mellitus, hypertension, obstructive sleep apnea in both arms. Appetite depression was larger in LSG arm. Conclusions: Preliminary results show equal effectiveness of laparoscopic sleeve gastrectomy and greater curvature plication. Further analysis is required to elucidate exact mechanisms of weight loss, long-term weight loss, and morbidity of both operations.


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Laparoscopic Sleeve Gastrectomy in Obese Adolescents A Raziel, N. Sakran, A. Szold, D. Goitein Assia medical, Assuta Hospital, TEL AVIV, Israel

What Does It Influences the Outcome of the Sleeve Gastrectomy, the Bougie or the Surgeon? M. Socas-Macias1, S. Morales-Conde1, A Barranco moreno2, M. Rubio Manzanare1, S. Garcia1, C. Jordan Chaves1, H. Cadet1, J. Padillo Ruiz1, J.L. Pereira1, P.P. Garcia Luna1, I. Alarcon del Agua1 1 HUVirgen del Rocio, SEVILLE, Spain; 2 Virgen del Rocio Hospital, SEVILLA, Spain

Background: Laparoscopic Sleeve Gastrectomy (LSG) is gaining credentials as a simple and efficient bariatric procedure with low surgical risk. Surgical treatment for morbid obesity is relatively rare in adolescents; hence few results have been accumulated so far. Herein, we report our data with adolescents after LSG surgery. Objectives: To prove safety and efficacy of LSG surgery in adolescent population Methods: Data was prospectively collected regarding adolescent patients undergoing LSG. All patients underwent pre- and post-operative medical and professional evaluations by a multi-disciplinary team. Results: Between the years 2006–2011, 32 adolescents underwent LSG in our center, (20 females and 12 males). Mean age was 16.75 years (14–18); mean weight was 121.88 kg (83–178); and mean BMI 43.23 (35–54). Thirty four comorbid conditions were identified. In all patients, LSG was the primary bariatric procedure. Mean operative time was 60 min (45–80). There were 2 (6.25%) complications, an early staple line leak and a late acute cholecystitis. There was no mortality. Mean percent excess weight loss (%EWL) at 1, 3, 6, 9,12, 24, 36, 48, and 60 months post surgery was 27.9%, 41.1%, 62.6%, 79.2%, 81.7%, 71%, 75%, 102.9% and 101.6%, respectively. Comorbidities were completely resolved or improved within one year following surgery in 82.4% and 17.6%, respectively. Conclusions: LSG is feasible and safe in morbidly obese adolescents, achieving efficient weight loss and impressive resolution of comorbidities. Further studies are required in order to evaluate the long-term results of this procedure, as well as its place among other bariatric options.

Introduction: Sleeve gastrectomy (SG) has been standardized as a sole technique due to the loose of weight obtained in the medium term, but it continuous been discussed if the size of the bougie or the surgeon, influences the EWL or the percentage of complications. Objective: To Analyze if there are any differences depending on the surgeon or the size of the bougie used in the SG, in relation to the loose of weight and complications. Materials and Methods: Retrospective Study (based on a prospective data base) of patients who underwent laparoscopic SG. Patients were operated on by 4 different surgeons (S1, S2, S3, S4), and two different bougies were used (40/58 fr). Results: 168 morbid obese patients (48 men/120 women) underwent SG. Medium age 42.9 yo (18–68) and BMI of 51.05. 100% performed by laparoscopy (21 patients: 12.5% SinglePort), 0% Conversions. Standardized technique performed in all the cases, using a 40 or 58 fr bougie depending of the preference of the surgeon. Medium hospital stay 3.6 days. Mortality 0.3%. Global morbidity 5.3%; 44.4% of the complicated patients required reoperation. Percentage of patient operated on by every surgeon: S1 21%, S2 27%, S3 26%, S4 27%; Bougie specified: 86 patients— 40 fr, 64 patients—58 fr. Maximum loose of weight at 2 years, 67% EWL: EWL 3 m (S1—30%, S2—27%, S3—28%, S4—29%), EWL 6 m (S1—52%, S2—50%, S3—46%, S4—46%), EWL 1 y (S1—63%, S2—65%, S3—55%, S4—56%), EWL 2 y (S1—60%, S2—68%, S3—61%, S4— 47%). Morbidity by surgeon (S1—11.4%, S2—2.2%, S3—7%, CS—4.4%). There were no SS difference between surgeons neither in the EWL (p: 0.22) nor in the percentage of complications. In relation to the size of the bougie: EWL 3 m (40 fr—28%, 58 fr—28%), EWL 6 m (40 fr—51%, 58 fr—46%), EWL 1y (40 fr—66%, 58 fr—55%), EWL 2 years (40 fr—70%, 58 fr—55%), being these differences SS from 6 month in favor of the 40 fr bougie (p: 0.005). Morbidity was also found superior with the 40 fr 8.2% against 4.8% (p: 0.518) Conclusion: Following a standardized technique, there are no SS differences in terms of complications or EWL depending on the surgeon, but there are SS differences in relation to EWL in favor of 40 fr bougie, being the percentage of complications superior in this case.



Iron Metabolism After Roux-en-Y Gastric Bypass or Sleeve Gastrectomy. Results from a Prospective Randomized Clinical Trial M. Vix, A. D’Urso, M. Diana, K.H. Liu, D. Mutter, J. Marescaux IRCAD-IHU, University Hospital of Strasbourg, STRASBOURG, France

Comparing Revision Procedures After Laparoscopic Adjustable Gastric Band Failure: Gastric Bypass vs. Sleeve Gastrectomy B.F. Schwack, J. Loy, H. Youn, M.S. Kurian, C.J. Ren Fielding, G.A. Fielding New York University School of Medicine, NEW YORK, NY, United States of America

Aims: Roux-en-Y Gastric Bypass (RYGB) could alter iron metabolism through different mechanisms including reduced gastric acid secretion and duodenal exclusion. Sleeve Gastrectomy (SG) could potentially have a better postoperative preservation of iron metabolism. The aim of this study is to report the 1-year results of iron metabolism changes in the setting of a prospective randomized clinical trial comparing RYGB vs. SG. Methods: One-hundred patients were randomly assigned to RYGB (n = 45) and SG (n = 55). Hemoglobin, serum iron, ferritin, folic acid, B12 vitamin were assessed at inclusion and after 1, 3, 6, and 12 months (M1, M3, M6, and M12). Eighty-eight patients completed a 1-year follow-up. Standard postoperative supplementation consisted in a multivitamin complex (AZINC optimal, Arkopharma) 2 pills per day for the first 30 postoperative days and iron (Tardyferon 80 mg) 2 pills per day, vitamin B12 (Cyanocobalamine, 1 mg) 1 intramuscular injection per month, folic acid 5 mg 2 pills per day when required. Results: Mean hemoglobin values were statistically significantly decreased when compared to inclusion values after both RYGB and SG at M6 and at M12, but there were no differences between the two procedures and absolute values remain within the normal range. Mean serum iron values presented a slight increase over time after both SG and RYGB. Ferritin values were stable over time in the SG group and were statistically significantly reduced in the RYGB group at M12 (159.1 ± 147.1 at inclusion vs. 80.6 ± 124.8 ng/mL; p = 0.03). Mean vitamin B12 values were similar in both groups although slightly lower after RYGB. Folic acid was statistically significantly reduced after RYGB when compared to SG at M12 (7 ± 3.9 vs. 5.1 ± 2.3 ng/mL; p = 0.04) Conclusion: The first year results of this randomized clinical trial may suggest a higher mobilization of iron stocks and/or worse absorption after RYGB when compared to SG. The low rate of uncontrolled deficiencies stresses the importance of stringent follow-up and adapted supplementation regimens to counterbalance micronutrient deficiencies after bariatric surgery.

Aims: Laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG) and roux-en-y gastric bypass (LRYGB) are safe and effective bariatric procedures. Weight loss failure occurs and revision procedures are often performed. Our aim is to review our experience converting LAGB failures into LRYGB and LSG. Methods: This is a retrospective review of 121 patients (2008–2012) who underwent bariatric revision procedures after weight loss failure or intolerance to LAGB. We compared patients revised into LRYGB and LSG. Parameters reviewed include 30-day readmissions, reoperations, operating time, length of stay (LOS), and percent excess weight loss (%EWL) from primary and secondary procedures. Four of 91 LAGB to LRYGB and 3 of 30 LAGB to LSG underwent open procedures. Results: Data on 121 revised patients was assessed 91 LAGB to LRYGB (Group 1) and 30 LAGB to LSG (Group 2). Group 1’s average OR time was 168.29 min; Group 2’s was 146.24 min (p = .031). Group 1’s mean LOS was 4.53 days while Group 2’s was 3.9 days (p = 0.628). Group 1 patients experienced 12 of 91 (13.19%) bypass related reoperations; Group 2 patients experienced 1 of 30 (3.33%) sleeve related reoperations (p = .133). Group 1 patients had 10 30-day readmissions (10.99%); Group 2 had 2 30-day readmissions (6.67%) (p = .496). Regarding the first year after conversion, %EWL from the revision was reviewed. The %EWL for the bypass versus sleeve group was 24.45 vs. 22.50 at 3 months, 44.22 vs 24.77 at 6 months, and 47.16 vs 34.12 at 12 months (p values respectively: 0.406, 0.002, 0.179). Of note, %EWL from pre-LAGB was: (bypass vs sleeve) 36.96 vs. 22.5 at 3 months, 49.07 vs 40.27 at 6 months, and 54.78 vs. 34.12 at a year. Conclusions: For patients exhibiting weight loss failure or intolerance to LAGB, both LSG and LRYGB are safe options with comparable length of stay, readmissions, and reoperations. Operative time is significantly shorter with conversion to LSG. Additional weight loss from the revision procedure is moderate in all cases. There was significantly better weight loss with the bypass at 6 months. When regarding the pre-LAGB weight, the revisions helped in the patient’s overall weight loss.

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Concomitant Cholecystectomy During Laparoscopic Bariatric Surgery A Raziel, N. Sakran, A. Szold, D. Goitein Assia Medical, Assuta Hospital, TEL AVIV, Israel

Evaluation of Laparoscopic Gastric Bypass in 250 Patients Older Than 60 Years H. Vanommeslaeghe, B. Deylgat, C. Vercauteren, I. Van De Caveye, B. Dillemans AZ Sint-Jan AV, BRUGES, Belgium

Introduction: Morbid obesity is associated with a high prevalence of cholelithiasis. Moreover, an increased risk of cholelithiasis exists during rapid weight loss. Prophylactic cholecystectomy combined with open bariatric surgery was advocated. However, for laparoscopic surgery, parallel cholecystectomy is still controversial. We report our experience with concomitant bariatric surgery and cholecystectomy in a multidisciplinary center for bariatric surgery. Methods: Concomitant bariatric surgery (BS) and cholecystectomy was performed only for patients diagnosed with symptomatic gallbladder stones prior to BS. A group of concomitant BS and cholecystectomy was compared to a large group of BS only. Demographic data (gender distribution, age, weight, BMI) as well as, comorbidities and complications were compared. Most cholecystectomies were performed in a retrograde approach because of enlarged fatty liver and intrahepatic location of the gallbladder. Results: The BS only group (1958 procedures between the years 2006–2012) consisted of Laparoscopic Adjustable Gastric Banding (LAGB) (53, 2.7%), Laparoscopic Roux-en-y Gastric Bypass (LRYGB) (114, 5.8%), and Laparoscopic Sleeve Gastrectomy (LSG) (1791, 91.5%). The concomitant surgery (CS) was performed on 124 patients during the same period. CS consisted of LRYGB (8, 6.5%), and LSG (116, 93.5%). Females were 65% in the BS group and 79% in the CS group. Median age was 42 and 45 in BS and CS groups, respectively. Average weight and average BMI were similar in both groups: 121.4 ± 16.4 and BMI 43.2 ± 4.4 and 119.0 ± 15.0 and BMI 43.6 ± 4.5 in BS and CS groups, respectively. Average number of comorbidities/patient in both groups was identical (3.6), showing similarity between patient types in both groups. Rate of common surgical complications was similar 30 (1.5%) hemorrhages and 21 (1.1%) leakages in the BS group and 3 (2.4%) and 1 (0.8%) in CS. There was one case (0.8%) of bile leakage. Of special interest is the diagnosis of bile carcinoma in 2 (1.6%) older female patients with large gallbladder stones. Conclusion: concomitant cholecystectomy during laparoscopic bariatric surgery is a safe procedure requiring only minor changes in surgery and hospitalization time. Additional complications are minimal. The concomitant surgery reduces the potential for future gallbladder-related morbidity, and the need for additional surgery.

Aims: In an elderly population, frequently suffering from multiple comorbidities, laparoscopic Roux-en-Y gastric bypass in considered a high risk procedure. The aim of this study was to evaluate the feasibility and safety of this procedure and its mid-term impact on long existing comorbidities (type two diabetes mellitus, hypertension, sleep apnea, joint pain and dyslipidemia). Method: A retrospective of all patients older than 60 years of age who underwent a laparoscopic Roux-en-Y gastric bypass between Oktober 2004 and July 2012 has been performed. Patient files were reviewed and patients were telephoned to obtain lacking data. Demographics, postoperative course, weight evolution and comorbidities were registered. Results: A total of 280 patients were included, 250 of which could be reached. Twenty four patients were lost to follow up and 6 patients died postoperatively of non-surgical causes. There were 161 women and 89 men. Mean age was 64.1 years (range 60–78 years). Mean BMI at surgery was 41.9 kg/m2 (range 27.4–68 kg/m2). Mean hospital stay was 4.3 days (range 2–19 days). In the early postoperative course there was no in hospital mortality, 27 (9.6%) patients suffered from postoperative complications and 7 (2.5%) patients needed to be readmitted. Mean follow-up was 2.6 years (range 3 months–7.9 years). In the late postoperative course mean BMI was reduced to 30.5 kg/m2 (range 20.8–45) and resolution or improvement of diabetes, hypertension, joint pain, sleep apnea and dyslipidemia was seen in 93% (69/74), 77% (127/165), 58% (95/165), 88% (66/75) and 77% (108/140) respectively. Conclusion: Laparoscopic Roux-en-Y gastric bypass is safe and feasible in an elderly population. All obesity related comorbidities improved during follow up.



Use of Platelets Rich Plasma in Prevention of Gastric Leak After Laparoscopic Sleeve Gastrectomy G. Casella, F. Pelle, E. Iallonardi, A. Genco, G. Ferrazza, F. Frangella, E. Soricelli, N. Basso, A. Redler ‘‘Sapienza,, University of Rome, ROME, Italy

Laparoscopic Sleeve Gastrectomy as a Day Case Procedure for Morbid Obesity, is It Feasible? Preliminary Results A. Zeineldin1, S. Soliman2, S. Elshakhs1, A. Moustafa1 1 Menoufia University Hospital, SHEBIN ELKOM, Egypt; 2Air Force Hospital, NEW CAIRO, Egypt

Aims: Laparoscopic sleeve gastrectomy (LSG) had gained a great popularity as a primary bariatric procedure for the treatment of morbid obesity and associated comorbidities. Staple line leakage, mainly at the gastroesophageal junction, is the most frequent and life-threatening complication. Aim of this study is to ascertain the technical feasibility of laparoscopic use of Platelets rich plasma (PRP) and to analyse its effect in the prevention of gastric leak after LSG. Methods: From March 2012 to May 2012, 20 patients underwent to LSG (10 male, age 44 ± 11 years, BMI 42.3 ± 5.45 kg/m2). Diabetes was present in 4 patients, Hypertension in 6 patients, OSAS in 3 patients. LSG was performed after complete mobilization of the gastric fundus, using 48 Fr gastric bougie and Echelon Endopath with gold cartridges; in all patients the staple line was reinforced with bovine pericardium and, at the gastroesophageal junction, with introflecting suture. PRP was prepared separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane of about 2 9 5 cm. It was activated by addition of 1 ml ethyl alcohol al 95% and 2 ml calcium gluconate to form a matrix of fibrin thick. The PRP preparation is cost efficient (less than 15 euros). The PRP was introduced directly through the trocar and it was positioned in the last cranial centimetres of the suture line. Results: No conversion and no intraoperative complications were registered. Mean operative time was 85 ± 31 min, not significant increased when compared with the operative time in all personal series of LSG (750 cases). At 8 months follow up no cases of leak or bleeding were observed. The use of PRP did not induce cases of reject or infection. Conclusions: The use of PRP during laparoscopy is feasible, does not require any special devices and is cost effective. Although in a small series of patients, it seems to be effective in the prevention of gastric leak after LSG, not increasing significantly the operative time.

Introduction: Laparoscopic sleeve gastrectomy (LSG) could be performed either as a primary or as a staged procedure for treatment of morbidly obese patients. Aim of this study: It was to assess the feasibility of performing LSG as a day case procedure for morbid obesity. Patients and Methods: A total of 25 patients were included in this study. All patients were selected according to inclusion and exclusion criteria after informed consent and counselling with a multidisciplinary team. The technique was performed through two 12 mm and three 5 mm ports, using Endo-GIA stapler to remove a longitudinal part of stomach, starting 6 cm from the pylorus, leaving a sleeve of stomach over 36 Fr bougie. The integrity of staple line was assessed by either insufflating air under saline or infusing methylene blue solution into the remaining new stomach. After operation, all patients received intravenous fluids and analgesia until they were able to tolerate oral fluids once they are fully recovered of anaesthesia. They were discharged home within 12 h with an information leaflet and a responsible adult to look after them at home. They were advised to call a member of the surgical team according to certain criteria to report symptoms as increasing pain or vomiting. Results: There were 15 females and 10 males with a median age of 42.6 ± 13.5 years and BMI of 51.5 ± 7.6 kg/m2. The operative time was 115.4 ± 36.7 min. Patients were seen 7, 14 and 30 days after surgery. Two patients were re-admitted for pain control and had investigations to exclude leakage. One patient was re-admitted for rehydration after oral fluids intolerance and vomiting. All the three patients were discharged home again after an overnight stay. Conclusion: Day case laparoscopic sleeve gastrectomy for treatment of morbidly obese patients is feasible but a larger series may be needed to evaluate it further.

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Can Total Laparoscopic Colectomy with Transanal Specimen Extraction Substitute Laparoscopic Assisted Left Colectomy? S. Saad, D. Schmischke, D. Politt Clinic Gummersbach, GUMMERSBACH, Germany

Retrieval Bags in Colorectal Surgery C. Mittermair1, S. Morales-Conde2, C. Obrist1, M. Socas2, K. Pimpl1, A. Barranco2, E. Brunner1, I. Alarcoń2, J. Schirnhofer1, H. Weiss3 1 St. John of God Hospital, SALZBURG, Austria; 2University Hospital Sevilla, SEVILLA, Spain; 3Austria

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). Aim: We investigated whether TLC can substitute laparoscopic assisted left colectomy (LAC) in a prospective observational study over a time period of three years in a german Academic Teaching Hospital. Methods: From Nov 2009 to Dec 2012 we performed TLC in 102 patients. Indications for left colectomy were diverticular disease, rectal prolapse, benign and malignant tumors up to 4 cm. Operative colon dissection was performed using 3 to 4 ports, the specimen was extracted via the anus with the help of a TEO-rectoscope. Colonic anastomosis was done with a circular stapler (Technical aspects will be presented in a short video clip.) Various parameters of technical performance and patient outcome were recorded during hospital stay and at a 1 month follow-up. Results: Mean operating time for TLC was 124 min., ranging from 140 min in the first 20 cases to 90 min in the last 20 cases. In 4 patients conversion to LAC was necessary due to a bulky inflammatory colon specimen. Postoperative complications required reoperation in 4 patients for anastomotic leakage (3) and ileus (1) and colonoscopic intervention in 2 patients for anastomotic bleeding (1) and stenosis (1), resulting in a 6% overall complication rate. Mean hospital stay was 5.8 days due to reduced pain intensity and fast recovery of gastrointestinal function. The proportion of TLC to LAC was 76% in 2010, 85% in 2011 and 95% in 2012 at our department. Conclusion: In the majority of patients undergoing minimally invasive left colectomy TLC can substitute LAC in order to further enhance patient outcome.

Introduction: Many efforts have been made to prevent intra-peritoneal and subcutaneous tumour seeding in colorectal cancer surgery. However, squeezing the specimen during retrieval in any minimal invasive technique might cause fluid and cell spillage. In this study specimen retrieval was carried out using a bag to analyse extra-intestinal fluid and cells after specimen retrieval. Material and Methods: Between May 2011 and December 2012, 67 patients with benign and malign colorectal diseases have been treated in two centres (Salzburg/Seville) by means of single port laparoscopic surgery. For specimen retrieval a tear-proof bag was used. The fluid in the bag was analysed for bacterial contamination and malignant cells, in cancer patients. Postoperative surveillance was performed by standard protocols including wound infection and abdominal complications. Results: Mean specimen length was measured 25 centimetres, mean patients BMI 26. Bacterial contamination was observed in 34 bags (61.7%). One wound infection was documented, intraabdominal abscess formation in two patients. Anastomotic leakage occurred twice. Malignant cells in the retrieval bag were observed in 4/37 (10.8%) oncological resections. Oncological follow up did not reveal any case of peritoneal metastasis yet. Conclusion: This findings strongly emphasize the importance of a retrieval bag in colorectal minimal invasive surgery.



Beneficial Effect of Laparoscopic Surgery on Long-Term Defecatory Function After Sphincter-Preserving Operation for Rectal Cancer M. Oya, N. Tagaya, H. Yoshiba, S. Shinichi, O. Takashi, T. Emiko, K. Shinichiro Koshigaya Hospital, Dokkyo Medical University, KOSHIGAYA, SAITAMA, Japan

Analysis of Factors that Affect the Success of Enhanced Recovery Program (ERP) Following Laparoscopic Colorectal Surgery N. Naguib, H Rafique, S.A. Masoud, A. Williams, A.G. Masoud Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

Indication of laparoscopic surgery for rectal cancer has been markedly extended in the recent years. Although laparoscopic surgery may have functional superiority over conventional open surgery, defecatory function after laparoscopic sphincter-preserving operation (SPO) for rectal cancer has not been well described. The aim of the current study is to compare long-term defecatory function after SPO between laparoscopic surgery and open surgery. A total of 33 patients more than 2 years after SPO for rectal cancer under a single surgeon were studied. Laparoscopic surgery and open surgery were carried out in 18 (LAP group) and 15 patients (Open group), respectively. 20 patients were male and 13 patients were female. Operative procedures were ordinary low anterior resection (LAR) with stapled anastomosis in 14 patients, super low anterior resection (SLAR) with stapled anastomosis in 9 patients, and intersphincteric resection (ISR in 10 patients. Neither age, gender, time since operation, or operative procedure significantly differed between LAP group and Open group. Defecatory function such as daily bowel frequency, fecal incontinence, defecatory urgency, and constipation was clinically evaluated using a written questionnaire at the time of hospital visit for postoperative follow-up. Either daily bowel frequency or constipation did not significantly differ between the two groups. Fecal incontinence evaluated using Wexner’s incontinence score, and defecatory urgency were significantly less severe in LAP group than in Open group. In laparoscopic rectal resection, surgical view of the pelvic cavity is much better than in open surgery. In addition, maneuvers in laparoscopic surgery in the pelvic cavity may be less traumatic, possibly due to the limited movement of surgical devices in the pelvic floor and to the remnant lower rectum, than in open surgery. These characteristics of laparoscopic surgery may be beneficial to postoperative defecatory function after SPO.

Aims: To study the effect of ERP on post-operative hospital stay on all patients who had LCS and to analyse the factors which may affect its success rate. Methods: A prospective database was maintained from June 2002-August 2012. ERP was introduced in May 2010. The following factors were included to study their individual effect on the postoperative hospital stay: ASA grade, age, gender, stoma, conversion, BMI, previous surgery, malignant pathology and the presence of metastases. ERP was considered successful if the hospital stay was = 3 days. Statistical analysis was performed using Fisher Exact Test, Student T-test and Kruskal-Wallis test for non-parametric analysis of the variance (ANOVA). Results: 240 patients had LCS. 101 patients since the introduction of ERP (median age 67; range 29–93), Male: Female ratio = 51:50. The conversion rate = 5/101 (4.95%), 5 patients stayed for 1 day. The overall success rate of ERP was 52/101 (51.5%). Individual analysis of the variables showed that Conversion was the only single factor which significantly affected the success rate of the ERP. There was no significant effect for age or gender on the enhanced recovery success rate, p = 0.121 and 0.197, respectively. Kruskal Wallis test showed a significant effect of ASA (p = 0.033), conversion (p = 0.035), and stoma (p = 0.004) on ERP but not previous abdominal surgery (p = 0.37), metastasis (p = 0.91) or BMI [ 35 (p = 0.895). In a subgroup analysis, the effect of the ERP was studied in young patients (less than 70 years old) with no severe systemic comorbidity (ASA I & II) or stoma. 35 patients were included in this subgroup who achieved success rate of 63% (22/35), p = 0.0226. Re-admission rate following successful ERP is 5/52 (9.6%) and following failed ERP is 7/49 (14.3%), p = 0.5. Mean hospital stay prior to ERP was 7.1 days (Median = 4) while after ERP is 6.98 days (Median = 3), p = 0.93. Conclusions: The success of ERP in LCS was 51.5%. This rate improved to 63% with appropriate patient selection. Conversion, ASA and stoma affected the success of ERP. The success of ERP in achieving 23:59 hospital stay at this stage of learning curve is 5%.

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Japanese D3 Resection in Laparoscopic Surgery for Colon Cancer Based on Similar Concepts to Complete Mesocolic Excision with Central Vascular Ligation T. Yatsuoka Saitama Cancer Center, SAITAMA, Japan

Single Port Colon Surgery-Experience with 500 Colonic Resections B. Vestweber Klinikum Leverkusen, LEVERKUSEN, Germany

Aims: Impressive outcomes concerning complete mesocolic excision (CME) and central vascular ligation (CVL) principles have been recently reported including in colon cancer. The Japanese Society for Cancer of the Colon and Rectum (JSCCR) recommends D3 resection (high ligation) for the advanced disease. Japanese D3 surgery is based on similar concepts to European CME with CVL. The techniques of standardized medial to lateral approach with high ligation of the vessels in laparoscopic colon cancer surgery aims at a specimen with intact anatomical layers and a maximum of lymph node retrieved. We reviewed the technical aspects and short-term outcomes of Japanese D3 Resection in standardized laparoscopic colectomy in single institution. Methods: Retrospectively obtained data from 223 patients of 127 stage II and 96 stage III colon cancers with R0 resection between 2007 and 2009 were analyzed. Patient data of two groups (laparoscopic colectomy and open colectomy) were compared. Laparoscopic colectomy (LC) was performed in 56 patients and conventional open colectomy (OC) in 167 patients. Results: The five years overall survival rates of OC group were 94.3% in stage II and 79.1% in stage III. None of patients of LC group died of cancer. The three year relapse-free survival (3yRFS) rates of stage II disease were 93.9% and 86.1% in LC group and OC group (p = 0.2215), respectively. The 3y-RFS rates of stage III were 85.1% and 71.1% in LC group and OC group (p = 0.1587). Distant metastasis occurred more frequently in OC group than in LC group (9.6% vs. 6.1% in stage II, p = 0.7270 and 21% vs. 8.7% in stage III, p = 0.2244). In two cases (1.2%) of OC group local recurrence occurred but there was no evidence of local recurrence in LC group. The number of lymph nodes retrieved was slightly higher in LC group than in OC group. Conclusion: We were able to reduce the rate of distant metastasis and local recurrence of stage II and III colon cancer by Japanese D3 resection similar to CME and CVL procedures. Also the survival improvement may be achieved for advanced disease by consequent application of the medial to lateral approach in laparoscopic colon cancer surgery with high ligation of the vessels.

Since laparoscopic colon resection could be established in surgical routine, there is a search for further reduction of the invasiveness. One acceptable way could be only one access instead of there or four ports and an additional incision for extraction of the specimen. We started with a prospective trial of single incision colonic procedures in 2009. The umbilicus or a potential stoma site was used for inserting the SILS-Port and also extraction of the specimen. Mainly benign colonic diseases were treated. Two surgeons started with those procedures. Now, ten surgeons are involved. The technique is standardized. Of 520 single port operations, 300 were because of diverticular disease, 89 of colon cancer, 55 of inflammatory bowel disease, 36 of colonic polyps, 15 single port transanal tumour resections (SPTTR), and some various procedures. The technique can be demonstrated in very short video clips. There were 249 male and 271 female patients. Mean operation time various significantly according to the different procedures; for anterior rectum/sigmoid resections because of diverticulitis mean 157 min (range 100–236 min). 37 (7%) were converted to open procedures. 89 (17%) of patients had postoperative complications. 18 (3.5%) anastomotic leakages, 32 (6.2%) wound infections. The SILS-technique is attractive because of cosmetic results using only one small incision, of 2.5–3.5 cm in the umbilicus, which often is no longer visible after one year. Other not visible incision (like vagina) create an additional trauma. The clinical data do not differ from most of the conventional laparoscopic trials. Despite some differences of instrument movements the procedure is not technically difficult and in our opinion the preferable method of laparoscopic colon surgery.



Pure Laparoscopic Anterior Resection: Natural Orifice Specimen Extraction Without Minilaparotomy S.C. Chang, T.L. Chen China medical university hospital, TAICHUNG, Taiwan

The Impact of Laparoscopic Surgery and Enhanced Recovery on Timing to Adjuvant Chemotherapy and Therefore Patient Mortality in Colorectal Cancer A.E. Hunter, G. Patrick, S. Wallis, J. Kynaston, N.K. Francis Yeovil District Hospital, YEOVIL, United Kingdom

Background: Since introduction of laparoscopic colectomy in 1992, it had become the trend of colorectal surgery. However, traditional laparoscopic colectomy need a minilaparotomy for specimen extraction and colon reconstruction. We performed laparoscopic anterior resection with nature orifice specimen extraction (NOSE) that can reduce the additional abdominal wound. The aim of this study is to introduce our technique and evaluate its feasibility and safety of short-term surgical outcomes. Patient and Material: Since Sep. 2011 to Sep 2012, patients with left side colon lesion were selected to perform laparoscopic colectomy in China Medical University Hospital. Inclusion criteria were location of colonic lesion below 40 cm from a.v and tumor size less than 4 cm. Exclusion criteria included visceral obesity, previous anal or vagina surgery and anal stenosis. Results: During this period, there were 30 patients undergoing laparoscopic AR with NOSE under the diagnosis of sigmoid colon cancer (n = 27), unresectable colon polyp (n = 2) and sigmoid volvulus (n = 1). Twenty patients were male and the other ten were female. Average age was 60.2y/o (range from 16 to 88-y/o). Most patients had no previous abdominal surgery, except two suffered from appendectomy and one received laparoscopic cholecystectomy. Our average operative time took 216 min (from 164 to 438 min) and estimated blood loss was about 30 ml. Specimen was retrieved by anus in 27 cases and by vagina in 3 cases. One cases was converted to open colectomy due to fecal contamination during operation. After operation, abdominal wound pain was uncommon and only 10 cases (33.3%) ever required Pathedine injection for pain control. Although there were 4 cases reporting positive ascites culture, none had clinical intraperitoneal infection symptom. Neither anastomotic leakage nor intraperitoneal abscess occurred in all patients. Median post-operative hospital stay was 4 days. Conclusion: Laparoscopic AR with NOSE had less postoperative pain and minimal operative complication. No intraperitoneal infection occurred in whole patients undergoing intracorporeal anastomosis. So this method is a safe and feasible for laparoscopic colorectal surgery and may be a good choice if the colon lesion was small.

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Aim: To establish whether enhanced recovery after surgery (ERAS) and a laparoscopic technique influences timing to adjuvant chemotherapy, and therefore mortality, in colorectal cancer patients. Method: Prospective data collection from 2004 to 2009 of all patients diagnosed with Dukes B or C colorectal cancer. Inclusion criteria were laparoscopic colorectal resection; enhanced recovery enrollment; requirement for adjuvant chemotherapy. Data outcome measures were length of hospital stay, timing to chemotherapy post-operatively, 3-year overall survival and disease-free survival. Results: One hundred and one consecutive patients were included in the study. Median age of patients was 68 years. Median length of hospital stay was 6 days (range 3 to 48) and median timing to chemotherapy was 54 days (range 27 to 267). Three-year overall survival of patients receiving chemotherapy was 77.2% (82.1% Dukes B and 75% Dukes C). Conclusion: Full implementation of ERAS and laparoscopic surgery for colorectal cancer has not reduced the time to receiving adjuvant chemotherapy. Further research is required to evaluate cause of delay in adjuvant chemotherapy for laparoscopic colorectal cancer patients within an ERAS programme to optimize quality of care and patient survival.


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Single-Port Laparoscopic Liver Surgery—170 Cases Review Y.K. You1, J.H. Han2, G.H. Na2, E.Y. Kim2, S.H. Lee2, H.J. Choi2, T.H. Hong2, S.K. Lee3, Y.C. Yoon4, S.J. Kim3, K.W. Kim5, I.Y. Park6, D.D. Rheu7, K.Y. Baek2, S.K. Park4, D.G. Kim2 1 The Catholic University Seoul St. Mary’s Hospital, SEOUL, Korea; 2 St.Mary’s Hospital, SEOUL, Korea; 4Daejeon St. Mary’s Hospital, DAEJEON, Korea; 5Incheon St. Mary’s Hospital, INCHEON, Korea; 6 Uijeongbu St. Mary’s Hospital, UIJEONGBU, Korea; 7Bucheon St. Mary’s Hospital, BUCHEON, Korea; 8St. Vincent Hospital, SUWON, Korea

Laparoscopic Versus Open Cholecystectomy for Gallbladder Lithiasis in Rural Morocco A. Majbar1, O. Benzekri2, S. Boulaaouane2, A. Fahimi2, A. Souadka1 1 Hoˆpital Ibn Sina, RABAT, Morocco; 2Hoˆpital la Marche Verte, MISSOUR, Morocco

Background: Single-port laparoscopic liver surgery has been performed sporadically. The aim of this study is to assess our experience with single-port laparoscopic liver surgery as one of the usual treatment modality for various kinds of hepatic diseases. Methods: We retrospectively review the medical records of 170 patients who performed singleport laparoscopic liver surgeries between Dec 2008 and Dec 2012 in the Catholic University Seoul St. Mary’s hospital. Results: 170 patients underwent single-port laparoscopic liver surgeries for variety of hepatic lesions. Of these, 87 were single-port laparoscopy-assisted right hepatectomy (right liver mobilization for donor right hepatectomy in living-donor liver transplantation). In 83 patients, various kinds of single-port laparoscopic liver resection were performed for hepatocellular carcinoma (n = 39), metastatic liver tumor (n = 18), intrahepatic duct stone disease (n = 9), cholangiocarcinoma (n = 5) and others (n = 12). For these patients, partial liver resection was carried out in 55 cases. 13 were left hepatectomy, 11 were left lateral sectionectomy, 4 were right hepatectomy. Two procedures were converted multiport laparoscopy due to instruments length limitation and ten were converted to open liver resection. There were no major perioperative complications in these cases. Conclusion: Single-port laparoscopic liver surgery seems to be a feasible approach for various kinds of liver diseases.

Aims: This study aims to compare, in a rural Moroccan hospital, outcomes (duration of stay and morbidity) and costs between laparoscopic and open cholecystectomy for gallbladder lithiasis. Methods: This is a non randomized prospective cohort analysis of consecutive patients who underwent cholecystectomy for gallbladder lithiasis in the provincial hospital ‘la Marche Verte’ in Boulemane province (Morocco) between January and December 2011. Two surgeons were working in the hospital at this period and the choice between open and laparoscopic approaches depended on surgeon’s skills. Duration of stay was calculated from time of surgery to time of discharge. Postoperative morbidity was assessed according to Clavien-Dindo classification. The cost was calculated by the addition of micro-costs to daily average cost, with the help of the hospital statistic unit. Results: In the period of study, 53 patients had laparoscopic surgery and 42 had laparotomy. There were no statistic differences between the two groups in terms of age, gender distribution, ASA classification and number of acute cholecystitis. Conversion rate to open surgery was 5.6% (three patients). Patients in the laparoscopic group had lower duration of stay (2.9 vs 4.7 days. p = 0.0001), lower serious complications (Clavien-Dindo score [ 1) (1.9% vs 14.3%. p = 0.04) and lower costs (162 euros vs 223 euros. p = 0.0001). Mortality was nul. Conclusion: Laparoscopic cholecystectomy for lithiasis has better outcomes and less costs compared to open surgery. The impact of these advantages is more important to rural patients. Laparoscopic cholecystectomy should be the standard of care for gallbladder lithiasis in patients in rural areas in developing countries.



Hydatid Recurrence After Surgical Treatment for Hydatid Cyst of the Liver H. Jerraya, M. Khalfallah, C. Dziri Charles Nicolle’s hospital, TUNIS, Tunesia

Our Experience of Minimally Invasive Treatment Of Choledocholithiasis M.Ye. Nychytaylo, P.V. Ogorodnik, O.M. Lytvynenko, A.V. Skums, A.G. Deynichenko, O.I. Lytvyn, V.V. Bilyaev, Ya.V. Romaniv National Institute of Surgery and Transplantology named by A.A.Shalimov, KIEV, Ukraine

Aim: This study aimed to identify the predictive factors of abdominal extra hepatic hydatid recurrence after surgical treatment for hydatid cyst of the liver. Methods: We retrospectively included all the patients operated on between January 1st 2008 and December 31st 2012, in the surgical unit ‘B’ of Charles Nicolle’s hospital (Tunisia), for hydatid recurrence. Sixteen men and 33 women, with a median age of 45 years, were included. For all patients, clinical variables, morphological and intra-operative characteristics concerning both the hydatid cysts previously treated and the recurrent cysts were collected. Surgical procedures were recorded as well as the immediate and long-term outcomes. Comparative studies were performed: ‘extra hepatic recurrence vs. No’, ‘peritoneal recurrence vs. No’ and ‘open approach vs. laparoscopic approach’. A univariate followed by a multivariate analysis were carried out to determine predictive factors of hydatid recurrence. Results: Comparative analysis showed that laparoscopic approach, segments II and III localization and specific postoperative complications during the first intervention were associated with a greater number of both peritoneal and extra hepatic hydatid recurrence. Multivariate analysis retained the laparoscopic approach as a predictive factor of both peritoneal recurrence (OR = 5.5, 95% CI = 1.56 ± 20, p = 0.008) and abdominal extra hepatic recurrence (OR = 3.54, 95% CI = 1.08 ± 11.49, p = 0.035). The comparison between laparoscopy and open approach for the treatment of hydatid cyst while respecting the intent to treat and using the method of extreme bias, showed that there was a tendency to treat hydatid cysts of segments II and III by laparoscopy when they were unique. Furthermore, specific post operative complications are more common after laparoscopic approach (p = 0.006) and hydatid recurrence times are shorter after laparoscopic approach (p = 0.003). On the other hand, the operating difficulties encountered during the intervention of hydatid recurrence are lower after a previous laparoscopic approach (p = 0.009). Conclusion: Laparoscopic approach for the treatment of liver hydatid cysts was associated with a higher rate of extra hepatic and peritoneal recurrence than open approach.

