Surg Endosc (2013) 27:S53–S166
DOI 10.1007/s00464-013-2876-9
20th International Congress of the European Association
for Endoscopic Surgery (EAES)
Brussels, Belgium, 20–23 June 2012
Poster Presentations
 Springer Science+Business Media New York 2013
P001 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC REINFORCEMENT OF THE ABDOMINAL
WALL AFTER EXCISION AND SPLIT SKIN GRAFTING OF
A LUNG CARCINOMA METASTASIS
H. Ali, Z.J.M. Rokan, B. Dodd, A. Nisar
Maidstone and Tunbridge Wells NHS trust, MAIDSTONE,
United Kingdom
Cutaneous abdominal metastasis from a primary lung tumour conveys
a poor prognosis. Abdominal wall reconstruction following tumour
resection usually involves construction of a myocutaneous flap, cre-
ating significant risk of hernia formation and increasing morbidity in
the palliative patient.
In the presented patient, loss of cutaneous continuity due to metastatic
tumour and subsequent radiotherapy resulted in a contaminated
operating field. As an alternative to a myocutaneous flap, a biological
mesh was laparoscopically placed deep to the abdominal wall
resection defect, providing reinforcement and reducing the risk of
prosthesis infection. Split skin grafting from a right thigh donor site
was then performed. To our knowledge, this is the first reported
laparoscopic mesh placement for the prevention of ventral hernia
formation following abdominal wall lung cancer metastasis resection.
It provides a quick, low morbidity alternative to more extensive
abdominal wall reconstruction enabling faster discharge from
hospital.
and Other Interventional Techniques
P002 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC SURGERY OF STOMACH AND
DUODENAL GASTROINTESTINAL STROMAL TUMORS
Y.G. Starkov, K.V. Shishin, I.Y. Nedoluzhko, M.M. Konstantinova,
S.V. Dzhantukhanova, N.A. Kurushkina, M.I. Vyborniy
Institute of Surgery n.a. A.V.Vishnevsky, MOSCOW, Russia
Introduction: Gastrointestinal stromal tumors (GISTs) are the most
common mesenchymal neoplasms of the gastrointestinal tract, which
compose 1% of all masses of this localization. Approximately
50–70% of GISTs originate in the stomach. The small intestine is the
second most common location, with 20–30% of GISTs arising from
the jejunoileum. Malignant potential of this kind of tumors have
determined active surgical tactics directed for its removal. Diagnostic
of early neoplasms and exclusion dissemination from gastrointestinal
stromal tumor granted different minimally invasive methods, partic-
ularly laparoscopic approach.
Materials and methods: Since 2008 till 2011 11 patients suspicious
GIST were treated. All patients underwent EUS, which confirmed
presumptive diagnosis. Abdomen CT showed non metastatic GIST in
all cases. 10 patients had tumor in stomach, 1 – in duodenum. In 3
cases lesions located in anterior gastric wall in stomach body, next 3
cases – posterior gastric wall subcardia area, also 2 cases – gastric
fundus and on one occasion greater curvature and angle of the
stomach. Tumors sizes ranged from 1.5 to 6.5 cm. All patients
underwent laparoscopic wedge resection of affected organ (in 1 case –
transgastral tumor removal under double endoscopic control).
Labeling of tumor margins was carried out with the help of laparo-
scopic ultrasound. Wedge resection was performed using ultrasound
scissors, intending 1 sm of the tumor margin. Tumors were extracted
in container from abdomen cavity. Gastotomy was closed up by
double-rowed interrupted sutures.
Results: Operation time was ranged from 75 to 320 min. Histology
and immunohistochemistry (IHC) confirmed GIST in 9 patients,
1 patient had aberrant pancreas. Tumor in duodenum was Brunner‘s
gland adenoma. According to IHC results none of the patients
required adjuvant therapy. Postoperative follow-up was during 1–3
year. Abdomen CT and upper GI endoscopy showed no pathological
changes. Recovery was uneventful.
Conclusion: Laparoscopic surgery is feasible, safe and effective
technique for GIST removal in selected patients.
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P003 – Abdominal Cavity and Abdominal Wall
OBTURATOR HERNIA CONTAINING THE OVARY IN
A YOUNG GIRL
P. Dorn, J. Knaus, P. Nussbaumer
Spital Lachen, LACHEN, Switzerland
Introduction: Obturator hernias are very rare and most commonly seen in elderly ([50 y)
and thin women. They present a diagnostic challenge as signs and symptoms are often
nonspecific, and the diagnosis is often only made intraoperatively after presenting with
bowel obstruction. Other symptoms include groin or hip pain; obturator neuralgia (How-
ship-Romberg sign) can also be present. Usually their content is small intestine, rarely
caecum or pelvic colon. The mortality rate for this type of hernia is higher than for other
abdominal wall hernias (13–40%). Various methods for open or laparoscopic repair were
described in the literature using autogenous tissue or synthetic material. We present an
unusual case of a young girl with an obturator hernia containing the right ovary.
Case report: A 13-years-old female patient presented with clinical signs and symptoms
suspicious of acute appendicitis for the duration of one day. General examinations revealed
tenderness localized around McBurney’s point. Routine hematological and biochemical
investigations including WBC and CRP were normal.
Ultrasonography of the abdomen showed an inconspicuously shaped appendix surrounded
by little free fluid. Because of a cumulative family history of complicated appendicitis, the
patient’s mother insisted on urgent laparoscopy and appendectomy. Surprisingly the
diagnostic laparoscopy revealed bilateral indirect inguinal hernias and a right-sided obtu-
rator hernia containing the ovary. Appendectomy was performed as intended, although the
appendix was macroscopically normal. We abstained from simultaneous mesh repair of the
hernias due to infectiological reasons. After an interval of four days bilateral endoscopic
mesh repair (TEP) was performed. The patient had an uneventful recovery with a hospital
stay of 1 day. She returned rapidly to normal physical activity and was without complaints
at follow-up after 3 months.
Conclusion: We present the rare case of a symptomatic obturator hernia containing the
ovary in a young girl. To our knowledge this is the first such report. Endoscopic mesh repair
has been shown to be a feasible and suitable approach to treat our patient, taking into
account the presence of multiple hernias.
P004 – Abdominal Cavity and Abdominal Wall
SURGICAL TECHNIQUES USING SMALL-DIAMETER
6FORCEPS (REDUCED PORT SURGERY) AND SAFETY
IN SINGLE-STAGE LAPAROSCOPIC SURGERY
FOR SYNCHRONOUS DOUBLE TUMORS
H. Kato, Y. Yamashita, M. Oishi, M. Kodera, K. Seshimo,
M. Yamamura, H. Ikeda, K. Mizuno, T. Toshima
Tottori Municipal Hospital, TOTTORI, Japan
In Japan, laparoscopic surgery has become standard treatment for gastrointestinal diseases,
and, currently, the application of reduced port techniques is being reviewed for cosmetic
reasons. In surgery for synchronous multiple tumors located in the upper and lower
abdomen, ports can be gathered at the umbilicus to reduce the number of incisions; how-
ever, this technique fixes the port location, requiring high-level surgical techniques. Thus,
we used small-diameter forceps for surgery which involves different surgical fields, while
gathering or reducing the number of ports to increase surgical safety and reduce surgeons’
stress.
This technique is also applied when one of the two surgical fields involves open surgery.
We combined laparoscopic and open surgeries to reduce incision sizes as much as possible,
by placing a port on an incision line of open surgery and using small- diameter forceps. The
combined use of laparoscopic surgery can improve cosmetic outcomes in patients requiring
open surgery, and the application of small-diameter forceps is considered to show above
mentioned merits.
In this study, we present a sigmoid colon cancer patient with synchronous liver metastasis
who required open surgery, in whom we successfully performed single-stage surgical
excision with the combined use of minimally invasive laparoscopic techniques using small-
diameter forceps. Laparoscopic sigmoidectomy was conducted first, followed by liver
subsegmentectomy (S6). A total of 4 ports were used for laparoscopic sigmoidectomy, after
reducing one port using small-diameter forceps (miniLap) inserting into the left upper
abdomen, and two ports at the umbilicus and right upper abdomen were created on an
incision line for open surgery. Subsequently, a reverse L-shaped incision was made at the
upper abdomen to pass the trocar, and liver subsegmentectomy was performed. The
duration of surgery was 454 minutes and blood loss was 240 ml.
For synchronous multiple tumors, combined use of laparoscopic surgery is beneficial for
reducing blood loss, as well as for safety, minimal invasiveness, and cosmetic reasons, but
it also facilitates surgery at the standard port sites with the use of small- diameter forceps,
suggesting that it can contribute to improve surgical safety by securing a sufficient surgical
view and reduce surgeons’ stress.
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P005 – Abdominal Cavity and Abdominal Wall
A SINGLE-CENTER EXPERIENCE IN SILS: A REVIEW
OF 65 CASES
Y.G. Starkov, K.V. Shishin, I.Y. Nedoluzhko, S.V. Dzhantukhanova,
M.I. Vyborniy, L. Vetygova
Institute of Surgery n.a. A.V.Vishnevsky, MOSCOW, Russia
Background: Single incision laparoscopic surgery (SILS) has been recently proposed to
reduce skin incisions and related post-operative pain and morbidity. The main concept of
the SILS technique is the using of a single incision, thus decreasing the number of ports and
surgical trauma. The current data has shown this approach to be feasible for a wide variety
of diverse procedures, performed earlier using traditional laparoscopic technique with the
number of ports.
Methods: In a period from October 2009 till December 2011, 65 surgical interventions were
performed using SILS technique. Laparoscopic cholecystectomy was performed in 54
patients with chronic calculous cholecystitis. Five patients underwent simple liver cysts
fenestration. One case is of interest due to its rarity – a stomach trichobezoar removal was
performed in a 21-years old female. Two surgical interventions were performed in patients
with GERD, one with achalasia and one with pyloric stenosis. Appendectomy was per-
formed using SILS technique in one patient.