Since the introduction of laparoscopic techniques, the management of patients with choledocholithiasis is in a stage of evolution. Over a 19-year period, from 1993 to 2012, 2030 patients presented with common bile duct (CBD) stones and calculous cholecystitis. Double stage treatment of choledocholithiasis by way of laparoscopic cholecystectomy following endoscopic sphincterotomy and stone removal was performed in 1510 cases. The following endoscopic procedures were performed: mechanical lithotripsy—in 475 (31.5%), and removal of CBD stones with Dormia basket in 1035 (68.5%) cases. 520 patients underwent laparoscopic cholecystectomy and common bile duct exploration simultaneously. Transcystic approach for CBD exploration was performed in 299 cases, and trans-CBD approach in 221 patients. Procedure was completed with cystic dump clipping in 148 (28.5%) patients, with external bile duct drainage in 349 (67.1%), and by means of intracorporeal bile duct suture in 23 (4.4%) cases. The success rate of CBD stones removal by usage of double stage treatment was 94.6%, and complications occurred in 46 (3.0%) patients. Laparoscopic CBD exploration resulted in ductal clearance in 92.5%, complications occurred in 28 (5.4%), converted in 12 cases. There were no mortality. Thus laparoscopic CBD exploration and double stage treatment of choledocholithiasis are both acceptable in patients undergoing laparoscopic cholecystectomy.

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Intraoperative Endoscopic Sphincterotomy for Management of Choledocholithiasis A.R. Elgeidie, M. Elshobary, Y. Naeem Gastroenterology Surgical Center, MANSOURA, Egypt

Optimization of Near-Infrared Fluorescence Cholangiography for Open and Laparoscopic Surgery F.P.R. Verbeek1, B.E. Schaafsma1, Q.R. Tummers1, J.R. Van der Vorst1, C.I. Baeten1, B.A. Bonsing1, J.V. Frangioni2, C.J.H. Van de Velde1, R.J. Swijnenburg1, A.L.Vahrmeijer1 1 Leiden University Medical Center, LEIDEN, The Netherlands; 2Beth Israel Deaconess Medical Center, BOSTON, United States of America

Background/Aim: The intraoperative use of endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy (LC) is a safe, single-stage, minimally invasive option for the management of gallbladder stones (GS) and concomitant common bile duct stones (CBDS). This study aims to report a single center experience in the use of intraoperative ERCP during LC and to compare between two techniques of combined laparoendoscopic management, which are laparoendoscopic Rendez-vous technique (LC/LERV) and standard ERCP after the completion of LC (post-LC intraoperative endoscopic sphincterotomy (LC/IOES)). Patients and Methods: Patients with GS and suspected CBDS were included. They were divided into 2 groups; LC/LERV and LC/IOES. Both groups were compared for failure of endoscopic sphincterotomy/stone extraction, operative time, conversion rate, mortality/morbidity, and length of hospital stay. Results: Between October 2007 and December 2012, 276 patients with GS and CBDS were eligible for inclusion in the study. They were prospectively randomized into 2 groups; LC/LERV (N = 132) and LC/IOES (N = 144). There were no differences in preoperative parameters between both groups. There was a significant difference in operative time (shorter for LC/IOES). No difference was noted in success/failure rate, post-ERCP pancreatitis. Conclusions: Both Standard ERCP after the completion of LC and LC/LERV are valid singlesession management for CBD stones, but LC-ERCP may be preferred.

Aims: During laparoscopic cholecystectomy, common bile duct injury is a rare but severe complication. To reduce the risk of injury, near-infrared (NIR) fluorescent cholangiography using Indocyanine Green (ICG) has been presented as a novel method to visualize the biliary system during surgery. To date, several studies have shown feasibility of this technique with ICG being injected shortly prior to surgery, however, liver background fluorescence is a major problem. The aim of the current study was to optimize dosage and timing of ICG for NIR fluorescent cholangiography using a quantitative intraoperative camera system during open HPB surgery. Subsequently, these results were validated during laparoscopic cholecystectomy using a laparoscopic fluorescence imaging system. Methods: A total of 27 patients who underwent NIR fluorescence imaging during open HPB surgery were analyzed to assess optimal dosage and timing of ICG administration. ICG was intravenously injected at doses ranging from 5 to 20 mg at either 30 min (early) or 24 h (delayed) preoperatively. Results: Mean fluorescence intensity of the liver was 8923 ± 2143, 13941 ± 8110, 726 ± 758 and 929 ± 433 arbitrary units for the 5 mg/30 min, 10 mg/30 min, 10 mg/24 h and 20 mg/24 h respectively. Liver signal was significantly lower in the delayed imaging groups compared to the early imaging groups (p \\/i [ 0.05). Importantly, no difference in CBD signal was observed between the groups, resulting in a significant increase in the CBD-to-liver contrast ratio during delayed imaging, which was optimal in the 10 mg/24 h group (ratio: 2.38 ± 1.37; p \ 0.05). Next, the optimal doses found for early (5 mg/30 min) and delayed imaging (10 mg/24 h) were applied to 2 groups of 4 patients (n = 8) undergoing laparoscopic cholecystectomy. Similarly, in the 10 mg/ 24 h group liver signal was much reduced, which enabled optimal discrimination of the bile ducts from surrounding tissue. Conclusions: To our knowledge this is the first study comparing the effect on dosage and timing of ICG administration for intraoperative NIR fluorescence cholangiography. During delayed imaging, minimal liver background signal is observed leading to improved CBD-to-liver contrast ratios. A dosage of 10 mg administered 24 h before surgery seems optimal for NIR fluorescence cholangiography during both open and laparoscopic surgery.



Single-Incision Versus Three-Incision Laparoscopic Cholecystectomy for Complicated and Uncomplicated Acute Cholecystitis: A Retrospective Study S.H. Chuang1, P.H Chen1, C.M. Chang1, C.S. Lin2 1 Mackay Memorial Hospital, Hsin-Chu Branch, HSINCHU CITY, Taiwan; 2National Chiao Tung University, HSIN-CHU, Taiwan

Emergency Cholecystectomy; An Economic Evaluation of Practice at a Regional Hepatobiliary Centre N. Misra, N. Grimes, V. Kaliyaperumal, S. Staettner, G.J. Poston, S.W. Fenwick, H.Z. Malik University Hospital Aintree, LIVERPOOL, United Kingdom

Aims: This study is to evaluate the feasibility and efficacy of single-incision laparoscopic cholecystectomy (SILC) for complicated and uncomplicated acute cholecystitis comparing with threeincision laparoscopic cholecystectomy (3ILC). Methods: One hundred and eight patients were enrolled. They all underwent SILC or 3ILC for acute cholecystitis by a single surgeon in a period of 39 months. Patient demography, pathologic findings, clinical data and operative outcomes were recorded. The patients were divided into complicated and uncomplicated groups according to the pathologic findings. Intragroup and intergroup comparisons were analyzed. Results: The postoperative length of hospital stay (PLOS) was significantly shorter in SILC subgroup in both complicated and uncomplicated groups (p \ 0.01 and \ 0.05, respectively). The operative time, estimated blood loss, postoperative narcotic use, total length of hospital stay (TLOS), conversion rates and complication rates were similar in both SILC and 3ILC subgroups. The complicated group had longer operative time (p \ 0.05), longer PLOS (p \ 0.001) and higher conversion rate (p \ 0.05) compared with uncomplicated group. Conclusions: SILC with conventional instruments is as safe and efficacious as traditional laparoscopic cholecystectomy for both complicated and uncomplicated acute cholecystitis in experience hands. It benefits patients a faster postoperative recovery without increasing complication rate. A low threshold for conversion is vital to patient safety. Further prospective and randomized trials are anticipated.

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Introduction: The debate as to how to best manage patients presenting acutely with complications of gallstones continues—whether to consider early emergency surgery or not. Perceptions of increased risk and cost still persist about the early approach. We report on our experience from a regional hepatobiliary centre. Methods: A retrospective study was conducted of all patients admitted with acute biliary symptoms, proceeding to cholecystectomy between January 2008 and August 2011. Costing data were calculated for each patient, including all theatre consumables, drugs and calculated cost for length of stay on a surgical ward. A decision tree analysis economic model was created, using input data derived from the clinical study as well as the individual patient level costs. Categorical data were analysed using the Chi squared test. Results: Of the 1888 patients who had a laparoscopic cholecystectomy during this period, 89 had an early laparoscopic cholecystectomy (eLC) and 310 patients went on to have a delayed cholecystectomy (dLC). Overall median length of stay for the eLC group was 6 days, and for the delayed group was 7 days. The risk of emergency readmissions whilst on the waiting list was 13% with a median stay of this emergency admission of 4.5 days. Mean operating time was longer in the eLC group—120 min vs. 60 min (p \ 0.05). Post operative ERCP rates were 3% for the eLC group and 0% for the dLC group (p = NS), proportion of patients requiring intervention were 6% for the eLC group as opposed to 0% for the dLC group (p = NS). Total calculated cost was £2663 for eLC and £2513 for dLC. Conclusion: Early cholecystectomy on the index admission appears to be safe, with an overall length of stay shorter for early cholecystectomy. The difference in costs was minimal per patient. But with NHS tariff (being around £3650 for eLC and £2900 for dLC), the difference in net monetary benefit was around £700 per patient in favour eLC pathway. In a hospital conducting around 200 cholecystectomies per year on patients for acute biliary disease this could translate to a cost saving of over £140,000 per year.


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Endoscopic Total Thyroidectomy for Graves’ Disease—Indications and Results A. Nakajo, H. Arima, M. Hirata, Y. Kijima, H. Yoshinaka, S. Natsugoe Kagoshima University, KAGOSHIMA CITY, KAGOSHIMA, Japan

Lateral Lymph Node Dissection in Thyroid Cancer by a Minimal, Function-Preserving Approach G. Wolf, A. Bradatsch Medical University of Graz, Austria

Introduction: In management of Graves’ disease, surgery to remove the thyroid gland is a common treatment option for many of these patients. We select total or near-total thyroidectomy to avoid postoperative recurrence of hyperthyroidism. In Graves’ disease, our indication criteria for endoscopic thyroidectomy are as follows. 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 thyroid gland which estimated weight is less than 100 g. We perform the endoscopic thyroidectomy using Video-Assisted Neck Surgery (VANS). VANS is gasless precordial approach with anterior neck skin lifting method developed by Professor Shimizu, Nippon medical college. In this study, we retrospectively investigated 26 patients of Graves’ disease who underwent videoassisted neck surgery (VANS) to evaluate its advantages or disadvantages. Material and Method: From June 2007 to September 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 clear endoscopic view. In endoscopic surgery, patients tends to be able to recover early from the sense of disorder around the neck. In endoscopic surgery, patients tends to be able to recover early from a sense of incongruity around the neck; and that is more remarkable in young 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 (16–120.1), and 40 g (21.2–93.5) in the latter. The median operative time was 319 min (194–420) vs 201 min (150–319) respectively.

Aims: Differentiated thyroid cancer frequently presents as ‘Low-Risk’- i.e. young, ([ 40 yrs) patients with small tumors ([2 cm, pT1a/b-grades). Evisceration surgery for lymph node dissection in the lateral cervical compartment should be obsolete due to the fact, that not only central, but also lateral lymphadenectomy can be performed by Minimal-Invasive Cervicotomy as a ‘ functionpreserving’ procedure. Completeness of resection, surgical and oncologic guidelines and safety were investigated. Material and Method: A Cohort of 42 ‘ Low-Risk’-patients (age [ 40, papillary thyroid cancer [ 2 cm), eligible for Minimal-invasive Thyroid Surgery, with suspected or proven malignancy and with negative cervical ultrasound for lymph nodes, underwent thyroidectomy and central and lateral lymph node dissection without extension of the minimal cervicotomy. The group was compared to 50 patients, operated by lateral incision lymphadenectomy Results: 35 out of 42 patients with pT1a/b-tumours had negative nodes, with an average of 9 nodes resected (min. 7; max. 19) per compartment; 6/42 had positive central nodes (1 to 3) and 1/42 positive lateral nodes. 2/42, who were node-negative at operation, developed lateral node enlargement after 28 to 48 months, despite administration of Radio-Iodine, with necessity of reintervention. 40/42 are disease-free after 6 to 42 months. Lateral incision pT1b-patients (negative ultrasound) were node-negative in 35/50, with 8 cases of central and 7 of lateral node involvement. 1 had re-operation after 3 months. Conclusion: In case of negative ultrasound, if ‘prophylactic node dissection’ is indicated, evisceration surgery should be replaced by (muscle and skin-) ‘ function-preserving procedures’, as oncologic guidelines can be met by minimal-incision lymph node dissection too.



Comparative Experimental Research of Extracervical Endosurgical Approaches in Thyroid Surgery S.I. Emelianov, I.A. Kurganov, D.Yu. Bogdanov, M.Sh. Mamistvalov, M.V. Kolesnikov, O.A. Agafonov Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, MOSCOW, Russia

Influence of Preoperative Thyroid Gland Volume on Postoperative Complications in Minimally Invasive Thyroid Surgery for Benign Disease F. Billmann1, T. Bokor-Billmann1, E. Kiffner2 1 Universita¨tsklinikum Freiburg, FREIBURG IM BREISGAU, Germany; 2St. Vincentius Kliniken, KARLSRUHE, Germany

There are two major issues that give reason for search of novel accesses in endocrine neck surgery. Firstly, it is remaining at high level frequency of recurrent laryngeal nerve injury and postoperative hypoparathyreosis. Second issue is formation of postoperative visible scar in the anterior neck that causes patients dissatisfaction with the performed surgery and leads to reduction in quality of life in postoperative period. Objectives: To study feasibility and safety level for thyroid surgeries via extracervical endosurgical approaches. Compare variations of surgical approaches (transaxillary, axillary-breast, axillary-retroauricular). Materials and Methods: Research was conducted in experiment on 15 cadavers (5 operations for each approach). All cadavers had normal weight associated with asthenic, normosthenic and hypersthenic constitution. Height of the cadavers was 157–186 cm, weight—53–84 kg, mean BMI—22.7. Overall 8 left and 7 right-sided surgeries were performed. Gas pressure was maintained at 6–8 mmHg. Observance of the stage-by-stage approach principle irrespective of type of access included 5 stages: making skin incisions, creation of primary working space, access to the gland, hemithyroidectomy and removal of the specimen. Results: Mean operation time in isolated transaxillary approach comprised 147 min (125–170), with skin incision taking 11 min, creation of primary working space—34 min, access to the gland—41 min, hemithyroidectomy—46 min and extraction of the specimen—15 min. Average duration of the surgery via axillary-breast approach amounted to 108 min (96–117). Completion of stages took 9, 23, 29, 34 and 13 min on average. Mean time of surgery through axillary-retroauricular approach was 113 min (99–130) with stages taking 8, 26, 31, 37 and 11 min. Identification and preservation of both parathyroid glands was achieved in all 15 cases. Recurrent laryngeal nerve was visualized in 3 cases of 5 via isolated transaxillary approach, in 4 cases of 5 from axillarybreast approach as well as via axillary-retroauricular access. Further dissection confirmed preservation of nerve anatomic integrity in all cases. Conclusions: Endosurgical extracervical approaches in thyroid surgery in our experiment showed feasibility and safety. Axillary-breast and axillary-retroauricular approaches may be put into practice.

Background and Aim: Thyroid surgery is known to have few complications (eg. injuries to the laryngeal nerve, hematoma, seroma, hypocalcemia). This might be the reason why patients are concerned about adverse outcomes in this type of surgery. In open procedures, authors have described thyroid gland volume to be a preoperative independent risk indicator for postoperative complications. Since the use of minimally invasive procedures to the thyroid is limited by a threshold thyroid volume of about 35–45 mL, studies investigating preoperative thyroid volume in relation to postoperative complications are scarce. The aim of our study was to evaluate a possible link between preoperative measured thyroid gland volume and postoperative complications in minimally invasive surgery (MIVAT) for benign disease. Methods: Eighty nine (89) patients who had a minimally invasive video-assisted thyroidectomy (MIVAT) for benign thyroid disease, between January 2010 and November 2011, were identified in a prospective maintained institutional register of thyroid surgery. Patients met following criteria: (1) thyroid volume £45 mL, (2) no prior cervical surgery, (3) benign disease in the histopathology, (4) no associated parathyroid pathology, (5) no initial thoracic approach needed, (6) operation by an experienced endocrine surgeon, (7) minimum follow-up of 1 year. Age, sex, time of evolution, symptoms, preoperative thyroid gland ultrasound-volume, and presence of associated hyperthyroidism or thyroiditis were analyzed as risk factors for complications. The ?2 test and a logistic regression analysis were applied. Results: Complications were presented by 8 patients (9.3%), corresponding to 3 transient hypoparathyroidisms, 2 transient recurrent laryngeal nerve injuries, 1 cervical hematoma, and 1 cervical seroma. The variables associated with the presence of these complications as independent risk factors were hyperthyroidism (p = 0.033; RR = 2.3), and thyroiditis (p = 0.042; RR = 1.2). Thyroid volume up to 45 mL seems not to be an independent risk factor. Conclusion: In endocrine surgery units, MIVAT can be safely performed for benign thyroid disease up to a preoperative thyroid volume of 45 mL; the main independent risk factors for the development of complications are hyperthyroidism and thyroiditis.

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Diffuse Optical Reflectance Spectrometry in Thyroid and Parathyroid Surgery R.M. Schols1, N.D. Bouvy1, F.P. Wieringa2, L. Alic2, L.P.S. Stassen1 1 Maastricht University Medical Center, MAASTRICHT, The Netherlands; 2Van’t Hoff Program on Medical Photonics, TNO, EINDHOVEN, The Netherlands

A Critical Appraisal of Laparoscopic Pancreatic Enucleations: Right-Sided Procedures (Pancreatic Head, Uncus) are not MiniInvasive Surgery R. Costi1, B. Randone2, F. Mal2, S. Basato2, H. Levard2, F. Marchesi1, S. Cecchini1, B. Gayet2 1 Universta` degli Studi di Parma, PARMA, Italy; 2Institut Mutualiste Montsouris, PARIS, France

Introduction: In thyroid and parathyroid surgery iatrogenic injury of the parathyroid glands or the recurrent laryngeal nerve (RLN) is a possible complication that needs to be prevented. The visible contrast between thyroid and parathyroid tissue is delicate to observe. The aim of this pilot study was to collect in vivo spectral reflectance-signatures of critical tissue types encountered during thyroid and parathyroid surgery, and to assess the presence of useful spectral distinctive features that might be applied for future devices enabling intraoperative tissue-specific image contrast enhancement. Methods: Wide-band spectra (350–1830 nm, 1 nm resolution) were collected in vivo during thyroid and parathyroid surgery. Subjected to tissue type accessibility, on average 2 tissue types per patient were measured. For each tissue type, 5 spectra were recorded per site, covering 1–2 sites per tissue type. Mean tissue spectra were calculated for all measured tissue types. After visually comparing these mean spectra, two spectral signature features for all individual measured sites were extracted: 1. Slope within the 650–700 nm range; 2. Amplitude gradient between dominant local reflectance minimum and maximum within 1350–1830 nm. Results: In 10 consecutive patients 158 in vivo spectra were recorded on 32 tissue sites. Based on the mean diffuse reflectance spectra for thyroid, parathyroid and RLN, the estimated features for the three tissue types were plotted. Significance was tested using a paired Student’s t-test and by applying a Holm–Bonferroni correction (criterion set to p \ 0.025). Regarding feature 1 significance was found for parathyroid (p = 0.003) and RLN (p = 0.006). With respect to feature 2 RLN was significant (p = 0.001). Both investigated spectral features seem to offer added value to distinguish between the studied tissue types. Conclusion: To our knowledge, this study is the first to date to investigate in vivo spectral reflectance-signatures of critical tissues encountered during parathyroid and thyroid surgery, far beyond the spectral detection boundary of the human eye (i.e. the infrared light spectrum). Within the recorded spectral reflectance-signatures we identified two spectral features which may be used for further developments towards intraoperative image contrast enhancement and thereby facilitate differentiation of tissue structures, either during open or endoscopic surgery.

Background: Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few retrospective, small-sized studies show encouraging results, especially following enucleations performed for lesions located in the left part of the pancreas, but do not allow for an evaluation of feasibility and effectiveness. Methods: Outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected preoperative, intraoperative (operating time, blood loss, conversion) and postoperative parameters (morbidity—in particular pancreatic fistula—, hospital stay and late outcome). Moreover, outcome of patients undergoing right- (head/uncus) and left-sided (neck/body/tail) pancreatic enucleation was analysed separately and compared. Results: Since 1997 through 2010, 25 patients (15 females) underwent laparoscopic pancreatic enucleation for various affections. Three procedures (12%) were converted to laparotomy, mean operating time was 158 min, and mean blood loss was 106 ml. Overall morbidity was 56% and rate of pancreatic fistula 32%. Outcome differed between patients undergoing right- and left-sided enucleations, operative time being 178 vs. 132 min, morbidity 64% vs. 45%, and median hospital stay 26 vs. 9 days, respectively. Conclusions: The laparoscopic enucleation of pancreatic tumors is feasible and safe, with high success rate and no mortality, but significant morbidity. Differently from left-sided enucleations, laparoscopy seems to be useless in right-sided procedures. Since pancreatic fistula is still the main cause of long-lasting morbidity, only technological upgrades in pancreas section/management will enable a reduction in morbidity and hospital stay, thus maximizing the potential advantages of laparoscopy.



Tractional Injury of Recurrent Laryngeal Nerve: Results of Continuous Intraoperative Neuromonitoring (CIONM) in Swine Models H.Y. Lee1, H.Y Kim2, J.W. Bae2, J.Y. You2 1 Korea University Anam Hospital, SEOUL, Korea; 2Korea University Medical Center, SEOUL, Korea

Laparoscopic Adrenalectomy for Large Adrenal Tumors S.I. Emelianov, I.A. Kurganov, D.Yu. Bogdanov, M.Sh. Mamistvalov Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, MOSCOW, Russia; Nowadays size of adrenal tumor is considered to be one of the key factors for laparoscopic adrenalectomy.

Background: Recurrent laryngeal nerve (RLN) palsy is the most common and serious complication after thyroid surgery. Several studies have shown that routine identification of the RLN with or without intraoperative neuromonitoring (IONM) has decreased rates of permanent RLN palsy; however, unexpected RLN palsy still occurs, even though the visual integrity was assured and most nerve injuries were not recognized intraoperatively. Moreover, little is known about the biomechanical properties of RLN and limits of stretching that the nerve may undergo before structural changes occur. Also, the injury pattern of nerves under traction is poorly understood. The aim of this study is to evaluate the tractional injuries of RLN using a swine model via continuous IONM. Method: Thirteen living orally intubated pigs weighing 30 kg to 40 kg underwent tractional injury to the RLNs. During stretching of the RLN, continuous IONM were performed using EMG endotracheal tube and NIM 3.0 response system. Follow-up examinations were carried out for 7 days using continuous IONM, and then fresh swine RLNs were harvested. All nerves were stretched to failure in an MTS materials testing machine at a rate of 1 cm/min (strain rate of 0.5%/ s). Load deformation and stress–strain curves were determined. Histological examination by scanning electron microscopy of the stretched nerves and normal control nerves was performed. Results: The average structural diameter of RLN was 1.5 mm (range 1.2–2.0 mm). The average intraoperative tractional force at the time of loss of signals (LOS) in continuous IONM was 3.5 N (range 2–6 N). At postoperative day 7, we observed normal electromyography of RLNs using continuous IONM in all swines. After harvesting of RLNs, stress–strain curves were determined. The ultimate strain and tensile strength of the RLNs were 21.5% and 6.6 MPa, respectively. The swine RLNs have an in situ strain of less than 15%. And, histological analysis by scanning electron microscopy showed no abnormal structural findings in nerves which are strained by less than 15%. We could find that the reversible tractional injury might not induce the structural damage of the swine RLNs. Conclusion: Tractional injury of RLNs caused by force of over 3.5 N or strain of over 15% in swine models.

Objective: To define capabilities and study technical features of laparoscopic adrenalectomy in patients with large adrenal tumors (over 5 cm in maximal size). Materials and Methods: Our background of laparoscopic adrenalectomies for large adrenal tumors comprises 17 surgeries. All of them were performed through the lateral transperitoneal approach. Right adrenal tumors were observed in 12 (70.6%), left-sided lesions—in 5 (29.4%) patients. Nosological forms of adrenal lesions were: adenoma (8 cases), pheochromocytoma (6), cyst (2), aldosteroma in 1 case. Results obtained in the research group were correlated with the surgical results of the control group of 51 patients after laparoscopic adrenalectomy for small and mid-size benign adrenal tumors through the lateral transperitoneal approach. In the control group right-sided lesion was revealed in 34 (66.7%) patients, left adrenal tumor in 17 (33.3%) patients. Results: Size of the specimen removed in the research group averaged 64 ± 13 mm (52–87 mm in right and 51–69 mm in left adrenalectomy). Mean diameter of the tumor in control group was 36 ± 12 mm (15–50 mm). Duration of the surgery for the tumors over 5 cm amounted to 101.2 ± 15.29 min while for the tumors under 5 cm—70.8 ± 11.25 min. Increase of time spending was noted at the stage of central vein identification (by 72.9%), adrenal gland and tumor en bloc dissection (by 121.7%) and extraction of the specimen from the abdominal cavity (by 42.6%). Rate of complications in the research group was 11.8%. Complications included intraoperative splenic injury in 1 case due to difficulties while tumor dissection (managed laparoscopically) and progressive preperitoneal hematoma in trocar site in 1 patient removed surgically. No conversions in the research group were performed. Complications in the control group developed in 9.8% of cases: hepatic injury in 1 case, splenic injury in 1 patient (managed laparoscopically), postoperative reactive pancreatitis in 2 cases. In 1 case growing subcapsular splenic hematoma was revealed during the surgery that required conversion to conventional splenectomy. Conclusions: Laparoscopic adrenalectomy for tumors 5–8 cm in size is feasible, effective and safe procedure.

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S21



Laparoscopic Learning Curve as a Prognostic Factor in Sphincter-Preservation Surgery of Rectal Cancer: A Lesson from a High Volume Single Surgeon S.B. Kang, S.M. Lee, H.K. Oh, S.Y. Lee, M.H. Ihn, D.W. Kim Seoul National University College of Medicine, Seoul National University Bundang, GYEONGGI-DO, Korea

Prospective Study of the Advantages of Transanal vs Transumbilical Extraction of the Specimen During Single Port Left Colectomy S. Morales-Conde, G. Jimeńez, A. Barranco, I. Alarcoń, J. Can˜ete, A. Navas, C. Meńdez, JM. Cadet, FJ. Padillo, M. Socas Universitary Hospital Virgen del Rocio, SEVILLE, Spain

Background: The oncologic effect of surgeon’s learning curve is not reported in laparoscopic resection of rectal cancer although it is rapidly penetrating in surgical practice. We aimed to determine the oncologic effects of laparoscopic experience in laparoscopic sphincter-preservation surgery of rectal cancer. Method: Between May 2003 and Dec 2011, a total 385 patients who underwent laparoscopic sphincter-preservation for rectal cancer by a single surgical team (S.-B. K.) were included in the study. Cumulative sum (CUSUM) method for operative time was used to determine the cut-off point to achieve experienced level of performance. Patient demographics, perioperative factors, and the experience levels were analyzed. Kaplan-Meier method and Cox proportional hazard model were used to evaluate prognostic value of learning curve on 3 year disease-free survival (DFS). Result: The CUSUM analysis demonstrated a learning curve of 138 cases according to operative time (mean 229.9 ± 72.9 vs 198.3 ± 74.0 min; p \ 0.001). Age, sex, TNM stage according to learning curve period were similar except that low rectal cancer were more in the experience period (11.6% vs 27.9%; p \ 0.001). Estimated blood loss (231.9 ± 243.3 vs. 149.3 ± 135.6 ml; p \ 0.001), conversion rates (7.2% vs 1.2%; p = 0.003) and hospital stay (10.8 ± 7.2 vs. 8.5 ± 3.6 days; p \ 0.001) were less in the experienced period. The anastomotic leakage rates were similar according to learning curve (3.6% vs 1.6%; p = 0.370). On a median follow-up of 31 months (interquartile range: 17.7–59.8 months), 3 year DFS was higher in the experienced period (88.1% vs 94.3%; p = 0.036). The systemic recurrence rate was decreased (13.7% vs 3.2%; p = 0.0002) while local recurrence rate was similar (1.4% vs 1.2%; p = 0.847). In the multivariable analysis, surgical learning curve was an independent factor for 3 year DFS (HR: 0.38, 95% confidence interval 0.15–0.75, p = 0.008). Conclusion: This study has demonstrated that a learning period of laparoscopic surgery for rectal cancer jeopardizes oncological safety. We suggest that surgeons are prepared to minimize learning curve period for laparoscopic sphincter-preservation surgery of rectal cancer.

Aim: Benefits of a minimally invasive surgical approach have been demonstrated in prospective clinical trials, decreasing postoperative pain and obteining better cosmetic and same oncologic outcomes. Single port laparoscopic surgery tries to improve the results of conventional laparoscopic surgery. Since most of the morbidity related to the incision during single port approach is associated to colonic surgery we have start performing the extraction of the specimen through the anus. Transanal natural orifice specimen extraction is a step forward in order to avoid complications associated, as wound infections or hernias. The aim is to show that single port laparoscopic colonic surgery with transanal natural orifice specimen extraction is an alternative technique, reducing morbidity of the surgical wound. Patients and Method: We present our series of single port left colectomy, which include 31 cases. Surgery was performed using a SILS devices through a transverse transumbilical incision in all cases, but the extraction of the specimen was performed in 19 cases through the umbilicus and 12 through the anus. The data was analyzed prospectively in order to detect the morbidity of the surgical wound and other related complications to the surgery. Results: Both series were homogeneous, but was statically difference in the length of the incision, being larger when transumbilical incision was performed (32.3 mm vs 23.1). There was no difference in general complications, lengths of the specimen, margins and the number of lymph nodes. Regarding complication related to the surgical wound, 2 superficial infections, one seroma and one incisional hernia were identified in the group where the specimen was removed through the umbilicus, while no complications were found in those patients in whom the transanal extraction of the specimen was performed. Conclusions: Single port laparoscopic colonic surgery with transanal natural orifice specimen extraction is a safe procedure in selected patients and reproducible in the hands of expert laparoscopic surgeons achieving similar oncological results than conventional laparoscopic approach. The benefits over single port left colectomy with transumbilical extraction are that avoid enlarging the incision, what decreases the possibilities of developing a hernia, also decreasing the morbidity associated to the surgical wound.



How to Reduce the Rate of Postoperative Complications After Laparoscopic Rectal Resection J.I. Tanaka, E. Hidaka, F. Ishida, S. Mukai, Y. Wada, T. Omoto, Y. Takehara, D. Takayanagi, K. Nakahara, C. Maeda, S. Kudo Showa University Northern Yokohama Hospital, YOKOHAMA, Japan

Systematic Review of Studies Comparing the Effectiveness of Trans-Anal Microsurgery Against Redical Resection in the Management of Early Rectal Cancer S Sajid, P. Leung, L. Craciunas, T. Miles, M.K. Baig Worthing Hospital, WORTHING, WEST SUSSEX, United Kingdom

Aim: Anastomotic leakage is one of the most serious complications after total meso-rectal excision for rectal cancer (TME), and it can be the major cause of postoperative mortality and morbidity. The objective of the present study is to elucidate whether the use of a trans-anal drainage (TAD) can reduce the leakage rate and re-operation rate after TME. Methods and Patients: From April 2010 to December 2012, ninety consecutive patients undergoing TME for rectal cancer were investigated in a single-institution. Since January 2011 TAD has been placed for over 90% patients after TME. Those patients were divided into two groups, with TAD (45) and without TAD (45). Clinico-pathological factors, surgery-related factors, leakage rate and re-operation rates were analyzed. Results: TAD could reduce the leakage rate after TME from 12.8% to 5.1%, and the rate of reoperation due to major leakage was reduced from 60% to 0%. Conclusions: Trans-anal drainage after TME seems effective to reduce the rate of anastomotic leakage and also be able to reduce the rate of re-operation due to major anastomotic leakage.

Objective: The objective of this article is to systematically analyze the published trials comparing the effectiveness of trans-anal endoscopic microsurgery (TEMS) versus radical resection (RR) in the management of early (T1 and T2) rectal cancers. Methods: Published trials comparing the effectiveness of TEMS versus RR for T1 and T2 rectal cancers were analyzed using RevManÒ, and combined outcomes were expressed as odds ratio (OR) and standardized mean difference (SMD). Results: Ten trials (four randomized trials and six comparative cohorts) recruiting 942 patients were retrieved from the electronic databases. There were 445 patients in the TEMS group and 438 patients in the RR group. There was a trend towards higher risk of local recurrence (OR, 2.78; 95% CI, 1.42, 5.44; z = 2.97; p \ 0.003) and overall recurrence (OR, 2.01; 95% CI, 1.18, 3.42; z = 2.57; p \ 0.01) following TEMS compared to RR. However, the risk of distant recurrence (OR, 0.87; 95% CI, 0.41, 1.83; z = 0.37; p = 0.71), overall survival (OR, 0.90; 95% CI, 0.49, 1.66; z = 0.33; p = 0.74) and mortality (OR, 0.70; 95% CI, 0.29, 1.70; z = 0.79; p = 0.43) were similar in both groups. TEMS was associated with shorter operative time (SMD, -4.50; 95% CI, 6.14, -2.86; z = 5.38; p \ 0.0001), length of hospital stay (SMD, -2.53; 95% CI, -3.70, -1.35; z = 4.22; p \ 0.0001) and reduced risk of postoperative complications (OR, 0.19; 95% CI, 0.08, 0.44; z = 3.94; p \ 0.0001). Conclusion: TEMS is associated with higher risk of local recurrence but it is equivalent to RR in terms of mortality, overall survival and risk of distant metastasis. In addition, TEMS leads to shorter operative time, length of hospital stay and reduced risk of postoperative complications. Therefore, TEMS may be offered routinely to patients with T1 and T2 rectal cancer.

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Anastomotic Leakage After Laparoscopic Single-Port Sigmoid Resection: Combined Transanal and Transabdominal Minimal Invasive Management W. Brunner, S. Bischofberger, N. Kalak Hospital Rorschach/St. Gallen, Switzerland

Local Recurrence in Rectal Cancer: Is It Possible to Define the Profile of Patients Potentially Candidate to Develop It? S. Fernańdez-Ananıń, E.M. Targarona, M. Pezzatini, C. Balague´, M.C. Matıńez, M.P. Hernańdez, J. Bollo, J.L. Pallare´s, N. Freixas, M. Trias Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Introduction: Laparoscopic colorectal surgery has become the gold standard in the therapy of benignant and malignant pathologies of the large bowl. Anastomotic leakage is still a reason for laparotomy; to apply a diverting stoma or perform a Hartman’s procedure is common. Laparoscopic treatment of an early detected anastomotic leakage is not frequent and only few cases are described in literature. In our video we demonstrate a combined minimal invasive transabdominal and transanal treatment concept in patients with early detected anastomotic leakage. Method: Two consecutive patients developing an anastomotic leakage after single-port laparoscopic sigmoid resection for stage II/III diverticulitis (Hanson & Stock) were treated with a combined minimal invasive approach. Anastomotic leakage was diagnosed by triple contrast computed tomography on postoperative day 4 in patient one and on postoperative day 7 in patient two. Operative treatment was performed immediately on the same day without delay. Results: In both patients a combined transanal and transabdominal approach was performed. Diagnostic laparoscopy was performed and extensive faecal peritonitis could be excluded in both patients. Using a single-port device, transanal inspection of the anastomosis was performed. In both patients anastomotic tissue margins were vital and the leakage affected a quarter of the anastomotic circumference. Transanal stitches were performed to close the anastomotic leakage. Laparoscopic transabdominal irrigation was performed and two suction drainages were places in the pelvis. Postoperative antibiotic treatment and a gradual return to slid food were performed. Uneventful postoperative course in both patients. Conclusion: Combined minimal invasive transabdominal and transanal treatment of an early detected anastomotic leakage is feasible and safe. With this technique laparotomy and a stoma can be avoided.

Objective: Despite the introduction of new and improved surgical techniques and neoadjuvant therapy, local recurrence (LR) of rectal cancer is challenging. The percentage of RL in rectal cancer has decreased significantly since the introduction of mesorectal total excision and preoperative chemoradiotherapy, but still represents a major problem associated with high morbidity and a shorter survival. The objective of this study is to determine whether it is possible to define the profile of the patient that may potentially develop a RL after undergoing laparoscopic curative resection for rectal cancer. Material and Methods: The series consists of 297 patients with rectal cancer surgery at our institution laparoscopic approach with curative intent between January 1998 and December 2011. Data on demographics, medical history, surgery and medical treatment, the histological features of the tumor, the TNM, monitoring and development of RL were analyzed. The variables were divided two groups: ‘primary tumor Dependent’ (type of surgery, degree of tumor differentiation, TNM, presence of vascular/lymphatic invasion, margin status and distal radial and the mean interval between primary surgery and detecting local recurrence) and ‘no dependent of the primary tumor’ dependent’(sex, age, body mass index, conversion rate, duration of surgery). Results: 30 patients developed RL after curative laparoscopically resection of rectal tumor. The 9% were male and 10% female. The results showed a rate of 10.1% RL, similar to that reported in the literature. The mean age of all patients was 70 years (range 38–88) while that for patients presenting RL was 75 (range 45–88). The recurrence rate was 12.6% in the first period (1998–2007), dropped sharply to 4.6% in the second period (2008–2011). During the first period only 22% of patients received neoadjuvant therapy underwent change in the second period were 78% who received. We performed a univariate studio and a multivariate analysis. Conclusion: The combination of neoadjuvant QT-RT, amending anatomoclinical tumor with optimal total mesorectal excision, achieve together, decrease the rate of local recurrence in rectal cancer. The multivariate analysis showed as independent variables for RL the presence of vascular invasion and affected lymph node.



Waist/Hip Ratio is a Better Risk Factor for Conversion During Laparoscopic Colorectal Surgery Than Body Mass Index A. Kartheuser1, D. Leonard1, F. Penninckx2, H. Paterson3, D. Brandt4, C. Remue1, C. Bugli5, E. Dozois6, N. Mortensen7, F. Ris8, E. Tiret9, WHR Study Group10 1 Cliniques universitaires Saint-Luc, BRUSSELS, Belgium; 2 Gasthuisberg University Hospital, LEUVEN, Belgium; 3Western General Hospital, EDINBURGH, United Kingdom; 4Hoˆpital StJoseph, GILLY, Belgium; 5Plateforme technologique de Support en Me´thodologie et Calcul Statistique, UCL, LOUVAIN-LA-NEUVE, Belgium; 6Mayo Clinic, ROCHESTER, United States of America; 7 Oxford University Hospitals, OXFORD, United Kingdom; 8Geneva University Hospital, GENEVA, Switzerland; 9Hoˆpital Saint-Antoine, PARIS, France; 10Waist Circumference Study Group, BRUSSELS, Belgium

Transanal Endoscopic Microsurgery in Rectal Cancer Treatment: Is It Justified? J. Jotautas, P. Zeromskas, E. Poskus, S. Mikalauskas, K. Strupas Vilnius University Hospital Santariskiu Klinikos, VILNIUS, Lithuania

Aim: Obesity is commonly defined by body mass index (BMI) but in the recent literature it has not been a consistent predictive factor for conversion during laparoscopic colorectal surgery. Waist/Hip Ratio (WHR), being a more specific indicator for intra-abdominal fat, may be a stronger risk factor. Our study aimed to determine whether abdominal obesity, defined by WHR, is a better predictor of conversion than BMI. Methods: A prospective multi-centric international study was performed in patients undergoing elective colorectal surgery. WHR and BMI were derived from body weight, height, waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify adjusted risk factors for intra- and postoperative outcomes. Results: 1349 patients (mean age: 64.8 y ± 13.2; 754 males, sex ratio M/F: 1.3) from 38 centres in 11 countries, who underwent elective colorectal surgery were included. There were 761 (56.4%) laparoscopic procedures (conversion rate : 12.7%). Median BMI was 25.6 [13.7–50.0], and WHR 0.96 [0.49–2.42]. Intra-operative adverse events occurred in 204 (15.1%) patients, medical complications in 178 (13.2%), surgical complications in 240 (17.8%) [78 (6.3%) anastomotic leak; 67 (5.0%) abdominal wall complication (AWC)]. Mortality was 0.7%. BMI was associated only with increased risk of AWC (OR = 39.5, RR 1.1, 95% CI [1.05–1.14]). Increasing WHR significantly increased the risk of conversion (OR 15.7, RR 4.1, 95% CI [2.0–8.4]), intra- (OR 11.0, RR 3.2, 95% CI [1.8–5.9]) and post-operative surgical complications (OR 7.7, RR 2.0, 95% CI [1.1–3.5]) medical complications (OR 13.2, RR 2.5, 95% CI [1.3–4.6]), anastomotic leak (OR 13.7, RR 3.3, 95% CI [1.2–9.2]), reoperations (OR 13.3, RR 2.9, 95% CI [1.0–8.0]) and death (OR = 653.1, RR 21.8, 95% CI [5.5–86.3]). After multivariate analysis, WHR predicted intra-operative complications, conversion, medical complications and re-interventions, whereas BMI was a risk factor only for abdominal wall complications. Conclusions: BMI was not predictive for conversion during laparoscopic colorectal surgery. In contrast, WHR was a strong predictive factor for conversion and other key surgical outcomes, supporting its use in routine clinical practice and in future colorectal surgical risk estimation models for conversion.

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Aims: Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery and may represent a possible treatment modality for early rectal cancer. TEM allows locally to complete resection of early rectal cancer as an alternative to conventional radical surgery. Methods: This study was a retrospective review of medical records. Patients were treated with TEM procedures at a large tertiary-care university hospital in Vilnius, Lithuania, in 2003–2012 years. Out of 208 patients who underwent local excision with transanal endoscopic microsurgery, 67 (30.4%) patients with rectal adenocarcinoma were included in the study. In all cases complete full-thickness excision was attempted. Results: No patients received preoperative chemotherapy. Tumors were classified as pTis in 40 patients (58.8%), as pT1 in 17 (25%), pT2 in 9 (13.2%), and pT3 in 1 (1.47%). The median operative time was 65.6 min. ± 43.14 min. Loss of blood was minimal: 0–30 ml. Intra-operative perforation occurred in 3%. In 61 (91.1%) cases R0 and 6 (8.9%) RX resection could be performed. The postoperative course was without any complications in 99.6% of patients. The mean follow-up was 62.56 ± 30.52 months. 5 (7.5%) patients had local recurrence. The rate of local recurrence for patients with pTis tumors was 2 (5%), for pT1 was 1 (5.9%), for pT2 was 1 (11.1%) and for pT3 was 1 (100%). 5 patients with local recurrence were eligible for salvage surgery: 1 had radical salvage resection, 2 had repeated ?EM, and 2 refused surgery. Overall 5-year survival was 100% in all 57 patients with pTis and pT1 tumors. Conclusion: TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of selected early rectal cancers.


S23


O097 - Paediatric Surgery

Impact of the Patient’s Anatomic and Pathologic Features on Rectal Cancer Specimen After Laparoscopic Total Mesorectal Excision (TME) S. Fernańdez-Ananıń, E.M. Targarona, J.C. Pernas, D. Hernańdez, M.C. Matıńez, M.P. Hernańdez, F. Marinello, M. Trias Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Laparoscopic Gastrostomy is Safer Than Percutaneous Endoscopic Gastrostomy in Children: Results of a Systematic Review and Meta-Analysis N. Suksamanapun, F.A. Mauritz, D.C. Van der Zee, M.Y.A. Van Herwaarden-Lindeboom Wilhelmina Children’s Hospital, University Medical Center Utrecht, UTRECHT, The Netherlands

Background: TME is the current standard surgical technique for treatment of low rectal cancer. TME is a demanding procedure which difficulty increases when approached by laparoscopy. Previously we demonstrated that pelvic anatomy and tumoral features has an impact on perioperative outcome (conversion, op. time an morbidity (Ann Surg, 2008, 247:642), however the impact of patient’s anatomy and tumor features on the surgical specimen is not well known. Aim: To evaluate the impact of the patient’s anatomic and pathologic features on the quality of the rectal specimen after laparoscopic TME. Methods: A series of 88 consecutive patients submitted to laparoscopic TME for low rectal cancer were prospectively evaluated. Preoperatively, a pelvic MRI was performed and the following parameters were recorded: bony pelvic diameters, tumor and prostate volume and diameters, radial margin of the tumor to the visceral fascia and tumor height, as well clinical (age, sex and BMI) and surgical details (op time, conversion, blood loss). These data were correlated with the postoperative pathologic findings (mesorectum quality and circumferential margin (CRM). Univariate and multivariate analyses were performed (SPSS) to determine the predictive significance of variables. Results: The mean age was 68 yr. (28–87) and 53 patients (60%) were male. The mean tumor distance from the anal verge was 78 mm (10–120). BMI average was 26.3. Surgical procedures included 69 low anterior resection and 19 APR. Conversion rate was 21%. Mesorectum was type A in 60 cases (63%), B in % and C in %. CRM was negative in 84 % (n:74). Univariate analysis showed that CRM positivity was related BMI (p \ 0.02), op. time (p \ 0.04) and subsacrumpromontory diameter (p \ 002). Incomplete mesorectum was related to greater blood loss (p \ 0.01) and longer op. time (p \ 0.04). Multivariate analysis showed that BMI was independently predictive for CRM positivity and op. time and age were independent predictors of the mesorectum quality. Conclusions: Clinical and anatomic features impact on the quality of the specimen after laparoscopic TME. This information could be of interest for the adequate selection of laparoscopic patients or during the learning curve of surgeons, assuring to maintain the optimal quality of the surgical specimen.

Background: Nowadays gastrostomy placement is a minimally invasive procedure via either percutaneous endoscopic gastrostomy (PEG) or laparoscopic assisted gastrostomy (LAG). Both procedures are widely used in pediatric patients. However, no consensus exists on which type of approach is best practice in these patients. Aim: The aim of this study was to determine if PEG or LAG is the most effective and safe procedure in pediatric patients requiring a gastrostomy Method: A systematic review and meta-analysis was performed according to the PRISMAstatement. PubMed, EMBASE, and the Cochrane Library were searched to identify eligible articles. Results were pooled in meta-analyses and expressed as risk ratios (RR). Results: Our extensive literature search provided 2,342 articles. After title, abstract and full-text screening five original studies comparing PEG to LAG placement in children were identified. All studies had retrospective study designs. The completion rate (PEG 98%; LAG 100%) and time to full-enteral feeds (PEG 0.7 and LAG 0.8 days) of both procedures were similar. No studies reported data comparing the efficacy of feeding via the gastrostomy or its effect on developing gastroesophageal reflux (GER). Major complications, such as intraperitoneal leakage (RR 0.28; p = 0.36; after tube exchange RR 3.14; p = 0.28) and persistence of the gastrocutaneous fistula after removal of the gastrostomy tube (RR 0.94; p = 0.92) were as frequently encountered after both PEG and LAG. However, PEG was associated with significantly more adjacent bowel injury (RR = 5.55; p = 0.05), early tube dislodgement (RR = 7.44; p = 0.02), and complications requiring reintervention under general anesthesia (RR = 2.79; p = 0.0008). The risk of developing minor complications was similar after both PEG and LAG placement. Conclusion: This systematic review and meta-analysis demonstrates a lack in studies comparing the effect of PEG and LAG on the efficacy of feeding via the gastrostomy tube and postoperative GER. However, major complications such as adjacent bowel injury, early tube dislodgements and complications requiring reintervention under general anesthesia were significantly less frequent after LAG. Therefore, we conclude that LAG is the safest approach and should be the first choice in children requiring gastrostomy placement.

O096 - Oesophageal Malignancies

O099 - Day Surgery

Simultaneously Combining the Thoracic and Abdominal Phase in Oesophageal Cancer Resection: Results in 16 Patients C. Vercauteren, J. Lesaffer, S. Van Cauwenberge, B. Dillemans, H. Vanommeslaeghe AZ Sint-Jan AV, BRUGES, Belgium

True Day Case Rate of Laparoscopic Cholecystectomy in a High-Volume Specialist Unit and a Review of Factors Contributing to Unplanned Overnight Stay A. Solodkyy, N. Oswald, F. DiFranco, S. Gergely, A. Harris Hinchingbrooke Hospital, HUNTINGDON, United Kingdom

Aims: Oesophageal cancer surgery remains a surgical challenge. The high morbidity is partly caused by the extensive operative time. Minimally invasive techniques are introduced to reduce the peri-operative morbidity. Both laparoscopy and thoracoscopy have proven to be useful, but have always been used either separately or consecutively. In our new concept, two surgical teams perform the abdominal and the thoracic phase simultaneously. Methods: Prospective study to evaluate the technical feasibility and outcome of combining laparoscopy with thoracoscopy or thoracotomy for oesophageal cancer resection by two surgical teams operating simultaneously. Between January and December 2012, 16 patients (10 males, 6 females) were included. Mean age was 69.3 years (59–84). Eight patients (50%) received neo-adjuvant radio-chemotherapy. Indications were mid-oesophageal carcinoma (n = 6, 38%), distal oesophageal carcinoma (n = 5, 31%), gastro-oesophageal junction carcinoma (n = 3, 19%) and gastrointestinal stromal tumour (n = 2, 12%). Results: The abdominal phase was performed laparoscopically in all patients. Simultaneously, the thoracic phase was conducted either by thoracoscopy or thoracotomy. The thoracic access was leftsided in 7 patients (44%) and right-sided in 9 (56%). The thoracic phase started by thoracotomy in 5 patients (31%) and by thoracoscopy in 11 (69%). In 7 of these 11 patients a conversion to thoracotomy was necessary, still the abdominal team proceeded simultaneously. Mean operative time was 228 min (120–360). In 4 patients (25%) the operation lasted less than 3 h. Thirty day mortality rate was 0%. Two patients (13%) developed a postoperative pneumonia. There were 3 anastomotic leaks (19%) (POD 4, 6, 25). One patient was treated by gastroscopic clipping, the second had a thoracoscopic suturing of the leak and the third was treated with a covered stent by gastroscopy. Mean hospital stay was 14 days (9–20). Conclusion: The idea of combining simultaneously both the thoracic and abdominal phase in oesophageal cancer surgery has never been put in practice. Our series of 16 patients demonstrate the technical feasibility for this one-stage approach. This concept can significantly reduce the operative time. Further experience and studies are necessary to unlock other potential advantages. This innovation may be an important break-through in the era of oesophageal cancer surgery

Aims: Laparoscopic cholecystectomy (LC) is the gold standard treatment for gallstones. It is recommended that at least 75% of these operations should be day cases both for optimal patient outcomes and cost-effectiveness. There is ambiguity of data presentation in the literature between so-called ‘23-hour’ stay and true day cases. The aim of this study was to assess our own rate of true day case surgery and review factors that prevent same-day discharge. Methods: Prospectively collected data of all elective LCs performed in the Upper Gastro-Intestinal unit in a District General Hospital over a 30-month period. Emergency cases and those requiring common bile duct exploration (CBDE) were excluded. All patients had telephone follow-up with a surgical practitioner at 4–6 weeks after operation. Data included demographics, operative data and reasons for both planned and unplanned overnight stay. Results: 500 patients underwent elective LC during this time period. 3 patients were excluded from the study due to requiring CBDE, therefore 497 cases were analysed. Male: Female ratio = 1:4, mean age 52 (16–85). 438 (88%) patients were planned day case and 59 (12%) patients were booked for planned overnight stay. Overall 332/497 patients undergoing elective LC (67%) were discharged on the same day and 106/497 (21%) required unplanned overnight stay. Mean operating time was 69.7 (19–202) min. There were zero conversions to open surgery. Factors contributing to unexpected overnight stay included per-operative complications extending operative time, postoperative retention of urine and late operation end time. 30-day re-admission rate was \ 2%. Conclusions: In this study the true day case rate of 67% 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 cohort of patients. Many unexpected overnight stays are unavoidable but this may potentially be reduced by a combination of patient preparation, selection and operation scheduling. This will improve patient experience and also have a cost benefit by reducing the added bed pressures and financial costs of an overnight hospital stay.

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O100 - Flexible Surgery

O104 - Pancreas

Endoluminal Surgical Triangulation: Overcoming Challenges of Colonic Endoscopic Submucosal Dissection with a New Flexible Endoscopic Surgical Platform M. Diana1, H. Chung1, K.H. Liu1, B. Dallemagne1, D. Mutter1, N. Demartines2, J. Marescaux1 1 IRCAD-IHU, University Hospital of Strasbourg, STRASBOURG, France; 2University Hospital of Lausanne, LAUSANNE, Switzerland

Technique of Laparoscopic Pancreaticojejunal Anastomosis During Totally Laparoscopic Pancreaticoduodenectomy for Cancer P.S. Tyutyunnik MSUMD, MOSCOW, Russia

Aims: Colonic Endoscopic Submucosal Dissection (ESD) is particularly challenging due to the limited ability of conventional endoscopic tools to achieve a good traction and exposure. The AnubisScope’ (Karl StorzÒ, Germany) is a new prototype of flexible endoscopic surgical platform, equipped with two 4.3 mm and one 3.2 mm working channels and two intuitive handles to manipulate the instruments with surgical triangulation. The aim of this study was to evaluate the feasibility of the colonic ESD using the AnubisScopeÒ in a porcine model and to compare the intraoperative outcomes with conventional endoscopic tools. Methods: A total of 9 ESDs were performed on 3 swine, at 25, 15 and 10 cm above the anal verge using the AnubiScopeÒ by a laparoscopic surgeon with no previous experience with ESDs. To obtain some comparative data for porcine colonic ESDs, considering the lack of experience of the surgeon, a total of 16 ESDs were performed on 5 pigs using conventional endoscopic tools by an endoscopist with large clinical experience with ESDs. Main steps included for both groups: scoring the area, submucosal injection of glycerol, pre-cut and submucosal dissection. Outcomes measured were: total procedure time, dissection time and speed, size of the specimen, completeness of dissection, en-bloc dissection and complications. Results: No perforations occurred in the Anubis group while there were 8 perforations (50%) in the conventional group (p = 0.02). Complete and en-bloc dissections were achieved in all cases in the Anubis group. Mean dissection time for the completed cases was statistically significantly shorter in the Anubis group 32.3 ± 16.1 vs. 55.87 ± 7.66 min (p = 0.0019). Mean size of the specimen was significantly higher in the conventional group: 1321 ± 230 mm2 when compared to the Anubis group 927.77 ± 229.96 mm2 (p = 0.003), but mean dissection speed (surface/time) was similar: 35.95 ± 18.93 mm2/min and 23.98 ± 5.02 mm2/min in the Anubis and conventional groups respectively (p = 0.1). Conclusion: Endoluminal surgical triangulation offered by the AnubiscopeÒ allowed for safe and effective colonic ESDs in a porcine model in the hands of a laparoscopic surgeon with no previous experience. This device could facilitate ESDs for colonic tumors and should be comparatively evaluated by both surgeons and endoscopists

O103 - Radiology/Imaging Mesenteric Angiography for Gastrointestinal Haemorrhage: A District General Hospital Experience W. Al-Jundi, K. Madbak, M. Galea, G. Williams, A. Harikrishnan Doncaster Royal Infirmary, DONCASTER, United Kingdom Background: Mesenteric angiography and embolisation has become integral in the management of acute gastrointestinal (GI) bleeding. The aim of this study is to present our experience in mesenteric angiography and embolisation in a district general hospital. Patients and Methods: A retrospective review was performed on 57 consecutive patients (age, 42–91 years; 33 men) who underwent emergency mesenteric angiograms for acute GI bleeding at our institution between June 2007 and August 2012. Only 35 patients (62%) were admitted originally with GI bleeding. 24 patients (42%) had upper GI bleeding while 33 patients (58%) had lower GI bleeding. In 26 angiograms (46%), superselective embolisation was performed. The technical success, clinical improvement, 30-day rebleeding and mortality, complications, and subsequent requirement for surgical intervention were recorded. Results: Prior to mesenteric angiography, 22 patients (39%) and 31 patients (54%) had a bleeding scan and endoscopy, respectively. In 26 angiograms (46%), active bleeding was identified and superselective embolisation was performed (group X), while 31 diagnostic angiograms (54%) did not reveal any active bleeding (group Y). Within group X, technical success was achieved in all embolisations, clinical improvement was achieved in 17 patients (67%), 9 patients rebled (35%), and 4 (15%) underwent surgery. Within group Y, 13 patients continued to bleed (42%) and 4 underwent surgery (13%). Overall, 4 patients (7%) were transferred to a central hospital for further management and 30 day mortality rate was 23%. The causes of death were primary bleeding in 12%, rebleeding in 7% and medical comorbidity in 4%. Conclusions: Mesenteric angiography proved efficient in eliciting the bleeding source and achieving clinical improvement when embolisation was performed. With few patients requiring transfer to a central hospital, our experience supports the utilisation of mesenteric angiography in our district hospital.

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Pancreaticojejunal anastomosis is the most complicated and important part of totally laparoscopic pancreaticoduodenectomy (TLPDE). There are just a few ways how deal with pancreaticojejunal anastomosis and results are different. The question of the best technique for pancreatic anastomosis after totally laparoscopic pancreaticoduodenalectomy is still open. For today technique of TLPDE and in particular pancreaticojejunal anastomosis is not standardized in different hospitals. Objectives: To show in detail our technique of performing pancreaticojejunal anastomosis during TLPDE for patients with cancer of the head of the pancreas and periampullary area. Methods: From January 2007 to December 2012 40 pancreaticoduodenectomy were performed by totally laparoscopic approach. Pancreaticojejunostomy is done 3 different ways: (A) A two layer end-to-side anastomosis was done by using 2 semicircle running sutures (front layer) and separate precise sutures to the main pancreatic duct (inner layer). (B) A single layer end-to-end invagination anastomosis by using 2 semicircle running sutures. (C) A single layer end-to-side invagination anastomosis with interrupted sutures. Usually pancreaticojejunostomy performs by Biosyn 4.0. We do not use any tubes when performing the pancreaticojejunostomy. Results: From January 2007 to December 2012 40 patients undergone laparoscopic pancreaticoduodenectomy at the single center by totally laparoscopic approach. Insufficiency of duct-tomucosa pancreaticojejunal anastomosis was observed in 10% of patients. Insufficiency of invagination pancreaticojejunal anastomosis was observed in 5% of patients. The mean time of performing of duct-to-mucosa pancreaticojejunal anastomosis was 55.8 min (34–75 min). The mean time of performing of invagination pancreatojejunal anastomosis was 45.5 min (31–68 min). Conclusion: TLPDE is a safe procedure for patients with cancer of the head of the pancreas and periampullary area. The invagination pancreaticojejunal anastomosis provides more safety and less time for performing.

O105 - Oesophageal and Oesophagogastric Junction Disorder Changes in Quality Of Life Following Different Therapies of Gerd B. Babic, W. Breithaupt, G. Varga, T. Schulz, K.H. Fuchs AGAPLESION Markus Krankenhaus Frankfurt, FRANKFURT AM MAIN, Germany Introduction: The management of Gastroesophageal reflux disease (GERD) includes medical and surgical therapy. Quality of Life (QL) is an important parameter both in selecting patients for surgery as well as assessing the therapeutic results. Few prospective follow-up data is available in patients, in whom different therapeutic plans were administered. Aim: The aim of this study is to compare the development of QL, measured with the Gastrointestinal Quality of Life Index (GIQLI), in different groups of patients, in whom (1) laparoscopic antireflux surgery (LARS) was performed, (2) in whom LARS was suggested, but Protonpumpinhibitor (PPI) therapy was continued and (3) in whom PPI-therapy was suggested to be continued. Methods: Over 3-year period patients, referred to our specialized center for GERD, were investigated history and physical examination, endoscopy, esophageal manometry and 24-h-pHmonitoring. In patients with severe GERD a LARS was suggested. Most patients followed the suggestion and had LARS (group 1). Others with severe GERD wanted to continue PPI-therapy (group 2). Patients with mild GERD were suggested to continue PPI-therapy, which they did (group 3). After 5 years of follow-up the patients from all groups were re-examined. Results: Follow-up: 60 months (36–96); Group 1: n = 86; QL pre/post 93/118; Group 2: n = 27; QL pre/post 96/107; Group 3: n = 43; QL pre/post 106/113. Only after LARS a significant difference and improvement in QL could be reached (p \ 0.0005). Conclusion: The study clearly shows the significant benefit in QL of GERD-patients after LARS. As well, the study demonstrates, that patients, who did not undergo the recommended surgical treatment, were not able to improve their QL significantly. Patients, who were recommended to continue conservative treatment, remained in a similar QL-level.


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O106 - Oesophageal and Oesophagogastric Junction Disorder


Patient Satisfaction After Laparoscopic Nissen-Rossetti Fundoplication: 89% of Patients Would Undergo the Procedure Again M.J. Courtney, R.L. Teasdale, R.K. Jain, B.R. Gopinath University Hospital of North Tees, STOCKTON-ON-TEES, United Kingdom

Laparoscopic Wedge Fundectomy for Collis Gastroplasty Creation in Patients with a Foreshortened Esophagus J. Zehetner, S.R. DeMeester, A. Shahin, E.T. Alicuben, T.R. DeMeester USC, United States of America

Aims: Laparoscopic Nissen-Rossetti fundoplication (NRF) has been shown to effectively reduce gastro-oesophageal reflux, and is subsequently commonly performed throughout Europe. It can, however, cause side-effects which affect patients’ quality of life. This study aims to assess patients’ satisfaction with the outcome of their NRF, in particular whether they would have the procedure again. Methods: A retrospective search was performed of a prospective database to identify all consecutive patients who had NRF performed by a single surgeon at a single unit (a UK district general hospital) between November 2008 and June 2012. A questionnaire was created asking patients to rate their current reflux symptoms, whether they required anti-acid medication, and whether they would choose to have the procedure again (should they still have their initial symptoms). A separate healthcare professional then contacted the patients via telephone call, asking them to partake in the survey. Exclusion criteria included re-do operations, refusal to complete the survey, and inability to be contacted. Results: 99 patients underwent consecutive primary NRF in the quoted period; all were completed laparoscopically. 71 were contacted and willing to complete the questionnaire. Of the 99, two had re-do operations (neither of whom were contactable), one had a reversal (primary operation included), and one died (so excluded). Median time since the operation was 33 months (range 5–48 months). Compared to pre-operatively, 72% (51) rated their current reflux-symptom severity as = 2/10, 23% (16) as 3–6/10, and 4% (3) as 7–10/10. One patient was unsure. At time of contacting, 21% (15) were taking regular anti-acid medication, 4% (3) on an as-required basis, and 75% (53) were not needing any anti-acid medication at all. Overall, 89% (63) of patients said that they would opt to have the procedure again. Conclusions: This study provides supporting evidence that NRF improves reflux symptoms (94% experienced improvement in reflux symptoms at median follow-up of 33 months and 79% no longer required regular anti-acid medication). The results of this study will aid counselling and reassurance of patients regarding the risks and benefits of NRF, as 89% of post-operative patients were sufficiently satisfied to choose the operation again.

O108 - Oesophageal and Oesophagogastric Junction Disorder Obesity Does not Affect the Outcome of Laparoscopic Antireflux Surgery O.O. Koch1, A. Kaindlstorfer2, S.A. Antoniou3, G. Ko¨hler1, K. Emmanuell1, R. Pointner2 1 Barmherzige Schwestern Linz, LINZ, Austria; 2General Hospital Zell am See, ZELL AM SEE, Austria; 3University General Hospital of Heraklion, HERAKLION, Greece Background: Studies on the influence of obesity on the outcome of laparoscopic antireflux surgery are scarce and results have been controversial. The aim of this work was to study the outcome of laparoscopic antireflux surgery in patients with body mass index (BMI) [ or = 30. Methods: From our prospective database we analysed the outcome of all patients with a BMI [ or = 30 who underwent laparoscopic antireflux surgery (Nissen or Toupet fundoplication) between November 2007 and September 2011 in the General Public Hospital of Zell am See. Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry and multichannel intraluminal impedance monitoring (MII) data were documented preoperatively and postoperatively. Follow up was one year after surgery. Pre and post-procedure data were compared. Statistical significance was set with a p-value \ 0.05. Results: Forty patients were identified. Mean BMI was 32.3 (range 30.1–41.8). Mean GIQLI improved significantly from 91.0 (± 16.9) to 116.1 (± 15.4) points. Symptoms improved (p \ 0.01), the general symptom score decreased from 49.7 to 23.3 points. Objective data improved too, mean lower esophageal sphincter pressure increased, DeMeester and number of refluxes decreased significantly. Two patients had to be reoperated (5%), one because of recurrent hiatal hernia and slipping of the wrap, the other one because of persistent dysphagia due to a to tight closure of the wrap. Conclusions: Obesity does not adversely affect the outcome of laparoscopic fundoplication.

Background: The Collis gastroplasty provides a surgical solution for a foreshortened esophagus, but has been associated with complications (dysphagia, postoperative esophagitis). In an effort to reduce the high hernia recurrence rate documented in patients with paraesophageal hernias or complicated reflux-disease that have laparoscopic repair, we have used the wedge-fundectomy Collis gastroplasty when there was less than 3 cm of intra-abdominal esophagus. The aim of this study was to assess the outcome of a laparoscopic wedge-fundectomy Collis gastroplasty, focusing on complications, post-operative dysphagia, esophagitis, and frequency of hernia recurrence. Methods: Records of 2820 patients that had an anti-reflux procedure from 1998 to June 2012 were reviewed. We identified 150 patients that had a Collis gastroplasty; of them 85 patients had laparoscopic Collis gastroplasty using the wedge fundectomy technique. Patients were recommended to have an endoscopy and annual videoesophagrams postoperatively. Results: The median age of the 85 patients (42 m/43f) was 66 years (range 37–84). The Collis gastroplasty was performed as part of a primary procedure in 74 patients (24 GERD, 50 PEH) and during a redo-procedure in 11 patients (4 GERD, 7 PEH). A Nissen fundoplication was added to the Collis gastroplasty in 56 patients (66%), and a Toupet in the remaining 29 patients. No patient had a staple-line leak or abscess after Collis gastroplasty, and the median hospital stay was 3.5 days (IQR 3–4.5). At a median follow-up of 12 months, 93% of patients were free of heartburn or regurgitation symptoms. Dysphagia was significantly less common after surgery (pre-operative: 58% vs. post-operative: 16%, p \ 0.0001). New-onset dysphagia developed in 2 patients. A postoperative endoscopy was performed in 54 patients (median of 6 months) and erosions were seen in 4 patients (9%). A small (1–2 cm) recurrent hernia was seen at a median follow-up of 6 months in 2 patients (2.4%). Conclusion: The laparoscopic wedge-fundectomy Collis gastroplasty can be done safely, and is associated with low prevalence of new-onset dysphagia and esophagitis. Further, it may reduce hernia recurrence. The addition of a Collis gastroplasty to an anti-reflux operation is an effective strategy in patients with short esophagus, and more liberal use is encouraged.

O110 - Oesophageal and Oesophagogastric Junction Disorder Long-Term Outcome and Quality of Life After Laparoscopic Treatment of Large Paraesophageal Hernia F. Marinello, E. Targarona, C. Balague´, J.L. Pallares, A. Carrasquer, S. Fernańdez-Ananıń, M. Trias, N. Freixas Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain Aims: To evaluate the long-term results of the laparoscopic approach to paraesophageal hernia (PEH) based on hernia recurrence rate and its impact on quality of life. Methods: All patients who underwent laparoscopic repair for PEH between November 1997 and March 2007 with a minimal follow-up of 48 months were identified. In 2011, all available patients were scheduled for an interview and an esophagogram. The patients were asked about the existence and/or persistence of symptoms and an objective quality of life (QoL) test was administered (GIQLI). Results: A total of 77 patients underwent surgery. The amount of stomach contained within the sac of the PEH was less than 50% in 39 patients (50%), greater than 50% in 31 (40%), and in 7 patients (9.5%) was completely intrathoracic. A 360° PTFe mesh was used for reinforce the repair in 6 cases, and a polyethylene mesh in 3. In 2011, 55 of the 77 patients were available for interview (71%) with a mean follow-up of 107 months (range: 48–160). Forty-three patients (66%) were asymptomatic and 12 patients (34%) reported symptoms. An esophagogram was performed in 43 cases (78%). Recurrence was found in 20 patients (46%) consisting on small sliding hernias of less than 3 cm in length. Thirty-seven patients (67%) answered the QoL test, which scored a mean of 111 points (range: 59–137. NV: 144). Patients with objective anatomic recurrence had a QoL score of 110 (range: 89–132) as compared to 122 in the non-recurrent hernia group (range 77–138, p \ 0.01). Conclusion: Laparoscopic PEH repair is clinically efficacious in the long-term. It is associated with up to 50% of small anatomical recurrences with acceptable quality of life values.

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Anti-Reflux Surgery for Lung Transplant Recipients: A Study of Efficacy and Safety N. Abbassi-Ghadi1, S. Kumar1, B. Cheung2, A. Knaggs1, E. Zacharakis1, K. Moorthy1, M. Carby2, G.B. Hanna1 1 Imperial College London, LONDON, United Kingdom; 2Harefield Hospital, UXBRIDGE, United Kingdom

Laparoscopic Repair of Hiatal Hernias: New Classification Supported by Long-Term Results V.V. Grubnik, A.V. Malynovskyi Odessa national medical university, ODESSA, Ukraine

Aims: The aim of this study was to determine the safety of anti-reflux surgery for lung transplant recipients and assess its impact on lung function. Methods: We retrospectively collected and analysed data from all lung transplant recipients who underwent anti-reflux surgery at St Mary’s Hospital London, from July 2005 to May 2012. The indications for surgery were (i) histological evidence of gastro-oesophageal reflux aspiration on bronchoscopy biopsies or (ii) positive Impedance study with symptomatic reflux or a consistent decline/fluctuating forced expiratory volume in 1 second (FEV1). We studied the difference in mean FEV1 and rate of change of FEV1, pre- and post-fundoplication. The safety of anti-reflux surgery was determined by post-operative morbidity and mortality and compared to predicted figures, using a risk prediction model based on the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (P-POSSUM). Results: Forty patients underwent laparoscopic Nissen’s fundoplication. Overall, mean FEV1 declined from 2119 ± 890 ml to 1967 ± 1027 ml (p = 0.027), and mean rate of change in FEV1 improved from -2.42 ± 4.40 ml/day to -0.41 ± 1.77 ml/day (p = 0.007). Patients referred for fundoplication based on histological evidence of reflux (n = 9) showed an improvement in rate of change of FEV1 from -3.39 ± 6.00 ml/day to -0.17 ± 1.50 (p = 0.057), and those with positive Impedance study and consistent decline in FEV1 (n = 13) showed a significant improvement from -3.62 ± 3.35 to -0.74 ± 2.33 (p = 0.021). Actual and predicted morbidity was 2.5% and 31%, respectively. Actual and predicted 30-day mortality was 0% and 1.9%, respectively. Conclusions: Anti-reflux surgery is safe for lung transplant recipients and results in an improvement in the rate of change in FEV1 in spite of a decline in mean FEV1 post-operatively.

O112 - Oesophageal and Oesophagogastric Junction Disorder Is There a Need to Standardise Endoscopic Assessment Prior to Undertaking Laparoscopic Revisional Antireflux Surgery? R. Parameswaran, Y. Abdulaal, T. Lo, A. Hamouda, H. Ali, A. Nisar Maidstone & Tunbridge Wells Hospital, MAIDSTONE, United Kingdom Aims: In addition to other investigations, preoperative endoscopic assessment by an experienced endoscopist prior to laparoscopic revisional antireflux surgery (LRAS) is the single most important test. The aim of this study was to compare endoscopic assessment between operating surgeons (OS) and other endoscopists (OE) prior to undertaking LRAS. Methods: The study was a retrospective review of endoscopic assessments prior to LRAS performed between January 2007 and February 2012 in a high-volume centre. Results: 30 LRAS were performed with OS and OE undertaking 16 and 14 endoscopies respectively. OS reported wrap status (69%), recurrent herniae (33%), and oesophagitis (17%) whilst OE identified recurrent herniae (33%) but only reported wrap status in 7% (p = 0.03). Correlation with operative findings for OS and OE groups were 75% and 36% respectively (p = 0.35). Conclusions: Endoscopic assessment prior to LRAS seems to be more informative with a higher correlation with operative findings when performed by the operating surgeon compared to other endoscopists. Preoperative endoscopic assessment prior to laparoscopic revisional antireflux surgery needs to be undertaken by an operating surgeon with experience in performing antireflux surgery in a high-volume centre. There may be a need to standardise endoscopic assessments prior to revisional antireflux surgery to help better plan these complex operations.

Background: Recurrences after repair of large and giant hiatal hernia reach 42 %. Mesh repair may decrease failure rate but bears risk of oesophageal complications. Aim of study was to analyse long-term results of different types of laparoscopic hiatal repair depending on hiatal surface area (HSA). Methods: Results from 787 procedures was analysed (fundoplication–Nissen only). Patients were divided into 3 groups according to HSA measured as described by Granderath et al. (2007). I group—343 patients with HSA \ 10 cm2 (small hernias) whom primary crural repair was performed. II group—358 patients with HSA 10–20 cm2 (large hernias) whom primary crural repair (Subgroup A) or mesh repair (Subgroup B) was performed. Among the latter subgroup, on-lay fixation of polypropylene mesh Prolene or the original technique of sub-lay repair by lightweight partially absorbable mesh Ultrapro was used. III group—86 patients with HSA [ 20 cm2 (giant hernias) whom mesh repair was performed. They were divided into 2 subgroups based on method of repair. Results: No patients received preoperative chemotherapy. Tumors were classified as pTis in 40 patients (58.8%), as pT1 in 17 (25%), pT2 in 9 (13.2%), and pT3 in 1 (1.47%). The median operative time was 65.6 min. ± 43.14 min. Loss of blood was minimal: 0–30 ml. Intra-operative perforation occurred in 3%. In 61 (91.1%) cases R0 and 6 (8.9%) RX resection could be performed. The postoperative course was without any complications in 99.6% of patients. The mean follow-up was 62.56 ± 30.52 months. 5 (7.5%) patients had local recurrence. The rate of local recurrence for patients with pTis tumors was 2 (5%), for pT1 was 1 (5.9%), for pT2 was 1 (11.1%) and for pT3 was 1 (100%). 5 patients with local recurrence were eligible for salvage surgery: 1 had radical salvage resection, 2 had repeated ?EM, and 2 refused surgery. Overall 5-year survival was 100% in all 57 patients with pTis and pT1 tumors. In I group there were 3.5 % recurrence and 1.9 % dysphagia rates. In II group there were 7.1 % recurrence and 6.5 % dysphagia rates. In II group Subgroup A there were 11.9 % recurrence and 2.2 % dysphagia rates. In II group Subgroup B there were 5.2 % recurrence and 8.2 % dysphagia rates. Comparing recurrence rates I group vs II group Subgroup A, we obtained statistically significant difference in favor of I group. Comparing recurrence rates II group Subgroup A vs Subgroup B, we obtained difference in favor of Subgroup B. Original method of sub-lay lightweight partially absorbable mesh repair provides similar dysphagia rate as primary repair. In III group there were 19 % recurrence and 8.8 % dysphagia rates. Conclusions: We advice to routinely measure HSA and use relative classification. Optimal repair for small hernias is primary suturing. For large hernias, original technique of sub-lay lightweight partially absorbable mesh repair seems to be the best. For giant hernias original technique provides results corresponding to the literature, although these results require improvement.

O114 - Emergency Surgery Appendicular Tumours in the Era of Laparoscopic Appendectomy M. Salama, M.S. Inder, S. El-Masry, N. Mahmud, L. Falcone, A.R.H. Nasr, M. Aremu, I. Ahmed Our Lady of Lourdes Hospital, DROGHEDA, CO LOUTH, Ireland Appendicular Tumours are rare, but clinically important. They can be unexpectedly discovered in an acute situation, so decision making may be difficult. The safety of laparoscopic appendectomy for the management of incidentally discovered Appendicular Tumours has not yet been established. Since an increasing numbers of appendectomies are performed laparoscopically, it is crucial to determine the impact of this approach on management of Appendicular Tumours. Aim: To determine the incidence of Appendicular Tumours with the impact of laparoscopic appendectomy in our institution, and to compare it with what is reported in literature. Methods: Retrospective review of the record of 650 patients who underwent appendectomy in our institution in 2 years period [2009–2010]. The primary Appendicular Tumours where identified from the Histopathology records in 8 cases. The clinical data, demographic details, histological pattern, tumour size, location in the appendix, investigations, surgical procedures and follow-up details where extracted from the patient charts. Results: of 650 appendectomies, 8 cases where diagnosed as primary Appendicular Tumours. Out of these 8 cases: 5 cases had carcinoid tumours (4 female and 1 male; 3 had only laparoscopic appendectomy; 1 had laparoscopic appendectomy followed by laparoscopic right hemi-colectomy; 1 had laparoscopy converted to open appendectomy, followed by right hemi-colectomy) 2 cases had adenocarcinoma (1 male and 1 female; the male had laparotomy + right hemicolectomy followed by chemotherapy, then recurrence followed by debulking surgery and chemo radiotherapy. The female had laparoscopic right hemi-colectomy) 1 case had low-grade mucinous adenoma and had laparoscopic appendectomy. There was no incidence of any mortality or major complications. Conclusion: Appendicular Tumours are rare and often unexpectedly discovered. The laparoscopic approach is safe and feasible in most cases. There is no firm consensus regarding prognosis, treatment of choice and outcome.

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The Use of a Single Hem-O-lok Plastic Clip in Securing the Base of the Appendix During Laparoscopic Appendectomy S. Delibegovic University Clinical Center, TUZLA, Bosnia-Herzegovina

Laparoscopic Versus Open Appendectomy in Pregnancy: A Comparative Analysis K.A. Kuzmichev, I.E. Khatkov, S.M. Chudnykh, E.S. Aliev MSUMD, MOSCOW, Russia

Background: During laparoscopic appendectomy (LA), the standard technique in securing of the base of the appendix is by endoloop ligatures or a stapler. We demonstrated earlier the possibility of the application of a double plastic Hem-o-lok clip in securing of the base of the appendix. The application of only one plastic clip would, however, lower the cost of the laparoscopic procedure even further and shorten the surgery time. The objective of this prospective study was to evaluate the possible advantages of securing of the base of the appendix using only one Hem-o-lok clip. Patients and Methods: The 90 patients with acute appendicitis were randomly divided into three groups: In the first group, the base of the appendix was secured using one endoloop ligature, in the second group using a 45-mm stapler, and in the third group using only one nonabsorbable Hem-olok clip. The data collected included age, gender, surgery time, time of endoloop/stapler/clip application, hospital stay, costs associated with these, and intra- and postoperative complications. Results: There were no significant differences in hospital stay among the three groups of patients; but the average time of the operation was significantly longer in the endoloop group than in the stapler group (p = 0.002), whereas the endoloop and Hem-o-lok groups were not statistically different (p = 0.22). The time of application of the endoloop was significantly longer than for the stapler (p \ 0.0001) and Hem-o-lok (p \ 0.0001) groups. The time of application of the stapler was significantly shorter than that of the Hem-o-lok (p \ 0.0001). However, the price of one endoloop is €28.85, for the stapler is €230.7, and for one Hem-o-lok clip is €2.35. Conclusion: The use of Hem-o-lok clip is as safe as an endoloop and/or stapler; however, the time of the laparoscopic procedure using the Hem-o-lok was shorter in comparison with the use of an endoloop, with the cost of the procedure being the lowest.