Results: All surgical interventions were performed through a single incision in the umbi-
licus using different Single-Port devices. There were no intra- and postoperative
complications, however it should be noted that there were significant intraoperative chal-
lenges. That is, the introducing of multiple instruments through a single port causes the
crowding of instruments due to their parallel position. The major drawback of the single
port approach technique is the failure of ‘‘triangulation’’ concept. The multiple instruments
required for a surgical procedure in this technique are competing for the same space inside
and outside of abdominal cavity, causing hand collisions externally and difficulty with
instrument manipulation internally. Using curved and articulated instruments can amelio-
rate some of these disadvantages. In the other hand the training of surgeons is of the great
importance.
Conclusion: We consider the using of additional minilaparoscopic instruments, inside-
outside suspending sutures, facilitating tissue tractions is reasonable in the cases of high risk
of intraoperative complications without significant decline of cosmetic result.
P006 – Abdominal Cavity and Abdominal Wall
EXPERIENCE OF TAPP FOR PATIENTS WITH
INCARCERATED INGUINAL HERNIA
D. Yaroshuk
National Medical University, KIEV, Ukraine
Introduction: During 2010 and 2011 years 26 patients with incarcerated indirect inguinal
hernia had laparoscopic TAPP allogerniaplastics.
Methods: All patients were males. Average age is 52 ± 8 years. Preoperative examination,
in addition to standard studies, included ultrasound with Dopplerography.
Time from the moment of infringement to the start of surgery is 140 ± 45 minutes.
Spontaneous reduction of hernia with the introduction of anesthesia is recorded in 19 cases.
At revision of the abdominal cavity hernial protrusion on the opposite side was found in 5
patients. The content of the hernia was a strand of omentum in 19 (73%) cases, a loop of
small intestine in 6 (23%) cases, a strand of omentum with a loop of small intestine in 1
(3.9%) cases. Viability of entrapment was assessed visually by transillumination of cold
light source. Resection of the strands of the greater omentum was performed for 4 (15.4%)
patients. Enterectomy was performed for 1 (3.9%) patients. Hernia correction with con-
tralateral side was performed for 4 (15.4%) patients.
Results: Postoperative complications of studied patients were not found. Hernia recurrence
in up to 2 years wasn’t observed.
Conclusions: Laparoscopic TAPP allogerniaplastics is applicable and safe for patients with
incarcerated inguinal hernia. Doppler examination of hernial content is necessary in the
preoperative examination of the patient.
Surg Endosc (2013) 27:S53–S166
P007 – Abdominal Cavity and Abdominal Wall
CONCEALED PERFORATION OF THE STOMACH WITH
DEVIOUS PRESENTATION: A CASE REPORT
A. Tsechpenakis1, E.D. Karafoka1, K.I. Tsigritis1, K.I. Bramis1,
N.I. Basios2, A.T. Kotzadimitriou2, K.I. Bramis1
1
Athens Euroclinic, ATHENS, Greece; 2University of Athens,
Laiko General Hospital, ATHENS, Greece
Aims: The purpose of this presentation is to demonstrate an interesting case of
chronic abdominal pain due to perforation of the anterior wall of the stomach by a
metal needle-like object which was laparoscopically removed.
Methods: A 27-year-old female caucasian patient (BMI 27) was admitted to the
outpatient department suffering from mild abdominal pain and pelvic discomfort for
more than two months. These symptoms were worsening on standing position. No
fever nor GI symptoms were reported. She had epigastric tenderness on physical
examination but negative digital rectal examination. All blood tests were within
normal values (Hct, WBC, CRP, Bil, ALT, AST, Amylase). The ultrasonography
showed fluid in the pelvis (ca. 300 cc) but no other intraabdominal pathology. The
CT scan revealed a small metal needle-like object nailed in the anterior wall of the
stomach. The patient underwent thorough upper GI endoscopy during which no
perforating object could be found and surgical approach under general anesthesia
was decided.
Results: The diagnostic laparoscopy revealed the perforating object literally
scratching the posterior surface of the right lobe of the liver on the level supine
position on the operating table. The object was free to irritate the anterior abdominal
wall peritoneum on the reverse Trendelenburg position. The object was easily
removed and the penetration site was reinforced with sutures on the standard lapa-
roscopic fashion. The patient was discharged on the 1st postoperative day.
Conclusion: Abdominal pain with no typical presentation or negative standard lab-
oratory testing often require further investigation as abdominal cavity is considered
to be ‘the Pandora’s box’ and the rarest case scenario is a possibility too.
P008 – Abdominal Cavity and Abdominal Wall
HERNIA OF FALCIFORM LIGAMENT AND
LAPAROSCOPIC REPAIR
V. Golash
Sultan Qaboos Hospital, SALALAH, Oman
Aims: There are several reports of internal herniation through a defect in the fal-
ciform ligaments but the hernia of falciform ligament has not been reported in this
laparoscopic era. Anatomically the round ligament inserts about 2 to 4 inch above
the umbilicus after that it passes into a canal in the extraperitoneal space and ends at
the umbilical cicatrix. The round ligament prolapsed into this extraperitoneal space
with a sac of peritoneum giving rise to true hernia. We present our experience and
treatment of this condition.
Methods: Of 547 laparoscopic ventral hernia repairs, the true hernia of falciform
ligament was observed in 15 patients. All patients were female, multipara and in age
group of 24–55 yrs of age. Presentation was of paraumbilical hernia. Majority of
patients had some degree of divarication of recti. The diagnosis of hernia of falci-
form ligament was not known before laparoscopy. The operative approach was same
as for the laparoscopic repair of ventral hernia from right side. On laparoscopy the
herniation of falciform ligament was seen in the hernia sac with or without other
contents in hernia. The contents were reduced and the hernia of falciform ligament
was confirmed by pulling on prolapsed part. The falciform ligament was taken down
completely to expose the hernial defect and to facilitate the placement of mesh. A
large size mesh was used to cover the hernia defect, divarication and the umbilicus
Results: The mean defect size was 28 cm2 but the mean size of mesh used was
706 cm2, much larger to the proportionate defect size to cover the divarication
recti and the umbilicus. There were no major postoperative complications and
no recurrence in last 10 years.
Conclusions: The treatment described for the hernia of falciform ligament in the pre-
laparoscopic era was laparotomy from xiphoid to below umbilicus. Laparoscopic
repair is a good example of benefit of minimal access surgery. The limitation of this
study is in its small size and recognition.
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P009 – Abdominal Cavity and Abdominal Wall
A SAFE AND FEASIBLE PROCEDURE FOR INTERMITTENT
VASCULAR OCCLUSION IN LAPAROSCOPIC
HEPATECTOMY
Y. Okuda, G. Honda, M. Kurata, S. Kobayashi, K. Tsuruta
Tokyo Metropolitan Cancer and Infectious diseases Center
Komagome Hospital, TOKYO, Japan
Aims: While the amount of blood loss during laparoscopic hepatectomy tends to be
smaller than that during open hepatectomy, nevertheless, intermittent vascular
occlusion controlling the hepatic inflow is useful to diminish the amount of blood
loss during laparoscopic hepatectomy. We describe our useful and convenient
method for intermittent vascular occlusion, which we standardized for laparoscopic
hepatectomy.
Methods: We encircle the hepatoduodenal ligament by passing 7 cm of a catheter’s
tip threaded with a cloth vessel tape through Winslow’s foramen. Then, we set the
next 20 cm of the catheter, through which the vessel tapes are threaded, through a
hole in the abdominal wall directly without a trocar, and use this as a tourniquet.
Results: In 20 patients subjected to this method, the mean time for its completion
was 354 seconds, and there were no complications.
Conclusion: This method can be carried out safely, easily and quickly.
If necessary, one more set can be added by the same method. And, the
area of vascular occlusion can be selected conveniently just like in an
open method.
P010 – Abdominal Cavity and Abdominal Wall
A LITERATURE REVIEW ON THE ROLE OF TOTALLY
EXTRA-PERITONEAL (TEP) REPAIRS FOR GROIN PAIN
IN ATHLETES
M.R.S. Siddiqui, M. Kovzel, S.J. Brennan, O.H. Priest, S.R. Preston,
Y. Soon
Guildford Hospital, GUILDFORD, United Kingdom
Objective: A literature review on the role of totally extra-peritoneal (TEP) hernia
repairs for groin pain in athletes.
Methods: Electronic databases were searched from January 1993 to
November 2011.
Results: There were 10 papers included in this 30% of cases were reported to have a
direct inguinal hernias, 22% had indirect inguinal hernias; 41% had dilated internal
rings. Of note 30% of cases had no macroscopic abnormality. Four studies reported
on an early follow up ranging between 3–6 weeks. Only minimal or mild symptoms
were reported. Up to 33% of patients had impaired ability to perform at peak levels.
Up to 53% of patients had persistence of symptoms at the early follow up. Total
follow up time ranged from 3–80 months and most patients were active (90–100%).
At long term follow up 3–10% were unable to play and 5% were reported as being
unable to train. Two studies from the same center reported on TEP surgery for
osteitis pubis and most patients returned to sporting activity after 4–8 weeks.
Conclusions: TEP repair is a good operative intervention in athletes with chronic
groin pain not relieved by conservative measures. Athletes recover quickly and
return to sport early.
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P011 – Abdominal Cavity and Abdominal Wall
PREEMPTIVE GALLBLADDER BED INFILTRATION
WITH LOCAL ANAESTHETICS BEFORE GALLBLADDER
DISSECTION IN LAPAROSCOPIC CHOLECYSTECTOMY.
I. Ivanovs1, M. Mihelsons2, V. Boka2, M. Saba1
1
Riga Hospital No. 1, RIGA, Latvia; 2University of Latvia, RIGA,
Latvia
Aims: Laparoscopic cholecystectomy is one of the most common surgical opera-
tions. The excessive stress response can increase postoperative morbidity.
Postoperative stress is induced by afferent impulses from operation field. Local
anaesthetics can block these impulses. A controversy exists over usage of local
anaesthetics during laparoscopic cholecystectomy. The aim of the study is to
investigate the method of the preemptive gallbladder bed infiltration with local
anaesthetics before gallbladder dissection.
Methods: 40 patients undergoing elective laparoscopic cholecystectomy were ran-
domised into 2 groups of 20 patients each. Group A (study group) received 20 ml 1%
Lidocaine injection – infiltration in gallbladder bed before gallbladder dissection.