Aims: to assess the outcomes of open and laparoscopic appendectomies in pregnant patients in a comparison and to analyze the features of laparoscopic appendectomy in pregnancy. Materials and Methods: in total, 68 women admitted to hospital with an acute abdomen during pregnancy were included to this study. Stages of gestation varied from 5 to 36 weeks, age differed from 16 to 40 years. From the total number of patients, 39 (57.3%) had the diagnosis of acute appendicitis confirmed, of acute cholecystitis—5 patients, acute intestinal obstruction—4 patients, acute mesenteric lymphadenitis—7 patients. 10 patients turned out to have no abdominal emergency. We have divided the patients with acute appendicitis into 2 groups: the first group (control, OA group) included 26 patients (66.7%) treated with open appendectomy (OA). The second (main, LA group) consisted of 13 (33.3%) patients who underwent laparoscopic appendectomy (LA). Results: There were no significant differences between the OA and LA groups in terms of age, gestation stage and hospital stay. The operating time was shorter in the LA group (35.8 ± 3.6 min vs. 67.8 ± 3.01 min in OA group). Postoperative pain was observed for 2 days in the OA group, while it was reduced to 1 day in the LA group and didn’t require narcotic analgesics. Also we compared the body temperature normalization rates, which showed less inflammatory process in the LA group—the temperature returned to normal limits on the 3rd day in 84.7%, on the 5th day— in 15.3% of patients of the LA group comparing to 38.5 and 61.5%, respectively, in the OA group. Conclusion: LA is associated with faster stabilization of homeostasis in pregnant patients and with better course of pregnancy in the postoperative period. Intra-abdominal pressure should be decreased to limit of 8–9 to 10–12 mmHg for the patients in 2nd trimester, as well as the first trocar insertion point should be moved to the subcostal area, while in the 1st trimester both pressure and insertion points could be conventional. LA could be a feasible, effective and safe alternative to open appendectomy in 1st and 2nd trimesters of pregnancy.



Suprapubic Single-Incision Laparoscopic Appendectomy: A Nonvisible-Scar Surgical Option D. Saavedra-Perez, O. Vidal, C. Ginesta, M. Valentini, J. Marti, G. Benarroch, J.C. Garcia-Valdecasas Hospital Clinic of Barcelona, BARCELONA, Spain

Adhesional Small Bowel Obstruction After Open and Laparoscopic Colorectal Surgery: A Prospective Longer-Term Study I. Capuano, L. Franceschilli, S. D’Ugo, S. Amirhassankhani, E. Picone, N. Di Lorenzo, A. Gaspari, P.P. Sileri Tor Vergata,, University, FRASCATI, Italy

Aims: At the present time, and given the increasing concern about body image, laparoscopic surgeons are faced with an increasing number of patients who want to conserve the umbilicus free of scars for cosmetic reasons. Single-incision laparoscopic surgery (SILS) using the suprapubic approach for appendectomy, while keeping the advantages of SILS through an umbilical incision, leaves the visible abdomen without scars. Moreover, insertion of an additional port in patients with retrocecal or purulent or gangrenous acute appendicitis requiring intra-abdominal drainage is avoided. This report describes the initial experience with suprapubic SILS appendectomy. Methods: Between September 2009 and September 2012, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of the authors’ institution and who agreed to undergo SILS appendectomy through the suprapubic approach were included in a prospective study. Demographics, clinical characteristics, and surgical outcomes were recorded. Results: A total of 30 patients with a mean age of 30 +- 3 years underwent suprapubic SILS appendectomy. The mean duration of the operation was 30 +- 5 min. Placement of a suction drain was necessary in four patients. The mean length of hospital stay was 2 +- 0.5 days. The operation was completed successfully in all patients, and conversion to either multiport or open surgery was not required. No intraoperative or postoperative complications occurred. In all patients, the appearance of the suprapubic wound was good at 7 days after surgery. Conclusion: Suprapubic SILS appendectomy offers better, cosmetically appealing results than the standard umbilical access. In case of retrocecal, purulent or gangrenous acute appendicitis, the view provided via the suprapubic approach makes access to and dissection of the appendix easier, and enables exteriorization of a drain without adding new lateral incisions.

Background: Open colorectal surgery (CRS) leads to high rates of adhesive small bowel obstruction (SBO) and incisional hernia development. We evaluated the cumulative incidence of access related complications in a cohort of patients who underwent open and laparoscopic CRS. Methods: We reviewed cases of elective or emergency CRS patients kept prospectively on a database and examined annually. Case notes were studied for SBO episodes requiring admission or reintervention. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, with peritoneal carcinosis, or with SBO secondary to local or peritoneal recurrence were excluded. Data were analyzed using Mann–Whitney U test and chi-square test. Results: From 01/03 to 01/13, 1084 patients satisfied our criteria and underwent elective (54.9%) or emergency (45.1%) CRS (64.1% open and 35.9% laparoscopic). Median follow-up was 51.9 months (range 0.2–111.0). Sixty-five patients (6%) experienced 85 SBO episodes and 23 required surgery (2.1%). There was a large variation in the time of first SBO occurrence, 42.8% occurred within 3 months, 28.2% between 3 and 12 months and 29% after 1 year. The risk of surgery at first admission for SBO 20.2% and the number of readmissions predicted the need of surgery. The risk of reoperation was greatest during the first year after CRS and steadily raised every year thereafter. SBO was higher after pelvic surgery or extensive resections compared to minor procedures (11.8% vs 2.5%). Likewise, SBO risk was higher after elective compared to emergency surgery (9.3% vs 5.8%), but similar after open compared to laparoscopic surgery (8.3% vs 6.1%). Any previous or additional surgery raised the overall risk of SBO from 4.5% to 13.8%. Conclusions: Colorectal surgery results in significant ongoing risk of SBO according to the colorectal type of procedure. This risk seems to be similar between laparoscopic and open approach, higher after elective surgery and for patients with previous surgery. Number of readmissions for SBO predicts the need of surgery.

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Comparison of Alvarado-Score and Clinical Judgement in the Diagnosis of Acute Appendicitis—Prospective, Randomized Trial E. Mań, G. La´za´r University of Szeged, SZEGED, Hungary

Appendicitis and Enterobius Vermicularis (E.V) M. Salama, T. Taha, M. Aremu, A.R.H. Nasr, I. Ahmed Our Lady of Lourdes Hospital, DROGHEDA, CO LOUTH, Ireland

Background: Acute appendicitis is the most common surgical condition that requires urgent intervention. Its differential diagnosis is very hard. The Alvarado-score is a clinical scoring system used in the diagnosis of suspected appendicitis. It contains 8 clinical signs and two laboratory values with a total 10 points. Aims: The aim of our study was to compare the diagnostic accuracy of the Alvarado-score to the clinical judgement for the prediction of acute appendicitis. Patients and Methods: Our prospective, randomized trial was carried out between 01.09.2011 and 31.09.2012. Patients over 18 years attending at our outpatient department with a suspicion for acute appendicitis were involved in our study. Patients were divided into two groups (A and B). The groups altered with the weeks. The management of patients in group A was based on the Alvaradoscore (points 1–4—emission, points 5–6—observation, points 7–10—acute operation). In group B the therapy was based on the decision of the chief surgeon (who didn’t know the Alvarado point of the patient). We compared the correlation of diagnosis to pathological finding in each group. Statistical analysis was made with SPSS 20 program. Results: A number of 233 patients were included in our study (group A n = 95, group B, n = 138), 66.5% of the patients was female (n = 155) and 33.5% was male (n = 78). The mean age was 34.6 years. The number of negative appendectomies was 8 in group A and 5 ingroup B (p = 0.084). In group B we found 20 patients who had positive pathological result, although depending on the Alvarado-score they did not need an operation. The specificity of the score was 88.91% vs. 94.8% of the clinical judgement. The score-pathological finding rank correlation was 0.523 (correlation was significant at the 0.01 level), the ROC analysis value was 0.837. We also specified the score with regression analysis, with the calculated new score system the ROC analysis result was 0.849. Conclusion: The Alvarado-score is a reliable tool in the diagnosis of acute appendicitis in the emergency room, but still the diagnostic accuracy of the traditional clinical judgement made by a chief surgeon is better.

Introduction: The presence of the parasite in the appendix was first reported by Fabrius in 1634. E.V found most commonly in the lumen of the appendix and can mimic acute appendicitis. The association between E.V infestation and acute appendicitis varies from 2.7 to 4.1%. Despite the role of E.V in appendicitis, it has been investigated for many years, and is still unclear and disputed. Aim: To determine the prevalence of E.V in surgically removed appendices and to assess the possible relation of the parasite to acute appendicitis Methods: A retrospective analysis of all the appendices that were removed in our institution over 2 years (Jan 2009–Dec 2010). Interval appendectomy and appendectomy as a part of other surgical procedures were excluded from our study. Results: 650 surgically removed appendices were examined. E.V was identified in 11 (1.7%) appendices from the patients with suspected acute appendicitis. The parasite was more frequently seen in histologically normal appendices (7/105) and less commonly associated with acute appendicitis (4 cases). 5 cases had laparoscopic appendectomy; 6 had open appendectomy. Male: 4 Female: 7 Conclusion: E.V can be seen in both normal and histologically-inflamed appendices. In our study, it was found more frequently in un-inflamed and histologically normal appendices. Surgeons need to be aware of this possibility especially while performing laparoscopic appendicectomies to minimize the risk of contamination.



The Laparoscopic Treatment of Perforated Duodenal Ulcer in Romania—A Multicentric Study F. Varcus1, F. Lazar1, M. Beuran2, C. Murgu2, St.O. Georgescu3, V. Sarbu3, D. Sabau3, C. Ciuce4 1 University of Medicine and Pharmacy, TIMISOARA, Romania; 2 Surgical Clinic, Emergency Hospital, BUCAREST, Romania; 3 Surgical Clinic 2, IASI, Romania; 4Surgical Clinic 1, CLUJ-NAPOCA, Romania

Choledocoscopy A.M. Maghiar, T.T. Maghiar, G.E. Dejeu, S. Suta Spitalul Pelican Oradea, ORADEA, Romania

Aims: The purpose of this retrospective study was to evaluate the results of laparoscopic treatment of the perforated duodenal ulcer (PDU) in 6 Romanian centres with great experience in laparoscopic surgery. Methods: Between 2006 and 2010, 186 patients (33 females and 153 men) aged from 18 to 77 years, were operated laparoscopicaly for PDU, by using 3 (61.0%), 4 (29%) or 5 (10.0%) trocars. Thirty nine (21.0%) of them had a weak, 120 (64.5%) an important and 27 (14.5%) a grave peritonitis. Procedures performed were: simple suture 74 (39.7%) patients, suture with epiplonoplasty 110 (59.1%) patients, only epiplonoplasty 1 (0.6%) patients, excision with suture 1 (0.6%) patients. All patients had abundant peritoneal cavity washing and tub drainage (1–3 tubs). Results: No patients received preoperative chemotherapy. Tumors were classified as pTis in 40 patients (58.8%), as pT1 in 17 (25%), pT2 in 9 (13.2%), and pT3 in 1 (1.47%). The median operative time was 65.6 ± 43.14 min. Loss of blood was minimal: 0–30 ml. Intra-operative perforation occurred in 3%. In 61 (91.1%) cases R0 and 6 (8.9%) RX resection could be performed. The postoperative course was without any complications in 99.6% of patients. The mean follow-up was 62.56 ± 30.52 months. 5 (7.5%) patients had local recurrence. The rate of local recurrence for patients with pTis tumors was 2 (5%), for pT1 was 1 (5.9%), for pT2 was 1 (11.1%) and for pT3 was 1 (100%). 5 patients with local recurrence were eligible for salvage surgery: 1 had radical salvage resection, 2 had repeated ?EM, and 2 refused surgery. Overall 5-year survival was 100% in all 57 patients with pTis and pT1 tumors. The interventions lasted between 30 and 120 min, with an average of 65 min, no mortality. Postoperative oral nutrition began after 24 h for 96 (51.6%) patients and after intestinal transit has restarted for 90 (48.4%) patients. The intestinal transit has restarted after 1–6 days (average 3.5 days), depending of the gravity of peritonitis. Complications were: parietal infections 2 (1.0%), duodenal fistula 1 (0.9%), abdominal abscesses 1 (0.9%), digestive haemorrhage 1 (0.5%) and duodenal stenosis 1 (0.5%). Hospitalization lasted between 2 and 13 days (average 6 days). In comparison with open techniques, patients had the same intravenous perfusions, less pain, less antibiotics, less dressings, less complications during postoperative evolution. Conclusion: Laparoscopic treatment of PDU is safe even in case of severe peritonitis, with less complications than in open procedures and faster patient’s recovery. Laparoscopic approach can be considered as golden standard to repair PDU.

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Laparoscopic cholecystectomy is the gold standard treatment of gallstones. But with increasing experience in laparoscopic surgery, laparoscopic common bile duct exploration has become a viable option, even a routine in some centers. The laparoscopic approach for common bile duct stones, confirmed or suspected, remains a complex and controversial topic. In addition cholecystectomy and open choledochotomy for stone extraction which is superior in results to ERCP, patients receiving laparoscopic cholecystectomy may benefit from intraoperative cholangiography and laparoscopic common bile duct stones extraction in one stage. This can be done by exploring the common bile duct by transcystic choledocoscopy or choledochotomy and choledocoscopy. We have an experience of 12 choledocoscopy’s for the extraction of common duct stones using the Dormia and Fogarty probes in the last 12 months. We used a flexible coledocoscope with one working channel and use a 10 mm trocar placed under the right costal margin. In 4 cases we used Kehr tube choledochal drainage for 2 weeks postoperatively, and in 6 cases we used primary coledocoraphia and subhepatic drainage. Postoperative evolution was favorable in all cases. In our experience laparoscopic choledochoscopy and common bile duct stone extraction is a feasible method of curative value at least equal to ERCP, but requires expertise in advanced laparoscopic surgery and specialized equipment (choledocoscope).


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Evaluation of the Optimal Timing of Laparoscopic Cholecystectomy for Acute Cholecystitis Focusing on the Severity Grade Y. Hara, M. Fujiogi, T. Nakano, G. Oda, M. Kawakami, Y. Nakajima, S. Shioiri, T. Kobayashi, M. Yasuno Tokyo Metropolitan Hiroo Hospital, TOKYO, Japan

Complications After Laparoscopic Cholecystectomy: Did We Reach Critical View of Safety. A Video Evaluation Study M. van Nieuwenhuizen, J.M.J. Schreinemakers, Z. Meyer, G.P. Van der Schelling, R.M.P.H. Crolla, A.M. Rijken Amphia Ziekenhuis Breda, BREDA, The Netherlands

Aims: The aim of this study was to evaluate the optimal timing of surgery for early and delayed laparoscopic cholecystectomy for acute cholecystitis focusing on the severity grade. Methods: From January 1, 2006 to December 31 2012, 94 patients underwent laparoscopic cholecystectomy for acute cholecystitis. 67 patients were classified as mild (grade I) acute cholecystitis, and 27 patients as moderate (grade II) based on the Tokyo guidelines. Patients who have bile duct stones simultaneously were excluded. There were no patients classified as severe (grade III) choelcystitis. Each patients of grade I and II cholecystits were compared between the timing of surgery. Results: Number of the patients who underwent surgery within 3 days, between 4 to 14 days and after the second week from symptom onset were 9, 32 and 26 for each in the group of grade I, and 3, 14 and 10 for each in the group of grade II. There were no differences in the operating time, blood loss, the rate of conversion to open surgery and the postoperative hospital stay between the period of operation both in the group of grade I and II. Meanwhile, total hospital stay was significantly (p \ 0.01) shorter in the earlier operation group in the both grade. Conclusions: Both for the grade I and II cholecystitis, earlier operation within 72 h could reduce the hospital stay without increasing the risk of complication. Although delayed surgery could be safe similarly with earlier one even in the grade II cholecystitis, it might increase the total hospital stay.

Background: Achieving the critical view of safety (CVS) before transection of the cystic artery and cystic duct is one of the most important ways to reduce biliary duct injury in laparoscopic cholecystectomy. We conducted a study to determine whether the requirements of CVS were obtained on video of patients with a complicated laparoscopic cholecystectomy. Methods: All consecutive patients, who had undergone a completed laparoscopic cholecystectomy for symptomatic gallstone disease between 2009 and 2011, were included. The videos of the operations of all patients with complications were reviewed and rated by two researchers and two gastro-intestinal surgeons independently. The reviewers answered consecutive questions about the items of CVS. Results: Eleven hundred and eight consecutive patients who had undergone a laparoscopic cholecystectomy were analyzed. Eighty-nine of the 1108 (8.6%) patients developed complications, 28 were male and 70 were female, with a mean age of 51 years. Sixty-six surgical videos were available for analysis. Nineteen patients (1.7%) had bile duct injuries. Six patients (0.6%) had a major bile duct injury, type B, D or E injury. According to the operative note of the 65 patients, in 80% CVS was reached. However, according to the reviewers of the videos in only 10.8% CVS was reached. In 89.2% more than one item of CVS was not reached. In case of biliary injuries, in none of the patients CVS was reached. Conclusion: We conclude that in complicated cases, CVS is reached in only few cases. Evaluating surgical videos of complicated laparoscopic cholecystectomy cases is important because it gives insight in the cause of complications and can and should be used to improve the technique.



Laparoscopic Common Bile Duct Exploration - Experience of 269 Patients with Common Bile Duct StonesB. Sutedja Gading Pluit Hospital, JAKARTA, Indonesia

Day Case Laparoscopic Cholecystectomy is Safe in Obese and Morbidly Obese Patients N. Misra, G. Singh, G. Sunderland, M. Shrotri University Hospital Aintree, LIVERPOOL, United Kingdom

About 10% among the patients with symptomatic gallstone disease have common bile duct stones. We report our experience of Laparoscopic Common Bile Duct Exploration (LCBDE) with Common Bile Duct (CBD) stones. During the period from January 1998 until December 2012, LCBDE was done in 269 patients (ps) with CBD stones in our two hospitals (Pluit Hospital and Gading Pluit Hospital in Jakarta, Indonesia), male: 156 ps, female: 113 ps, ages between 17–92 years. The pre-operative diagnosis was done based on Labor Finding, supported by US and MRCP examination. In 63 of the patients (23%) the LCBDE was done via transcystic approach, the other 206 ps (77%) via transcholedocal exploration with T tube (242 ps) or primer closure (17 ps). The operation time: 90–225 min. Post op. hospital stay: 2–14 days. Conversion to open CBDE: 8 ps due to bleeding (2), severe adhesion (3) and impacted stones (3). Retained stones: 3 ps. Complication: bile leakage (4), T tube dislocation (2), subphrenic abscess (2) and sepsis (2). There were 3 death cases: sepsis (1) and irreversible hepatic failure (2). Conclusion: Laparoscopic Common Bile Duct Exploration for CBD stones is feasible and save with the advantages of the minimally invasive surgery, but advanced laparoscopic facility and proper training for surgeon is needed to achieve the good result.

Introduction: Between 2009 and 2010, more than 63,000 gall bladders were removed laparoscopically in the UK, 12,000 as day cases. A Cochrane review in 2008 recommended the day case approach as a safe and effective intervention, but expressed reservations about its safety in obese patients. Many units consider obesity and morbid obesity as a contraindication to day case cholecystectomy. Methods: A prospective database of a single surgeon’s experience with day case cholecystectomy between 2005 and 2011 was interrogated. Primary endpoints were extension to overnight stay and secondary endpoints were operating time and immediate and delayed post-operative complications. Outcomes for categorical data were analysed using the Chi squared test. Results: 179 patients were identified. 102 had a BMI between 18.5 and 29 (normal BMI–nBMI), 50 patients had a high BMI (hBMI) in the obese range (30–39), and 27 patients were morbidly obese (moBMI). There was a non significant increase in the percentage of patients who had an extension to overnight stay from nBMI to the hBMI and moBMI cohorts—14–16 and 22% respectively (p = 0.89 and 0.43). Mean operating time was equivalent between all groups (between 45 and 56 min). Immediate post-operative complications were more common in nBMI (12/ 102–11.7%) than the hBMI group (3/50–6%), but not the moBMI group (4/27–15%), but this was not significant (p = 0.35 and p = 0.92). There was a higher rate of delayed complications in the hBMI group (24/50; 48%; p \ 0.01)), but not the moBMI group (5/27; 18.5%; p = 0.65). The most common delayed complication was wound infection. There were no conversions to open operation in either of the groups. Conclusion: Laparoscopic cholecystectomy is a safe and effective procedure in the day case setting for patients who are obese, and morbidly obese. There is a significant increase in trend for minor complications, but not for serious complications. The percentage of patients completing their stay as a day case was similar between non-obese, obese and morbidly obese patients.

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Intraoperative Imaging for Laparoscopic Anatomical Hepatectomy Using Indocyanine Green (ICG) and FluorescenceImage Laparoscope H. Inagaki Osuga Hospital, NAGOYA, Japan

Novel Technique for Pure Laparoscopic Hepatectomy in Semiprone Position Using Dual Handling Technique with Bipolar Irrigation System T. Ikeda, Y. Maehara Kyushu University, FUKUOKA, Japan

Introduction: Mapping of the liver segment is extremely useful for anatomical liver resection. Conventional hepatic segment identification requires the puncture of segmental portal branch under the intraoperative ultrasonography and stain by blue dye injection. This technique is easy for open surgery, however, difficult in laparoscopic surgery. Recently, visualization of the hepatic segment by using indocyanine green (ICG) and fluorescence-image laparoscope was reported. Therefore, we introduced this new technique for laparoscopic anatomical hepatectomy. Patients and Methods: We performed 3 cases of laparoscopic hepatectomy using ICG fluorescence imaging. Identification of resection area is confirmed by injecting ICG into the segmental portal branch with the fluorescence-image laparoscopic observation. After the hepatectomy was completed, ICG was administered intravenously to confirm the cutting surface bile leak. Patient 1 was 50 y/o female with metastatic liver tumor and underwent pure laparoscopic central segmentectomy. Patient 2 was 24 y/o male with metastatic liver tumor of neuroendocrine carcinoma and pure laparoscopic S7 sub-segmentectomy was performed. Patient 3 was metastatc liver tumor of rectal cancer and partial hepatectomy was performed. Results: In patient 2, segment 7 was detected as bright area by injecting ICG to the S7 portal branch. The resectional line of the parenchyma could also be confirmed and intraoperative visualization of the segmental line was possible. In all three cases, we could visualize the sectional image of bile ducts on the cutting surface and there were no bile duct leakage to ligate. No postoperative bile leaks were occurred. In Case 1, we could not puncture the segmental branch because of her obesity. There were no complications related to the ICG injection. Conclusions: For the pure laparoscopic hepatectomy, fluorescence imaging of ICG is considered to be useful technique as visualization of resectional segment and bile leak test after the hepatectomy.

Objective: To evaluate the safety and usefulness of laparoscopic liver resection in the semi-prone position in patients with tumors in the anterosuperior and posterior segments. Background: Laparoscopic liver resection is a common treatment for hepatic tumors in the lower edge and lateral segments. Patients with tumors in the anterosuperior and posterior segments often undergo open surgery and major hepatectomy. We developed a novel method of performing laparoscopic liver resection in the semi-prone position using dual handling technique and bipolar irrigation system. Methods: Of 135 patients who underwent laparoscopic liver resection at our center from June 1994 to June 2012, we retrospectively studied the patients with tumors in the anterosuperior and posterior segments. Patients who underwent surgery before July 2008 were placed supine, and patients who underwent surgery from July 2008 were placed semi-prone. Results: Seven of 40 patients (17.5%) who underwent surgery before July 2008 had tumors in the anterosuperior and posterior segments, compared with 58 of 94 patients (47.9%) who underwent later surgery (p \ 0.001). There were no conversions to open surgery, reoperations, major complications, or deaths. The semi-prone group had a significantly higher proportion of patients who underwent partial resection or segmentectomy of segment 7 and 8, lower intraoperative blood loss, and shorter hospital stay than the supine group (all p \ 0.05). Postoperative complication rates were similar between groups. Conclusions: Laparoscopic liver resection in the semi-prone position is safe, and increases the number of patients who can be treated by laparoscopic surgery without increasing the frequency of major hepatectomy.



Is It Possible to go Beyond the Golden 72 Hours Limit for Early Cholecystectomy for Acute Cholecystitis? L. Degrate, A.L. Ciravegna, M. Luperto, M. Guaglio, M. Maternini, M. Garancini, L. Gianotti, F. Romano, F. Uggeri San Gerardo Hospital, MONZA, Italy

Laparoscopic Cholecystectomy in Acute Gallstone Pancreatitis in Index Hospital Admission: Feasibility and Safety A.K. Sangrasi, A.A. Laghari, M.R. Abbasi, K.A.H. Talpur, J.N. Qureshi Liaquat University of Medical & Health Sciences, HYDERABAD, Pakistan

Background: Early laparoscopic cholecystectomy (ELC) is considered the treatment of choice for patients with acute cholecystitis (AC). The optimal timing of ELC is controversial without consensus about the cut-off time of the acute period. Aim: To verify the management of patients admitted with AC and their outcome after surgery. Methods: All patients undergoing cholecystectomy for AC from 2006 to 2012 were stratified into two groups: IAC (initial admission cholecystectomy) and DC (delayed cholecystectomy). A subgroup of patients undergoing cholecystectomy within 72 h of symptoms (immediate cholecystectomy, IC) was furtherly defined. Results: 316 consecutive patients were analyzed. IAC group included 262 patients (82.9%), DC group 54 patients (17.1%). The two groups were not different for conversion rate, operation’s length and complication rates, but the total length of hospitalization was longer in DC patients (p = 0.001). IC group included 66 patients (20.9%), that resulted to be comparable to IAC patients for conversion rate, length of operation, postoperative morbidity and postoperative hospital stay. Conclusions: The timing of cholecystectomy for AC within the initial admission does not influence the conversion rate nor the postoperative morbidity. The golden 72 h should not be considered a limit to perform LC, provided that the surgical operation is carried out during the initial hospital admission.

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Aims: Acute gallstone pancreatitis is quite common throughout the globe. Conventionally definitive cholecystectomy has been delayed in index hospital admission. Since the last decade timing of cholecystectomy is gradually shifting towards the earlier phase of disease and currently gallstone pancreatitis is being evaluated as a further indication for laparoscopic cholecystectomy. There is also great concern regarding compliance of patients for definitive surgery due to poverty, ignorance and illiteracy in developing countries. The aim of this study was to assess the feasibility and safety of laparoscopic cholecystectomy as a definitive treatment in patients with mild and resolving gall stone pancreatitis. Methods: This was a prospective study from July 2009 to June 2012. Patients were diagnosed by clinical examination, biochemical tests, ultrasonography and contrast enhanced CT. Patients with mild form of the disease (Ranson Score B 3) and who showed clinical improvement were offered laparoscopic cholecystectomy in index hospital admission. Those who were unfit for surgery were referred for endoscopic sphincterotomy. Common bile duct stones were excluded preoperatively. Results: A total of 38 patients were admitted with acute gallstone pancreatitis in the study period. The mean age of patients was 43.6 years with male to female ratio of 27/9. 22 (57.8%) patients were selected for laparoscopic cholecystectomy and procedure was completed successfully. 10 (26.3%) patients were referred for endoscopic sphincterotomy and 6 (15.7%) went without any definitive treatment. Mean duration of time from onset of symptoms and laparoscopic cholecystectomy was 7 days (range 4–10). Mean duration of operative time was 75 min and hospital stay was 7 days. There was no operative mortality. No any major intra-operative or post-operative complication was recorded. 2 patients (9%) had minor complications. Conclusion: Laparoscopic cholecystectomy can be safely performed in selected cases of mild gallstone pancreatitis in order to prevent further attacks of acute pancreatitis and other consequences of delayed treatment. Furthermore it solves problem of noncompliance of patients in third world countries where many patients are lost for definitive treatment.


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Routine Intraoperative Cholangiography in Laparoscopic Cholecystectomy—Yes or No? T. Burgstaller, O.O. Koch, G. Ko¨hler, V. Kalcher, L. Manzenreiter, K. Emmanuel Barmherzige Schwestern Linz, LINZ, Austria

Single-Step Conversion of Gastric Banding to Roux-En-Y Gastric Bypass is Feasible and safe: A Single Centre Study of 559 Patients B. Dillemans, B. Defoort, C. Vercauteren, S. Vandenhaute, F. Akin, S. Van Cauwenberge AZ Sint-Jan AV, BRUGES, Belgium

Background: Whether or not to routinely perform intraoperative cholangiography in laparoscopic cholecystectomy remains controversial. Methods: Retrospective analysis of 1520 consecutive laparoscopic cholecystectomies with standard intraoperative cholangiography (IOC) in our department during a five-year period from 2007–2011. Patients admitted with biliary pancreatitis and patients with preoperative ultrasound and/or elevated liver enzymes clearly suggestive of choledocholithiasis (‘high risk’) received ERCP prior to surgery and where excluded from analysis (n = 301). Patients with intraoperative ERCP for choledocholithiasis discovered by IOC, who had remotely elevated liver enzymes preoperatively, where considered ‘intermediate risk’ (n = 13) and where also excluded, as intraoperative cholangiography in these patients would not be termed ‘routine’ but rather ‘elective’. Results: 1206 patients with a low risk of choledocholithiasis received ‘routine’ intraoperative cholangiography. 14 routine cholangiograms (1.16%) where suggestive of choledocholithiasis. In 13 patients (1.08%), bile duct stones were confirmed by intraoperative (n = 11) and scheduled postoperative (n = 2) ERCP and successfully removed. In 1 patient, intraoperative ERCP revealed a concrement-free bile duct (99.92% specificity). No bile duct stones were missed on IOC (100% sensitivity). In 4 patients (0.33%), intraoperative ERCP was performed implementing a rendezvous technique. In these patients, routine IOC possibly avoided subsequent operative revision. There were 2 major bile duct lesions in routine IOC patients (0.17%). Routine IOC did not cause any morbidity. Conclusions: Considering the cost of operating time and material, the benefit of performing routine IOC in terms of correctly detected choledocholithiasis (1.08%) and possibly avoided reoperation (0.33%) is low. IOC will therefore no longer be performed routinely in our department.

Conversion from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) can be mandatory to achieve additional weight loss or to resolve band-related problems. The safety of this revisional procedure has only been reported in small study groups. The aim of this study was to determine the early mortality and morbidity, and to evaluate whether a single-step procedure is as safe as a two-step procedure. Methods: A retrospective review of a prospectively maintained database was completed from October 2004 to December 2012 at AZ Sint-Jan Hospital AV Bruges. Of the 724 patients who had a secondary gastric bypass (after LABG), only 559 patients with the gastric banding still in situ, were included. Either a single-step procedure (LABG removal combined with RYGB) or a two-step procedure (LABG removal followed by RYGB in a second procedure) was performed. An analysis of the 30 day morbidity and mortality was performed. Results: A single-step procedure was performed in 423 patients (75.7%), a two-step procedure in 136 (24.3%). In 2011 and 2012, a single-step procedure was achieved in 91.9%. (When performed in two steps, the interval to conversion was 4.5 months.) No mortality or anastomotic leakage was observed. Only 34 patients (6.1%) had a 30-day complication, most commonly a hemorrhage (2.9%). There was no significant difference between the single-step and two-step patients. Conclusion: Conversion of LABG to RYGB is a therapeutic option with a very low morbidity and zero-mortality. These excellent results can be explained by the full-standardized surgical technique, the meticulous dissection and construction of the gastric pouch and the gastro-enterostomy (circular anastomosis) and the tailored approach for a one or two step procedure. In due course, there was a significant increase in performing the conversion from LABG to RYGB -single-staged- according to an important learning curve, with the same complication-rate.



Internal Hernia After Laparoscopic Roux-En-Y Gastric Bypass: A Correlation Between Radiological and Operative Findings H.D. Goudsmedt, B. Deylgat, D. Van Der Fraenen, S. Van Cauwenberge, B. Dillemans AZ Sint-Jan Brugge-Oostende AV, BRUGGE, Belgium

Comparison of Two Neuromuscular Anesthetics Reversal in Obese Patients Undergoing Bariatric Surgery—A Prospective Study A Raziel1, G. Messinger2, N. Sakran1, A. Szold1, D. Goitein1 1 Assia medical, Assuta Hospital, TEL AVIV, Israel; 2Assuta Hospital, TEL AVIV, Israel

Introduction: Even tough internal hernia after laparoscopic Roux-en-Y gastric bypass is a well known entity for bariatric surgeons and radiologists, accurate diagnosis remains difficult. Most surgeons advocate a low threshold for CT scan and when in doubt laparoscopy/-tomy. The aim of this study was to compare the radiological diagnosis and the operative findings in patients undergoing explorative laparoscopy for abdominal pain after antecolic Roux-en-Y gastric bypass. Methods: A retrospective analysis of all gastric bypass patients who underwent an explorative laparoscopy between January 2007 and August 2012 has been performed. Radiological and operative reports were compared. Results: One hundred and nineteen patients underwent an explorative laparoscopy for abdominal pain after antecolic Roux-en-Y gastric bypass, 105 of which had a preoperative CT-scan. Seventy four patients suffered from an internal hernia (45 at the Petersons space, 20 at the jejuno-jejunostomy, 9 at both sites), 21 suffered from adhesions, 15 had stigmata of chronic friction of the mesodefects and 9 had a negative exploration. Eight patients (6.7%) required a conversion and no bowel resections had to be performed. Twenty three (39.6%) patients had a false negative and 10 (21.3%) patients a false positive CT-scan. For detection of an internal hernia computed tomography had an overall sensitivity of 61.7% and specificity of 77.8% in our population. Conclusion: Internal hernia after antecolic Roux-en-Y gastric bypass remains a difficult diagnosis. A CT-scan can help confirming the diagnosis, but a high index of suspicion with a low threshold for explorative laparoscopy/-tomy remains the cornerstone of good treatment.

Introduction: Maintaining a patent airway and accurate defending reflexes from the upper airway are crucial in morbidly obese patients due to their sometimes borderline vital functions. As such, a complete recovery of neuromuscular function after general anesthesia is essential to avoid postoperative residual curarization (PORC) in the postoperative period, influencing respiratory function. Unfortunately, the functions of the larynx and pharynx muscles are among the last to be restored after muscle relaxation during general anesthesia. Neuromuscular blocking agents are an important component of modern anesthetic practice to improve surgical conditions by suppression of voluntary or reflex muscle movements. After surgery, reversal agents such as Neostigmine are commonly administered to accelerate the recovery of neuromuscular function. Sugammadex is a modified g-cyclodextrin specifically developed for rapid reversal of a Rocuronium-induced neuromuscular blockade. Specific doses of Sugammadex rapidly reverse specific degree of neuromuscular blockade after Rocuronium. The aim of this study was to blindly compare these two drugs in bariatric surgery for morbidly obese individuals. Methods: The study was a prospective, double arm study. The Sugammadex arm included 21 and the Neostigmine group 19 morbid obese subjects that were scheduled for bariatric surgery. The subjects were randomly selected to receive Neostigmine or Sugammadex for reversal of neuromuscular blockade. At the end of surgery and when two responses were achieved on the Train of Four (TOF) stimulation, either Sugammadex or Neostigmine-Atropine in the proper dosage was administered in a fast bolus and time to achieve 90% of TOF was measured. Level of consciousness as well as respiratory function, nausea/vomiting, and general feeling were recorded before transfer to post anesthesia care unit (PACU), in the PACU and during hospitalization to monitor the effect of the drugs. Results: No differences were seen between the two groups in their level of consciousness in the PACU, respiratory function, nausea/vomiting, and general feeling. The time from the induction of the reversal to the transfer to the PACU with both drugs was not different as we were using only moderate neuromuscular block. Conclusion: Sugammadex facilitates reversal of neuromuscular blockade after bariatric surgery, depending on depth on neuromuscular blockade induced.

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Does the Type of Suture in the Anastomosis and the Closure of the Petersen’s Space Influence the Outcome After the Gastric Bypass? M. Socas-Macias1, S. Morales-Conde1, A Barranco moreno2, M. Rubio Manzanare1, S. Garcia1, C. Jordan Chaves1, H. Cadet1, J. Padillo Ruiz1, J.L. Pereira1, P.P. Garcia Luna1, I. Alarcon del Agua1 1 HUVirgen del Rocio, SEVILLE, Spain; 2Virgen del Rocio Hospital, SEVILLA, Spain

Mixed Meal Tolerance Test vs. Continuous Glucose Monitoring R. Kefurt, C. Reiler, A. Bohdjalian, F. Langer, P. Markus, K. Schindler, A. Tu¨rkcan, A. Hofer, B. Ludvik, G. Prager Medical University of Vienna, VIENNA, Austria

Aim: The analysis our results entails technical improves, that finally associates benefits for our patients due to the reduction of the rate of complications. Objective: To present the outcome of patients who underwent gastric bypass (GBP), analyzing the impact of two technical improves: the use of reabsorbable suture in the gastrointestinal anastomosis and the closure of the Petersen’s space. Materials and Methods: Retrospective Study (based on a prospective data base) of patients who underwent a GBP during 5 years. Patients were operated on by 3 surgeons (S1, S2, S3). Standardized technique: alimentary/biliary limb 150/40 cm, gastric pouch performed under the second vessel of the lesser curvature with a 32fr bougie. Side-by-side anastomosis with EndoGIAÒ and closure of the enterotomy with reabsorbable continuous suture. Closure of the mesentery gap with irreabsorbable purse-string sutures. No closure of the Petersen’s at the beginning of the series. Detected problems: internal hernias through the Petersen’s and an important number of patients with ulcers at the gastrointestinal anastomosis. Technical improves introduced: systematic closure of Petersen’s with three irreabsorbable purse-string sutures and closure of the enterotomy at the gastrointestinal anastomosis with a reabsorbable suture. Results: 138 morbid obese patient (33 men/105 women). Medium age 38.5 yo (20–58). Medium BMI 45.58. 100% performed by laparoscopy (17 patients: 12.3% SinglePort), 0% Conversions. Medium hospital stay 5.1 days. Mortality 0%. Mayor morbidity 3.6%: 60% of the complicated patients required reoperation. Maximum loose of weight at 2 years, 69% EWL: EWL 3 m—36%, EWL 6 m—55%, EWL 1 year—60%, EWL 2 years-69%, EWL 3 years—62%, EWL 4 years— 62%. Irreabsorbable suture used in the gastrointestinal anastomosis in 89 patients while in 49 a reabsorbable one was used. 9% of the cases developed an ulcer against 8.2% (p: 1.00), and 6.7% stenosis against 0% respectively (p: 0.089). In the first 69 patients we did not close the Petersen, suffering an internal hernia 10% of the cases, against 1.4% where we close it (p: 0.062) Conclusion: Technical improves performed in GBP entails a reduction in morbidity: the reabsorbable suture does not seem to reduce the percentage of ulcers but reduces the percentage of stenosis, while the closure of the Petersen’s space associates a drastic reduction of the internal hernias.