Infiltration was done with special non-traumatic needle for gallbladder bed infil-
tration to avoid liver puncture. Group B (control group) received no treatment. Stress
markers were measured at the end of operation, in 4 hours and 1 day after operation.
Pain intensity was measured with Visual Analog Scale (VAS) in 1 hour, 4 hours and
1 day after operation. Postoperative monitoring was done by personal blinded to the
procedure. Diclofenac and opioids were given as rescue analgesic when demanded
by patient in postoperative period.
Results: Cortisol level in the study group at the end of operation was lower compared
with the control group: 24.9 mkg/dl vs. 36.1 mkg/dl (p\0.05). The study group had
less VAS score in the 1st hour after operation compared with control group: 20.4 vs.
30.5 (p \ 0.05). The rescue analgesic requirement was significantly lower in the
study group 2, 15 vs. 3.9 (p \ 0.05). The length of hospital stay after operation was
lower in the study group 1.2 vs. 1.7 days (p \ 0.05). Average operation time in the
study group was slightly lower 47,3 min vs. 54.8 min (p \ 0.1) and significantly
lower was the risk of gallbladder wall perforation with bile effusion during gall-
bladder dissection: 0.1 vs. 0.2.
Conclusion: Gallbladder bed infiltration with 1% Lidocaine before gallbladder dis-
section is a safe method and can decrease postoperative stress and pain. This method
can decrease consumption of postoperative analgesics and facilitate early discharge
from hospital. The gallbladder bed infiltration also decreases risk of gallbladder wall
perforation during gallbladder dissection.
P012 – Abdominal Cavity and Abdominal Wall
REDUCED PORT TAPP WITH BJ NEEDLE
A. Kamei
Medical Topia Soka, SAITAMA SOUKA, Japan
To gain better cosmetic results, we have been trying to reduce both the number
and the size of ports in conventional TAPP (Transabdominal preperitoneal
hernia repair). Considering the safety and facilitation of the operation on the
other hand, we prefer using ‘BJ needle’ which is a 2 mm needle grasper with a
high rigidity. We performed three different types of reduced port surgery,
SILS-POP (Single incision laparoscopic surgery plus one puncture) with
multichannel port plus BJ needle, DILS (Double incision laparoscopic surgery)
with multichannel port plus 5 mm, and three-port-surgery with BJ needle
(BJ-TAPP).
The indication of reduced port surgery depends on the patient’s request. As for
operation method, preperitoneal space was dissected from the abdominal
cavity, a mesh sheet was placed and fixed with tacks, and the defect of the
peritoneum was closed by hand sew.
During March 2011 through December 2011, we have experienced 40 cases of
conventional TAPP (12 mm, 5 mm, 5 mm) and 23 cases of Reduced Port TAPP
including SILS-POP (11 cases), DILS (7 cases), BJ-TAPP (5 cases). BJ needle
was useful in grasping peritoneum, dissection with gauze, suturing and making
knots. The average operation time was 60 minutes in conventional TAPP,
whereas it was 68 minutes in SILS, 63 minutes in DILS and 66 minutes in BJ-
TAPP. There was no intraoperative and postoperative complication. The cos-
metic result was satisfactory in all patients. Reduced port surgery with BJ
needle was safely performed. We consider BJ needle as a useful device to gain
both good cosmetic result and better quality of the reduced port surgery.
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P013 – Abdominal Cavity and Abdominal Wall
ABDOMINAL RECRUITMENT MANEUVER DURING
LAPAROSCOPY IMPROVES SURGICAL WORKSPACE.
J.P. Mulier, B. Dillemans, E. Van Dessel, F. Akin
AZ Sint Jan Brugge-Oostende, BRUGES, Belgium
Abdominal workspace is measured as the inflated CO2 volume. If the inflated vol-
ume is less than 2 liters at 20 mmHg during a deep neuromuscular block and the
surgeon has problems of insufficient workspace the intra abdominal pressure (IAP) is
shortly increased with 1 liter using an abdominal recruitment method (ARM). The
ARM consists of a 1 L balloon connected to the CO2 inflation line with a one way
valve included and a manometer. On a moment of extra space need one liter
workspace can be inflated manual. The pressure stay elevated as indicated by the
manometer and will slowly drop according to the leakage at the trocars.
A very low workspace is more frequent in patients never operated before, woman
without children and morbid obese patients with a central obesity distribution who
did not lose weight before surgery. Patients are informed that the lowest IAP possible
will be used but that sometimes higher pressures are needed to avoid a laparotomy.
7 patients scheduled for a laparoscopic gastric bypass procedure in 2011 under deep
NMB did not reach a workspace of 2 liters at 20 mmHg. An average volume of 1.6 ±
0.3 L was reached. The resting pressure (PV0) was high: 10 ± 3 mmHg and the
compliance small: 0.18 ± 0.04 L/mmHg. Peep was elevated with 5 cmH2O above
the initial peep between 7 and 10 cmH2O, cardiac output was increased and blood
pressure elevated above 120 mmHg before the abdominal volume was increased
with 1 liter. Pressure rose according to the compliance to maximum 40 mmHg for a
short moment. Due to trocar leak, the pressure declined again fast minimizing the
negative impact of high IAP. Recruiting the abdomen was not permanent and extra
inflation was needed at crucial steps when hemodynamic possible. After laparoscopy
the abdominal compliance did not change more than what was expected by the effect
of a pneumoperitoneum only. Compliance was 0.21 ± 0.04 L/mmHg after lapa-
roscopy.
By increasing the workspace with this method the pouch construction remained
difficult but was possible without laparotomy.
P014 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC VENTRAL HERNIA REPAIR IN OBESE
AND MORBIDLY OBESE PATIENTS UNDER SPINAL
ANESTHESIA
D. Symeonidis, I. Baloyiannis, G. Koukoulis, I. Chatzinikolaou,
I. Mamaloudis, G. Tzovaras
University Hospital of Larissa, LARISSA, Greece
Aims: Ventral hernias in obese patients represent a challenging clinical scenario. We have
previously reported on the efficacy of laparoscopic repair of ventral hernias under spinal
anesthesia in patients with a BMI of less than 30. The aim of the present study was the
expansion of the use of this technique in obese patients.
Methods: From January 2006 until May 2010, twenty-three obese and morbidly obese patients
having elective laparoscopic ventral hernia repair under spinal anesthesia were included in this
study. We looked primarily for intra-operative incidences as well as immediate postoperative
complications. Long term results and especially recurrences were also evaluated.
Results: No conversion of either the anesthetic or the surgical technique was observed.
Median operative time was 55 minutes (range 20–100 minutes). During surgery, six patients
complained of shoulder pain (28.5%) while three patients (14.3%) developed bradycardia.
Postoperatively, nausea and/or vomiting were recorded in four patients (19%), four patients
(19%) experienced urinary retention and one patient developed wound infection. The
median length of hospital stay was one day (range 1–2). A recurrence was diagnosed in one
patient twelve months after the operation.
Conclusion: Laparoscopic ventral hernia repair under spinal anesthesia in obese and mor-
bidly obese patients proved feasible and safe in our experience. However, further,
prospective comparative studies are needed in order to establish our proposed method of
anesthesia for laparoscopic ventral hernia repair in obese patients as a valid approach with
wide acceptance.
Surg Endosc (2013) 27:S53–S166
P015 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC REPAIR OF BILATERAL ACUTE
RUPTURED DIAPHRAGMATIC HERNIA AND
A RECURRENT VENTRAL HERNIA IN A SINGLE PATIENT
V. Golash
Sultan Qaboos Hospital, SALALAH, Oman
Aims: To validate the use of laparoscopy in the diagnosis, management and treat-
ment of ruptured diaphragmatic hernia in acute settings in a hemodynamically stable
patient. Laparoscopy avoided the major thoraco-abdominal surgery.
Methods: A 31 year old patient was admitted with the history of acute onset severe
abdominal pain, vomiting and difficulty in breathing. She had undergone laparo-
scopic repair of a large ventral hernia one month prior to her admission. X-ray chest
and CT scan revealed herniation of small intestine, colon, spleen and pancreas in the
chest through a large defect in left diaphragm. Port position for laparoscopy was
same as for hiatus hernia repair. The rupture in left diaphragm was 10.5 cm. The
hernial contents were reduced. An intercostal tube drain was inserted under lapa-
roscopic view. The defect was large and not suitable for primary suture and the
hernia was repaired using a 15 9 15 prolene mesh. She presented again six months
after her left ruptured diaphragmatic hernia repair with severe respiratory distress. A
thoracoabdominal CT revealed ruptured right diaphragmatic hernia this time with
herniation of small intestine and colon. On Laparoscopy a ruptured right diaphrag-
matic hernia of 12 cm was seen in posterior superior aspect. The small and large
intestine were reduced . The diaphragmatic defect was repaired with nylon sutures
and further reinforced with dual mesh.
Results: There were no conversion to open and no intraoperative or postoperative
complications. There has been no recurrence in one year.
Conclusions: Laparoscopic repair of acute rupture diaphragmatic hernia is feasible in
a hemodynamically stable patient. It provides good visibility, easy reduction of
herniated organs and if necessary thorax exploration. We successfully repaired
bilateral ruptured diaphragmatic hernia with mesh and recurrent ventral hernia in a
single patient by laparoscopy
P016 – Abdominal Cavity and Abdominal Wall
SELECTION THE METHOD OF THE HERNIOPLASTY AND
IT’S INFLUENCE ON THE QUALITY OF PATIENTS LIFE
G.R. Askerkhanov, F.P. Aytekova, I.S. Ibragimov,
M.A. Kazakmurzaev, M.G. Garunov
Medical centre named after Askerkhanov R.P., MAKHACHKALA,
Russia
Purpose: Study of the late results of surgical treatment of the inguinal hernia (IH) by
the method of evaluating the quality of life (QL) and reproductive function of
patients with the use of psycho-diagnostic test ‘SF-36 HEALTH STATUS SUR-
VEY’ and with assessment of spermogramm before and after the operation for 4–6
month and on expiration of 1 year.
Material and Methods: In our studies are examined the methods of tensioning the
rear wall of inguinal channel by the tension method (TM) (on Bassini-116 of
patients), by the nontensioning method (NTM) (on Lichtenstein -288 patients) and
the method of transabdominal preperitoneal hernia repair (TAPP) – 44 of patients).
We conducted a prospective analysis of the results of surgical treatment of 448
patients with IH, separated by the method of Bunak in three age groups: up to 30
years, 30–50 years, 50 years old.
Results: Analysis of treatment results showed that the frequency of postoperative
complications of TM is 17,2%, NTM – 6.4% and TAPP – 2%. QL of patients with
the IH to the larger degree deteriorates with the age. Thus, in Group I before surgery
(QL) better than patients in groups II and III. A postoperative comparative study of
the dynamics of QL using the test in patients shows that the restoration of the
physical and psychological components of the health after operation TAPP passes
better and is more rapid (psychological component in year – 24.2%; physical –
25.8%) than NTM (psychological – 11.4%, physical – 17,3%) and TM (psycho-
logical – 11.5%, physical – 16.7%). The results of spermogramm show the stability
of the indices of the ejaculate 6 months after TAPP. In 3 months after the traditional
methods of herniotomy reduction in the fertility of ejaculate remains.
Conclusions: Thus, taking into account the recovery time of the physical and psy-
chological components of health after operation in patients with the application of
TAPP, and also the unquestionable advantage of this procedure in the men of
reproductive age, including the disturbance of the fertility of ejaculate it gives
grounds to speak about superiority TAPP over the NTM and TM of hernioplasty.
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P017 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL
PATCH PLASTY (TAPP) FOR A PRIMARY SUPERIOR
TRIANGLE LUMBAR HERNIA (GRYNFELTT’S HERNIA)
M. Hosono, Y. Asakura, A. Arimoto, T. Yoshikawa, N. Ueno,
T. Ienaga
Takatsuki General Hospital, TAKATSUKI, OSAKA, Japan
To repair a posterior abdominal wall hernia is difficult because the surrounding
tissues are generally so weak that it is difficult to sew the bony portions of the hernia
boundaries. As there are few descriptions on lumbar hernia, no one surgeon accu-
mulates enough clinical experience to standardize the surgical technique.
We applied laparoscopic transabdominal preperitoneal patch plasty (TAPP), which
were developed and refined with inguinal hernias, for the repair of Grynfeltt’s hernia.
A 97 years old woman was found to have a superior triangle lumbar hernia with 3 cm
in diameter sized defect. We approached her laparoscopically.
A part of descending colon was incarcerated into the hernia sac. The descending
colon was first mobilized form the retroperitoneum and the incarceration was
released. A large pocket was made in the extraperitoneal space around the defect, so
as to accept a large mesh graft. An appropriate size piece of polypropylene mesh was
placed and fixed over the fascia around the hernia defect. Running suturing closure
of the peritoneum was performed.
Our experience in TAPP for inguinal hernias revealed that it is technically feasible,
has minimal morbidity and discomfort, and allows a prompt discharge and the quick
return to the normal activities. The same laparoscopic methods were applied to
lumbar hernia.
Laparoscopic visualization of the hernia affords an excellent view of the edge of the
fascial defect. The size of the hernia can be measured so accurately that mesh can be
tailored as needed.
This paper is a description of our personal surgical technique for the laparoscopic
approach for the superior triangle lumbar hernia.
P018 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC TREATMENT OF INCISIONAL
HERNIAS – A RETROSPECTIVE ANALYSIS AFTER
ONE YEAR OF EXPERIENCE
A.C. Miron, V.D. Calu, C.M. Giulea, R.D.G. Parvuletu
Elias Emergency Hospital, BUCHAREST, Romania
Aims: Laparoscopic treatment of incisional hernias is gaining acceptance among
surgeons. The technique is feasible, reproducible and is following classic principles
of hernia surgery. Dimiishing parietal trauma is a major advantage of this technique,
especially at overweight and obese patients.
Methods: We studied a group of 30 patients, 21 with incisional hernias, 5 with
umbilical hernias and 4 with epigastric hernias, operated laparoscopically in Elias
Surgical Clinic in the past 12 months. The study deals particularly with the first
group of patients, with incisional hernias.
Results: Regarding Body Mass Index (BMI) the group stratified into 3 categories:
BMI \ 25 – 7 pts, BMI \ 30 – 9 pts, BMI [ 30 – 5 pts. The postoperative outcome
was similar in the overweight and obese patients compared with normal weight
patients. The overweight and obese patients operated laparoscopically had a much
better outcome than similar type of patients that underwent open surgery.
Conclusions: The good postoperative results seemed to show that this procedure is
safe and effective.
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P019 – Abdominal Cavity and Abdominal Wall
RANDOMIZED CLINICAL TRIAL COMPARING
MACROPOROUS PTFE MESH AND MICROPOROUS
POLYPROPYLENE IN TOTALLY EXTRAPERITONEAL
HERNIA REPAIR. ONE YEAR RESULTS
I. Alarcón1, S. Morales-Conde1, J. Bellido-Luque2, M. Socas1,
A. Navas1, A. Barranco1, J. Cañete1, S. Garcia1, H. Cadet1, J. Padillo1
1
Hospital Universitario Virgen del Rocio, SEVILLE, Spain; 2Hospital
General Básico de Riotinto, SEVILLE, Spain
Background: New advances in the development of laparoscopic inguinal hernia must
focus on patients outcome aspects such as chronic pain, comfort or foreign body
reaction. The aim of this study was to find out whether the lightweight PTFE mesh
improves patients outcomes at these aspects.
Methods: Double blind prospective randomized clinical trial with 50 male patients
with bilateral inguinal hernia, where TEP repair would be performed with a ran-
domized use of a polypropylene Heavyweight mesh or a PTFE Lightweight mesh on
each side. Postoperative data is collected in successive consults seven days, one
month, three months, six months and one year after the surgery using a visual analog
scale (VAS).
Results: We present the final results of our study, continuing with our early results of
this study presented last year in this congress, confirming the lack of significative
differences in both meshes in long term outcome.
Conclusion; Lightweight mesh appear to have advantages in terms of lesser pain and
discomfort in early postoperative period, with no significant difference at one year.
P020 – Abdominal Cavity and Abdominal Wall
AN EXPERIENCE OF COMBINING ALLOPLASTY
OF VENTRAL INCISIONAL HERNIAS WITH
ABDOMINOPLASTY IN OBESE PATIENTS
O.L. Nesterenko1, O.A. Belchuk2, Y.S. Danylkiv1
1
ROCL, RIVNE, Ukraine; 2ROCLDC, RIVNE, Ukraine
Topicality: Surgical treatment of ventral hernias in patients with various stages of obesity
remains a rather acute problem, and methods of surgical treatment are still under discussion.
Purpose: Outlining the expediency of combining the alloplasty of ventral hernia with
abdominoplasty in patients with various stages of obesity.
Materials and methods: The analysis of surgical treatment of 52 patients with ventral
hernias in combination with abdominoplasty was conducted. The sample included 1 male
and 51 female. The average age of patients was 59 years (from 42 to 75 years). 31 patients
were diagnosed with the 1st stage obesity, 15 patients – with the 2nd stage, and 6 patients
with the 3rd stage obesity. Hernial orifices up to 10 cm in diameter were noted in 27
patients, 10 to 20 cm – in 18, and over 20 cm – in 7 patients. The Pitanguy alloplasty was
performed for 35 patients, and 9 more patients underwent a ‘mercedes’ alloplasty. The
interventions for 8 patients were combined with navel ectopy.
Results: The efficiency of treatment was evaluated by comparing the study sample men-
tioned above to the control group (N = 53) who underwent the ventral hernia alloplasty
without abdominoplasty. Those were the patients who refused abdominoplasty or who had
surgery before 2006. The patients from the study sample proceeded to upright position and
active walking in 6–8 hours after surgery. This can be explained by a significant reduction
of subcutaneous tissue on the anterior abdominal wall and less pronounced pain syndrome.
All the patients in the study group demonstrated a good cosmetic effect. Complications
associated with abdominoplasty were observed in 2 patients who developed partial necrosis
of skin of the ectopic navel. 5 patients developed seromas of subcutaneous tissue and
haematomas. Suppuration of the wound was noted in 1 patient.
Conclusion: 1. The ventral hernia alloplasty is expedient to combine with abdominoplasty.
2. Abdominoplasty in combination with ventral hernia alloplasty allows patients to
promptly proceed to active movement during the post-surgical period. 3. The combination
of these interventions allows to simplify the technical performance of the alloplasty and
reach a good cosmetic effect.
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P021 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC TOTALLY EXTRAPERITONEAL
INGUINAL HERNIA SURGERY: SHOULD ONE FEAR
THE LEARNING CURVE?
C. Markakis1, N. Paschalidis2, M. Voultsos2, A. Marinis2, S. Rizos2
1
University of Athens, ATHENS, Greece; 2Tzaneio General Hospital,
PIRAEUS, Greece
Aims: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is currently
an established surgical technique which boasts equivalent recurrence rates to those of
open reconstruction and is associated with better quality of life and chronic pain
scores. However, partly due to the differences in surgical anatomy compared to the
open Lichtenstein technique, TEP is technically challenging with a steep learning
curve; it is thought to require formal extensive training prior to its execution. This
has discouraged surgeons not practicing in major centres from adopting this tech-
nique. Our aim is to present the results of TEP repairs performed on 70 consecutive
patients with inguinal hernias and to assess whether the learning curve had an effect
on postoperative outcomes.
Methods: An experienced laparoscopic surgeon was trained in TEP hernia repair
during a 7-day course. Between 2009 and 2011, 87 TEP procedures were performed
for primary inguinal hernias in 70 patients (17 bilateral cases) using a standardized
technique (three subumbilical ports, blunt telescopic dissection, polypropylene mesh
without fixation). A prospective database containing in-hospital and follow-up data
was created. We compared the results of 26 patients operated on during the first year
(considered to fall within the learning curve) with those of the remaining 44 patients.