Introduction: The methods for revealing Hypoglycaemia following Gastric Bypass (RYGB) are discussed controversial in literature; the aim of this study was to compare Mixed Meal Tolerance Test (MMT) against Continuous Glucose Monitoring (CGM) 24 h over several days. Methods: 29 morbidly obese patients (25 f/4 m; mean age 45a; mean BMI 48.1 kg/m2) were screened for hypoglycaemia (\65 mg/dl) 4 years after RYGB using MMT and CGM for 5 days. During MMT blood sugar, C-Peptide and Insulin were sampled at -10, 0, 15, 30, 60, 90, 120, 180and 240-min. Results: One patient was excluded due to incompliance and 4 patients showed invalid data in the CGM (2 with pathologic MMT). Hypoglycaemia (CGM or MMT) was recorded in 22 out of 29 patients (75.8%), in 20 out of 29 (68.9%) using CGM and 13 out of 29 (44.8%) using MMT. In all patients max blood Insulin levels during MMT were detected in the range from 15–30 min, C-Peptide peak between 30–60 min. Hypoglycaemia occurred in 77% after 60 min, 15% after 90 min and 8% after 120 min during MMT (n = 13). In the 9 patients with hypoglycaemia in CGM and normal MMT, the lowest blood sugar levels were recorded in 22% after 60 min, 44% (90 min),11% (120 min) and 22% (180 min) during MMT. Mean elevation of Insulin and C-Peptide was during MMT in patients without hypoglycaemia (n = 4) 22.4 lU/ml; 4.3 ng/ml, in those with hypoglycaemia in the CGM (n = 9) 71.5 lU/ml; 6.8 ng/ml and in patients with abnormal MMT (n = 13) 71.24 lU/ml; 9 ng/ml. Conclusion: Continuous Glucose Monitoring (CGM) has a higher rate of detecting Hypoglycaemia following RYGB than MMT. Hypoglycemia after MMT occurred in 92% of patients between 60–120 min reflecting hyperinsulinemic hypoglycemia. Additionally detected hypoglycaemia using CGM might reflect bad eating habits.



Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Gastric Bypass for Morbid Obesity and Type 2 Diabetes: A Meta-Analysis G. Scozzari, A. Arezzo, R. Passera, M. De Angelis, A. Salvai, M. Morino University of Torino, TORINO, Italy

Ergonomic Problems Encountered During Laparoendoscopic Single-Site Cholecystectomy A. Morandeira-Rivas1, L. Millań-Casas1, C. Sedano-Vizcaino1, M. Ramı´rez-Ortega1, M.L. Herrero-Bogajo1, J.M. Tenias-Burillo1, L. Gimeńez-Salillas2, C. Moreno-Sanz1 1 ´ ZAR DE SAN JUAN, Mancha Centro General Hospital, ALCA Spain; 2Hospital Clıńico Universitario Lozano Blesa, ZARAGOZA, Spain

Aims: Although LSG and LGB represent to date the most widely performed bariatric procedures, controversy still persist about their efficacy in terms of long-term weight loss and T2DM remission, due to the lack of high-quality comparison studies. Aim of the study was to perform a systematic review and meta-analysis of randomized and non-randomized prospective clinical trials comparing laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LGB) for morbid obesity and type II diabetes mellitus (T2DM) treatment, in terms of safety and efficacy. Methods: Studies published until October 2012 that prospectively compare LSG and LGB were identified through Medline and Embase databases (PROSPERO Registration number CRD42012003195). A meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model; publication bias was assessed by funnel plot, heterogeneity by the I2 test and subgroup analysis. Anastomotic leakages, surgical reintervention and T2DM remission at 12-month follow-up were compared using relative risk (RR); operative time, 6-month excess weight loss% (EWL%) and 12-month EWL% were compared using mean difference (MD). Results: Nineteen studies were included, representing 3259 patients (1123 LSG, 2136 LGB). LSG was associated with shorter operative times (MD -29.08 min, 95% CI 48.79–9.36, p = 0.004), while the risk for surgical reinterventions (RR 0.61, 95% CI 0.26–1.42, p = 0.252) and leakages (RR 1.54, 95% CI 0.60–3.96, p = 0.365) was not significantly different. LSG was associated with lower excess weight loss at 6 months (MD -8.10%, 95% CI -17.35 to 1.15, p = 0.086) and 12 months (MD -8.27%, 95% CI -15.89 to -0.85, p = 0.029) and lower T2DM remission rates at 12 months (RR 0.82, 95% CI 0.73–0.92, p \ 0.001). Conclusions: LSG can be performed safely with shorter operative times and similar complications rates, but LGB shows greater weight loss and T2DM remission rates at 12-month follow-up.

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Aim: Ergonomic issues are frequently reported by surgeons performing laparoendoscopic singlesite (LESS) surgery. This study aimed to investigate ergonomic risk among surgeons performing laparoendoscopic single-site cholecystectomy (LESSC) Methods: Fifteen LESSCs were videotaped to analyse surgeon’s posture. Participating surgeons were experienced in LESS surgery. Two cameras were used, one in front and one at the side of the surgeon. Recordings of surgeries were divided into different tasks and subtasks, and the observational RULA (Rapid Upper Limb Assessment) method was used to assess postural load of the surgeons. Results: Finally, 150 postures were chosen from operating room images recorded with the camcorders. Rapid upper limb assessments identified ergonomic risk for surgeons during LESSC, with high physical demands in the upper limbs and trunk. Overall RULA scores ranged from 3 to 7, with action levels 2 or 3 in most postures, indicating the need for further investigation and intervention. Conclusions: In LESSC, the issues with space both inside and outside of the abdominal cavity cause excessive postural load in the upper limbs and trunk. More in-depth ergonomic studies are needed. Acknowledgments: This study was supported by a Fundacioń Mutua Madrilena Research Grant.


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Single Port/Incision Laparoscopic Surgery Compared with Standard 3 Port Laparoscopic Surgery for Appendicectomy—A Randomised Controlled Trial M. Malik1, J.A. Cook2, A. Duncan2, Z.H. Krukowski1, G. MacLennan2, K. McCormack2, I. Ahmed2 1 Aberdeen Royal Infirmary, ABERDEEN, United Kingdom; 2HSRU, University of Aberdeen, ABERDEEN, United Kingdom

Analysis of Endoscopy-Assisted and Laparoscopic Intragastric Surgery in an Experimental Model of Gastric Submucosal Pseudotumor F.M. Sanchez Margallo, F. Pe´rez Duarte, M.A. Sańchez Hurtado Minimally Invasive Surgery Centre, CACERES, Spain

Aims: The aim of this study was to compare the effectiveness of single port/incision laparoscopic surgery (SPILS) with standard 3-port laparoscopic surgery for appendicectomy in adults. Feasibility data was collected to evaluate generalisability to other single port techniques such as cholecystectomy. Methods: A single centre randomised controlled trial. Participants were randomised to receive either SPILS or Standard 3-port laparoscopic appendicectomy. The primary patient reported outcomes were body image and cosmesis at six weeks. The primary clinical outcome was pain at one to seven days. Secondary outcomes included: duration of operation; conversion rates; complication rates; use of analgesia; hospital readmission rates; reoperation rates; and time to return to normal activities. Results: Seventy-nine patients were randomised. Sixty-seven completed the day one to seven diary and 55 completed the six week follow up. SPILS patients answered significantly more favourably to the items in the body image scale [5.6 (1.0) versus 7.0 (3.3), mean (SD); -1.4 (95% CI -2.8 to 1.5; p = 0.03)] and the cosmetic scale [18.9 (4.1) versus 15.3 (5.8), 3.6 (95% CI 0.7 to 6.5; p = 0.016)] compared with patients in the standard group. The duration of operation was shorter for SPILS and patients required less morphine in recovery. However, there were no statistically significant differences in other outcomes. Conclusions: Patient-reported body image and cosmesis outcomes were better, and surgical outcomes were similar following SPILS. However, the SPILS procedure is more technically demanding and may not be achievable or necessary in routine clinical care. Further assessment of the findings is needed through larger multicentre studies.

Objective: This study aimed to evaluate the feasibility and usefulness of the combination of flexible endoscopy and laparoscopy during minimally invasive intragastric treatment of experimental submucosal pseudotumors located at the level of Z-line. Methods and Procedures: Six healthy female pigs underwent a transparietal injection of sterile alginate at the level of Z-line area creating a model of gastric submucosal pseudotumor The operative procedures included intragastric surgery with endoscopic vision (n = 3) and intragastric surgery with gastrotomy and laparoscopic vision (n = 3), using a two minilaparoscopic portals or single-port technique, respectively. The pseudotumors were resected and the gastric mucosal layer was closed using intracorporeal sutures. The gastrotomy and the minilaparotomy were closed in a multilayered fashion. Results: The pseudotumors ranged in size from 3 to 6 cm in diameter. The access of the intragastric cavity was successfully performed in all animals without complications. The transgastric approaches were performed without any complication in all animals. More technical difficulties were encountered in the transgastric approach with endoscopic vision. The duration of the operations ranged from 70 to 130 min. No complications were encountered on the postoperative followup. After one-month exploratory laparotomy not showed alterations in abdominal cavity. Conclusions: This experiment showed the usefulness of porcine model for research in minimally invasive intragastric surgery. The application of transgastric endoscopic-assisted and laparoscopic surgery to submucosal pseudotumor of the stomach are technically feasible, safe and reproducible and may be an useful alternative to open surgery and endoscopic techniques. Additional studies will be necessary to establish the role of transgastric surgery in the treatment of gastric cancer.



Advanced Minimal Invasive Methods in Cholecystectomy—Single Port and Transvaginal Compared with The Gold Standard Conventional Laparoscopic Approach W. Brunner, P. Folie, F. Pianka, S. Bischofberger, N. Kalak Hospital Rorschach/St. Gallen, Switzerland

Laparoscopic Right Hemicolectomy: Can an Inferior Approach be Superior? A.C. Durham-Hall, S. Flexer, D. May, J. Robinson, J. Griffith Bradford Teaching Hospitals, BRADFORD, United Kingdom

Background: Conventional Laparoscopic Cholecystectomy (CL-ChE) currently is the gold standard for removal of the gallbladder. Transvaginal Cholecystectomy (TV-ChE) as well as Single Incision Surgery (SI-ChE) appears to be established in specialized centres due to some advantages. Herein we compare both cohorts of advanced methods with the gold standard. Methods: From September 2008 to July 2009 we prospectively collected data of patients who underwent TV-ChE (n = 102) and compared it to prospectively recorded data of SI-ChE (n = 100), since July 2011. Since CL-ChE of course still is routinely used we were able to compare both cohorts with the gold standard (n = 100, April to October 2012). Results: Average age in patients of SI- was 51 yr, 52 yr in the TV- and 56 yr in the CL-group. Patients in SI- were slightly healthier (ASA) than patients in TV-group. Indication for surgery in the SI-, TV- and CL-group were sympt. Cholecystolithiasis and chronic cholecystits in 75%, 74% and 79% of cases, respectively, acute cholecystitis in the remaining cases. Previous abdominal surgery was performed in 14% of SI-, 47% of TV- and 16% of CL-patients. Mean OP-time was 62 min (25–170) in the TV-, 78 min (27–174) in the SI- and 83 min (30–259) in the CL-group. Residents operated on 14% TV-, 50% SI- and 33% of CL-group. Additional ports were needed in TV- and SI-group 21% and 34%, respectively (CL-ChE: use of four ports anyway). Conversion to open 8 times was necessary in CL-, once in SI- and never in TV-group. Hospital stay in the TVwas 3.3 days on average (1–15) compared to 3.2 days (1–13) in the SI- and 3.9 days (2–20) in the CL-group. We didn’t observe any intraoperative incidents in all groups. Mayor postoperative complications we observed in the TV- in 2%, in CL- in 3% of cases and none in SI-group. Minor complications occurred in 12.7% in TV-, in 2% in SI- and 8% in CL-group. Conclusions: TV-ChE and SI-ChE are safe and less invasive than CL-ChE. There’s no striking difference concerning complications. OP-time is shorter in advanced methods. Regarding conversion rate and hospital stay there is no disadvantage in the advanced surgery groups as well.

Introduction: Hohenberger has demonstrated that complete mesocolic excision (CME) and central vascular ligation (CVL) improves 5 year survival in colonic resection by approximately 15%. This relies upon an open approach and cannot be easily replicated laparoscopically. Evidence suggests that laparoscopic surgery could potentially result in smaller specimens compared to open resections. During laparoscopic right hemicolectomy we routinely mobilise the right colon utilising an inferior sub-ileal approach which facilitates CVL of the ileocolic pedicle at its origin on the SMA. This study aimed to analyse this approach with respect to the parameters of specimen quality described by Hohenberger. Methods: 30 consecutive patients underwent laparoscopic right hemicolectomy for colonic adenocarcinoma performed by two surgeons over a 2-year period. Distance of tumour to HVL and distance from proximal and distal resection margins were measured. Lymph node count was also performed using standard techniques. Results: Our standard laparoscopic approach removed a similar amount of tissue compared to Hohenberger. Mean distance of tumour to the high vascular tie was 127.5 mm vs 128.7 mm from Hohenberger. The mean lymph node yield was 21. The mean length of bowel resected proximal and distal to the tumour was 159.9 mm and 121 mm respectively. All specimens had an intact mesocolon upon direct inspection. Conclusions: The inferior approach during laparoscopic right hemicolectomy results in high quality specimens and is comparable to the results published by Hohenberger during open surgical resection with CME and CVL. In our institution, our 5 year survival data is comparable to that published by Hohenberger.

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Single Incision Laparoscopic Surgery. Anaysis of the Spanish National Registry C. Moreno-Sanz1, A. Morandeira-Rivas1, J.M. Tenias-Burillo1, O. Vidal-Pe´rez2, S. Morales-Conde3, J. Garijo-Alvarez4, J. Barri-Trunas5, C. Duran-Escribano6, R. Villallonga-Puy7, E. Targarona-Soler8 1 La Mancha Centro General Hospital, ALCAZAR DE SAN JUAN, Spain; 2Clinic Universitary Hospital, BARCELONA, Spain; 3Virgen del Rocio Universitary Hospital, SEVILLE, Spain; 4Torrejon Hospital, MADRID, Spain; 5Hospitalet General Hospital, BARCELONA, Spain; 6Virgen de la Paloma Hospital, MADRID, Spain; 7Vall D’Hebron Hospital, BARCELONA, Spain; 8Sant Pau Hospital, BARCELONA, Spain

Endolumenal Colon Occlusion (Coloshield) Reduces Peritoneal Contamination During Transrectal Hybrid Notes Cholecystectomy: A Porcine Survival Study G.R. Linke1, B. Carstensen1, J. Senft1, A. Mischnik1, R. Warschkow2, B.P. Mu¨ller-Stich1 1 Heidelberg University Hospital, HEIDELBERG, Germany; 2 University of Heidelberg, HEIDELBERG, Germany

Aim: Laparoscopic surgery through a single incision is an innovative concept which is a challenge for surgeons to implement and develop. The interest aroused by these techniques in Spain led to the Endoscopy Section of the Spanish Association of Surgeons (AEC) to start a National Register for Single-Incision Surgery (RNCIU). The aim of this study was to collect the primary clinical data, techniques, and the possible complications of these techniques in Spain. Methods: Data were gathered using a form available on the AEC website. The forms included in this study correspond to those received between June 2010 and June 2012. Results: A total of 35 centers had taken part during the study period, with 1648 forms being collected. The surgeries performed included 62.2% cholecystectomies, 22% appendectomies and 7.8% colectomies. Procedures on solid organs (3.4%), bariatric surgery (2.7%), and various hernia repairs (1.9%), were also registered. Technical and technologic features are described for each group of procedures. The overall incidence of complications was 0.8%. The mortality rate in the series was 0.1%. Conclusions: Single incision laparoscopic surgery is a novel concept that is not beyond our scientific community. The results of the Register demonstrate the feasibility of numerous effective and safe procedures. Finally, the RNCIU is an important data source to be able to study sub-groups of diseases in detail, with the aim of advancing the knowledge of these techniques and generating scientific evidence.

Aims: Several studies have demonstrated the feasibility of transrectal NOTES. However, transrectal NOTES has not yet found its way into clinical routine due to fear of transrectal contamination and related infectious complications. To enable an efficient and enduring decontamination of the transrectal access area we developed a device for reversible endolumenal colon occlusion (ColoShield). The aim of this controlled porcine survival study was to evaluate the value of ColoShield in reducing peritoneal contamination during transrectal hybrid NOTES cholecystectomy (trCCE). Methods: A total of 15 pigs were included and underwent trCCE either with endolumenal colon occlusion using ColoShield (study group, n = 7) or without colon occlusion (control group, n = 8). Prior to trCCE, a standardized disinfective rectal washout was performed in both groups. Rectal swab samples were taken after closure of the rectal incision. Peritoneal biopsies for microbiological evaluation were obtained at the end of trCCE and at necropsy after 7 days. Results: TrCCE could be performed without complications in all animals, and all pigs survived the 7 day period inconspicuous. Rectal swab samples after access closure revealed a contamination in 14% (1/7) of animals in the study group and in 63% (5/8) of animals in the control group (p = 0.057). Peritoneal contamination rate at the end of trCCE was significantly lower using ColoShield compared to trCCE without colon occlusion (14% (1/7) vs. 75% (6/8); p = 0.019). Peritoneal contamination rate at necropsy was 29% (2/7) in the study group and 25% (2/8) in the control group (p = 0.877). Conclusion: ColoShield is efficient in reducing peritoneal contamination during trCCE. However, although there is a significant difference in peritoneal contamination between both groups at the end of the procedure, no difference in peritoneal contamination rate or clinical signs of a peritoneal infection were found at necropsy.



Laparoscopic Assisted Colonoscopy A.J. Quyn1, Z. Vujovic1, N.A. Henderson2, D. Ziyaie1, R.J.C. Steele1, K.L. Campbell2 1 University of Dundee, DUNDEE, United Kingdom; 2Ninewells Hospital, DUNDEE, United Kingdom

A Modular Magnetic Anastomotic Device for Minimally Invasive Digestive Anastomosis. Proof of Concept and Preliminary Data in the Pig Model M. Diana1, D. Mutter1, V. Lindner2, H. Chung1, N. Demartines3, J. Marescaux1 1 IRCAD-IHU, University Hospital of Strasbourg, STRASBOURG, France; 2Regional Hospital of Mulhouse, MULHOUSE, France; 3 University Hospital of Lausanne, LAUSANNE, Switzerland

Introduction: Since flexible endoscopy of the colon was introduced in 1963 it has been the gold standard diagnostic test for evaluation of colonic disease. However, the BSG audit of 9000 colonoscopies highlighted a completion rate of 57%. Reasons for failure include previous abdominal surgery in particular previous hysterectomy. An incomplete colonoscopy is usually followed up with a barium enema or more recently CT colonography to complete the assessment of the colon. Patients then found to have [ 1 cm polyps represent a significant management dilemma. This study describes our experience using laparoscopy to facilitate complete colonoscopy and polypectomy in such patients. Methods: All patients presenting to Ninewells Hospital between January 2008 and August 2012 with an incomplete colonoscopy and polyp detection on subsequent examinations were included in our analysis. Patients underwent a standard three port laparoscopy with appropriate colonic mobilisation and division of adhesions. Under direct vision with laparoscopic assistance, a colonoscopy would be performed with minimal standard insufflations and since 2011 CO2 insufflation. Primary end points for analysis were completion of colonoscopy and polypectomy. Secondary end points for analysis were intra-operative complications, post-operative morbidity and successful standard follow-up colonoscopy. Results: Twelve patients have undergone laparoscopic assisted colonoscopy and polypectomy during the study period. All patients had previously failed colonoscopy with subsequent radiological examinations detecting [ 1 cm polyps. A positive bowel screening result was the indication for colonoscopy in six patients. Complete colonoscopy to caecum was successful in all twelve patients. Mean polyp detection was 2.1 polyps per patient (range 1–5). The radiologically identified polyps were excised in all cases and retrieved in 11. One patient had an iatrogenic enterotomy during adhesiolysis which was identified during the procedure and repaired laparoscopically and made an uneventful post-operative recovery. Three patients have since undergone successful colonoscopy under sedation. Conclusion: Laparoscopic assisted colonoscopy allows patients with known colonic polyps and previously failed colonoscopy undergo safe polypectomy without segmental resection. This less invasive procedure yields recovery times similar to colonoscopy alone, avoiding the complications of a segmental resection. In addition, patients who have undergone laparoscopic adhesiolysis and colonic mobilisation have successful routine colonoscopy in the future.

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Aims: The aim of this study was to assess the feasibility of minimally invasive digestive anastomosis using a novel modular magnetic anastomotic device made of a set of two flexible chains of magnetic elements. The assembly possesses a non-deployed linear configuration which allows to introduce it through a dedicated small-sized applicator (8 mm in diameter) into the bowel where it takes the deployed form. A ‘Mercedes-shaped’ centering suture connecting the ring to the center allows to control the mating between the two deployed rings. Methods: Eight pigs were involved in a two-week survival experimental study. Five colorectal anastomoses and three jejunojejunostomies were performed using a three-port approach. The proximal device was inserted by a percutaneous endoscopic technique, the colon was divided just below the proximal magnet and the distal magnet was delivered transanally to connect with the proximal one. For jejunojejunostomies, the magnetic chain was injected in its linear configuration through a TeflonÒ tube inserted into a small enterotomy. Once totally delivered in the bowel lumen, the device self-assembled into a ring shape. Subsequently, the second part of the device was injected into a more distal loop through the same port. The two centering sutures were tied together extracorporeally. By pulling on the sutures and using a pushing-knot, the magnets were connected. Necropsy was performed at Post-Operative Day 14 in both groups. Ex vivo strain testing was performed to determine the compression force delivered by the magnetic device on the intestinal tissue. Burst pressure of the anastomosis and histological evaluation were also performed. Results: Average time to full patency was 5 days for colorectal anastomosis. Burst pressure of all anastomoses was greater than 110 mmHg. Mean strain force to detach the devices was 6.1 ± 0.98 and 12.88 ± 1.34 N in colorectal and jejunojejunal connections respectively (p = 0.035). Pathology showed that all the anastomoses were sealed with mild to moderate inflammation score. Conclusions: The modular magnetic anastomotic system showed enormous potential to create minimally invasive digestive anastomoses and may represent a valuable alternative to stapled anastomoses. The prototype requires further refinements in order to define the optimal magnetic force and the most adapted delivery system.


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O155 - Clinical Practice and Evaluation

Systemic and Local Doxorubicin Distribution After Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in the Human Patient M.A. Reymond1, T. Mu¨rdter2, R. Kerb2, W. Solass3, U. Giger-Pabst1, M. Schwab2, J. Zieren1 1 Ruhr-University Bochum, HERNE, Germany; 2Dr. MargareteFischer-Bosch Institute for Clinical Pharmacology, STUTTGART, Germany; 3Ruhr-University, BOCHUM, Germany

Laparoscopic Gastro-Intestinal Anastomoses Using Knotless Barbed Sutures are Safe and Reproducible: A Single-Center Experience in 201 Patients O. Facy1, M. Goergen2, L. Arru2, G. Orlando2, A. Sanchez-Ramos2, A. Legrand2, J.S. Azagra2 1 University Hospital Dijon, DIJON, France; 2University Hospital, LUXEMBOURG, Luxembourg

Background: Limitations of intraperitoneal chemotherapy (IPC) include poor drug distribution within the abdominal cavity and poor distribution into the tissue. Application of chemotherapy as a therapeutic aerosol under pressure has been shown to improve these limitations in various models. We now present the first pharmacological data obtained with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) in the human patient. Methods: A dose of 1.5 mg/m2 body surface doxorubicin was administered as an intraperitoneal aerosol at a pressure of 12 mmHg for 30 min and a temperature of 37°C in 8 consecutive PIPAC procedures. Blood samples were drawn before, during and up to 12 h after the application and doxorubicin plasma levels were determined by UHPLC-MS/MS using [13C2H3]-doxorubicin as internal standard. Pharmacokinetic parameters were derived by noncompartmental analysis using Winnonlin 6.3. The area under the plasma concentration-time curve (AUC) was calculated up to the time of the last quantifiable plasma concentration. At the end of the procedure tissue biopsies were taken and snap frozen for doxorubicin analysis. Results: The preliminary pharmacokinetic analysis is based on the plasma concentration-time data from 3 patients. The plasma concentration-time curve fitted best to a 2-compartment model with 1st order absorption (Fig. 1). Highest doxorubicin plasma concentrations (4.0–6.2 ng/ml) were reached with the end of nebulization (15–45 min after beginning of nebulization). Doxorubicin was eliminated from the body with a clearance (Cl/F) of 2.6–6.0 ml/min. Half-lives and AUCs ranged from 86 to 468 min and 415 to 915 ng/ml*min, respectively. Tissue concentration of doxorubicin was variable with mean ± SD 1.70 ± 1.45 lg/g. Fluorescence microscopy showed a nuclear presence of doxorubicin throughout the whole peritoneal layer into the properitoneal fatty tissue with the highest concentration within 100 to 200 lm from the surface. Conclusion: Pharmacokinetic analysis after PIPAC administration of doxorubicin shows a favourable profile with outstanding ratio between systemic and local drug concentration. Delivering chemotherapy as a pressurized aerosol might be a significant progress in overcoming the current limitations of intraperitoneal chemotherapy.

Aims: Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties to knot the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but its results for intestinal anastomosis are not clear. The aim of this study is to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture. Methods: Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-LocÒ, Covidien, Mansfield, USA) were used for all laparoscopic intestinal anastomoses: one in cases of closure of intestinal openings after mechanical anastomoses and two in cases of hand-sewn anastomoses. Results: No patients received preoperative chemotherapy. Tumors were classified as pTis in 40 patients (58.8%), as pT1 in 17 (25%), pT2 in 9 (13.2%), and pT3 in 1 (1.47%). The median operative time was 65.6 min. ± 43.14 min. Loss of blood was minimal: 0–30 ml. Intra-operative perforation occurred in 3%. In 61 (91.1%) cases R0 and 6 (8.9%) RX resection could be performed. The postoperative course was without any complications in 99.6% of patients. The mean follow-up was 62.56 ± 30.52 months. 5 (7.5%) patients had local recurrence. The rate of local recurrence for patients with pTis tumors was 2 (5%), for pT1 was 1 (5.9%), for pT2 was 1 (11.1%) and for pT3 was 1 (100%). 5 patients with local recurrence were eligible for salvage surgery: 1 had radical salvage resection, 2 had repeated ?EM, and 2 refused surgery. Overall 5-year survival was 100% in all 57 patients with pTis and pT1 tumors. Over a period of one year, 201 consecutive patients required 220 laparoscopic anastomoses: gastrojejunostomy (N = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileo-colostomy (N = 15), colo-colostomy (N = 1), esophago-jejunostomy (N = 5) and jejuno-jejunostomies (N = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophago-jejunostomy and was managed conservatively. There was one selflimited anastomotic bleeding and no anastomotic stenosis at 6 months of follow-up. Conclusions: The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.



Single-Incision Laparoscopic Surgery for Colorectal Malignancy Through Future Ileostomy Site: Is It Possible to Perform Real ‘Scarless’ Surgery? J.A. Yun1, S.H. Yun1, Y.A. Park1, Y.B. Cho1, H.C. Kim1, W.Y. Lee1, H.K. Chun2 1 Samsung Medical Center, SEOUL, Korea; 2Kangbuk Samsung Hospital, SEOUL, Korea

Characteristics of BMI24-34 Diabetics Patients that Obtained 100% Resolution by Tailored One Anastomosis Gastric Bypass M. Garciacaballero1, J. Martinez-Moreno1, J.A. Toval1, J. Mata1, D. Osorio1, F. Miralles2, A. Minguez1, A. Reyes-Ortiz1 1 University Malaga, MALAGA, Spain; 2Associated UH ParqueSanAntonio, MALAGA, Spain

Aims: In the current trend of less invasive surgery, single incision laparoscopic (SIL) surgery has been proposed to reduce surgical trauma more than conventional laparoscopic surgery. The aim of this study is to show the procedural outcomes of SIL surgery including low anterior resection for malignancy, especially through future ileostomy site. Methods: Between August 2011 and November 2012, 54 patients who underwent primary singleincision laparoscopic surgeries through future ileostomy site with one additional port at the Samsung Medical Center were recruited to participate in this study. The SIL surgeries including pelvic dissection procedure were performed using a hand-made glove port through future ileostomy site. One 12 mm-trocar was routinely added in right lower quadrant for each surgery. After anastomosis, protective ileostomy was made and Jackson-Pratt drainage catheter was inserted via right lower quadrant trocar site. Theoretically, the patients could have ‘scarless abdomen’ after surgery. Results: Among 54 patients, 20 (37.0%) were female. Mean age was 60 years old (range 25 to 87) and 51 patients (94.4%) were diagnosed as rectal cancer. 30 (55.6%) had underwent preoperative concurrent chemoradiation. 3 patients were diagnosed as stage IV rectal cancer. All operations initially started by SIL approach through future ileostomy site with one additional 12 mm trocar on right lower quadrant. Two patients were reckoned as impossible cases to perform sphincter saving and anastomoses during surgery, and underwent each abdomino-perineal resection and Hartmann’s operation. After closing the ileostomy site, new incision was made to do permanent sigmoid colostomy. Another additional trocar on left lower quadrant for traction and dissection during pelvic phase was needed in two patients. Conversion of operative method to open surgery occurred in one case due to sacral plexus bleeding. Overall complication rate was 18.5% and there was no mortality related to the surgery itself. Upon the pathologic examination, resection margins were all clear. Conclusion: SIL surgery including pelvic dissection via future ileostomy site with one additional port for lower rectal cancer was feasible method and it showed acceptable complication rate. The operation method could visually enable ‘scarless’ surgery in the era of minimally invasive surgery.

Introduction: Considering the high cost of life-long conservative therapy of Diabetes Mellitus type 2 (DM2) and its complications and the severe impact DM2 has on quality of life, surgical metabolic intervention may become the most reasonable solution in many cases based on the superb results obtained so far. The objective of the analysis is to evaluate the characteristics of the patients that solving 100% their metabolic disturbance with tailored one anastomosis gastric bypass (BAGUA). Materials and Methods: We analysed 40 patients (14 BMI 24–29 and 26 BMI 30–34), 50% insulin-dependent, 68% male, age between 40 and 80 years (mean 55). We evaluated years of evolution of DM2 between 1 and 30 (mean 14). Pre-operative basal glycemia between 84 and 302 mg/dl (mean 180). Pre-operative HbA1c between 5.9 years 12% (mean 8.1). Fasting C Peptide levels between 0.9 and 4.7 ng/ml (mean 2.5). Furthermore 88% of patients presented a pre-operative metabolic syndrom (MS) and 40% one or more DM2 complications. One patient was operated previously by open surgery and in two umbilical hernia surgery was associated. Tailored BAGUA excluded between 100 (BMI 24–29) and 150 cm (BMI 30–34) distal to Treitz ligament. Results: No patients received preoperative chemotherapy. Tumors were classified as pTis in 40 patients (58.8%), as pT1 in 17 (25%), pT2 in 9 (13.2%), and pT3 in 1 (1.47%). The median operative time was 65.6 min. ± 43.14 min. Loss of blood was minimal: 0–30 ml. Intra-operative perforation occurred in 3%. In 61 (91.1%) cases R0 and 6 (8.9%) RX resection could be performed. The postoperative course was without any complications in 99.6% of patients. The mean follow-up was 62.56 ± 30.52 months. 5 (7.5%) patients had local recurrence. The rate of local recurrence for patients with pTis tumors was 2 (5%), for pT1 was 1 (5.9%), for pT2 was 1 (11.1%) and for pT3 was 1 (100%). 5 patients with local recurrence were eligible for salvage surgery: 1 had radical salvage resection, 2 had repeated ?EM, and 2 refused surgery. Overall 5-year survival was 100% in all 57 patients with pTis and pT1 tumors. Four patients were rejected: 3 due to cardiac ischemia that need stent implantation before gastric bypass surgery and 1 kidney dialysis before renal transplant. All operated patients stay without any treatment for DM2 and MS since surgery. Operative time ranged 50 to 70 min (mean 60) in primary surgery. Hospital stay was 48 h in all cases. One patient was reoperated 12 h after surgery due to stapler line gastric pouch bleeding. HbA1c levels were \ 7% in all operated patients 6 months after surgery. Conclusions: Metabolic surgery by tailored BAGUA can accomplished a complete resolution of diabetes and the concomitant MS even in cases of advanced disease in insulin dependent patients while pancreas conserve a function level inside the normal range (fasting C Peptide 0.8–4.0 ng/ml). We do not found response differences related to pre-operative BMI.

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First Clinical Experience with Pressurized Intraperitoneal Aerosol Chemotherapy in Patients with Gastric Cancer and Peritoneal Carcinomatosis M.A. Reymond1, U. Giger-Pabst1, W. Solass2, A. Tannapfel2, D. Strumberg1, J. Zieren1 1 Ruhr-University Bochum, HERNE, Germany; 2Ruhr-University, BOCHUM, Germany

Combined Endoscopic and Laparoscopic Intra-Gastric Tumor Removal: A Procedure for Sub-Epithelial Tumor Located Next to the Esophagogastric Junction S. Udomsawaengsup1, S. Punchai2, A. Techagumpuch1, K. Tepmalai3, S. Pungpapong1, C. Tharavej1, P. Navicharern1 1 Chulalongkorn University/Chula Minimally Invasive Surgery Center, BANGKOK, Thailand; 2Khonkaen University, KHONKAEN, Thailand; 3Chaingmai University, CHAINGMAI, Thailand

Introduction: Peritoneal carcinomatosis (PC) from gastric cancer (GC) has an extremely poor prognosis. We have developed an innovative therapy, Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC), which improves local tumor drug uptake and can be combined with systemic chemotherapy.1,2 PIPAC achieves outstanding local biodisponibility with low systemic exposure.3 Liver and renal toxicity are minimal.4 The procedure is safe for health workers.5 We present first results obtained in end-stage patients suffering PC from gastric origin. Methods: Since 1.12.2011 we have performed 16 PIPAC applications in 7 patients with end-stage PC from GC, with no remaining evidence-based therapeutic option (compassionate use). Mean age was 60.6 ± 16.4 years. Patients were followed-up until Dec, 2012 or until death. Tumor response was assessed by macroscopy (PCI), microscopy and apoptosis determination (TUNEL). Results: Mean operating time (PIPAC alone) was 98 ± 26 min. Two intraoperative complications were noted (access lesion by adhesions). PIPAC could be repeated at 6-weeks intervals (4x: n = 1; 3x: n = 2: 2x: n = 2; 1x: n = 2). One patient (ASA IV, Karnovsky 30%, refractory ascites) died postoperatively due to anasarca. A single adverse event [ 2 CTCAE was noted after PIPAC alone (GPT increase). Performance index (Karnofsky) increased from 66 ± 23 % to 74 ± 18 % after therapy. Five patients were eligible for response assessment after repeated PIPAC. Two patients showed complete intraperitoneal remission (CR), three partial remission (PR). Four patients are alive. Median survival has not been reached after a mean follow-up of 7 months. Conclusion: These results are encouraging, PIPAC induced a complete intraperitoneal remission in 2/7 patients with PC from GC. PIPAC is well tolerated and improves patient’s performance. First survival data are encouraging. Further studies are now planned to determine efficacy. References: 1. 2. 3. 4. 5.

Solaß W et al. Surg Endosc. 2012 Jul;26(7):1849–55. Solass W et al. Surg Endosc. 2012 Mar;26(3):847–52. Blanco A et al. Ann Surg Oncol (in press). Data on file. Data on file.

Introduction: Laparoscopic wedge resection is applicable for sub-epithelial lesion on the anterior gastric wall or greater curvature. Lesion located close to the esophagogastric junction is remained challenging. Methods: Laparoscopic wedge resection was chosen for anterior and/or greater curvature lesions. The combined endoscopic and laparoscopic intra-gastric tumor removal was selected for the tumor located close to the esophagogastric junction. In brief, after completing the diagnostic endoscopy. The CRE dilator (18–20 mm) was applied to occlude the pylorus to maintain gastric inflation. Three 5-mm blunted-tip trocars were carefully inserted directly into the gastric lumen. Free margin resection was safely done using the Harmonic Scalpel under direct vision of a five-mm, 30-degree laparoscopy. Bleeding was secured and gastric wall defect was approximated with intra-gastric suturing. Tumor was then retrieved endoscopically. The procedure was concluded with laparoscopic repair of port site gastric defects. We collected patients who had gastric sub-epithelial tumor removed. Patients who underwent combined endoscopic and laparoscopic intra-gastric tumor removal were analyzed. Results: From January 2010 to December 2012, there were 31 patients who had gastric subepithelial tumor removal by Chula Minimally Invasive Surgery Center. Eighteen had laparoscopic wedge resection. Thirteen underwent combined endoscopic and laparoscopic intra-gastric tumor removal. Of these, 9 cases were female. Mean age was 45 years old (range; 37–82). All except one case had successfully performed without any major complication. One case that was failed the first attempt of port placement had a successful resection 3 months later. The operative time was 95 min (range; 65–180). Blood loss was 20 ml (range; 2–200). Post-operative pain score at 1st postoperative day was 2.8 (range; 1–5). The mean hospital stay was 3.4 days (range; 3–6). The pathology results were 7 GISTs, 4 Leiomyomas, 1 ectopic pancreas and 1 carcinoid tumor. Average tumor size was 1.9 cm (range; 1–6) Conclusion: Combined endoscopic and laparoscopic intra-gastric tumor removal is safe and effective for sub-epithelial tumor located next to the esophagogastric junction.



Acid and Non-Acid Gastro-Oesophageal Reflux Following Sleeve Gastrectomy J. Hayat1, S. Mansour1, A. Wan1, A.P. Poullis1, E. Yazaki2, D. Sifrim2, J.Y. Kang1 1 St. George’s University of London, LONDON, United Kingdom; 2 Barts and the London School of Medicine and Dentistry, LONDON, United Kingdom

Benefit of Total Laparoscopic Distal Gastrectomy for Overweight and Obese Patients with Gastric Cancer M. Sugimoto, T. Kinoshita, Y. Kato, N. Gotohda, S. Takahashi, H. Shibasaki, M. Konishi National Cancer Center Hospital East, KASHIWA, CHIBA, Japan

Aim: To determine the effect of sleeve gastrectomy on gastro-oesophageal reflux and to investigate underlying pathophysiological mechanisms. Methods: Sixteen patients (median age 45.5 (range 25–71)) with morbid obesity underwent high resolution oesophageal manometry and 24 h ambulatory pH-impedance monitoring at least two weeks pre-op and 3 months post sleeve gastrectomy. All patients documented reflux and dysphagia symptoms at the time of testing. Nine patients also underwent concurrent gastric emptying with 13C labelled octanoate breath test. Results: Mean Body Mass Index (BMI) fell from 49 (range 41.3–58.3) to 38.5 (35–46.3). 5/16 patients reported new or worsening reflux symptoms (31%). There was a reduction in basal Lower Oesophageal Sphincter (LOS) pressure: 14.4 mmHg (9.7–28.5) pre-op vs 8.9 mmHg (0.7–40.5) post-op (p \ 0.02) and an increase in intra-gastric pressure and Gastro-Oesophageal (G-O) pressure gradient: 8.3 mmHg (4.7–12.8) pre-op vs 10.4 mmHg (5.3–22.7) post-op (p \ 0.01). 8/16 patients had severe hypomotility pre-op and 9/16 post-op. 3/16 patients had pathological acid reflux pre-op, 5/16 patients having de novo reflux post-op (total of 7/16 acid reflux post-op). Mean total acid exposure time pre-op was 1.8% (0.5–5%) increasing to 4.35% (0.2–12.4%) (p \ 0.02) post-op. There was an increase in the number of acid: 18 (8–31) pre-op vs 29 (13–38) post-op (p \ 0.0001), and non-acid reflux episodes: 13 (7–19) pre-op vs 52 (35–84) post-op (p \ 0.0001). Non-acid reflux episodes occurred predominantly in the post-prandial period. Gastric half emptying time (t1/ 2) was significantly shorter post op 193.1 min (range 113–433) vs 115.8 min (range 82–170) (p \ 0.05). The duration of the lag phase (tlag) was also shorter pre-op (mean 138.8 min (84–272)) vs 70 min (30–111) post-op (p \ 0.01). Conclusion: Both acid and non-acid gastro-oesophageal reflux is increased three months after sleeve gastrectomy with 31% of patients developing de novo acid reflux post-op. This is despite a reduction in the parietal cell mass and accelerated gastric emptying. A reduction in LOS pressure and increased gastro-oesophageal pressure gradient are likely to be contributing factors. Future studies should determine whether decreased gastric compliance stimulates an increased number of transient lower oesophageal sphincter relaxations.