Results: The operative time was significantly longer in the learning curve group.
There was no significant difference in recurrence rates between the two groups,
despite the longer follow-up period in the learning curve group and no difference in
postoperative pain or quality of life scores at matched time intervals.
Conclusions: Every surgeon interested in performing laparoscopic TEP inguinal
hernia repair without formal training should be aware of the significant learning
curve inherent to this technique, which is mainly evident from the prolonged
operative time. It is, however, possible for experienced laparoscopic surgeons to
learn and perform the operation safely and efficiently, without adverse outcomes.
P022 – Abdominal Cavity and Abdominal Wall
SINGLE INCISION TOTALLY EXTRA PERITONEAL
INGUINAL HERNIA REPAIR WITH SELF-FIXATING MESH
N. Wada, T. Furukawa, Y. Kitagawa
Keio University School of Medicine, TOKYO, Japan
Aims: In laparoscopic hernia repair, secure mesh fixation is an important factor for
successful surgery. Tacking devices are frequently used for this purpose. In some
cases, however, tacks may cause tissue damage resulting in bleeding and chronic
pain. We developed a novel technique for single-incision laparoscopic totally
extraperitoneal (TEP) inguinal hernioplasty feasible even under local anesthesia. The
mesh used in this procedure has self-fixating property and need no tacking. Here we
show the short-term outcome of this successful procedure.
Methods: From January to December 2011, a consecutive group of 30 adult patients
with bilateral inguinal hernia was included in this study. Patients with obesity,
inguinoscrotal hernia, irreducible hernia or coagulopathy were excluded from this
study. Short-term outcomes were determined via a retrospective review of available
medical records. No preoperative bowel preparation or urinary catheterization was
needed. Under conscious sedation and local anesthesia, single incision of 30 mm in
the lower abdomen was made and a wound protector with sealing silicon cap was
placed. Two 5 mm and a 12 mm trocars were used. The preperitoneal space was
inflated with carbon dioxide gas at 8 mmHg constant pressure. A flat self-fixating
mesh with resorbable microgrip (Parietex ProGrip; Covidien, Inc., Norwalk, CT,
USA) was installed through the 12 mm trocar. No tacking devices were required.
Results: The mean age was 64.3 (SD = 9.5) and male sex was 93%. Median oper-
ating time was 134 min [range: 81–255]. Intraoperative and immediate postoperative
complications were not observed. Pneumoperitoneum due to peritoneal injury was
occurred in 4 cases (13.3 %) and managed by inserting a flat silicon disk to keep the
preperitoneal space inflated. We observed 11 seromas (36.7 %) at 2 weeks after
surgery. During median follow-up of 196 days, we had one hernia recurrence (3.3
%), in which unilateral indirect hernia was developed after direct hernia repair due to
inadequate mesh placement on internal ring.
Conclusions: Short term outcomes of single-incision laparoscopic TEP inguinal
hernioplasty using self-fixating mesh were similar to those of conventional TEP or
open hernia repair. This novel procedure is a promising strategy to reduce the
invasiveness and cost of hernia repair.
Surg Endosc (2013) 27:S53–S166
P023 – Abdominal Cavity and Abdominal Wall
COMPLICATIONS IN LAPAROSCOPIC AND OPEN
COLORECTAL RESECTIONS: A SINGLE SURGEON
EXPERIENCE
I. Stipancic, M. Knezevic, J. Bakovic, M. Miocinovic, T. Kolak,
R. Klicek, I. Runjic
Clinical Hospital Dubrava, ZAGREB, Croatia
Aims: Open or laparoscopic colorectal surgery burden risks of various complica-
tions. This prospective study was designed to examine the complications and
outcome after open and laparoscopic colorectal resections done by a single surgeon.
Methods: Laparoscopic colectomy patients from a prospective database were mat-
ched for age, gender, and disease-related grouping to patients who underwent the
same operation by the open approach over the same period (2005 to 2010) in Clinical
Hospital ‘Dubrava’ Zagreb Croatia. Analysis and the 2 groups were compared for
intraoperative and postoperative complications.
Results: A total of 137 patients (119 for malignant and 18 for benign conditions)
underwent elective laparoscopic (68) and open (69) resections. Conversion rate was
13.24% in laparoscopic resections (9 of 68). Majority of conversion (7 of 9) were
preemptive and 2 of 9 due to intraoperative complications (1 uncontrolled bleeding
and 1 lesion of the ureter). Reasons for conversion were T4 tumor in 5 pts and bulky
tumors in 2 pts. Intraoperative complications developed only in 2 patients submitted
to laparoscopic resection (2/68, 2.94 %). In open surgery no intraoperative com-
plications were detected. Postoperative complications occurred in 15 of 137 (10.95
%). Overall postoperative complication rate for laparoscopic resection was 6 of 68
(8.82%) versus 9 of 69 (13.04%) for open resection. Wound infection developed in 8
pts: 5 of 69 (7,25%) in open and 3 of 68 (4.41%) in laparoscopic surgery. Anasto-
motic leak occurred only after low rectal resections in 4 of 76 (5.26%); 3 of 50 (6%)
after laparoscopic and 1 of 26 (3.85%) after open approach. Other complications
included postoperative paralytic ileus and small bowel obstruction in 3 pts all after
open resections. The rate of complications requiring reoperation was similar in both
groups; 5 of 68 (8.62%) in laparoscopic and 5 of 69 (7,24%) in open group. Hospital
stay for patients with complications was significantly longer (range 8–71 days).
Conclusion: In our series laparoscopic colorectal surgery showed more intraopera-
tive complications but overall postoperative complications occurred more frequent in
open surgery. Although the number of patients is too small for serious conclusions
but it seems that shows some trends.
P024 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC RECONSTRUCTION OF THE GIT AFTER
THE OPEN ABDOMEN OPERATIONS
D. Simecková, M. Vraný, M. Man, M. Dudek
Hospital Jablonec nad Nisou, JABLONEC NAD NISOU,
Czech Republic
Aims: Reconstruction of GIT after open abdomen operations resulting with enter-
ostomy demands extensive laparotomia, which involves significantly higher risk of
morbidity. The aim of our study is to evaluate our experience with renewing con-
tinuity of the bowel in laparoscopic way.
Methods: We review the results obtained on patients, who underwent reconstruction
of the GIT in retrospective study. We considered the early postoperative outcome,
duration of the operation, type of th
Results: 61 patients underwent laparoscopic reconstruction of the GIT. Out of them
43 patients underwent the reconstruction for leftsided stomy (70.5%) and 18 patients
(29.5%) for rightsided stomy. 17 patients (27,8%) had ventral hernia. Conversion
was needed on the leftsided stomy in one case (1.6–total 2.3%), conversion to hand
assisted technic was needed 3 times (4.9%–total 6.9%). Conversion in rightsided
stomy was needed 5 times (8.2%–total 27.8%). In general 6 conversions to open
abdomen was needed – 9.8%. The reasons were: very tough adhesions, unclear
anatomy and perforation of the small intestine. The average operation time in case of
the leftsided stomy was 133 minutes and of rightsided 162 minutes. The average
blood lose was 150 ml. Peristalsis was renewed the 2 day after operation for the
leftsided stomy, 3–5 day after the operation for rightsided stomy. Wound infection in
the place of stomy appeared in 5 cases (8.2%). Intraabdominal abscess once – it was
solved by percutaneous drainage. Hernia in cicatrice appeared 6 times (9.8%).
Mortality was 0.
Conclusion: Laparoscopic reconstruction of the GIT is demanding performance due
to the numerous adhesions because of the previous diseases and revisions. Our
results show, that this operation can be done safely with relatively low morbidity.
That is why the laparoscopic way is a very good option to open access.
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P025 – Abdominal Cavity and Abdominal Wall
HIGH SENSITIVITY AND SPECIFICITY OF ADHESION
MAPPING BY ULTRASOUND EXAMINATION
Y. Kondo, M. Nishizaki, T. Fujiwara
Okayama University, OKAYAMA, Japan
Aims: Adhesions are a common complication to surgery in patients with presence of
previous open surgery, peritonitis, or an intra-abdominal mesh. Trocar-related
injuries during laparoscopic access occur most often secondary to adhesions from
prior abdominal surgery. By detecting areas of restricted viscera slide, which is the
longitudinal movement of the intraabdominal viscera, the transabdominal ultrasound
examination can identify intra-abdominal adhesions and predict the location of
adhesions to the abdominal wall. A lot of literatures have been reported its usefulness
in predicting adhesions. The aim of the current study was to assess the sensitivity and
the specificity of transabdominal ultrasound examination in identifying intra-
abdominal adhesions.
Methods: Transcutaneous ultrasound examination was performed on 54 patients with
previous open or laparoscopic surgical procedures presenting a laparoscopic surgery.
A searching area of abdomen was divided into four quadrants and umbilicus. Each
quadrant was categorized as no adhesions (free movement), omental adhesions
(chaotic movement), or severe adhesions (no movement). After the mapping, we
decided the first trocar site at a quadrant demonstrated free movement.
Results: The first trocar was successfully inserted without complications in all
patients after ultrasound mapping. Sensitivity and specificity in predicting adhesions
were over 90%.
Conclusions: Transcutaneous ultrasound can significantly detect intra-abdominal
adhesions prior to laparoscopy. This technique is very useful as a noninvasive
method to avoid the trocar-related injuries.
P026 – Abdominal Cavity and Abdominal Wall
TRANSABDOMINAL ANATOMY OF INGUINAL REGION
M. Beuran1, I. Negoi1, S. Paun1, A. Runcanu1, M. Vartic1, F. Filipoiu2
1
Emergency Hospital of Bucharest, BUCHAREST, Romania,
2
University of Medicine and Pharmacy Carol Davila, BUCHAREST,
Romania
Background: Although inguinal hernia is a common disease, with more than 2 mil.
surgical procedures every year worldwide, the laparoscopy faces the surgeon with
properitoneal inguinal space, whose anatomy is quite challenging starting from the
anterior aproach of the abdominal wall.
Aim: To observe the laparoscopic anatomy of groin.