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Background: Laparoscopic distal gastrectomy for gastric cancer has been firmly established in recent decades but is still difficult especially for obese patients, as with open surgery. The aim of this study was to evaluate the perioperative outcome of total laparoscopic distal gastrectomy (TLDG) in early gastric cancer patients with body mass index (BMI) of more than 25, and consider countermeasures to this. Methods: The perioperative outcome of 42 patients with BMI of more than 25 (overweight or obese group; OWG) and 216 patients with BMI of less than 25 (normal or underweight group; NWG) who underwent TLDG between September 2010 and December 2012 was compared. Results: BMI was 26.0 ± 1.4 in OWG and 22.0 ± 2.1 in NWG (p \ 0.001). There was no difference in age, sex, American Society of Anesthesiologists score, presence of diabetes, retrieved lymph node number, metastatic lymph node number, and metastatic lymph node ratio. There were significant differences between the two groups with respect to the extent of lymph node dissection (OWG, D1 11.9%; D1 + 66.7%; D2, 21.4%; NWG, D1 5.2%; D1 + 51.7%; D2 43.1%; p = 0.020) and tumor size (OWG, 25.5 ± 20.2 mm; NWG, 33.0 ± 17.2 mm; p = 0.005). Differences in operation time (OWG, 212 ± 31 min.; NWG, 200 ± 35 min.; p = 0.005) and estimated blood loss (OWG, 15 ± 22 ml.; NWG, 10 ± 34 ml; p = 0.013) seemed to have minimal impact clinically. Postoperative complications including infectious complications and recovery after surgery did not differ between the groups. Conclusions: TLDG for overweight and obese patients was managed safely. It was considered to be difficult, but sufficiently feasible.


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Laparoscopic Redo Fundoplication With and Without Mesh V.V. Grubnik, A.V. Malynovskyi, V.V. Ilyashenko, A.V. Grubnik Odessa national medical university, ODESSA, Ukraine

Mesh in Laparoscopic Large Hiatal Hernia Repair: A Systematic Review of the Literature E.J.B. Furnee1, E.J. Hazebroek2 1 Diakonessenhuis Utrecht, UTRECHT, The Netherlands; 2 St. Antonius Hospital Nieuwegein, NIEUWEGEIN, The Netherlands

Background: Outcomes after redo fundoplication (RF) in recurrent GERD may have lower success rate with higher morbidity than after primary fundoplication (PF). Many studies show that use of mesh dramatically reduce the rate of recurrent hernias. The aim of study was to evaluate the role of mesh in RF. Methods: We prospectively followed 48 patients (29 women and 19 men, mean age 51.2 ± 3.5 years) who required RF. These patients were part of series of laparoscopic anti-reflux operations (1780) done between 1994 and 2011. Indications were: recurrent GERD and migration of wrap (21 patients), paraesophageal recurrent hernias (17 patients), slipped wraps (5), disruption of wrap (5). Mean time interval between PF and RF was 36.4 months (range, 2 months–10 years). RF was done using 4 trocars. In cases of paraesophageal herniation, the hernia sac was mobilized and excised. In 26 patients we used lightweight mesh for hiatal repair, in 22 patients hiatal closure was performed by sutures. Results: No patients received preoperative chemotherapy. Tumors were classified as pTis in 40 patients (58.8%), as pT1 in 17 (25%), pT2 in 9 (13.2%), and pT3 in 1 (1.47%). The median operative time was 65.6 min. ± 43.14 min. Loss of blood was minimal: 0–30 ml. Intra-operative perforation occurred in 3%. In 61 (91.1%) cases R0 and 6 (8.9%) RX resection could be performed. The postoperative course was without any complications in 99.6% of patients. The mean follow-up was 62.56 ± 30.52 months. 5 (7.5%) patients had local recurrence. The rate of local recurrence for patients with pTis tumors was 2 (5%), for pT1 was 1 (5.9%), for pT2 was 1 (11.1%) and for pT3 was 1 (100%). 5 patients with local recurrence were eligible for salvage surgery: 1 had radical salvage resection, 2 had repeated ?EM, and 2 refused surgery. Overall 5-year survival was 100% in all 57 patients with pTis and pT1 tumors. All 48 RF were completed laparoscopically. Mean operative time was 79.4 ± 10.2 min in RF compared to 52.3 ± 5.6 min in PF (p \ 0.05). Intraoperative complications occurred in 5 (10 %) patients from both groups. There were no perforations of either esophagus or stomach. Mean hospital stay was 3.6 ± 0.5 days in both groups. 46 patients were followed after RF with a mean period of 26.8 ± 4.2 months. Mean De Meester score decreased from 89.6 ± 5.2 to 23.8 ± 4.8 (p \ 0.05). They showed a significant decrease in symptom score from 29.0 ± 2.9 to 10.7 ± 2.5 (p \ 0.01). There were no recurrent hernias in group of 26 patients who were reoperated using mesh. Recurrent hernias were detected in 2 patients from 22, who where reoperated without mesh. In summary, good results were obtained in 89 % in the mesh group, and in 71 % in patients operated without mesh. Conclusions: Laparoscopic RF leads to good objective outcome. The use of lightweight mesh may improve results of RF and decrease the rate of recurrences, especially in patients with paraesophageal hernias.

The aim of this study was to outline the currently available literature on the use of mesh in laparoscopic large hiatal hernia repair. A structured search of the literature was performed in the electronic database of Medline, Embase and Cochrane Central Register of Controlled trials. Studies were selected based on in- and exclusion criteria, methodologically assessed and data were acquired by a standard data extraction form. A total of 26 studies met the inclusion criteria. There were three randomized controlled trials, seven prospective and five retrospective cohort studies and five prospective and one retrospective casecontrol studies. The study design was not reported in the remaining studies. In the included studies, laparoscopic hiatal hernia repair was performed with mesh in 924 patients (mesh group) and without mesh in 340 patients (non-mesh group). The type of mesh used was very different; polypropylene in six, bio-mesh in nine, polytetrafluoroethylene (PTFE) in two, expanded PTFE (ePTFE) in two and composite polypropylene-PTFE in another two. At least two different kinds of mesh were used in five studies. The mean (± SEM) area of the mesh was 51.9 ± 10.8 cm2. The mesh was positioned posterior to the oesophagus in 15 studies (57.7%), around the oesophagus in five (19.2%), anterior in two (7.7%), semicircular in two (7.7%) and the position was not reported in two studies (7.7%). Radiological and/or endoscopic follow-up was performed after a mean (± SEM) period of 25.2 ± 4.0 months. There was no or only a small recurrence (recurrent hiatal hernia \ 2 cm) in 385 of the 451 available patients (85.4%) in the mesh group and in 182 of 247 (73.7%) in the non-mesh group. An oesophageal erosion was reported in one patient (0.2%). Two patients (0.5%) had dysphagia due to extensive adhesion formation around the mesh. Conclusions: The use of mesh in the repair of large hiatal hernias is promising with regard to the reduction of anatomical recurrences. However, many different kinds and configurations of mesh are available. Therefore, high quality randomized controlled trials should be performed to obtain the most effective and safe mesh on the long term.



Endoscopic Clipping to Help Recognize Anatomical Failures After Nissen Fundoplication L.I. Barkhatov1, K. Airazat2, B. Edwin1 1 Oslo University Hospital - Rikshospitalet Oslo, OSLO, Norway; 2 Sykehuset Telemark Health Trust - Skein hospital, SKEIN, Norway

Is Staging Laparoscopy Necessary in Patients Undergoing Modern Staging for Oesophago-Gastric Cancer H. Ali1, A. Abouleid2, A. Ghaffar2, L. Zhang2, M. Khalil2, A. Patel2, A. Hamouda2, A. Nisar2 1 Maidstone and Tunbridge Wells NHS trust, MAIDSTONE, United Kingdom; 2Maidstone and Tunbridge Wells hospital, MAIDSTONE, United Kingdom

Background: Laparoscopic antireflux surgery (LARS) is the gold standard in surgical treatment of patients with GERD. Despite high rate of successful outcomes after LARS, nearly 15% of these patients get recurrence of symptoms or develop new gastrointestinal symptoms. Some of them required redo procedures. It could be demanding to reveal anatomical failure after previous fundoplication. This requires wide experience, and precise diagnosis is often lacking. In this study we present a method which assists in recognition of anatomical failures after Nissen fundoplication. Material and Methods: Five patients with previous laparoscopic Nissen fundoplication, who has severe gastrointestinal symptoms and became candidates to redo surgery were analyzed. All patients underwent video contrast investigation of esophagus and stomach and esophagogastroduodenoscopy. During the esophagogastroduodenoscopy two radiopaque metal clips were placed to mark Z-line (CMZL). It was done to achieve precise visualization of gastroesophageal junction area at the video contrast investigation. Distinction between conclusions after the ordinary video contrast investigation, video contrast investigation with CMZL and intraoperative finding was analyzed. Results: All patients underwent laparoscopic fundoplication without complications and with good postoperative results. Comparison of diagnosis using ordinary video contrast study, video contrast study with CMZL and intraoperative finding is presented. There were four misdiagnosed cases in five patients by contrast investigation without clips. Endoscopic clipping helped to recognize correctly all anatomical failures. Conclusion: The treatment of failed fundoplication is a difficult problem with complicated diagnostics. Inclusion of endoscopic clipping into routine practice helps to investigate anatomical failures, which can reduce numbers of misdiagnosis and helps to perform redo fundoplication in appropriate patients.

Aims: To assess the possible role of laparoscopy in preoperative staging of oesophagogastric cancer after laparoscopic resection has become one of the treatment options. Methods: Staging laparoscopy was carried out for 99 consecutive patients who were considered for curative oesophagogastric resection and had undergone complete set of staging invitation. The outcomes were measured in terms of changing treatment decision, operating time, intra and postoperative complications, hospital stay and the need for interventional procedures such as feeding jejunostomy. Results: 99 patients with oesophagogastric cancer had staging laparoscopy. The mean operative time was 39.8 min and the hospital stay ranged from 0 to 29 days (mean 0.7 day). 4/99 patients had feeding jejunostomy at time of staging laparoscopy (4%). No Intraoperative complications or conversion to open procedure were detected. 2/99 had postoperative complications (2%): pneumonia and infection at the jejunostomy site respectively. Staging laparoscopy had changed treatment decision in 8/99 patients (8.1%) where no further curative resection was attempted due to involvement of peritoneum (3%), omentum (1%), liver (1%), fixation of the stomach (3%). Conclusions: From this retrospective study staging laparoscopy is found to be safe and useful in detecting peritoneal omental and liver disease despite negative staging modalities.

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Laparoscopic Common Bile Duct Exploration as Single Step Management for Incidentally Diagnosed Common Bile Duct Stones A. Umezawa, T. Watanabe, Y. Seki, K. Kasama, Y. Negishi, Y. Kurokawa Yotsuya Medical Cube, TOKYO, Japan

Real-Time Fluorescence Imaging of Biliary Anatomy Using ICG During Single-Incision Laparoscopic Cholecystectomy N. Tagaya, Y. Kubota, A. Suzuki, N. Makino, K. Hirano, K. Saito, T. Okuyama, S. Kouketsu, E. Takeshita, Y. Sugamata, H. Yoshiba, S. Sameshima, M. Oya Dokkyo Medical University Koshigaya Hospital, SAITAMA, Japan

Background: Treatment for common bile duct stones (CBDs) has been performed broadly with two different manners, one is laparoscopic cholecystectomy (LC) with endoscopic treatment (ERCP), and another is single stage by open or laparoscopic surgery (CBDE). The strategies for incidentally diagnosed CBDs during LC are always argumentation, because clinical models are not always accurate in predicting CBDs, post operative ERCP is not always successful and may cause reoperations, and patient’s expectation for successful completion of laparoscopic surgery. Aims: To determine the feasibility of laparoscopic CBDE approaches for CBDs, especially transcystic duct exploration (LTCE). Methods: We perform intraoperative cholangiography (IOC) routinely during LC. Once confirming the diagnosis of CBDs with IOC, laparoscopic CBDE is carried out according to the number and size of stones. The number less than four and the size under 8 mm are indication for LTCE. Others are indicated for transcholedochal exploration (LCHE). Results: Of 915 LC cases, 40 were successfully performed laparoscopic CBDE. All CBDs were demonstrated by IOC. In 4 patients, preoperative ERCP was performed, and there were remaining stones. 14 patients Incidentally diagnosed CBDs by IOC (incidentally diagnosed CBDs). LTCE was performed 22 patients which include incidentally diagnosed 11 (78%), while LCHE was performed 18 patients. One LTCE patient had converted into LCHE because tear of the cystic duct. Mean operative time was 151.2 min (LTCE: 143.7, LCHE: 159.5). There was no conversion to open surgery, no major complication, and no retained stone. Mean number of CBDs was 2.2 (LTCE was 1.9, LCHE was 2.6) and its mean size was 7.7 mm (5.3 mm, 9.8 mm). The length of postoperative hospitalization for LTCE was 2.2 days, and for LCHE was 2.9 days. Conclusions: One of the key of LTCE is uncomplicated post operative course like simple laparoscopic cholecystectomy, and LTCE makes it possible to manage incidentally diagnosed CBDs without injuring common bile duct. Although there are limitations to the indication, LTCE is feasible and should be the first line of treatment for CBDs. With LCHE as redeeming approach, both approaches can lead feasible clinical outcomes for CBDE.

Background: We evaluate the real-time fluorescence imaging of biliary anatomy with cholangiography and angiography using indocyanine green (ICG) during single-incision laparoscopic cholecystectomy. Patients and Methods: This study enrolled 10 patients who underwent single-incision laparoscopic cholecystectomy. ICG was injected 3–4 h before exploration. Under general anesthesia, we observed biliary anatomy under the guidance of real-time fluorescence imaging producing by a 10-mm laparoscope with an infra-red ray. The flow of the cystic artery after re-injection of ICG was also observed by the same laparoscope. Laparoscopic cholecystectomy was performed by a standard manner. Results: We obtained the clear vision of biliary tract in all patients. The cystic artery was also identified approximately 10 s after re-injection of ICG in 7 cases. There were no particular perioperative complications related with an intravenous injection of ICG. After obtaining the critical view, cystic duct and artery were clearly identified by ICG fluorescence imaging. Conclusion: The advantages of this method are no cannulation manner into cystic duct, no arrangement of X-ray equipment and no radioactivity. ICG fluorescence imaging is a safe and useful tool for the navigation of biliary anatomy with cholangiography and angiography during single-incision laparoscopic cholecystectomy.



Two-Incision Laparoscopic Cholecystectomy K. Terro1, S. Al Shanafey2 1 Specialized Medical Center Hospital, RIYADH, Saudi Arabia; 2 King Faisal Specialized Hospital and Research Center, RIYADH, Saudi Arabia

Laparoscopic Bioimpedancemetry of the Liver D.N. Panchenkov1, S.D. Leonov1, Yu.V. Ivanov2, R.B. Alikhanov3, A.A. Nechunaev1, D.Yu. Agibalov2, G.B. Aleksanyan1 1 A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 2Federal Research Clinical Center of Specialized Medical Care and Medical Technol, MOSCOW, Russia; 3 M.V. Lomonosov Moscow State University, MOSCOW, Russia

Introduction: Minimally invasive techniques have advanced tremendously over the last few decades and lately reduced incision surgery has emerged as a safe feasible option with cosmetic benefits. We report our experience with two-incision laparoscopic cholecystectomy at a private practice set up. Methods: A prospective data collection of patients who underwent laparoscopic cholecystectomy with two-incision technique was conducted during the period from February 2009 to May 2012. The procedures were performed utilizing the standard laparoscopic instruments and trocars. A supraumbilical incision accommodating two 5 mlm trocars and a xiphoid incision accommodating a 5 mlm trocar were utilized. Extra ports/incisions were added when deemed necessary. All procedures were performed in the standard fashion by one surgeon. The study was approved by the local research and ethics committees. Results: during that period, 213 patients were managed with laparoscopic colecystectomy utilizing the two-incision technique. There were 153 females and 60 males with a mean age of 36.4 years (17–65). Mean of the body-mass index (BMI) was 30 (17–63). Ten patients had acute cholecystitis (3 hydropic), and 203 had biliary colic. Two patients were pregnants (18 and 21 weeks of gestation), 7 patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 12 had umbilical hernias repaired simultaneously. All procedures were completed successfully laparoscopically patients, and 21 patients needed an extra port insertion. The latter was mostly used with high BMIs. Mean operative time was 27.8 min (15–70). Nine patients required one dose of Demerol, ten required one dose of Tramal (anti-inflammatory), and all patients were maintained on paracetamol postoperatively for pain control. Nine patients were done as day-surgery procedures and the mean hospital stay was 1.3 days (0–4). 3 patients developed minor wound infections and one patient had mild pancreatitis. Conclusion: Two-incision laparoscopic cholecystectomy is safe and feasible and can be performed utilizing the standard laparoscopic instruments. It has the potential for cost containment and superior cosmetic benefits.

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The estimation of the functional condition of liver parenchyma is an important component in surgical treatment of patients with liver tumors. Measurement of electric impedance (bio-impedancemetry) could be an informative diagnostic method, permitting to clarify the functional reserve of the liver in patients who are scheduled to undergone liver resection. Aim of the Study: To work out the methodology of laparoscopic bio-impedancemetry of the liver. Materials and Methods: Laparoscopic bioimpedancemetry (LBIM) performed to 42 patients during planned cholecystectomy (n = 23), liver cyst fenestration (n = 3), liver resection combined with radiofrequent ablation of colorectal metastases (n = 3), nephrectomy (n = 4), diagnostic laparoscopy (n = 9). Bioimpedancemetry (BIM) performed with bipolar needle electrodes and the original device for measurement of full electric impedance of biological tissues ‘BIM II’ (patent of Russian Federation ‘- 2366360). The value of electric impedance determined in one zone of the electrode injection in series on three frequencies—2, 10, 20 kHz. Results: When analyzing the results of the study valid differences were noticed between the electric impedance of intact liver and the liver with cirrhotic and metastatic changes. Conclusion: LBIM of the liver is available, safe and informative diagnostic method, which permits to clarify the functional condition of the liver. The results of LBIM could be useful in planning of major liver resections and prediction of outcome of surgical treatment of patients with liver pathology.


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Cystic Duct Anomalies and Their Surgical Implications During Laparoscopic Cholecystectomy K.A.H. Talpur, A.A. Laghari, A.M. Malik, A.K. Sangrasi, J.N. Qureshi Liaquat University of Medical & Health Sciences, JAMSHORO, SINDH, Pakistan

Role of Laparoscopic Lavage in Perforated Colonic Diverticulitis I. Triantafyllidis, C. Demertzidis Veria General Hospital, VERIA, Greece

Objectives: The main purpose of study was to assess anomalies of cystic duct and their surgical importance during laparoscopic cholecystectomy because the knowledge of anatomy of cystic duct with confluence of CBD is important factor to avoid ductal injuries in biliary surgery. Methods: The study was conducted at Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan, over 775 patients of cholelithiasis undergoing for laparoscopic cholecystectomy in duration of 3 years from January 2009 to December 2011. Results: The site of confluence of cystic duct and common bile duct was surveyed in 775 patients during laparoscopic cholecystectomy. Abnormal confluence was found in 56 cases (7.22%) with common anomalies in form of long cystic duct (17.85%), short cystic duct (26.78%), double cystic duct (12.57%) low site insertion (19.64%), anterior, posterior spiral insertion (12.15%). The surgical problems encountered due to these variations were cystic duct avulsion, right hepatic duct injury, CBD injury, bleeding and biliary leaks. Conclusion: The anatomical variations of cystic duct are usually considered of little clinical significance by many surgeons but can be responsible for various difficulties in surgical procedures, ductal injuries and morbidity and mortality if not recognized properly.

Introduction: Hartmann’s procedure is the standard approach for acute perforated diverticulitis. Laparoscopic peritoneal lavage may control abdominal sepsis avoiding a laparotomy with stoma creation. Material and Methods: Retrospective study of patients with perforated colonic diverticulitis who were managed in our department with laparoscopic lavage of the peritoneal cavity during the last 5 years. The primary endpoints of our study were morbidity and mortality rates, hospital stay, relapse of symptoms, whereas the secondary endpoints were Hinchey classification of diverticulitis and patients’ demographic data. Results: Twenty four patients, 15 males and 9 females, were included in our study. In all patients there was a radiological diagnosis of perforation. Nine patients presented with Hinchey class IIb diverticulitis, and the remaining 15 with class III diverticulitis. Median hospital stay was 9 days. Four patients experienced early recurrence of symptoms. Mortality rate was zero. Two patients presented persistent abdominal pain and fever due to inadequate drainage of the peritoneal cavity. Conclusion: Laparoscopic lavage of acute perforated diverticulitis could be a safe and feasible alternative to classical Hartmann’s procedure with less morbidity and no need for stoma creation compared to open surgery, in selected patients.



Polyp Surveillance Colonoscopy—How are We Actually Doing? M. Nnaji, C. Ng, G. Kaur Scunthorpe General Hospital, SCUNTHORPE, United Kingdom

Functional End to End Anastomosis with Circular Stapler and Reinforcement is the Most Reliable Method After Low Anterior Resection for Rectal Cancer T. Ikeda, R. Kumashiro, K. Taketani, K. Ando, S. Ida, K. Kimura, K. Saeki, E. Oki, M. Morita, T. Kusumoto, Y. Maehara Kyushu University, FUKUOKA, Japan

Aim: Surveillance colonoscopy in people with adenomatous polyps can potentially prevent progression to colorectal cancer. The British Society of Gastroenterology (BSG) introduced colonoscopic surveillance guidelines in 2002 (revised in 2010). What is uncertain however is whether clinicians are adhering to the BSG guidelines and requesting follow up colonoscopies accordingly. Previous audit carried out by our Department showed that only 21 % of patients having colonoscopy follow up were compliant with the BSG guidelines. After recommendations had been made our aim was to re-audit and investigate any improvement in compliance. Methods: This was a retrospective audit of the 51 patients identified via our Information services database as having polyp surveillance colonoscopies during the period of January to December 2012. We used patient’s case notes and histology findings derived from their first colonoscopy and the BSG guidelines to identify patients who had were non compliant with the guidelines. Results: Only 13/51 (25.5%) patients were identified as having colonoscopies requested correctly. 0% patients in the low risk category, 41.7% in the intermediate risk group and 21.4% in the high risk group had appropriate timing of colonoscopy. 7 patients who had had previous metaplastic/ hyperplastic polyps had an unnecessary follow-up colonoscopy. Reasons for non -compliance with guidelines was poor visualization, checking polyp excision and failure of polyp excision, but in the main, just that the BSG guidelines had not been followed by clinicians. Conclusion: These results suggest that endoscopists are bringing patients back earlier than expected for their follow-up colonoscopies. Compliance with guidelines is higher in the higher risk group, suggesting the overly cautious decision making on the part of the clinicians, with obvious financial implications. In this era of financial constraints, it is important that endoscopists abide by the BSG guidelines when requesting polyp surveillance colonoscopies. Continued education and audit will be used to drive this message home

Background: Endoscopic evaluation of anastomotic leakage after DST has shown that all anastomotic dehiscences were on the anastomosis line of the circular stapler (CS), with two-thirds located at the overlap of the linear stapler (LS) with the CS and the other third located in the middle of the points of overlap. Purpose: To develop the most reliable anastomosis technique that can supersede DST. Methods: The rectum and proximal colon were removed from the pig pelvic cavity, and four types of anastomoses were performed on the proximal and anal sides of each rectum, including DST (n = 4), functional end to anastomosis (FEEA) with the linear stapler (FEEA-LS, n = 5), FEEA with the circular stapler (FEEA-CS, n = 4) and hand-sewn reinforcement added to FEEA-CS (FEEA-CS + HR, n = 4). FEEA-CS was performed by inserting the anvil into the lumen of the colon and impaling the anvil shaft on both sides the mesocolon about 2 cm from the stump of the colon. The cartridge-carrying instrument was inserted into the rectal lumen from the opposite side of the anastomosis and the side wall of the rectum was impaled with the central rod. The anvil shaft and central rod were joined and closed, bringing the stumps of the rectum and colon together. For FEEA-CS + HR, the corners of the rectum and colon stumps, located on the opposite sides, were sutured, followed by suturing of each stump to the wall to cover the CS anastomosis line. The bursting pressure in each group was tested by air-filling. Results: The bursting pressures in the DST (n = 4), OL (n = 4), SS (n = 5), and SS + HR (n = 4) groups were 10.3 ± 3.9, 11.3 ± 2.3, 34.8 ± 1.7, 49.8 ± 22.7 and 80.5 ± 24.6 mmHg, respectively. Pressures were significantly higher in the OL and SS than in the DST groups (p \ 0.001, Mann-Whitney U-test) and were higher in the SS + HR than in the SS and OL groups (p \ 0.001). Conclusions: FEEA-CS + HR the most reliable technique for anastomosis that does not require covering stoma.

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Laparoscopic Wedge Resection in Deep Infiltrating Endometriosis of the Rectum-Indication, Outcome and Future Application A. Petter-Puchner, R. Fortelny, F. Berger, G. Hudelist, H. Salzer, K.S. Glaser Wilhelminenspital, VIENNA, Austria

Laparoscopic Colorectal Resection of T4 Achieving Equivalence in Outcomes to T3 Cancer K.M. Mohiuddin, T. Wilson, N. Randhawa, R.K. Maitra, J.P. Williams, A. Banerjea, C. Maxwell-Armstrong, A. Acheson Nottingham University Hospitals, NOTTINGHAM, United Kingdom

Introduction: Deep infiltrating endometriosis of the rectum (DIER) is a painful disease which often is diagnosed late in life and can the associated with severe complications, eg ileus. Laparoscopy has triggered the quest for ever less invasive and moderate resection techniques. In this work we compare full segment rectum resection to wedge resection. Methods: At our certified center for the treatment of endometriosis 62 patients have been operated laparoscopically in a two year observation period. 46 time a full segment resection was performed and in 16 patients a wedge resection only. A protective ileostomy was not created routinely. The indication for wedge resection was based on localized DIER and good accessibility. Results: Full segment resection led to one dehiscence of a low rectum anastomosis requiring a Hartmann salvage operation. Wedge resection led to satisfying results without major complications. Conclusion: Considering our experiences wedge resection of DIER in selected cases is a safe and effective procedure which could also be performed more easily in single incision techniques than full segment resection.

Aim: T4 cancer resection laparoscopically is a challenge but it can vary depending on the site or structures involved. Oncological clearance should be the paramount consideration in planning the procedure but T4 tumour need not to be automatic exclusion for laparoscopic resection. We compared the outcomes of laparoscopic resections of T4 and T3 cancers. Methods: Data regarding patients with histologically T4 and T3 operated since 2006–2012 were collected prospectively and analysed. We compared all T4 with T3 tumours where the intent of treatment was curative resection laparoscopically. All available clinic-pathological variables possibly associated with the outcomes were compared. Results: A total of 72 (M: F = 36:36) patients with T4 and 229 (M: F = 120:109) patients with T3 who underwent laparoscopic resections were included. The demographic data (Mean Age 70 yrs vs 66 yrs, Mean BMI 26 vs 27, Median ASA 2 vs 2) didn’t differ significantly between groups. The procedure performed based on tumour location, Right colon (51% T4 vs 49% T3), Left colon (11% T4 vs 12% T3), Rectum (36% T4 vs 36%). The mean operating time (178 min T4 vs 170 min T3, p = 0.41), Blood loss (138 ml T4 vs 126 ml T3, p = 0.388), Conversion rate (13% T4 vs 10% T3, p = 0.140), Length of stay (5 days T4 vs 4 days T3, p = 0.462). The overall complication rate was higher in T4 (33%, 24/72 pts) in contrast to (19.3%, 44/229 pts) in T3 (p = 0.128), and is due to more number of wound complication (11/72) in T4 but no significant difference in anastomotic leak (4%, 3/72 pts T4 vs 4.3%, 10/229 pts T3). The R1 resection rate was 5.5% (4/72, T4) compared to 3% (7/229) in T3 group (p = 0.17). After mean follow up of 17.5 months (T4) & 21 months (T3), the overall survival was 84% in T4 compared to 89% in T3. The local recurrence was 9.7% and systemic recurrence 11% in T4 comparable to 2% & 10% in T3 respectively. Conclusion: Short term oncological outcomes for T4 tumours are comparable to T3 cancer after laparoscopic resection. Larger series are required to see if there is any difference in long term outcomes.



Transanal Endoscopic Microsurgery for Rectal Lesions: Is It Safe to Use Fast Track Protocol for Early Discharge? M. Paquin-Gobeil, S. Duhaime, I. Yang, I. Raiche, R. Auer, J. Mamazza, R. Boushey, H. Moloo The Ottawa Hospital, OTTAWA, Canada

Laparoscopic Ileocolic Resection for Crohn’s Disease: A Series of 42 Consecutive Patients J. Sampson, S. Delgado, R. Bravo, R. Corcelles, D. Momblan, A. Ibarzabal, J.C. Baanante, A.M. Lacy Hospital Clinic de Barcelona, BARCELONA, Spain

Aim: To determine if discharge within 24 h post transanal endoscopic microsurgery (TEM) has worse outcomes compared to routine 72 h admission. Methods: We conducted a retrospective study of TEM patients at our tertiary institution between October 2009 and November 2012. Surgeries were performed by 2 colorectal surgeons with similar TEM training and experience but different postoperative care pathways. Patients in Group A were sent home within 24 h without prophylactic antibiotics while patients in Group B were kept for 72 h and discharged with antibiotics. For both groups, we looked at demographics, surgical pathology, operation time, tumor size, peri-operative complications, length of stay, readmission rate and Clavian-Dindo Classification at 30 days. Results: We had 27 patients for Group A and 29 for Group B. Demographic data were similar in each group except for ASA score (median of 3 in A and 2 in B). The 2 groups had similar pathologies The operative time for Group A was 111 min (with 3 conversions) vs 77 min for Group B (no conversion). The median length of stay was 26 h for Group A and 77 h for Group B. The average size of the tumor was 2 ± 0.4 cm in each Group. The 2 groups had similar intraoperative complications (1 patient needed transfusion in Group A). One patient per group developed a fistula; both patients had previous pelvic surgery, while the Group A patient also had neo-adjuvant radiation. No patients in Group A and 22 patients in Group B were sent home with prophylactic antibiotics. Overall, 3 patients per group had other kinds of complications. The Clavian-Dindo classification at 30 days was 0 in both groups and no patient died. Only 1 patient was re-admitted to the hospital in Group A. Conclusions: In our experience, early discharge post-TEM procedure does not change outcomes despite patients in Group A having more comorbidities (ASA 3). Also, antimicrobial therapy does not prevent post-operative complications. Early discharge is a safe approach to TEM and is costeffective.

The aim of this study was to assess the immediate postoperative outcomes of a series of consecutive patients treated by laparoscopic assisted ileocolic resection for ileocecal Crohn’s disease in a tertiary teaching hospital. From February 2005 to September 2011 forty two patients underwent laparoscopic ileocolic resection for Crohn’s disease. Data were collected prospectively and the variables included: patient0 s demographics, medical history, details of the operative procedure, postoperative course, complications and recurrence rate. Each statistical analysis was performed with SPSS II program, version 19 for Windows (SPSS, Inc., Chicago, IL). 42 consecutive patients (16 men and 26 women) with a mean age of 32 years underwent laparoscopic ileocolic resection for Crohn’s disease. The mean length of time from diagnosis to surgery was 7 years. 14 patients had prior abdominal surgery. Indications for surgery were obstructive symptoms 73.8%, fistulae 21.4% and abscess 4.8%. Mean operating time was 99 min (50–150). Conversion rate 2.4%. There were not intraoperative adverse events. The postoperative complications rate was 4.8% due to prolonged ileuses treated with conservative management. Resumption for oral diet was 43 h (range, 24–120). The mean length of hospital stay was 5 days (range, 2–15). The recurrence rate was 45% with a median follow up of 38.4 months, none of the patients required additional surgical treatment. This study shows that laparoscopic ileocolic resection for the treatment of Crohn’s disease is safe, feasible even when abscesses and fistulae are present without major postoperative complications.

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O184 - Education

O186 - Training

Attitudes of UK Trainees Towards the use of Live Anaesthetised Animals in Surgical Simulation Training R.L. Wild University of Sheffield, SHEFFIELD, United Kingdom

Development of a Cadaveric Extra-Levator Abdomino-Perineal Excision (ELAPE) Course, with LOREC National Development Programme for Low Rectal Cancer K.J. Gash1, J. Foster2, E. Cox2, F. Carter2, R. Longman3, A. Acheson4, A. Horgan5, B. Moran6, N. Francis2 1 Cheltenham General Hospital, CHELTENHAM, United Kingdom; 2 Yeovil District Hospital NHS Foundation Trust, YEOVIL, United Kingdom; 3Bristol Royal Infirmary, BRISTOL, United Kingdom; 4 Nottingham University Hospitals, NOTTINGHAM, United Kingdom; 5Newcastle-upon-Tyne Hospitals, NEWCASTLE, United Kingdom; 6Hampshire Hospitals NHS Foundation Trust, BASINGSTOKE, United Kingdom

Aims: UK legislation restricts the use of live anaesthetised animals for surgical training to rodents for microvascular techniques only. With simulation playing an increasingly important role in the surgical curriculum, especially in laparoscopic surgery, this study aims to assess contemporary attitudes of UK surgical trainees towards the use of live animals in surgical training. Methods: A self-administered 15-point survey was distributed amongst surgical trainees attending national educational events from 1st September to 31st October 2012. Responses were recorded using a 7-point Likert scale. Results: 219 surveys were returned (74%) and 203 completed responses analysed. Respondents were made up of all training grades (114 male [56%], 89 female [44%]). 95% of trainees feel comfortable about training on cadaveric animal models compared with 65% who feel comfortable, particularly males (p \ 0.001), about operating on live anaesthetised animals. 72% agree that live animals would add more value to a training course and 61% feel that UK trainees are disadvantaged due to the law restricting the use of live animals, with male trainees more strongly in agreement (p \ 0.001). 66% of trainees, especially females (p \ 0.001), believe that members of the public would find training on anesthetised animals unacceptable. 57% support the UK law being changed to remove restrictions on using live animals for training. Trainees (16%) who had previously operated on live animals overseas felt more strongly that practising on live animals would be beneficial for training but also that the use of live animal models is difficult to justify when an alternative virtual reality (VR) or synthetic simulation system is available (p = 0.044). 92% agree that maximum educational use should be made out of any animals used for training, including multi-speciality training and use of residual tissue for research. Only 9% feel that technology offered by VR simulators, such as the LapMentor, provides more realistic modalities for training than live animal models. Conclusions: While the fidelity of VR simulators remains limited, there is support amongst trainees for the wider use of live animal models in surgical training. However, this would require a change in legislation to align with European law and public opinion must be considered.

Aim: Evaluate intensive workshops aiming to train consultant colorectal surgeons in Extra-Levator Abdomino-Perineal Excision (ELAPE), and evaluate a fresh-frozen cadaveric model for training in laparoscopic rectal procedures. Methods: ELAPE has been advocated to improve oncological outcomes in low rectal cancer. The UK Low Rectal Cancer National Development Programme (LOREC) is a government-funded programme to improve outcomes and quality of life for patients with low rectal cancer. The programme has supported the development and implementation of cadaveric training workshops to train surgeons in technical skills to perform ELAPE. Three centres, (Bristol, Newcastle and Nottingham), delivered the same programme. Delegates completed pre-course questionnaires detailing level of experience, and were subsequently assigned to an expert trainer, based on individual needs. Delegates performed laparoscopic or open TME dissection and the perineal phase of ELAPE (prone), on fresh-frozen cadavers. Global Assessment Score (GAS) forms were used by delegates to enable formative self-evaluation and feedback on the educational value of the cadaveric model was given using five-point Likert scales. Results: Fifty-one consultant delegates attended one of 8 workshops. Prior experience in ELAPE was limited, with only median 5 (range 0–10) supine ELAPE and median 0 (0–85) prone ELAPE procedures performed by delegates. Only 28% of delegates, reported that they were confident in ELAPE perineal dissection prior to the workshop. Pneumoperitoneum was successfully established, although greater gas leakage was observed than with living tissue. 95% of delegates were able to successfully complete laparoscopic abdominal and TME dissection. Despite lack of blood flow, most delegates agreed that meticulous dissection was not greatly compromised (median score 2, IQR 1–3). Tissue properties and colour allowed easy identification of anatomy (median score 2, IQR 1–2), and tissue planes were relatively easy to appreciate (median score 2, IQR 2–3)—demonstrating high-fidelity. 95% of delegates either ‘strongly agreed’ or ‘agreed’ that they had greater confidence with cylindrical APE dissection and that the workshop would influence their future practice. Conclusions: The vast majority of consultants reported improved confidence in performing ELAPE after attending the workshop, demonstrating its effectiveness. Fresh frozen cadavers represent a high-fidelity model for training in complex laparoscopic rectal procedures.

O185 - Education

O187 - Training

Prospective Comparison of Different Teaching Methods for Learning Laparoscopic Suturing—Videoteching vs. Step-by-Step Hand-Out A. Kirschniak, S. Axt, U. Niwa, C. Ehrenberg, C Falch, S. Mu¨ller ¨ BINGEN, Germany University hospital Tu¨bingen, TU

Big Five Personality Traits can Predict Improved Endoscopic Surgical Performance of Medical Students M. Hattori, H. Egi, H. Sawada, K. Kawaguchi, T. Suzuki, Y. Kurita, H. Ohdan Hiroshima University, HIROSHIMA, Japan

Introduction: Hands-on training is a fundamental part of the surgical education and training, especially regarding the learning of laparoscopic technique skills. Different teaching methods are used for this purpose in the meantime. For the structured learning of these processes ‘nodal points’ can be helpful. The aim of this study was to compare the learning success by learning a laparoscopic suture gained by using video teaching material vs. the use of a work book with step-by-step instructions. Material and Methods: 45 study participants without any practical surgical knowledge (students of medicine and medical technology, 1–3rd term) were compared prospectively. After an online survey designed to evaluate possible hand skills, a pre-test were carried out to check laparoscopic skills. In the main experiment, a video introduction to demonstrate the technique of making a laparoscopic suture was shown. It was followed by the division of the groups. Permanently repeating video demonstrations of the task were presented to Group 1. Group 2 received a hand-out with ‘‘nodal points’’ of the task. Then the study participants had 90 min time to exercise the laparoscopic suture using these methods. The learning success was measured based on five nodes to be carried out within 35 min with a standardized evaluation questionnaire and analyzed by using a standardized scale. Results: The study participants of the video group (n = 22) scored within of test time of 35 min compared to the hand-out group (n = 23) 3.55 vs. 4.17 sufficiency nodes on average (p = 0.06). In the standardized point scale of the suture reached the video group 3.49 vs. 3.60 points (p = 0.38). In the standardized point scale of making the suture reached the video group 26.76 vs. 30.58 points (p = 0.11). The average time per suture was by the video group at 1343.5 s (22.39 min) vs. 1312.7 s (21.87 min) (p = 0.397). Conclusion: The structured step-by-step guide is an effective teaching tool for mediation of laparoscopic skills. The number of performed sutures is in the hand-out group at the same quality level significantly higher.

Background: In psychology, after attempts to develop a general taxonomy of stable personality traits, five key personality factors (the Big Five) were identified: Extraversion, Neuroticism, Openness to experience, Conscientiousness, and Agreeableness. These traits represent the primary dimensions of individual variation in cognitive, behavioral, and emotional tendencies and are associated with health and mortality to a degree comparable to socioeconomic status and intelligence. However, there are no reports showing any relationship between these personality traits and endoscopic surgical skills. The purpose of this study was to assess the impact of the Big Five personality traits on endoscopic surgical skills of medical students. Methods: Endoscopic surgical skills of medical students were assessed using the Hiroshima University Endoscopic Surgical Assessment Device (HUESAD). The participants performed HUESAD tasks 10 times before they underwent training. After completion of simulator training, they again performed the tasks 10 times. Thereafter, they answered a Big Five personality trait questionnaire (Extraversion, Neuroticism, Openness to experience, Conscientiousness, and Agreeableness). Spearman’s coefficients of correlation were calculated for assessing the relationships between the personality traits and the HUESAD assessment scores. Results: No significant correlation was found between the personality traits and the HUESAD assessment scores before training. The endoscopic surgical skills improved significantly after training (t(38) = 8.11, p \ 0.05). The Big Five personality traits were correlated with improved endoscopic surgical performance after training (r = 0.44, p \ 0.05). Moreover, statistically significant positive correlations were observed between Conscientiousness and the improvement rate (r = 0.36, p \ 0.05). Conclusions The results suggest that medical students scoring high on Conscientiousness are more likely to have improved endoscopic surgical skills, regardless of their initial skills. The ability to predict endoscopic surgical skills would be useful for designing tailor-made training programs in safety and high-quality operation.

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O188 - Training

O190 - Training

Comparing Skills Performance of Laparoscopic Tasks In Two Dimension Vs Three Dimension Monitors: A Randomised Control Study B. Alaraimi1, W.S. ElBakbak2, S.J. Sarker2, S.H. Makkiyah2, A. Al-Marzouq2, R. Goriparthi2, P. Patel1 1 Royal London Hospital, LONDON, United Kingdom; 2Barts Cancer Institute, LONDON, United Kingdom

A Serious Game to Improve Situation Awareness in Laparoscopic Surgery M. Graafland, W.A. Bemelman, M.P. Schijven Academisch Medisch Centrum, AMSTERDAM, The Netherlands

Aim: To compare the difference in performance of Fundamentals of Laparoscopic Surgery (FLS) tasks in 2D and 3D monitors by novices in term of completion time, repetitions and errors. Methods: Fifty medical students who were novices to laparoscopy and with no uncorrected visual problem randomly allocated to 2D or 3D group. All practiced on simulator following FLS curriculum until proficiency achieved. The four tasks practiced were peg transfer, endoloop, extracorporeal and intracorporeal suturing. The 3D group underwent an adaptation exercise before the training to be able to appreciate the stereoscopic vision. Data analysed by SPSS using t-tests and Mann-Whitney U tests to obtain P-values. Results: All candidates completed the training. The median number of repetitions and errors were lower in the 3D vs. 2D; 108 vs. 121 (p = 0.008) and 27 vs. 105 (p = 0.000) respectively. The median performance time (min) in 3D group 216 was less compared to 2D group 247 (p = 0.266). In peg transfer task the 3D group took significantly more time (= 148 min) than the 2D group (= 122 min) (p = 0.001); whereas in endoloop, extracorporeal suturing and intracorporeal suturing tasks the 3D group spent less time to complete the training with p values of 0.048, 0.002 and 0.003 correspondingly. Conclusion: Performance of the FLS tasks in terms of number of repetitions and errors were significantly better by the 3D group. The 2D group performed the first task in significantly less time than the 3D group which can be related to the adaptation time needed for 3D candidates. However in more advanced tasks the 3D group performance time was significantly less than the 2D group.

Introduction: Situation awareness is the ability of an operator to perceive signs and signals from the operation environment and comprehend their meaning in the procedure as it evolves. Improved situation awareness has been associated with a reduced amount of technical errors in laparoscopic surgery, yet no methods currently exist for off-site training of this non-technical skill (Mishra et al. Surg Endosc. 2008 Jan;22(1):68–73). A serious game was therefore developed, directed at surgical residents. Serious games are new and potent instruments for medical education, blending interactive learning with challenge, providing a motivating training setting. Aim of this study is to prove face- and construct validity. Methods: The serious game was developed through a multidisciplinary effort, involving game designers and surgical specialists. It is an interactive computer game that can be enrolled on tablet or smartphone to enhance accessibility. The player is challenged to play an entertaining game, not directed at improving skills itself. While playing the game, the player meets instrumentation problems or hemodynamic complications derived from real laparoscopic surgery presented by realistic sights and sounds. The player then enters a troubleshooting mode, similar to the operation room. To improve the score, the player needs to solve the real-life laparoscopic surgical challenges encountered, thereby improving the ability to comprehend difficult situations. 10 novice surgical residents and 10 laparoscopic surgeons played the game for a predetermined amount of levels. Scores on different outcome parameters were compared between both groups to determine statistically significant differences, indicating construct validity. Participants filled out a questionnaire on the games’ usability and resemblance to reality. Results: The developed serious game will be presented to the audience interactively, together with the results of the validity study. Discussion: This study represents the preliminary results of a novel training modality for laparoscopic surgery, i.e. serious gaming. Important steps in developing a valid serious game aimed at training situation awareness are outlined. This study could contribute to the introduction of valid, fun and effective off-site training for ‘non-technical skills’, applicable on mobile computer platforms. The ultimate goal is to support patient safety.

O189 - Training

O192 - Training

Randomised Controlled Trial of the Impact of an Ideal Feedback System on Remodelling the Psychodynamic Approach of Laparoscopic Surgical Trainees M.K. Riaz, B. Tang, I.S. Tait, A. Alijani, D. Yap Ninewells hospital, DUNDEE, United Kingdom

Validating the Force and Motion Surgical Trainer (Formost); What Did We Learn so far T. Horeman1, F.W. Jansen2, J.J. Van den Dobbelsteen1, J. Dankelman1 1 TU-Delft, DELFT, The Netherlands; 2Leiden Medical Center, LEIDEN, The Netherlands

Aims: To analyse the impact of video error signature feedback (VESF) system on error reduction during a laparoscopic task performance, in comparison with the current gold standard. Methods: Twenty laparoscopic novice candidates were randomised into groups (VESF vs PF). Both performed a task of tying a laparoscopic double knot in four stages. Potential errors were categorised as cognitive and skill based. Respective feedbacks were provided as paper (current gold standard) and video error signature. Errors with rate and probability, proficiency gain, time execution per stage at task and subtask level were studied. Results: 1613 errors were recorded while studying 6490 individual movements in 80 tasks, 320 subtasks and 2080 steps in all stages. Both groups were similar in baseline assessments. VESF group demonstrated significant enhancement in skills by enacting less errors (p \ 0.05). Candidates from VESF group (10/10; 100%) gained the desired proficiency (Stage 2, 3, 4; p \ 0.01); whereas, less than one third (3/10; 30%) from PF group achieved this standard. Time execution was similar. VESF group demonstrated reduced error rate and probability. Cognitive based errors were 41% vs 59% and skills based errors were 37% vs 63% in VESF and PF groups respectively (p \ 0.01). Interrater reliability among trainers for error detection was similar (p = 0.96; ICC). Conclusions: Video error signature feedback (VESF) is an augmented terminal feedback system which facilitates the development of psychodynamic approach of a laparoscopic trainee by influencing the cognitive framework of a laparoscopic task.

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When equipped with motion and force sensors, box-trainers can be good alternatives for relatively expensive Virtual Reality (VR) trainers. As in VR trainers, the sensors in a box trainer could provide the trainee with objective information about his performance. In 2010, a force tracking box trainer was validated for a suture task and used for classification of participants. Based on Force parameters alone it was possible to correctly classify 84% of all participants as an expert or novice. Recently, the TrEndo and ForceTRAP were combined into a Force and Motion Surgical trainer (ForMoST). The ForMoST tracks instrument motion and tissue manipulation forces during all kind of training tasks. The aim of this study is to develop new training tasks for ForMoST that reflect safe tissue handling. Secondary we investigated the added value of force parameters in respect to existing motion and time parameters as path length, motion volume and time. Based on existing training tasks of the Dutch C.O.B.R.A skills training course and VUmc’s advances suturing course, two new tasks were developed for ForMoST. In respect to most existing tasks, the new dynamic position tasks require adequate force and motion of both instruments for completion with good results. Three groups with different experience levels in laparoscopy were asked to perform both tasks (i.e. novices n = 24, intermediates n = 36, experts n = 16). The results indicate a 0% and 37% correlation between force and motion parameters in the expert group for task 1 and task 2. No correlation was found between motion and force parameters in the novices and intermediates group. Moreover, the discriminating power of the force parameters was comparable with the discriminating power of existing motion parameters. Finally, the results showed a threefold higher STD in the force parameters in the intermediate group compared with the novice and expert group. This indicates that training on task-time and instrument motion has a negative effect on the tissue manipulation skills of some students. All results indicate that training and assessment of tissue handling skills should not be forgotten in any educational skills training program.


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Trocar Site Hernia Incidence in Bariatric Surgery Patients G. Scozzari, M. Zanini, R. Principato, S. Arolfo, M. Toppino, M. Morino University of Torino, TORINO, Italy

Stenting to Treat Leakage After Sleeve Gastrectomy: Our Experience in Bariatric Surgery R. Kefurt, A. Bohdjalian, F. Langer, G. Prager Medical University of Vienna, VIENNA, Austria

Aims: Trocar Site Hernia (TSH) represent a rare but probably understudied complication of laparoscopic surgery. Reported pooled prevalence in a recent systematic review was 0.5%, but available data are based only on symptomatic patients, while it seems to be higher when routinely assessed. Furthermore, although obesity has been reported as a main risk factor for TSH, evidence on post-bariatric surgery incidence of both symptomatic and asymptomatic TSH are lacking. Aim of the study was to assess the incidence of TSH in post-bariatric surgery patients. Methods: Patients who underwent laparoscopic or robotic-assisted Roux-en-Y gastric bypass between November 2007 and June 2012 underwent a clinical assessment and an ultrasonography (US) study of the abdominal wall. Results: Globally, 111 patients entered the study; mean preoperative age, weight and BMI were 44.5 years, 129.5 kg and 47.0 kg/m2 respectively. At surgery, 34 patients were diabetic (30.6%), 53 had arterial hypertension (47.8%), 43 had sleep apnea (38.7%) and 26 were smokers (23.4%). Mean operative time was 218.9 min (range, 90–435); the number of trocar used was 7 in 36 cases (32.4%), 6 in 69 (62.2%) and 4 or 5 in 6 (5.4%). At the clinical evaluation, no TSH were evident. Nevertheless, at the US evaluation, 39 patients showed one or more TSH (incidence rate 35.1%), although it was asymptomatic in all cases. Comparing patients with and without TSH, there were no significant differences in terms of preoperative diabetes, hypertension, sleep apnea and smoking incidence rates. Conclusions: The present study confirmed that in the post-bariatric surgery patients the clinical evaluation of the abdominal wall is highly inaccurate, while the US study showed to be an efficient diagnostic tool. Moreover, the main result of the present study was that although clinically silent, TSH showed an high incidence rate in a bariatric surgery population, thus suggesting that it represent a strongly underestimated postoperative complication, potentially leading to large hernias, abdominal pain and reoperations.

Introduction: Leaks after sleeve gastrectomy (SG) are a rare, but severe complication. Several strategies for leak repair such as stent-implantation, fibrin-glue for sealing, drainage-placement or Endo-VAC are described in the literature. Methods: Stents in combination with drainage were used as a primary-treatment for leakage. After identifying the leak (gastroscopy) different stent-types (Polyflex, Niti-S) were placed (X-raycontrol). Drains placed near the leak in all cases to prevent abscess-formation. A gastrograffinswallow in the follow-up was used to show eventually-delayed-persistent-leakage. The regular residence-time of a stent was 6–7 weeks. In case of dislocation the residence-time was shortened to the time-till-dislocation. In case of persistent-leakage overlapping-stent-placement (Stent-in-Stent) to cover more distance or stent-removal-with application of a longer and wider stent were performed and-or-autologous-fibrin-glue was injected into chronic-fistulas (gastroscopy). Results: 14 Patients were treated with stents suffering from staple line leakage after SG 2005–2010. A complete leak remission could be reached in 64% (n = 9) after stent-implantation as a single-treatment. 4 of these 9 patients showed a complete remission of the leakage within the regular stent-residence-time. In the other 5patients the stent had to be replaced between 2–4 times until a complete remission was achieved. Four (28%) of 14 patients were treated with a stent and autologous-fibrin-glue. 1 patient with no sufficient result was treated with an Endo-VAC. Dislocation-and-fistula were the main cause for restenting and-or usage of autologous-fibrin-glue. Stenting alone or in combination with fibrin-glue finally resulted in sealing of the leakage in 93%. Conclusions: Stent-implantation with-or-without autologous-fibrin-glue showed to be an effective treatment with a satisfying outcome (total-remission-rate 93%). Stents enable oral-feeding and help to avoid risky reoperations.



Clinical Presentation of Late Gastrogastric Fistula After Roux-En-Y Gastric Bypass: Experience of a High-Volume Bariatric Centre D. Van Der Fraenen, B. Defoort, B. Dillemans AZ Sint Jan Hospital, BRUGES, Belgium

Changes in Signs of Depression Following Laparoscopic Gastric Banding Z.H. Perry1, A. Manor2, E. Avinoach1, B. Nemetz2, O. Gibor1, Y. Glazer1, S. Mizrahi1, B. Kirshtein1 1 Soroka University Medical Center, BEER-SHEVA, Israel; 2 Ben-Gurion University, BEER-SHEVA, Israel

Aims: Gastrogastric fistula (GGF) are a rare complication following divided gastric bypass procedure (GBP). Different mechanisms for early GGF have been reviewed, ranging from flaws in surgical technique to staple-line disruption. Up till now, no report of symptoms and risk factors for GGF occurring late ([ 6 months after divided GBP) has been made. Methods: Data of all surgical procedures performed for GGF after divided GBP between January 2005 and December 2012 were reviewed. Patient characteristics, symptoms and risk factors were evaluated. Results: Twenty-one patients underwent surgery for GGF after GBP. About 86% (18/21) of the primary procedures were performed at our center. We perform more than 1200 laparoscopic Rouxen-Y GBP on yearly basis. Mean interval between initial and revisional surgical procedure was 33 months (range 6–64 months). Most common symptoms were pain (57.1%) and food intolerance (47.6%). Significant weight-regain due to loss of restriction was present in only 37.8%; surprisingly, in 75% of these patients as a solitary symptom. Clearly, marginal ulcers are linked closely with the occurrence of GGF: about 70% of patients had a documented history of ulcer disease after GBP. Two major risk factors for development of marginal ulceration, i.e. smoking and regular use of non-steroid anti-inflammatory drugs (NSAID) seem to correlate highly with GGF, in 52.6% and 31.6% of patients respectively. Helicobacter pylori was not routinely investigated. Conclusion: GGF is not easy to diagnose based on clinical presentation. Weight-regain can be a marker for late GGF, but we have to keep in mind that 20–30% of GBP-patients will have significant weight-regain on the long term. Symptoms such as pain or food intolerance are frequent but not specific, as a majority of these patients have a history of marginal ulcers which produce similar symptoms. Moreover, they share the same risk factors such as smoking and NSAID-use. We strongly believe that in most cases, late GGF are a direct consequence of marginal ulcers that perforate and protrude the posterior gastro-enterostomy site and thereby create a fistula to the excluded stomach. In case of GBP we therefore prescribe lifelong PPI-therapy to patients that smoke or utilize NSAID regularly.

Background: Morbid obesity is an epidemic spreading worldwide. Surgical treatment for obesity (bariatric surgery) has evolved over the past years, with laparoscopic gastric banding procedure (LGB) gaining popularity as the least invasive form. Though Obesity has a major impact on physical and mental health of the patients, the nature and relationship between obesity and depression, and the influence of major weight loss on depression remains unclear. The current study will try to assess and compare symptoms of depression during 1–11 years after LGB surgery. Methods: About 3000 LGB procedures were performed between January 1997 and December 2007, at the department of surgery A, in Soroka University Medical Center. 203 patients were included in our cross-sectional study. We used Patient Health Questionnaire 9 (PHQ-9) to assess and measure the severity of depression. Additional data was collected from patients’ chart and demographic data, psychiatric illness and treatment before surgery, BMI before surgery and at the time of interview, excess weight loss (%EWL), primer bariatric surgery, and additional surgery for repair, reposition and exchange rate of the band. Results: We found a significant correlation between PHQ-9 score and weight loss after surgery as measured by %EWL (p \ 0.001, r = -0.223), and between PHQ-9 score and self-esteem after the surgery (p \ 0.01, r = -0.347). Self-esteem after the surgery was also found to be correlated significantly with %EWL (p = 0.001, r = -0.223). We also found a significant gender related differences—men’s self-esteem before surgery was significantly higher than women’s (p = 0.037), while self-esteem after surgery was the same between the groups. PHQ-9 score was significantly higher in women (5.34) than in men (3.39), (p = 0.01). Conclusions: Weight loss had the highest impact on symptoms of depression and quality of life— success at weight loss correlated with lower risk for developing symptoms of depression, higher self-esteem after surgery, and higher satisfaction from the procedure. We also found that women had a greater tendency for developing symptoms of depression, but their self-esteem after the surgery improved beyond men’s self-esteem.

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Primary Versus Revisional Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity D.V. Dardamanis, J.B. Navez, L. Coubeau, M.T. Marechal, B. Navez Cliniques Universitaires St Luc, Universite´ catholique de Louvain, BRUSSELS, Belgium

Laparoscopic Surgery Reduces the Risk of Iatrogenic Hernias—Using Computed Tomography as a Tool for Diagnosis H. Rafique, N. Naguib, A. Williams, J.M. Soukias, A.G. Masoud Prince Charles hospital, CARDIFF, United Kingdom

Aims: The purpose of the study was to compare the results in terms of morbidity, conversion rate and excess weight loss in all our consecutive patients in a single-centre, single-surgeon and singletechnique series of primary versus revisional LRYGB after Vertical Banded Gastroplasties (VBG) or Laparoscopic Adjustable Gastric Banding (LAGB). Methods: A retrospective analysis of all patients that underwent a LRYGB was performed for the period 2004–2011. Demographics, preoperative body mass index (BMI), co-morbidities, operation time, conversion rate, peroperative and postoperative complications, hospitalisation period and % of excess BMI loss were investigated. Gasto-jejunal anastomosis was performed manually, termino-lateraly, with a biliopancreatic limb of 75 cm and an alimentary limb of 150 cm. Results: 311 gastric bypass operations were performed, 228 were primary and 83 revisional (34 after LAGB and 49 after VBG). Sex ratio (F/M) was 9/1. Median age for pLRYGB was 42 and for rLRYGB 48 years old. Median follow-up was 18 months (range 3–60 months). Median BMI (kg/ m2) before bypass was 44.6 for pLRYGB and 41 for rLRYGB. Operative time and length of stay were longer for rLRYGB 165 vs. 240 min. (p \ 0.001) and 6.2 versus 7.5 days (p = 0.013). Morbidity rate was 7% in pLRYGB versus 8.4% in rLRYGB (p = 0.4). There were no fistulas coming from the gastrojejunal anastomosis. Conversion rate to laparotomy was 0.9% for the primary group and 7.2% for revisional (p = 0.005). The median % of excess BMI loss for primary operations at 12, 18 and 24 months follow up were respectively 73.5, 75.1 and 73.7% versus 52.7 and 53.3 and 48.2% for revisional (p \ 0.001). By subdividing the rLRYGB according to the initial gastroplasty, excess BMI loss was 71.5% after LAGB and 48.7% after VBG at 18 months follow up (p \ 0.001). Conclusions: Revisional gastric bypass is a feasible and safe operation with a higher conversion rate in comparison with primary bypass but not statistical difference in terms of morbidity. There was a significantly lower % of excess BMI loss after revisional gastric bypass comparing to primary bypass and also after VBG compared to LAGB.

Aims: Laparoscopic surgery is associated with less morbidity, rapid recovery and shorter hospital stay. In theory the smaller incisions associated with laparoscopic surgery reduces the risk of iatrogenic hernia (IatH). The overall aim of this study was to compare the incidence of IatHs in both laparoscopic and open colorectal surgery using computed tomography (CT) scanning. Methods: All elective colorectal resections, who underwent subsequent post-operative CT scanning, between 2001–2011, were included. Those with less than 12 months follow-up were excluded. All malignant colorectal cases underwent annual CT for 5 years, while for benign cases CT was required if clinically indicated. A consultant radiologist, blind to the original reports, reviewed the CT images to check for the presence of IatHs. Operative records were scrutinised to determine those who underwent IatH repair. IatH were classified as incisional, parastomal and portsite hernias. The Fisher exact test was used to calculate significance. Results: 264 patients fulfilled inclusion criteria (147 laparoscopic cases, 117 open cases). In these groups, there were 65 IatHs (32 incisional, 26 parastomal, 7 port-site hernias). 8 IatHs were diagnosed on original CT reporting, 50 on repeat reporting and 7 were repaired on clinical grounds i.e. not identified on CT. The incidence of IatHs was 29/147 (19.7%) following laparoscopic surgery and 36/117 (30.8%) following open surgery (p = 0.039). The incidence of incisional hernias was 8/147 (5.5%) following laparoscopic surgery versus 24/117 (20.5%) following open surgery (p = 0.002). The incidence of parastomal hernias was 14/49 (28.6%) following laparoscopic surgery versus 12/67 (17.9%) following open surgery (p = 0.185). The incidence of postsite hernias was 7/147 (4.8%). The incidence of IatHs that required repair was 13/65 (20%). There were 4 emergency cases (1 port-site hernias, 3 burst abdomens) and 9 elective repairs (5 parastomal, 4 incisional). Conclusions: Laparoscopic surgery significantly reduced the incidence of IatH and incisional hernias. There was no significant difference in the incidence of parastomal hernias between the two groups. The majority of IatHs, including port-site hernias, were asymptomatic and therefore did not require surgical correction. Reporting on IatHs should be an integral part of a CT report.



Impact of Roux-en Y Gastric Bypass vs. Sleeve Gastrectomy on Vitamin D Metabolism: Short Term Results from a Prospective Randomized Clinical Trial M. Vix1, K.H. Liu1, M. Diana1, A. D’Urso1, D. Mutter1, H.S. Wu2, J. Marescaux1 1 IRCAD-IHU, University Hospital of Strasbourg, STRASBOURG, France; 2Show Chwan Health Care System, CHANGHUA, Taiwan

Prognostic Value of Age for Chronic Postoperative Inguinal Pain H.R. Langeveld1, P. Klitsie1, H. Smedinga1, H. Eker1, M. Van’t Riet2, W. Weidema3, Y. Vergouwe1, H.J. Bonjer4, J. Jeekel1, J. Lange1 1 Erasmus MC, ROTTERDAM, The Netherlands; 2Reinier de Graaf Hospital, DELFT, The Netherlands; 3Ikazia Hospital, ROTTERDAM, The Netherlands; 4Free University Medical Center, AMSTERDAM, The Netherlands

Aims: Vitamin D deficiency is more frequently observed in the obese population when compared to normal weight counterpart. Roux-en-Y gastric bypass (RYGB) impairs significantly the intestinal absorption of vitamin D and the Ca2 + homeostasis. Sleeve Gastrectomy (SG) is as effective as RYGB in the improvement of obesity-related co-morbidities and is associated with fewer postoperative nutritional. The aim of this study is to assess the evolution of Vitamin D and Parathormone values after RYGB vs. SG in a prospective randomized clinical trial and to correlate the changes with weight loss. Methods: One-hundred patients were randomly assigned to RYGB (n = 45) and SG (n = 55). Vitamin D, PTH and Calcium were assessed at inclusion and after 1, 3, 6 and 12 months (M1, M3, M6 and M12). Eighty-eight patients completed 1-year follow-up. Results: Mean post-operative M1, M3, M6 and M12 excess weight loss (EWL %) was 25.39%, 43.47%, 63.75% and 80.38% vs. 25.25%, 51.32%, 64.67% and 82.97% in RYGB and SG respectively, with no statistically significant difference. Vitamin D values were statistically significantly higher after SG when compared to RYGB at M3 (61.57 pmol/l, SD 14.29 vs. 54.81 SD 7.65; p = 0.01), and at M12 (59.83 pmol/l, SD 6.41 vs. 56.15 SD 8.18; p = 0.02). Vitamin D deficiency rate decreased from 84.62% to 35% at M6 (p = 0.04) and 48% at M12 (p = 0.01) in the SG group, while there was no significant improvement in the RYGB group. Serum PTH level was decreased significantly in the SG group by M3 (44.8 ng/l vs. 28.6; p = 0.03), M6 (44.9 ng/l vs. 25.8; p = 0.017) and M12 (41.4 ng/l vs. 20.5; p = 0.017). Secondary hyperparathyroidism rate was 20.83% and 24% at M1 (p = 1), 16.67% and 8% at M3 (p = 0.41), 14.29 and 0% at M6 (p = 0.08), 15% and 0% at M12 (p = 0.23) in RYGB and SG respectively. Conclusions: Patients after Gastric Bypass present a significantly higher postoperative Vitamin D deficiency and higher serum levels of Parathormone when compared to Sleeve Gastrectomy. These findings suggest the need for systematic supplementation and a more stringent follow-up after RYGB.

Background: Young age has been described as a risk factor on development of chronic pain after several surgical procedures. Chronic postoperative inguinal pain (CPIP) is considered the most common and serious long term problem after inguinal hernia repair. Little research has been done to identify age as a risk factor for CPIP. Methods: The database of a randomized trial; the LEVEL trial, including 722 patients, TEP versus Lichtenstein, was used for analysis. Primary outcome was postoperative pain. Data on incidence and intensity of preoperative pain, postoperative pain, CPIP and age specific risk on development of CPIP were assessed. In addition, age related to CPIP and surgical technique, location of pain and hernia type was analyzed. Results: Younger (18–40 years) and middle-aged patients (40–60 years) had more frequently preoperative pain than the elderly ([ 60 years); 54%, 55% and 41% respectively. Intensity of pain during the first three post-operative days was higher in young patients (VAS 5.5 vs. 4.5 vs. 3.9 on day 1 and 3.8 vs. 2.9 vs. 2.6 on day 3) and presented more often with CPIP at 1 year after surgery; 43% vs. 29% vs. 19%. CPIP was localized mainly in the groin for all age groups. Indirect type hernias were more common in younger patients (77% vs. 51% and 48%). Neither hernia type nor surgical technique was related to CPIP. Conclusion: CPIP is a common problem. Younger patients had a higher risk on preoperative pain and a higher risk on CPIP, mainly localized in the groin. Hernia type and surgical technique did not influence results. Age has a prognostic value on CPIP.

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Importance of Material, Pore and Weight Mesh in Functional Recovery After Endoscopic Repair of Inguinal Hernias: Prospective Randomized Clinical Trial I. Alarcon1, S. Morales-Conde1, A. Barranco1, J. Bellido2, H. Cadet1, F.J. Padillo1, M. Socas1 1 Hospital Universitario Virgen del Rocio, SEVILLE, Spain; 2Rio Tinto Hospital, HUELVA, Spain

Self Fixating Vs High Weight Mesh in Endoscopic Extraperitoneal Hernia Repair. Preliminary Results of a Prospective Randomized Controlled Trial J. Gomez Menchero, J.A. Bellido Luque, J.F. Guadalajara Jurado, J.M. Suarez Grau, J. Garcia Moreno, I. Duran Ferreras, E. Ruiz Lupian˜ez, R. Moreno Romero Hospital General Basico de Riotinto, MINAS DE RIOTINTO. (HUELVA), Spain

Background: Considerable advantages over open repair have been proved with the laparoscopic inguinal hernia repair. Regarding prosthetic material, the density of the mesh has been associated to the size of the pore. The large pore of lightweight meshes is conditioned by less amount of material used. Previous studies compare light and heavyweight polypropylene meshes. In order to get a proper comparison of the behaviour of meshes in the inguinal region it is important to include the material and the pore size. Endpoint: Compare patient-reported outcome with the use of either a Polytetrafluoroethylene (PTFE) large pore mesh (LP-PTFE) vs a small pore polypropylene mesh (SP-PPL). Methods: prospective double blind randomized trial was performed. 54 Patients with bilateral inguinal hernia without contraindication for a totally extraperitoneal approach (TEP) hernia repair were included. Both Meshes were assigned by randomization to each side in each patient. Postoperative data is collected in successive consults seven days, one, three, six and twelve months after the surgery using a visual analog scale (VAS). Results: Mean age: 49.8. Mean BMI: 26.6. Discomfort scores with SP-PPL were significantly higher than LP-PTFE scores at 1 moth (Mean: 7, IQR: 10 vs Mean: 1.7, IQR: 0, p = 0.003), 3 moths (Mean: 6.9, IQR: 10 vs Mean:1.7, IQR:0, p = 0.003) and 6 moths (Mean: 2.8, IQR: 0 vs Mean: 0.1, IQR:0, p = 0.015) after surgery. No significant differences were noted on pain at rest, although LP-PTFE mesh showed a significantly lower score (Mean: 10, IQR: 13) than SP-PPL (Mean: 17.5, IQR: 27.75) at 7 days postoperatively (p 0.025) regarding pain at movement. With regard to testicular pain, LP-PTFE VAS were lower than SP-PPL at 7 days (Mean: 5.7, IQR: 1 vs Mean: 17.1, IQR: 29.6, p = 0.005), 1 month (Mean: 0.8, IQR: 0 vs Mean: 7, IQR: 6.5, p = 0.004) and 3 months (Mean: 0.8, IQR: 0 vs Mean: 6.9, IQR: 6.5, p = 0.004). No recurrence was observed. No major complications occurred. The incidence of seroma was higher with SP-PPL at 7 days, 1 and 3 months, but without statistical significance. Conclusion: Large pore lightweight mesh appears to have advantages in terms of lesser pain and discomfort in early postoperative period, with no significant difference at one year.

New techniques like the use of Low Weight Meshes and Self-Fixating Meshes have been described in order to reduce postoperative chronic pain and recurrences. We present the preliminary results of a prospective randomized controlled trial comparing SFM to HWM and fibrin fixation in TEP surgery. Objective: To compare clinical outcomes following Self-Fixating Mesh SFM (ParietexTM ProgripTM) and High Weight Mesh HWM (3DMAXTM BARDTM) in Totally Endoscopic Extraperitoneal hernia repair (TEP) Methods: Between June 2012 and January 2013, 12 patients affected by uni or bilateral inguinal hernia were included and randomized in Group 1 (G1: SFM) and 10 patients in Group 2 (G2: HWM + Fibrin). The primary outcome measure is the postoperative pain (VAS scale) and secondary the recurrences rate, life quality (SF 36 Test), inguinal cord injuries, postoperative complications, and long term differences between both methods (1 year). (Preoperative and post Doppler ultrasonography and scanner was performed to evaluate inguinal cord damage.) Results: Average age in two groups was 44 years old (G1) and 44.08 (G2). A total number of 15 hernias were treated in G1 and 18 in G2. Preoperative VAS average in G1 was 3 and 4 in G2. Setting mesh average time was 3 min and 30 s in G1 and 3 min and 55 s in G2 and a higher technical difficulty in G1. Postoperative follow up was stabilized in 24 h, 7 days, 1 month, 6 and 1 year. Postoperative pain in 30 days in G1 (VAS \ 6) was higher than G2 (VAS \ 4). Four patients were affected by haematoma in port site in G1 and 5 in G2. Seroma’s incidence was higher in G2 (2 cases). Chronic pain or discomfort incidence was higher in G2 (5) than G1 (1). There are not significant differences in Life’s quality. There are not recurrences in 6 months follow up. Conclusions: In 6 months outcome, SFM group shows a similar VAS of postoperative pain than HWM group but more technical difficulties. HWM is a more feasible and reproducible technique with a higher rate of chronic pain or discomfort.



Combined Open and Laparoscopic Repair of Large and Complicated Incisional Hernia W. Brunner, N. Kalak, F. Arnegger, S. Bischofberger Hospital Rorschach/St. Gallen, Switzerland

Medium Term Follow Up of Patients with Iatrogenic Common Bile Duct Injury F. Turcu1, C. Dragomirescu1, S. Pletea2, B. Banescu1, B. Dumbrava1, D. Ulmeanu3, N. Iordache1 1 Sf. IOAN Hospital, BUCHAREST, Romania; 2County Hospital, BRAILA, Romania; 3Regina Maria, BUCHAREST, Romania

Objective: The advantages of laparoscopic repair of incisional hernia in the abdominal wall (IPOM) compared to open onlay or sublay procedures are well documented. The presence of intraabdominal adhesions, which are not laparoscopically dissectible, is considered a limitation for the laparoscopic approach. Primary open approach or conversion to open surgery in these cases is usual. Method: We present an open-laparoscopic hybrid technique, suited for patients with extensive intraabdominal adhesions, which employs the advantages of open adhesiolysis with the benefits of laparoscopic mesh positioning. Result: Surgery is primarily started laparoscopically with open approach technique or Verres needle from the left upper quadrant. In case the intraabdominal adhesions cannot be divided in laparoscopic technique, conversion to open adhesiolysis is performed. Bowel damage can be avoided respectively more easily identified and treated by sutures. Subsequently, the mesh is placed on site into the abdominal cavity, before the abdominal wall is closed. Through pre-positioned trocars or respectively in open technique introduced trocars, the mesh is laparoscopically placed and attached to the abdominal wall in its final position by absorbable tackers. Conclusion: The presented technique combines the advantage of open adhesiolysis and laparoscopic hernia repair without the extensive trauma to the exterior abdominal wall of an open onlay or sublay mesh placement.

The goal of this study was to increase the awareness of the problem of iatrogenic common bile duct injury. Methods: A retrospective review of the biliary primary or redo reconstructions performed at our clinic for iatrogenic injuries was done. A total of 39 cases were followed for 1 to 19 (mean 9.4 ± 5.3) years in order to asses their long-term outcomes. Results: There were 11 Strasberg D lesions and 28 Strasberg E lesions. The mortality rate was 7.7% (3 patients). The outcomes were good in 82% cases (32 patients). Overall there were 127 surgical, radiological or endoscopic interventions (mean 3.3 ± 2.1). We have counted 98 (mean 2.6 ± 2.9) complications, 125 (mean 3.2 ± 2.4) hospital admissions, and 1381 (mean 36 ± 21) hospitalization days. General and local sepsis were the main risk factors for the failure of the biliary reconstruction. Conclusions: As a rule, iatrogenic common bile duct injuries have a complicated postoperative course, with many hospital admissions and surgical, endoscopic or radiological interventions. Before biliary reconstruction, every attempt must be done to prevent or control general and local sepsis. Biliary injuries are more easy to prevent than to treat.

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Single-Incision Laparoscopic Common Bile Duct Exploration with Conventional Instruments: An Innovative Technique and Preliminary Comparative Study S.H. Chuang1, C.S. Lin2 1 Mackay Memorial Hospital, Hsin-Chu Branch, HSINCHU CITY, Taiwan; 2National Chiao Tung University, HSIN-CHU, Taiwan

Changing Concepts in the Management of Liver Hydatid Disease C. Duta, D. Barjica, C. Lazar, A. Dobrescu, F. Lazar Univeristy of Medicine and Pharmacy, TIMISOARA, Romania

Aims: To introduce an innovative technique: single-incision laparoscopic common bile duct exploration (SILCBDE). A preliminary comparison between SILCBDE and traditional laparoscopic common bile duct exploration (LCBDE) was analyzed retrospectively. Methods: Twenty-nine consecutive patients underwent LCBDE for choledocholithiasis by a single surgeon in a period of 16 months. Seventeen traditional three or four-incision LCBDE and twelve SILCBDE were attempted. Concomitant cholecystectomy was performed in all the operations. Only conventional laparoscopic instruments and a 5-mm flexible choledochoscope were used. The intra-operative cholangiograms were taken by a portable C-arm in the operating room. Results: In the traditional LCBDE group, bile duct stone was removed via transcystic route in seven patients (41.2%) and via choledochotomy in ten patients (58.8%). In the SILCBDE group, eleven choledochotomies were fulfilled when one operation was converted to a four-incision transcystic procedure. No conversion to an open operation was needed. There was no statistical difference between these two groups in patient demography, clinical data and operative outcomes, except the SILCBDE group had a higher rate of acute cholecystitis than the traditional group (91.7% and 52.9%, respectively; p \ 0.05). The stone clearance rate was 94.1% in the traditional group and was 100% in the SILCBDE group. The complication rate was 11.8% (two patients, Clavien-Dindo classification grade II and IIIa) in the traditional group and was 8.3% (one patient, Clavien-Dindo classification grade II) in the SILCBDE group. The average follow-up period was 3.24 months (0.5–12 months). Conclusions: SILCBDE is a safe and efficacious alternative to the treatment of choledocholithiasis. Before adopting this novel technique, a surgeon should be well-experienced in both single-incision laparoscopic cholecystectomy and LCBDE via choledochotomy and primary closure of bile duct.

In the last decades the treatment of liver hydatidosis has changed. Surgery has remained the mainstay for the treatment only for complicated hydatid cyst. For simple hydatid cysts, uncomplicated there are very good therapeutic alternatives: medical treatment alone, echo-guided puncture, laparoscopic treatment. Several reports have confirmed the feasibility of minimally invasive approach for the treatment of liver hydatidosis. The authors review a series of 324 cases of hepatic hydatidosis submitted to surgery over the period of 15 years, from 1996 to 2010, comparing the results of conservative and surgical procedures. Only in 68 cases (20.9 %) we performed open surgery for complicated liver hydatid cysts. In 16.6 % of cases (54 pts) we performed laparoscopic approach and 202 patients (62.3 % of cases) were treated by PAIR (puncture, aspiration, injection, respiration) technique. The patients were successfully treated and the mean follow-up time was 54.7 +/- 15.5 months involving ultrasound, computed tomography and serology tests showed no local recurrence or spread of the disease. The patients treated by PAIR were cured in 95.6 % and those treated laparoscopically were cured in 90.5 %. In 10 cases from the first lot was necessary to perform another puncture up to 2 years later, because the cavity didn’t disappear. In 4 patients we performed a classical operation for two hepatic abscess and 2 biliary fistulas. 2 patients from the laparoscopic lot developed one subhepatic abscess and one biliary fistula that required open surgery. In conclusion the procedure the treatment of hepatic hydatidosis should be tailored to the needs of each patient, depending on the size, location and complications of the cyst and high surgical risk should be avoided in view of the benign nature of the disease.