Method: During 20 transabdominal properitoneal (TAPP) laparoscopic and robotic
hernia repair, the dissection was performed, trying to identify all anatomic landmarks
of properitoneal space. We have dissected 14 retroinguinal regions, on 7 formalin
bodies. We have closely followed the main steps of surgical TAPP procedure.
Results: First we have seen the anatomical landmarks of inguinal fossae. After the
anterior parietal peritoneum incision we saw the posterior and then anterior lamina of
transversalis fascia. After the preperitoneal fat tissue removal we observed the most
problematic areas for the laparoscopist: ‘Corona mortis’(CM), ‘Triangle of
Doom’(TD) and ‘Triangle of Pain’(TP). Within the ‘TD’ we observed the externe
iliac vessels and the genital branch of genito femoral nerve (GF). Within the TP we
observed the femoral nerve, femoral branch of GF, femoral cutanat anterior nerve
and the ilio-inguinal nerve. We have found CM as an arterial anastomosis in 7 cases,
as a venous anastomosis in 9 cases. The mean distance to pubic symphysis was 42
mm. We found 11 cases with iliopubic vessels.
Conclusions: Understanding the anatomical landmarks and variability of properito-
neal space of Bogros is of primary importance in performing a laparoscopic
approach for groin hernias.
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P027 – Abdominal Cavity and Abdominal Wall
THREE YEAR EXPERIENCE OF LAPAROSCOPIC AND
OPEN RESECTION FOR COLON AND RECTAL CANCER
B.V. Martian, D. Pavelescu
Emergency Clinical Hospital, BUCHAREST, Romania
Background: Laparoscopic surgery for colon and rectal cancer can offer equal oncological
outcomes to open surgery when performed by an experienced team. The short-term benefits
of laparoscopic surgery are a faster recovery of gastrointestinal functions, reduced pain,
shorter hospital stay and a faster return to normal activity. This study aimed to compare the
results of patients who underwent laparoscopic (LCR) and open resections (OCR) for
colorectal cancer.
Methods: Between May 2008 and September 2011, 52 patients with colorectal carcinoma
underwent LCR. These patients were compared with 90 cases underwent conventional OCR
by same surgical team. Clinical data about the patients were collected prospectively.
Comparison of the operative details and postoperative outcomes between laparoscopic and
open surgery was performed.
Results: There was no difference in the age, gender and tumor status between the two
groups. Also there was no difference in number of lymph nodes evaluates on specimens.
The operating time was a little longer in the laparoscopic group (P [0.05), but the blood
loss was less (P = 0.0371). Patients with laparoscopic resection had earlier return of bowel
function and earlier resumption of diet (p = 0.0001) as well as shorter median hospital
stay(P = 0.0147).
Conclusion: Laparoscopic surgery is feasible and safe for patients with colon and rectal
cancer and provides benefits during the postoperative period without increased morbidity or
mortality.
P028 – Abdominal Cavity and Abdominal Wall
DYNAMIC LAPAROSCOPY AS THE METHOD
OF POSTOPERATIVE PERITONITIS PREVENTION
R.V. Bondarev, A.A. Orekhov, S.S. Selivanov
State Medical University, LUGANSK, Ukraine
Aims: To define the diagnostic laparoscopy tactics for the following possible complications
prevention: a) postoperative peritonitis formation as the result of interintestinal anasto-
moses (IIA) seams inconsistency; b) vain (unnecessary) relaparotomy performance in case
of IIA solvency.
Methods: The diagnostic laparoscopy during the postoperative period was made in 9
patients who were operated concerning the restrained hernia (n = 3), stomach traumas (n =
2), acute small intestine ulcers (n = 1), a small intestine excess (n = 2) and acute adhesive
intestinal impassability (n = 1). The goal of this intervention was to estimate the IIA
integrity. The laparoscopy was executed for an hided form of IIA inconsistency exception 4
days (n = 9) after the operation, repeatedly – 6 days (n = 2) after the operation. The
following conditions were considered as the indications for a diagnostic laparoscopy: a) the
consistent intestinal paresis, b) the excrements and gases excretion delay, c) evening
hyperthermia, d) patients weakness, e) periodic fever episodes, f) exact peritoneal symp-
toms absence and g) the intestinal drainages emptiness. 4–7 days after the operation we
considered also the terms of a possible seams inconsistency from the moment of operation.
We didn’t used the diagnostic X-rays contrast methods because of their delayed diagnostic
value or – sometimes – due to their hypoinformative validity in patients with intestinal
paresis.
Results: We excluded IIA inconsistency in 7 patients (77,8 % of all cases). IIA was
diagnosed 4 days after the operation (in 1 patient) and 6 days after the operation (in 1
patient). There were no clinical signs of peritonitis in these patients.
Conclusions: Thus, the diagnostic laparoscopy after urgent surgical interventions with IIA
formation is an obvious complex treatment component that allows to avoid the vain rela-
parotomies. It helps also to diagnose the IIA inconsistency and postoperative peritonitis
formation.
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P029 – Abdominal Cavity and Abdominal Wall
PNEUMOTHORAX, PNEUMOMEDIASTINUM
AND PNEUMOPERICARDIUM COMBINED WITH
RETROPERITONEAL AIR AFTER LAPAROSCOPIC
EXTRAPERITONEAL INGUINAL HERNIA REPAIR
M. Voultsos, N. Paschalidis, C. Markakis, A. Marinis, S. Rizos
Tzaneio General Hospital, ATHENS, Greece
Aims: The percentage of inguinal hernia repair via the laparoscopic totally extraperitoneal
(TEP) technique has been steadily – albeit slowly – increasing. Although this technique has
been shown, on the whole, to be safe, it has nevertheless been associated with certain
complications, which do not occur with the open Lichtenstein technique. Our aim is to
present a patient with postoperative pneumothorax, pneumomediastinum, pneumopericar-
dium, subcutaneous emphysema and retroperitoneal air and provide insight concerning the
etiology of such rare complications.
Methods: We describe the case of a 60 year old Caucasian male admitted for repair of a
right inguinal hernia using the TEP approach. The operation was completed uneventfully
using a standardized technique (three subumbilical ports, blunt telescopic dissection,
polypropylene mesh without fixation). Operative time was 88 min and blood loss was
minimal. The patient was then transported to the anesthesiology postoperative recovery
ward, where he complained of mild chest pain. Upon transfer to the surgical ward symp-
toms worsened and further testing with a computed tomography scan revealed bilateral
pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema and
retroperitoneal air.
Results: The patient was conservatively treated and was discharged the next day after repeat
X-rays revealed satisfactory resolution of the pneumothoraces.
Conclusions: There have been 8 more published cases in the literature of TEP repair
complicated by pneumothorax, pneumomediastinum and/or subcutaneous emphysema. This
is the first report of a concurrent pneumopericardium and retroperitoneal air to date. These
complications are very rare with many hypothesized causes. We suggest that air escape
along major vessel pathways through the retroperitoneal space and into the thorax was
responsible for the clinical findings in our patient. It is advisable to keep low insufflation
pressure, reduce operative time and avoid unnecessary tissue dissection when performing
TEP inguinal hernia repair.
P030 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC ASSISTED TRANSVAGINAL
INTRAPERITONEAL ONLAY MESH IN ABDOMINAL WALL
HERNIA – AN ALTERNATIVE FOR TRADITIONAL
LAPAROSCOPIC PROCEDURE
S. Pohle, A. Descloux, T. Kocher, A. Keerl
Kantonsspital Baden, BADEN, Switzerland
Aims: Natural orifice transluminal endoscopic surgery (NOTES) is a less-invasive alter-
native for traditional laparoscopic surgery. NOTES becoming a standard technique is safe
and feasible. Laparoscopic intraperitoneal onlay mesh (IPOM) is a standard procedure for
abdominal wall hernias. As far as trocar hernias a known complication and the presence of
abdominal wall hernias might be a risk factor for developing a new hernia after laparo-
scopic repair, we were looking for a possibility decreasing this risk. We wanted to show that
NOTES technique in hernia repair is an alternative to the common procedures.
Methods: In our clinic NOTES cholecystectomy is a standard procedure, so the special
equipment was available. So far 3 patients with abdominal wall hernia underwent the
NOTES procedure after gynaecological examination and patient consent. The documen-
tation of the procedure was made by digital videodisc. The patients were controlled in a
clinical and gynaecological examination 3 weeks after the procedure.
Technique/Results: The abdomen was punctured with a Veress-needle and the capno-
peritoneum was applied. The access was dilated with an expandable sleeve trocar to 5 mm
and a camera was inserted. The patient was switched to Trendelenburg position and under
visual control 2 trocars (12 mm and flexible 5 mm) were inserted transvaginally into the
pouch of Douglas. A 10 mm-camera was inserted through the 12 mm vaginal trocar and
with electrosurgical cutting devices the falciform ligament and the intraabdominal adipose
tissue was removed around the hernia for a correct placement of the mesh. After preparation
a composite mesh was introduced into the abdominal cavity via the 12 mm trocar and fixed
with resorbable fixations in a way that the margin of the hernia was at least 5 cm overlapped
by the mesh. The patients were able to leave the hospital 3 days after the procedure. 3
weeks after the procedure no complications could be recognized and all patients were happy
with the result.
Conclusion: Laparoscopic assisted transvaginal intraperitoneal onlay mesh in abdominal
wall hernia is a safe and feasible alternative for traditional laparoscopic surgery. About the
presumed decrease of trocar hernias no conclusion can be made so far. Further investigation
and randomised clinical trials are necessary.
Surg Endosc (2013) 27:S53–S166
P031 – Abdominal Cavity and Abdominal Wall
SINGLE INCISION LAPAROSCOPIC VS. CONVENTIONAL
TAPP: A MATCHED PAIRS ANALYSIS
C. Mittermair, J. Schirnhofer, M. Biebl, K. Pimpl, C. Obrist,
A. Guenther, R. Frass, N. Waldstein, H. Weiss
SJOG Hospital, SALZBURG, Austria
Introduction: Single incision laparoscopy (SIL) and other novel techniques are
sweeping minimally invasive surgery standards. In laparoscopic hernia repair, the
conventional (3-port) TAPP is an established procedure, whereas SIL TAPP lacks of
clinical experience. Our aim was to compare these two methods concerning feasi-
bility and outcome.
Material and Methods: This study comprises 225 procedures conducted between
2007 and 2011. 75 conventional TAPP (Group 1) were matched with 150 SIL TAPP
(Group 2) concerning age, BMI, type of hernia, morbidity and professional status of
the surgeon (senior, fellow, resident). Parameters, such as intraoperative complica-
tions, operative time, postoperative pain within 24 hours and 3 days, the appearance
of chronic pain and recurrence of hernia were compared.
Results: No major complication occurred in both groups. Operative time was shorter
in Group 1 (45.9 vs. 56.2 min, p \ 0.05), postoperative pain was lower in Group 2
(24 hours and 3 days). Chronic pain yielded at 5.3% and 4.6% (n.s.) in Group 1 and
Group 2, respectively. Recurrent Hernia were observed in 2 (Group 1) and 3 patients
(Group 2) (2.6% and 2%, n.s.).
Conclusion: SIL TAPP offers a feasible alternative to standard laparoscopic TAPP
with an advance in postoperative pain and cosmetics. Downside is a slightly longer
operative time.
P032 – Abdominal Cavity and Abdominal Wall
JUSTIFICATIN FOR THE LAPAROSCOPIC TREATMENT
OF PERFORATED DUODENAL ULCER
P.N. Romashchenko, N.A. Maystrenko, P.A. Sidorchuk, A.I. Babich,
A.A. Dzhalavyan
Military Medical Academy, ST.PETERSBURG, Russia
The aim of the study – to determine the indications for laparoscopic interventions in
patients with perforated duodenal ulcer (PDU).
The results of examination and surgical treatment of 157 patients with PDU, were in
clinic for the past 18 years. Generalized peritonitis (GP) was diagnosed in 142
(90.4%) patients, localized in 15 (9.6%). GP in the reactive phase was diagnosed in
123 (78.3%) patients, toxic in 19 (12.1%). GP in the reactive phase characterized by
the presence of abdominal serous or serous-fibrinous, and toxic – purulent or serous-
fibrinous exudate. In the GP in the reactive phase performed (1) truncal vagotomy
with drainage operation stomach (TV+D) and excision of the ulcer in 103 (65.6%)
patients; (2) excision and closure of perforated ulcer (CPU) – in 54 (34.4%). CPU in
34 (21.7%) of 54 patients performed by laparoscopy. In all cases carried out sani-
tation and drainage of the abdominal cavity. Diagnosis of GP in the toxic phase in 19
(12.1%) patients required excision and not only CPU, sanitation and drainage of the
abdominal cavity, but also of nasal gastric-intestinal intubation. It was established
that in patients operated by laparoscopic method, the postoperative period was
characterized by a more auspicious flow than after open surgery. Analysis of
treatment results of patients operated allowed to formulate the indications for lap-
aroscopic closure of the PDU: (1) lack of cicatricial-ulcer deformation of
pyloroduodenal zone, (2) diameter perforated ulcers less than 1.0 cm (3) width of the
ulcer perifocal infiltration less than 0.5 cm, and (4) the absence of peritonitis in the
toxic phase.
Thus, the application of laparoscopic interventions in perforated duodenal ulcer at
the established indications, will perform at the first stage ulcer closure with biopsy of
the edges, to adequately sanitize and drain the peritoneal cavity. Mandatory second
stage is a morphological study of the biopsy, the assessment of gastric secretion,
determination of antibody titer to ulcerogenic strains of H. pylori, the study of
psycho-physiological status of the patient and his compliance. Integral assessment of
these indicators would justify a comprehensive program of drug therapy, or select an
option pathogenetic surgery.
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P033 – Abdominal Cavity and Abdominal Wall
USING ENDOVIDEOSURGICAL TECHNOLOGIES
IN TREATMENT OF ELDERLY COLORECTAL
CANCER PATIENTS
P.N. Romashchenko, A.I. Babich, N.A. Maystrenko, G.N. Kchrykov,
O.A. Medgidov, D.M. Yaroshenko, O.A. Grechkina
Military Medical Academy, ST. PETERSBURG, Russia
Aim: To specify an indications to using endovideosurgical technologies in treatment
elderly colorectal cancer patients.
The results of surgical treatment 90 colorectal cancer elderly patients for 5 years are
analysed. The TNM stages were: I – in 7, II – 40, III – 21, IV – 22 people. An
operative-anesthetic risk by ASA scale constitutes I-III mark – 76 cases, IV – 14.
Consideration to oncologic illness prevalence and extent of operative-anesthetic risk,
laparoscopic operations were realized to 6 patients only: anterior resection of rectum
(n = 2), sigmoidectomy (n = 2), right hemicolectomy (n = 1) and colon continuity
reconstruction after sigmostoma (n = 1). TNM stage I are in 2 cases, II – in 4. An
operative-anesthetic risk by ASA are I – in 3 people, II – in 2 and III in 1 case.
The reasons of open operations fulfillment (n = 84) were: an oncologic process
prevalence (TNM – III–IV stage) in 43 patients, stenosis and bowel obstruction signs
– in 15, an operative-anesthetic risk by ASA scale IV – in 14, open abdominal
operations made earlier – in 7, refusal from laparoscopic operations – in 5 people.
Established that indications to endovideosurgical operations in elderly colorectal
cancer patients are I-II TNM stages, tumor without stenosis and bowel obstruction
signs, an operative-anesthetic risk by ASA scale I-III, cicatrical and abdominal
adhesions absence. Study of operations outputs revealed that elderly patients oper-
ated by colorectal cancer make more active and begin an oral nutrition on 2 day of
postoperative period, need in less anaesthetics and note better quality of life in early
terms after operation.
P034 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC APPENDECTOMY
IN PREGNANCY – CASE REPORT
V. Ninger1, J. Majernik1, D. Bis1, P. Hanousek1, J. Simsa2
1
Hospital Chrudim, CHRUDIM, Czech Republic; 2Thomaeyr0 s
University Hospital, PRAGUE, Czech Republic
Introduction: Appendicitis is one of the most common causes for surgery during
pregnancy. Appendicitis in pregnancy represents a challenge for surgeon, both in
terms of diagnosis as well as treatment and choice of operation access.
Aims: Acute appendicitis is one of the most common causes requiring urgent sur-
gical intervention in pregnancy. Diagnosis of appendicitis is complicated by
physiological and anatomical changes, which appears during pregnancy. The fre-
quency of interruption by perforated appendix ranges from 20% to 35% (1, 6). Early
diagnosis, indication for surgical intervention and selected surgical approach are
therefore important.
Methods and Results: Case report: The 25 years old patient at 11th week of preg-
nancy with acute appendicitis. The patient was indicated in consultation with
gynecologist to laparoscopic appendectomy with ulcerative phlegmonous appendi-
citis findings. According to operating findings, patient treated with antibiotics
(cephalosporins). after consulting gynecologist. In the postoperative period, a
decrease of leukocytosis occurs. Furthermore, the patient has no subjective com-
plaints, wounds are healing by per primam, soft abdomen palpactive painless.
Gynecological examination was performed 2 nd postoperative day with vital fetus
finding with normal fetal development (Figs. 1a, b). Patient released to ambulant
care the 5th postoperative day. After 3 weeks planned inspection performed in
ambulance – patient subjectively without any complications, the wound healed by
per primam, vital fetus.
Conclusion: Laparoscopic appendectomy in pregnant patients is comparatively safe
method as open appendectomy. Laparoscopy offers advantages such as reducing the
amount of opioids representing a risk to the fetus, better surgical visualization and
exploration of the entire abdominal cavity, less postoperative pain, faster postop-
erative recovery and lower risk of hernia in the scar.
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P035 – Abdominal Cavity and Abdominal Wall
ADVANCED LAPARO ENDOSCOPIC SINGLE SITE
SURGERY – EXPERIENCE AT A UNIVERSITY HOSPITAL
IN COLOMBIA
F. Arias, N. Prada, N. Cortes, A. Duran, V. Cuevas, A. Torres,
J. Dussan, A. Montenegro, F. Cabrera, A. Rojas, E. Londoño,
R. Garcia-Duperly
Fundacion Santafe de Bogota, BOGOTA, Colombia
Aim: Major advances in technology have led to the development of less invasive techniques
such as Transluminal Natural Orifice Endoscopic Surgery and Laparo- Endoscopic Single-
site Surgery (LESS), being the latter the most popular. The aim of this paper is to show our
experience in single access laparoscopic surgery at Hospital Universitario Fundación Santa
Fé de Bogota.
Methods: This is a retrospective case series study from ‘Hospital Universitario Fundación
Santa Fé de Bogotá’ of patients who underwent laparo endoscopic single-site surgery. Four
devices were used: Triport, Gelport, SILSPORT and a hybrid device (Alexis retractor
and a latex glove).
Results: Over a period of 42 months (between July 2008 and December 2011) 308 patients
were operated. The most frequently performed procedures were appendectomies (55.5%)
and cholecystectomies (31%), with an average length of hospital stay of 17.9 hours and 14.9
hours respectively. One cholecystectomy was converted to a conventional laparoscopy with
no surgical site infections or perioperative complications associated with the technique. The
average postoperative pain for all interventions evaluated with visual analog scale was 2.4/
10.
Conclusion: Laparo-Endoscopic Surgery by Single incision is a feasible technique even in
complex procedures. The rate of hospital stay is less than 24 hours for appendectomies and
cholecystectomies, and postoperative pain and wound infection rates are low. In addition,
this technique offers the advantage of an excellent cosmetic result.
P036 – Abdominal Cavity and Abdominal Wall
METHOD OF FIXATION AS PAIN PREDICTOR ET
LAPAROSCOPIC HERNIA REPAIR
V. Zivanovic, G. Vasic, R. Scepanovic, R. Perunovic, M. Milanovic
KBC Dr D.Misovic University hospital, BELGRADE, Serbia
Laparoscopic incisional and recurrent hernia repair using a double layer mesh in an
intraabdominal position after complete adhesiolysis with three different method of
mesh fixation.