In Octogenarians, is Rendez-Vous Technique as Effective as in Younger Patients, or Should a Sequential Treatment be Preferred? R. Costi, R. Faraci, L. Mariani, E. Cudazzo, A. Zarzavadjian Le Bian, F. Beggi, C. Castro Ruiz, F. Plantone, D. Di Mauro Universta` degli Studi di Parma, PARMA, Italy

Laparoscopic Hepatobiliary pancreatic Surgery Guided by a Novel 3-Dimensional Virtual Laparoscopy T. Aoki, M. Murakami, A. Fujimori, Y. Enami, R. Koike, T. Koizumi, K. Yamada, M. Watanabe, K. Otsuka, T. Kato Showa University, SHINAGAWA, Japan

Background: The treatment of cholecysto-choledochal lithiasis (CCL) requires cholecystectomy and common bile duct clearance, which can be achieved surgically or with a combination of surgery and endoscopy. The latter includes a two-stage-approach, which implies preoperative retrograde cholangiography (ERC) and sphincterotomy (ST) followed by delayed laparoscopic cholecystectomy (LC) (or vice versa) or a one-stage-approach, namely the Rendez-vous technique (RVT), where ERC, ST and LC are performed during the same procedure. No data on the use of the RVT in octogenarians are reported in the literature so far. The main purpose of the study is to show whether the RVT is as effective in elderly as in younger patients; as a secondary goal, results of RVT are compared to those of a two-stage-sequentialtreatment (TSST) in octogenarians in order to identify the best approach to such a population, with special emphasis on hospital costs. Materials and Methods: Prospectively collected data of 131 consecutive patients undergoing RVT for CCL were retrospectively analysed. Two analyses were performed: (1) results of RVT (operative time, conversion rate, CBD clearance, morbidity/mortality, hospital stay, costs and need for further endoscopy) were compared between octogenarians and younger patients; (2) results of RVT in the very elderly were compared to those of 27 octogenarians undergoing TSST for CCL. Results: Octogenarians undergoing RVT were in significantly poorer general conditions than younger patients; RVT in the octogenarian group yielded a higher conversion rate (p \ 0.0001) and a longer hospital stay (p \ 0.05) than in younger patients, while no differences in the rates of CBD clearance, surgery-related morbidity, mortality and costs were recorded. Although octogenarians undergoing RVT were in significantly poorer general conditions than those undergoing TSST, the results of the two approaches were similar. Conclusions: Although octogenarians were in significantly poorer general conditions, RVT in the very elderly seems to be as cost-effective as in younger patients; nevertheless, it may lead to higher conversion rate and longer hospital stay. In octogenarians, RVT is not inferior to TSST and is a feasible option for the treatment of CCL even for patients in poor conditions (ASA3).

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Background: The objective of this work is to evaluate a new concept of 3-dimensional (3D) virtual laparoscopy (3DVL) to navigate laparoscopic hepatectomy (LH) or pancreatectomy (LP). The major advantage of this new system is that it is able to show the improved intraoperative anatomic orientation on a viewpoint of laparoscope. Methods: Twenty-nine patients who suffer from liver neoplasm (HCC, metastatic liver tumors) and twelve patients who suffer from pancreatic tumor (IPMN, MCN, insulinoma) performed preoperative mapping before LH or LP in our hospital. Computed tomography study of each patient was performed and hepatic structures and major vessels surrounding pancreas were confirmed from 3DVL (VINCENT: Fujifilm medical, Tokyo, Japan). Moreover, the virtual laparoscopy indicate the accurate port position for LH and LP. The surgeon planned the resection preoperatively and read the resection mapping as reference guidance during the procedure. Operative record and pathological finding were analyzed after operation in each case. Results: All of patients successfully performed the navigation aid using 3DVL before surgery. Especially, position of ports using this system were determined and navigated for the surgical procedure in 100% of cases. Main vessel branches in the liver and surrounding pancreas displayed in this system were identified and confirmed during the surgical procedure. Median blood loss in LH or LP was 44 g, 175 g respectively. Median operative time in LH or LDP was 75 min, 195 min, respectively. Conclusions: 3DVL with a ‘‘laparoscopic eye’’ does efficiently display preoperative or intraoperative 3D data and enables safer and more accurate laparoscopic hepatobiliary pancreatic surgery.


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O218 - Technology

Totally Laparoscopic Major-Complex Liver Resections With and Without Intermittent Vascular Clamping M.G. Spampinato1, F. Puleo2, M. Arvanitakis2, D. Cassini1, S. Orlandi1, F. Manoochehri1, B. Gnocato1, F. Selvaggi1, T. Filosa1, G. Baldazzi1 1 Policlinico di Abano Terme, ABANOTERME, Italy; 2Erasme University Hospital, BRUSSELS, Belgium

Utility of Needle-Type Robot with High-Sensitive Micro Touch Censors in Regenerative Therapy by Multi Piercing Surgery O. Takeshi Kyushu University, FUKUOKA, Japan

Background: Encouraging results have been reported in term of feasibility, safety and oncologic outcomes for major (= 3 segments) or complex for location (right posterior segments) totally laparoscopic liver resections (TLLR). In these setting technical issues such as use of intermittent vascular clamping has not been clearly investigated. Aim: to assess the perioperative outcome of totally laparoscopic liver resections (TLLR) performed with or without Intermittent Pringle’s Manoeuvre (IPM). Materials Methods: From October 2008 to October 2012 a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in two groups according to use of PM during the operation: -Group A (PM series) 13 patients; -Group B (without PM series) 11 patients. Data from a prospectively collected database were retrospectively analysed and compared for perioperative and short term oncologic outcome. Results: The two groups were found similar for patient characteristics, neoplasm and type of resections performed. Assessing the perioperative outcome, a statistic significant improvement was found in Group B in terms of number of perioperative blood transfusion (p = 0.05) and first flatus (p = 0.013). Postoperatively, there was no difference in terms of morbidity-mortality rate, hospital stay and oncologic outcomes between group A and B. Conclusions: Our data suggest that major-complex TLLR performed without IPM receive less blood transfusion and have a quicker recovery of bowel function following surgery. Prospective studies are needed to clarify this issue on a large scale.

Purpose: We established Multi Piercing Surgery, which is a Needlescopic Surgery assisted by NOTES. Additionally, we developed a new micro censor, which could be implemented at robot finger. We also successfully produced a commercially-supplied model attached to 3-mm diameter needle-type robot. By using the sensors, regeneration therapy into the targeted organ can be allowed. Needle type robot is convenient for using 3-mm diameter electro-controlled forceps. We successfully conducted a preclinical study on local regenerative stem cell therapy using vulnerable stem cells block for diabetes. Methods: The needle type robot was used to perform the study in six pigs. We induced a 10-mm diameter flexible endoscope through the rectal wall opening upon identifying the peritoneal reflection of rectum by use of 5-mm small diameter ultrasonic waves. The needle type robot has one joint of 3 mm in diameter. The robot has a mono-polar electric power source at the hand tip. Concerning four of them, the needle-type robot was used to inject regenerated cell colloid liquid including fat stem cells into the targeted pancreas. At first we settled dummy atrophic pancreatic region as the target area. The retroperitoneum was detached from the pancreatic parenchyma along about 5 mm by electrocoagulation. Subsequently, the catheter was led into the detached pocket and used to inject stem cells. On the other hand, the vulnerable stem cells block was led into the detached retroperitoneal pocket and covered by remaining retroperitoneum of the other two pigs instead of injecting regenerated cell colloid liquid. Results: We completed the implantation by injecting regenerated cell colloid liquid into pancreas without damaging any abdominal organs, nor producing an inflammatory reaction. It was also possible to implant fat block containing regenerated cells into the pancreatic tissue without damaging regenerated cell block through feedback of touch censors. There was no problem with gastrectomy and hepatectomy. Conclusion: MPS assisted by the robot equipped with both high-sensitive touch censors and multimotion memory sequence buttons has suggested the possibility of safe and effective minimally invasive regenerative medicine of pancreas.


O219

Prospective Randomized Study Comparing Single Incision vs. Standard Laparoscopic Cholecystectomy T. Artis1, C. Kucuk2, A. Akay2, G. Zararsiz3, E. Sozuer2 1 Istanbul Medeniyet University, Medical School, Istanbul, Turkey; 2 Erciyes University Medical School, Kayseri, Istanbul, Turkey; 3 Hacettepe University Medical School, ANKARA, Turkey

Laparoscopic Transperitoneal Single Incision Surgery for Left Adrenalectomy. A Prospective Study G. Dıáz Del Gobbo, O. Vidal, E. Astudillo, M. Valentini, C. Ginesta, J. Sampson, N.J. Hidalgo, A. Martinez, J.J. Espert, J.C. Garcia-Valdecasas, L. Fernańdez-Cruz Hospital Clinic of Barcelona, BARCELONA, Spain

Aim: Single incision laparoscopic surgery (SILS) have 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 compare prospectively the outcomes of SILS and standard cholecystectomy. Material and Methods: Between June 2009 and December 2010, we analyzed the surgical outcomes of 60 patients who underwent SILS and standard cholecystectomy (30 patient of each group) 5 patients from each group had acute cholecystitis (16.6 %). Patients were randomly assigned for SILS. Before the procedure SILS was described and specifically consent for SILS for SILS were obtained. SILS cholecystectomy was performed by one single surgeon (TA).Technically 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 operative time, postoperative complications, hospital length of stay and hernia occurrence in long term follow up. And additionally patient satisfaction was also obtained from the SILS patients. Results: SILS cholecystectomy could be performed on 27 of 30 patients (90%). These 3 patients converted to standard cholecystectomy because of acute cholecystitis. Four (13.3%) patients form SILS cholecystectomy and 5 (16.6%) in standard cholecystectomy group had acute cholecystitis. In 25 patient (92.5%) in SILS cholecystectomy group critical view of safety was accomplished. Mean operative times were 50 ± 18 min and 40 ± 6 min in SILS and standard cholecystectomy groups respectively (p [ 0.05).Hospital length of stay was comparable in both groups (p [ 0.05) Complication rates were also comparable in both groups. One patient from each group had experienced complication (0.33%) (p [ 0.05) One patient who had acute cholecystitis from SILS cholecystectomy group readmitted with jaundice on postop. day 10. Partially occlusion of common bile duct was treated with balloon dilatation. Biloma which was percutaneously drained occurred in one patient from standard group developed. In two years follow-up in one patient from SILS cholecystectomy group incisional hernia occurred. (0.33%) in contrary none in the standard group (p [ 0.05) Conclusion: Although SILS cholecystectomy seems challenging, it has a short learning curve for the surgeons who perform advanced laparoscopic surgery. Meticulous attention is needed for acute cholecystitis patients. Overall surgical outcomes are comparable. Better cosmetic results may be the attractive for patients. For the long term outcome particularly hernia occurrence could be the twist point of the procedure.

Background: Laparoscopic adrenalectomy by using three or more trocars is a widely spread procedure for the treatment of adrenal masses. Our work describes the experience in surgery through single incision (SILS) for the transperitoneal approach to the left adrenal gland. Materials and Methods: We performed a prospective study between April 2010 and April 2013, including patients admitted for elective surgical treatment of left adrenal masses, that measured less than 5 cm, which agreed to participate. The patients were operated on by surgeons specially trained in this type of surgery, using the same surgical technique in all of them. The only entrance was left subcostal incision of 2.5 cm. The variables of our SILS adrenalectomy were compared with those of patients operated with conventional laparoscopic technique during the same period. Results: We collected 40 patients in each group. The intervention was successfully completed in all patients, without requiring conversion to open surgery. The mean operative time in the SILS group was 80 min and 75 min in the laparoscopy group (P [ 0.05). No case in the SILS group required an extension of the incision to remove the specimen intact, compared with 27 in the conventional group (p \ 0.05). No intraoperative or postoperative complications were observed. No statistically significant differences in postoperative pain, early oral intake, final diagnosis or hospital stay. Conclusion: SILS left adrenalectomy is a safe alternative, feasible in selected patients. The clinical advantages, aesthetic and functional still must be demonstrated.

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Age as a Long-Term Prognostic Factor in Bariatric Surgery G. Scozzari University of Torino, TORINO, Italy

Is Stroke Volume Optimization Really Necessary in Laparoscopic Colorectal Surgery? A. Day, R. Smith, W. Fawcett, M. Scott, T.A. Rockall University of Surrey Postgraduate Medical School, GUILDFORD, United Kingdom

Objective: To analyze the potential effects of preoperative age on postoperative weight loss in patients who underwent Roux-en-Y gastric bypass (RYGBP) with long-term follow-up data. Background: The reasons for individual differences in surgically induced weight loss are not completely understood. To date, there are no available studies specifically aimed at analyzing the effects of age on weight loss in patients undergoing the same operation and with long-term followup data. Methods: Retrospective analysis of prospectively collected data for all patients who underwent RYGBP between 2006 and 2010. To evaluate weight loss, we used preoperative and follow-up body mass index (BMI), analyzed by the mixed-effects linear model for repeated measures. To evaluate age effects, patients were classified in quartiles (= 35 years, 36–42 years, 43–51 years, = 52 years). Results: A total of 489 patients entered the study; preoperatively, the younger group showed a significantly higher BMI (mean BMI: 48.2 in patients aged = 35 years, 46.9 in 36–42 years, 45.5 in 43–51 years, 45.7 in = 52 years, p = 0.014) and a higher percentage of super-obesity (41.6% among patients aged = 35 years, 28.1% among 36–42 years, 27.6% among 43–51 years, 28.3% among = 52 years, p = 0.047). In spite of this, younger patients experienced a significantly greater and prolonged BMI decrease during the entire follow-up period and the BMI trend over time resulted significantly modified according to age quartiles (p = 0.036). Conclusions: This study provides a new prognostic factor in bariatric surgery: patient age. Because advanced age represents a risk factor for complications and mortality, and given that bariatric surgery may not be as effective in older patients compared to younger subjects, we believe that surgical indications in patients older than 50 years should be carefully weighed up.

Aim: There is growing evidence that goal directed fluid therapy (GDFT) improves outcome in laparoscopic colorectal surgery. NICE recommends the use of the oesophageal Doppler monitor (ODM) in major surgery. Perhaps an alternative formulaic approach to fluid administration could provide a cheap safe alternative to stroke volume optimisation. Methods: A randomized clinical trial (NCT01128088) was conducted between 2010–2011. Patients were randomized to receive either Hartmann’s solution or 6% Volulyte as the fluid administered by GDFT with an ODM. Volumes of fluid administered to achieve stroke volume (SV) optimization prior to pneumoperitoneum were recorded. Results: 120 patients completed the study (60 in each group). The mean amount (ml/kg) to achieve SV optimization in the 6%Volulyte group was 7.33 significantly less than the Hartmann’s group at 9.96 (p \ 0.0005). Range of fluids (ml/kg) required to achieve SV optimization was 3.28–17.92 in the 6% Volulyte group and 3.39–20.08 in the Hartmann’s group. There was no difference in the length of stay or number of complications between the groups. Conclusion: There is a large range of fluid required to achieve SV optimization across the cohort of patients undergoing laparoscopic colorectal surgery. It would seem that this can only be achieved adequately with the aid of GDFT. Key statement: Optimal fluid administration in laparoscopic colorectal surgery requires an individualized goal directed approach.


O223 - AMAZING TECHNOLOGIES

Gasless Single Incision Laparoscopy in Children R. Shalaby, A.R. Amin, A.H. Samaha, M. Ismail Al-Azhar University, CAIRO, NASR CITY, Egypt

A Novel Laparoscopic Suction Device for Applying Precise Aspiration During Laparoscopic Surgery: Sponge-Tip Suction Tube T.M. Azar, A.A. Uzar, M. Eryilmaz, O. Altinel, S. Demirbas, I. Arslan, T. Tufan Gulhane Military Medical Academy, ANKARA, Turkey

Background: Pneumoperitoneum during laparoscopic surgery represents some an unavoidable complications and problems. The desire to reduce pain while achieving improved cosmetic results has recently led to the introduction of single incision laparoscopic surgery (SILS). There have been recent reports that SILS is feasible also for children. However, gasless single incision laparoscopic surgery (GSILS) has not been published before. The aim of this study is to describe our initial experiences with gasless single incision laparoscopic surgery in children (GSILS). Material and Methods: The study was conducted at Al-Azhar University Hospital in the period from October 2009 to October 2012. The reports of 171 children subjected to GSILS were studied and reviewed. The main outcome measurements were; feasibility and safety of the technique, operative time and cosmetic results. Technique: Under direct vision, intra-peritoneal retractor was inserted into the abdominal cavity through trans-umbilical incision. Then, the retractor was attached to the wire of the frame of Abdominal Liver Retractor. After raising the abdominal wall manually, the scope and working instruments were inserted through the same incision and the standard laparoscopic procedures were started. Results: One-hundred and seventy-one children underwent GSILS were analyzed. They were 129 males and 42 females with a mean age of 4 ± 12 years (range 3–14 years). GSIL appendectomy was done for 49 cases, cholecystectomy for 15 patients, inguinal hernia repair for 30 cases, Hirschsprung disease for 30 cases, varicocelectomy for 23 cases, 1st stage Stephen–Fowler’s procedure for 16 cases and ovarian cystectomy for 8 cases. Gasless retraction created a sufficient abdominal space and good exposure. All cases were completed laparoscopically without conversion. No intraoperative complications. The operative time was relatively long in the first few cases, but decreased with the development of experience. Conclusion: GSILS is feasible, safe and very promising to achieve scarless surgery in addition to avoidance of the adverse effects of CO2 on children. Further comparative studies with a larger patient series are mandatory before the technique can be generally recommended.

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Aspiration of the intra-abdominal fluid and debris is usually needed during different stages of the operation. This is necessary to protect the intra-abdominal space from contamination and/or to remove blood or tissue fluids occurring during the operation. It is also essential for obtaining a clean surgical area. Aspiration of the intra-abdominal fluid is relatively more difficult in laparoscopic surgery because of the suctioning of the omentum and intestine with the aspirator. In this paper, we report on a new suction device (sponge tip suction tube; STST), which allows the surgeon easier suctioning of intra-abdominal fluid. STST has an additional sponge tip and air channel, which prevents the device from suctioning intra-abdominal organs, such as the intestine and omentum. We tested the efficacy of STST in a simulated intra-abdominal space, such as a large transparent plastic bag with fresh sheep intestine-omentum and with 2000 cc of physiologic saline solution and 14 mmHg of air pressure. Whereas the suctioning of all the fluid was difficult and time consuming when the conventional suction unit was used, all of the saline solution was easily and quickly suctioned when STST was used. In conclusion, STST provides a safe, fast, and complete fluid extraction.


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Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): Technical Aspects M.A. Reymond, U. Giger-Pabst, J. Zieren Ruhr-University Bochum, HERNE, Germany

Bio-Inspired Spring-Loaded Biopsy Harvester F. Jelinek, P. Breedveld Delft University of Technology, DELFT, The Netherlands

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel approach for treating peritoneal carcinomatosis. This video describes the technical aspects of the procedure. After insufflation of a 12 mmHg capnoperitoneum at 37°C, two balloon trocars (Applied Medical, Dusseldorf) are inserted through the abdominal wall. Tightness of the abdomen is controlled. Explorative laparoscopy is performed, extent of peritoneal disease (Peritoneal Carcinomatosis Index, PCI) determined and video-documented. Parietal biopsies are taken for histology. Ascites is removed and volume documented. A nebulizer (MIP, Reger Medizintechnik, Rottweil) is connected to a high-pressure injector (Injektron 82 M, MedTron, Saarbruecken) and inserted into the abdomen. A pressurized aerosol containing cisplatin (Hexal, Barleben) at a dose of 7.5 mg/m2 body surface in a 150 ml NaCl 0.9% solution is applied for 30 min via nebulizer and injector followed by doxorubicin (Hexal, Barleben) 1.5 mg/m2 in 50 ml NaCl 0.9%. The toxic aerosol is exhausted through a closed system (CAWS: closed aerosol waste system) into the external environment. Finally, trocars are retracted and laparoscopy ended.

Background: Laparoscopic techniques for superficial biopsy involve lengthy inaccurate trials usually using a laparoscopic forceps. Potential associated hazards, e.g. cancer spread, demand a more reliable alternative—a precise robust biopsy harvester. Aim: Design a steerable laparoscopic instrument tip, incorporating a centrally positioned glass fibre for optical diagnostics (Differential Pathlength Spectroscopy), a cylindrical cutter for accurate, reliable biopsy and a sample storage container for pathology purposes. Description: Biologically-inspired by sea urchin’s Aristotle’s lantern, we designed a novel crownshaped collapsible cutter enabling rapid simultaneous high-precision tissue incision and enclosure. Preceding in-vitro experiments revealed decreasing tissue deformation with increasing cutter penetration speed. Thus, to attain high accuracy, the container-embedded cutter is operated by a high-speed spring mechanism. Results: Real-sized harvester prototype, developed at TU Delft, exhibits flawless cutter operation in-vitro; later to be evaluated in-vivo. With addition of removable container segment, the harvester could provide a comfortable solution towards safe, accurate laparoscopic biopsy.



Single-Port Laparoscopic Sigmoidectomy Using Internal Retractor: Technical Note P.Y. Levant1, L. De Poncheville2, E. Drapier2, A. Smirnoff2 1 CH La rochelle St Louis, LA ROCHELLE, France ; 2Clinique Capio du Mail, LA ROCHELLE, France

New Overhead Illumination Device for Laparoscopic Surgery A. Takai, M. Hatano, K. Tamura, J. Watanebe, T. Taiji, F. Kushihata, Y. Takada Ehime University School of Medicine, TOON, Japan

Single incision laparoscopic colectomy has become established as a minimally invasive surgical approach. However, there are still difficulties concerning effective triangulation and countertraction. Our desire to reproduce strictly the same intervention as with standard laparoscopy that is to say a medial to lateral dissection, led us to design an internal retractor. Herein we present our experience using new internal retractors (referred to as Endosuspend) to provide retraction during Single-port Laparoscopic sigmoidectomy (SPLS). SPLS due to multiple episodes of diverticulis was performed on 10 patients at our institution. The appliedTM single-port system was used for trans umbilical access. The Endosuspend device was introduced into the abdomen at the outset of the operation through the 25 mm umbilical incision. The jaws of the device were used to grasp the colon and the peritoneal wall thereby allowing perfect retraction during a medial-to-lateral approach. Successful sigmoidectomy was accomplished in all cases. There were no intraoperative complications. The median operative time was 108 min, and the median postoperative hospital stay was 6 days. Adequate retraction was accomplished in all cases. The Endosuspend exposure technique was successfully used in all patients and markedly improved the exposure of the mesenteric vessels during SPLS. The main advantage of this device is that it not only leaves no visible marks but it can also be adjusted repeatedly throughout the operation to allow for optimal triangulation. The Endosuspend innovative exposure technique enables easy and safe sigmoidectomy.

Background: A laparoscope configuration in which the light source surrounds the object lens creates shadowless images because the optical and light axes are aligned in the same direction. Such shadowless images result in reduced depth perception because shadows are the most primitive cues for ascribing three-dimensionality. Aim: To develop a new stand-alone overhead illumination device able to create shadows by altering the direction of the optical and light axes. Project Description: We succeeded in producing the device in 2011. Its unique open hexagonal shape and flexibility with light-emitting diode panels made the device suitable for insertion into the abdominal cavity via a small incision. However, glare emerged as a severe problem, especially for hepatectomy, so modifications were made to the device in 2012. Preliminary Results: Laparoscopic surgeries, even for hepatectomy, were performed without glare in porcine models using the modified illumination device.

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Investigation of Staple Height Effects on Tissue Oxygenation and Blood Flow Following Surgical Transection M. Godek Covidien Surgical Solutions, NORTH HAVEN, United States of America

Thoracoscopic Color and Fluorescence Imaging System for Sentinel Node Mapping in Porcine Lung H.K. Kim1, Y.H. Quan1, Y. Oh1, Y.H. Choi2, B.M. Kim2, Y.H. Choi1 1 Korea University College of Medicine, Korea University Guro Hospital, SEOUL, Korea; 2Korea University, SEOUL, Korea

Background: Staple height variability ostensibly contributes to tissue perfusion and healing, i.e., a larger closed staple height may allow a greater volume or increased rate of blood flow to compressed tissue as compared to a smaller final closed staple height, potentially expediting tissue recovery. Aim: Examine the relationship between staple height and tissue reperfusion by measuring blood flow and tissue oxygenation of staple lines with a range of staple heights. Project Description: The investigative methods described here examine the relationship between staple height and tissue reperfusion by measuring blood flow and tissue oxygenation of staple lines. Preliminary Results: Results indicated that tissue reperfusion occurred when the closed staple height was = 2 mm, but no significant tissue reperfusion was observed at a final closed height of * 1.5 mm, suggesting that a greater degree of perfusion occurs as the staple height is increased despite the small differences in the final closed height.

Background: We developed a thoracoscopic Intraoperative Color and Fluorescence Imaging system (ICFIS), providing convenient thoracoscopic sentinel lymph node (SLN) mapping conditions to the surgeons Aim: We conducted preclinical study the thoracoscopic ICFIS in SLN mapping in the large animal model. Project Description: A commercially available standard rigid thoracoscope is mounted to the established ICFIS. The entire procedures were recorded using color and near infrared (NIR) charge coupled device (CCD) cameras simultaneously and the two images merged by real time image processing software. Preliminary Results: This newly developed thoracoscopic ICFIS successfully visualized the SLNs in animal experiments. The SLNs were identified 100% for porcine lung model under in vivo conditions. Real-time image processing software overcame the low signal of NIR fluorescence images.



In Vivo Optical Characterization of Critical Tissues During Colorectal Surgery R.M. Schols1, L Alic2, G.L. Beets1, S.O. Breukink1, F.P. Wieringa2, L.P.S. Stassen1 1 Maastricht University Medical Center, MAASTRICHT, The Netherlands; 2Netherlands Organization for Applied Scientific Research TNO, EINDHOVEN, The Netherlands

Novel 3D Laparoscopy System with Convergence Control and Smart Binocular Disparity Y.W. Kim1, H.B. Yang2 1 National Cancer Center, GOYANG, Korea; 2Sometech Inc., SEOUL, Korea

Background: During colorectal surgical dissections, recognizing essential anatomy is crucial to prevent iatrogenic injury. This study builds forth upon previously identified new inherent anatomical spectral contrasts in fresh human colonic samples. Aim: Assessment of optical spectrometry for discriminating critical tissues (colon, adipose tissue, artery, vein and ureter) in colorectal surgery. Project Description: Acquisition of in vivo AND ex vivo wide-band diffuse reflectance spectra (350–1830 nm) during colorectal surgery, analysis of all separate tissue spectra using principal component analysis (PCA) and comparing tissue categories. Preliminary Results: In 6 consecutive patients 156 in vivo spectra (32 tissue spots) and 118 ex vivo spectra (24 tissue spots) were collected. PCA derived parameters were used to differentiate between tissue types. Distinctive spectral contrast features (partly within wavelengths invisible to the naked human eye) could indeed be identified for all tissue types. Visualizing these invisible contrasts may enhance surgical imaging (either during open or endoscopic surgery).

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Background: Although there have been 3D laparoscopy system (3DLS), various technological limitations making dizziness and fatigue disappointed surgeons so far. Aim: We developed novel high definition 3DLS to make a comfortable and high quality 3D view and applied to advanced cancer surgery to see its benefit. Project Description: Main characteristics of this system are convergence control and binocular disparity control. Based on 5 cm as a main working distance, working distance is possible to be adjusted from 3 cm as a close distance to 10 cm as a long distance, and convergence can be adjusted manually according to the working distance. Binocular disparity control makes this system like human eyes to see an object with optimal binocular disparity to make a comfortable stereoscopic view. Preliminary Results: All surgeons used this system quickly adapted without specific complaint of dizziness or fatigue of eyes for over 2 h operations.


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Skills Acquisition and Retention Using Virtual Reality A. Bouhelal, W. Elbakbak, B. Alaraimi, H. Patel, B. Patel Basrt and The London, LONDON, United Kingdom

Endoscopic Surgery Telementoring ‘A Simple Solution’ M.Y. Seleem1, M.A.R. Shazli2 1 Cairo university, CAIRO, Egypt; 2Minister of health, CAIRO, Egypt

Background: In the ever-escalating procedural complexity in the era of minimal invasive surgery embracing new technology for training is a necessity not a luxury. Aim: We objectively investigated the efficacy of surgical VR training and retention of skills using a validated curriculum with expert performance as benchmark for proficiency. Methods: 30 novices were randomly recruited and trained toward FLC on a Lap Mentor, Simbionix. The novices were retested 1 year later to investigate the retention of skills. Results: Time taken to finish FLC decreased from 9:57 to 7:10 min in MTST of 30:04 min. NOM improved from 551 to 363, TPL improved from 1368–807 cm in 3.4 trials p \ 0.000 One year later. We investigated the retention of skills 90% stayed within time proficiency, 80% within economy of movement and 60% remained within TPL proficiency p \ 0.000. Conclusion: VR provides individualized training and the skills acquired are maintained irrespective to training.

Background: Telementoring is an important tool for on job training allowing a junior laparoscopic surgeon to perform surgeries with distant control and interaction with an experienced surgeon. This technique is very suitable for remote areas with inequity of expertise Aim: To introduce a simple way of, web based, tele mentoring for endoscopic surgeons Project Description: Developing an E-learning website with a connection port for online telementoring of live surgery ‘audio-video’ allowing interaction between surgeons without the need of any complicated hardware interface and no limitation of bandwidth Preliminary Results: The website has been already activated and test phase of broadcasting already accomplished. The next phase will be pressure test followed by launching of the first version



Development of the Bipolar Irrigation System ‘Silicone Jacket Irrigator’ for the Safe, Effective and Economical Use of Electric Surgery T.I. Ikeda, R.K. Kumashiro, K.T. Taketani, H.K. Kawano, Y.M. Maehara Kyushu University, FUKUOKA, Japan

Mathematical Modelling of Force Transmission in Laparoscopic Graspers L. Hunter1, J. Barrie2, P. Culmer1, A. Hood2, A. Neville1, D. Jayne2 1 University of Leeds, LEEDS, United Kingdom; 2St James’ Hospital, LEEDS, United Kingdom

Background: Approximately 40,000 patients suffer electrosurgery-related injuries each year. Many of these accidents occur in monopolar electrosurgery using a return electrode. Purposes: The Silicone Jacket Irrigator (SJI) is coated with silicone that is not denatured or degraded at 200°C and can be applied to a variety of bipolar electrosurgery devices like a jacket. It allows the tips of bipolar electrosurgery devices to be irrigated with saline through narrow canals (1.0 ± 0.3 mm in diameter). The SJI has been developed for use with endoscopic surgical instruments of 3 mm and 5 mm external diameter. Conclusions: SJI can be attached to standard reusable bipolar electrosurgery equipment and is effective and safe in a variety of endoscopic surgical procedures. The device reduces the requirements for other disposable surgical equipment, so it is also economical. SJI was protected by patent in Japan in January 2013.

Background: Minimally invasive surgery is increasingly popular but complexities can lead to tissue damage through inappropriate tissue manipulation. In particular, graspers apply a range of forces to tissue but little is known about their link to tissue damage. Aim: To develop a mathematical model of an atraumatic short fenestrated grasper (Surgical Innovation Ltd.) that links tool-tip output force and jaw angle to input movement applied by the surgeon. Project Description: A mechanical grasper model was developed assuming a frictionless linkage system. The tool-tip output was found for a range of surgically relevant input force and displacements (0–100 N and 0–2.6 mm) informed by in-vivo studies. Preliminary Results: The tool-tip forces range from 4.04% to 7.48% of input force, where maximum force transmission occurs at a jaw angle of 17.36°. Future developments will include frictional losses and linking tool-tip output to histological measurements of tissue damage.

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Electropermanent Magnets for Transabdominal Anchoring P.J. Cantillon-Murphy1, P.J. Brennan1, J. Tugwell1, K. O’Donoghue1, R.A. Cahill2 1 University College Cork, CORK, Ireland; 2Beaumont Hospital, DUBLIN, Ireland

An In-Vivo Study Of injected Ferrofluids for Tissue Manipulation in Minimal Invasive Surgery Y.S. Lin1, A. Hood1, P. Culmer1, T. Liskiewicz1, D.G. Jayne2, A. Neville1 1 University of Leeds, LEEDS, United Kingdom; 2St James’ University Hospital, LEEDS, United Kingdom

Background: There is significant scope for magnet technology to improve outcomes in current endoscopic and surgical intervention. Two clear and present difficulties with current magnet technologies are (i) the undesired attraction to surgical instruments and (ii) the heating associated with electromagnets. Aim/Project Description: The goal of this work was to identify and prototype a technical solution to these two difficulties which retains the usefulness of magnetic attraction in clinical transabdominal anchoring. The solution is electropermanent’ magnetic coupling; a hybrid technology which comprises a permanent magnet which can be turned on or off as required. Preliminary Results: A working benchtop prototype has been constructed weighing less than 1 kg, capable of transabdominal coupling at separation of 5 cm with no active power dissipation. The magnet is controlled by a single pulsed input to switch between the ‘on’ and ‘off’ states. Preclinical (porcine) evaluation is scheduled for May 2013.

Nanoscale Iron-Oxide ferrofluids exhibit a special property, ‘superparamagnetism’, that induces an attractive force toward an external magnetic field. The aim of this project is to investigate the use of ferrofluid for tissue retraction during Minimally Invasive Surgery (MIS). In vivo porcine experiments were performed in which 0.3 ml of ferrofluid (20% by weight) containing 10 nm particles was injected subserosally into the small and large bowel. A 0.6 Tesla magnetic field was applied using a combination of 10 mm and 20 mm diameter Neodymium Iron Boron magnets. The vertical retraction distance was measured and video was captured. Maximum vertical retraction was 7 cm. This work demonstrates the ability to retract tissue, using small volumes of ferrofluid, without the need to mechanically grasp it.



Micro-Scale Bio-Inspired Structured Polymer Surfaces for Tissue Adhesion, Traction and Friction A.M. Bell1, A. Hood2, J. Barrie2, G. Taylor2, D. Jayne2, A. Neville1, P.H. Gaskell1 1 University of Leeds, LEEDS, United Kingdom; 2St James’ Hospital, LEEDS, United Kingdom

Dexte´rite´: Experience in Obesity Surgery M.G. Esposito, V. Bottino, V. Di maio, G. Ciorra, G. Marte, M. Nunziante, P. Maida Ospedale Evangelico Villa Betania -Naples- Italy, NAPLES, Italy

Background: Iatrogenic bowel injury from laparoscopic instruments is a rare but devastating complication of minimally invasive surgery. Instruments are increasingly used to friable, inflamed tissue and are not known to be truly atraumatic. Aim: To produce a micro-structured polymer surface capable of attaching to and detaching from tissue, with minimal tissue damage. Project Description: This project investigates the fabrication of a bio-inspired surface using an imprinting technique, and how adhesion is generated on a wet surface by such structures. Testing is performed both in- and ex-vivo against peritoneum and a mathematical model is being developed incorporating capillary and Stefan forces. Preliminary Results: Preliminary results show adhesion generated by the surfaces of interest is capable of supporting a 2 g mass both in- and ex-vivo. This provides direction for further research investigating the effects of varying surface geometry and chemistry to identify an optimum surface for providing maximum adhesion and friction.

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The Authors present a pilot experience with robotic laparoscopic surgical instruments in Obesity Surgery. The Robot Dexte´rite´ of Dexte´rite´ Surgical is a robotic arm useful in laparoscopy.The cost and ease of use in terms of management in the operating room make it a tool with greater efficiency compared to other instruments. Not requiring space ‘dedicated’ can be inserted between the laparoscopic surgical instruments without any difficulty adding management. It has been standardized a 3–4 h training with increasing difficulty to obtain a good level in the learning curve. The tip of the instrument, currently represented by a needle holder facilitates suturing in confined spaces being smaller than the conventional instruments, and having in themselves the seven degrees of freedom typical of the robot. Furthermore, the tip can perform a complete movement of 360 °. The dexterity of movement saves time, reduces fatigue, facilitating the suture and improving the accuracy improves surgical performance.


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O240 - AMAZING TECHNOLOGIES Endo-PaC: A New Way of Investigating Control Interfacing for Medical Instruments C. Fan, F. Jelinek, D. Dodou, P. Breedveld Delft University of Technology, DELFT, The Netherlands Background: For surgeries carried out transluminally or through instrument-created pathways (i.e., pathway surgery), instruments with multiple steerable segments (manoeuvrable instruments) have been introduced, but their controllability (e.g., dexterous steering and performance effectiveness) remains unexplored. Aim: A research platform, Endo-PaC (Endoscopic Path Controller), is designed for investigating manual controllability of manoeuvrable instruments. Project Description: Endo-PaC consists of a mechanism mimicking the shaft and handle of a manoeuvrable instrument, in combination with custom-developed software that simulates curved 3D pathways with dynamic parameters (e.g., length, diameter and curvature). Experiments with Endo-PaC and novice subjects are currently being carried out, in which control methods (thumb/ wrist), control motion-mappings (parallel/reversed) and control strategies (rotation/reflection) are systematically investigated. Preliminary Results: Current results indicate that subjects experienced lower physical demand and had shorter path lengths with thumb than with wrist control, and performed more effectively with parallel than with reversed mapping.

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

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

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

Abstracts of the 16th ESOT Congress, 8-11 September 2013, Vienna, Austria.

Abstracts of the Fourth International IASSIDD Europe Regional Congress 14-17 July, 2014, Vienna, Austria.

Abstracts of the Annual European Congress of Rheumatology EULAR. June 12-15, 2013. Madrid, Spain.

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

Abstracts of the 1st Congress of the European Academy of Neurology, Berlin, Germany, June 2015.

Abstracts from the 3rd International PPRI Conference, October 12-13, 2015, Vienna, Austria.

Abstracts from the 26th National Congress of the Italian Society of Geriatric Surgery, 19-22 June 2013, Naples, Italy.

Abstracts of the XXIV European Congress of Perinatal Medicine, June 4-7, 2014, Florence, Italy.

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

Abstracts of the ILTS 20(th) Annual International Congress, June 3-7, 2014, London, United Kingdom.

Abstracts of the 11th European Congress on Epileptology, 29 June - 3 July, 2014, Stockholm, Sweden.

The Eighteenth Annual Meeting of the European Association of Echocardiography, December 3-6, 2014, Vienna, Austria.

50th International Liver Congress: update on viral hepatitis: 22-26 April 2015, Vienna, Austria.

Abstracts of the German, Austrian, and Swiss Society for Hematology and Oncology. October 18-22, 2013. Vienna, Austria.

[On the 20th European Congress of Radiology in Vienna].

International Society for Biomedical Research on Alcoholism, 6th Congress. Bristol, England, June 21-27, 1992. Abstracts.

Abstracts of the 11th European congress on Telepathology and 5th International Congress on Virtual Microscopy, June 6-9, 2012, Venice, Italy.

Abstracts of papers presented at the 39th European Organization for Caries Research (ORCA) Congress. Helsinki, June 24-28, 1992.

Abstracts of the 12th European Society for Pediatric Dermatology (ESPD) Congress, 12-14 June, 2014, Kiel, Germany.

Congress summary: 21st Congress of the International Society for Rotary Blood Pumps.

Proceedings of the 21st European Pediatric Rheumatology (PReS) Congress.