From January 2011 till January 2012 we perform 22 operations for ventral, ventral
incisional and recurrent ventral incisional hernia. We use double layer mesh (Pro-
ceedTM surgical mesh, Ethicon Inc., J&J, USA). Pneumoperitoneum was created with
open technique. After creating adequate pneumoperitoneum (12–14 mmHg), we
introduce 5 mm working port. After complete adhesiolysis we introduce mesh with or
without preformed tranfascial sutures through camera port. Mesh was fixed in 1st group
with transfascial nonresorbable sutures only, 2nd group with transfascial nonresorb-
able sutures and with AbsorbaTackTM, Covidien USA and 3rd group with Securestrep,
Ethicon Inc., J&J, USA only. Minimum over-lap around the defect was 5 cm.
There were 22 patient with hernia repair of which 59% recurrent (1 till 4th previous
surgical attempts) on procedure after complete adhesiolysis there was 3.2 (range
1–5) defects per patients. Patients mean age was 56 year with BMI 35.9 kg/m2. With
previous surgical history 82%. Mean time for procedure was 87 min and mean
postoperative stay 1.7 days.
Those 22 patients were divided in to the three groups. First 8 pt. where MESH was
fixated with transfascial nonresorbable sutures only (between two sutures was 4–5
cm space). Second group 9 pt. with transfascial sutures only at the corners of mesh
and with absorbatacks in between. Third group 5 pt. with mesh fixation with
securestraps only. All groups received on operative day same analgesics protocol,
but second and third day there was difference between groups. Mean pain according
to the Visual analog scale VAS was 7,25; 7,33 and 6.2 respectively in those groups.
There was significantly less need for analgesics in third group comparing to first and
second group on second and third postoperative day according to date collected on
postoperative interview managed on 7th postoperative day.
Laparoscopic hernia repair is effective and safe using adequate mesh (5 cm over
lapping) but There is still question of what is the best fixation method calculating the
risk of inappropriate fixation and postoperative pain.
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Surg Endosc (2013) 27:S53–S166
P037 – Abdominal Cavity and Abdominal Wall
IPOM TECHNIQUE – SAFE PRIMARY ACCESS SELECTION
FOR THE FIRST TROCAR
G. Vasic1, V. Zivanovic1, D. Vasic2, R. Perunovic1, R. Scepanovic1
1
UCHC ‘Dr Dragisa Misovic-Dedinje’, BELGRADE, Serbia; 2PHC
‘Rakovica’, BELGRADE, Serbia
Aim: Problem of an incisional hernia is where and how to place first trocar for a certain
intake into abdominal cavity. The aim of this study is to determine the most convenient
place and way of insertion of a trocar in regard of a previous abdominal operations and
adhesion formation.
Methods: With patients to whom laparoscopic incisional hernia repair was performed, the
most crucial phase is the access to the peritoneal cavity and to decide where the first trocar
will take a place. Previous abdominal surgical history and size of one or more fascial defect,
ultrasound examination of abdominal wall and adhesion formation, dimension of a mesh
and positioning of it with transfascial sutures determines adequate choice for the first trocar.
It is necessary to determine right distance from the fascial defect and of a mesh which must
overlap edge of defect for atleast 3–4 cm for safe work and for fixing of a mesh. Upper left
quadrant of abdomen of our patients was exact and safe place of scarves and adhesion
formation. Place of a first trocar is laterally moved away enough from the edge of a mesh
and from the left costal arc as well because of undisturbed manoeuver and of the fixation of
a mesh. Open-access technique is mandatory for pneumoperitoneum creation.
Results: From 2003 till 2011 on 81 patients with recurrent incisional hernia was performed
intraperitoneal on lay mesh technique-IPOM. Preoperatively we have performed palpation
of fascial defect and ultrasound examination of abdominal wall and with surgical finding of
existence of a fascial defect and adhesion formation, it was noticeable that upper left
quadrant of abdominal wall is the place where has no adhesion and open-access technique is
safe to create pneumoperitoneum. On this way 72 patients have been approached (86.4 %).
There was none visceral injuries, no major vascular or epigastrical vessel injuries nor
significant bleeding and other complications on the place of the first trocar.
Conclusion: Upper left quadrant of abdominal wall stands for optimal place as an open-
access technique first trocar placing and is recommended to access the abdominal cavity.
P038 – Abdominal Cavity and Abdominal Wall
RECTUS MUSCLES DIASTASIS SUTURE-AND-MESH
REPAIR THROUGH LAPAROSCOPIC MINI-INVASIVE
APPROACH, COMPARING ABSORBABLE VERSUS NON
ABSORBABLE MESH BARRIERS
G. Pozzi
Quisisana Clinic, ROME, Italy
Aims: Restore physiologic functionality of abdominal wall by re-approximating the rectus
abdominis muscles when compromised by diastasis and ventral hernias. 20 cases from
January 2010 to December 2011, minimum follow up 6 months.
Methods: Elected patients under 65 years old ASA1 – ASA2 without cardio-respiratory
disease, maximum inter-rectal distance of 8 cm. Surgical mini-laparoscopic technique: first
5 cases performed with 3 lateral accesses, further 15 cases with 3 sopra-pubic aesthetic
approaches. In cases requiring umbilicus re-implant a 5 mm accessory incision was per-
formed. Two continuous PDS sutures executed to re-approximate the rectus muscles from
xiphoid to pubis, as in Rives technique, to restore physiologic function of abdominal wall.
Repair was consolidated placing an intra-peritoneal prosthetic mesh to buttress and reduce
tension on the suture line. First 10 cases performed with a dual sided polypropylene/ePTFE
Bard Composix LP mesh (permanent barrier), second 10 cases with Ventralight ST light
polypropylene with hyaluronic acid (absorbable barrier). In both series each mesh was
secured with 50% Absorbable fixation System Sorbafix, and 50% Permanent Fixation
Permafix.
Results: In all cases abdominal functioning was successfully restored, with no higher pain
related to the suture compared to tension free IPOM repair reported in literature, but
allowing for a more physiologic and aesthetic outcome. Cases with the sopra-pubic
approach allowed for an easier reconstruction, less short and long term pain, more satis-
factory aesthetic results. Reconstruction of linea alba and defect closure didn’t determine
higher pain, nor symptomatic or chronic seroma formation. The kind of mesh and fixation
didn’t cause intra operative bleeding, nor relevant post-operative or chronic pain were
observed. No relevant differences observed in terms of seroma and pain among the two
mesh kind. No recurrences up to date, 100% follow up.
Conclusions: Mini-laparoscopic re-approximations of rectus muscles is a feasible technique
that resulting in improved abdominal wall functionality, better aesthetic results with no
increase of pain and less seroma formation compared to classic tension free IPOM lapa-
roscopic repair. Though the Composix LP (permanent barrier) and the Ventralight ST
(absorbable barrier) group showed comparable results, the absorbable barrier may offer an
advantage over time, leaving less foreign material implanted.
Surg Endosc (2013) 27:S53–S166
P039 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC VENTRAL HERNIA REPAIR WITH
THE COMPOSIX LP MESH
I. Triantafyllidis, A. Astreinidou, M. Dimitriadou, V. Papadopoulos,
N. Mpenetatos, C. Demertzidis
Veria General Hospital, VERIA, Greece
Introduction: Laparoscopy has become a popular approach for ventral hernia
repair. The purpose of this study is to present our early experience and evaluate
the efficacy and safety of laparoscopic ventral hernia repair by the use of
Composix LP Mesh.
Material and methods: During the period from January 2009 to January 2012,
59 patients (21 with incisional hernias, 30 with umbilical and 8 with epigastric
hernias) underwent laparoscopic ventral hernia repair at our department.
Results: The procedure was completed at 55 patients. Four conversions
occurred in cases of incisional hernias. The mean VAS score of postoperative
pain at first 24 h was 4. The mean postoperative time was 49 min and mean
postoperative hospitalization was 2 days. Superficial surgical site infection
occurred in 2 patients, while seromas in 7 patients and were managed con-
servatively. During a mean follow-up period of 11 months, one recurrence was
observed.
Conclusion: Our early experience of using the Composix LP Mesh demon-
strates an effective and safe prosthetic material for laparoscopic ventral hernia
repair.
P040 – Abdominal Cavity and Abdominal Wall
LAPAROSCOPIC TRANSABDOMINAL PREPPERITONEAL
APPROACH (TAPP) FOR INGUINAL HERNIA REPAIR:
SINGLE CENTER THREE YEARS EXPERIENCE
I. Triantafyllidis, A. Astreinidou, M. Dimitriadou, C. Demertzidis
Veria General Hospital, VERIA, Greece
Background: Laparoscopic hernia repair is an effective method for treating
inguinal hernias. It has several significant advantages over the tension-free
open repair. The purpose of this study is to present our experience on trans-
abdominal preperitoneal approach for inguinal hernia repair and to evaluate the
efficacy and safety of the technique.
Patients and Methods: We reviewed retrospectively the TAPP procedures for
inguinal hernias performed between January 2009 and January 2012 in our
department. There were 111 males and 12 females with mean age 54.3 years
and inguinal hernia treated by TAPP procedure.
Results: A total of 129 TAPP procedures were performed. The mean operating
time was 53 min and the mean hospitalization time was 3 days. No conversion
was observed. Seven patients had complications (in two cases intraopera-
tively). Two recurrences occurred during a mean follow-up period of 7.3
months.
Conclusions: TAPP is an efficient technique for inguinal hernia repair. The low
recurrence rate and low morbidity makes it an attractive method for routine
treatment of inguinal hernias.
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P041 – Abdominal Cavity and Abdominal Wall
THE ROLE OF DIAGNOSTIC LAPAROSCOPY IN
A DISTRICT GENERAL HOSPITAL
I. Triantafyllidis, A. Astreinidou, M. Dimitriadou, C. Demertzidis
Veria General Hospital, VERIA, Greece
Background: Diagnostic laparoscopy is a powerful tool, allowing direct vision
of the abdominal organs with a minimally invasive procedure that may be
extended into a definitive operation. Although multiple uses of diagnostic
laparoscopy have been described, the purpose of this study is to identify the
most frequent uses within a district general hospital.
Material and Methods: We reviewed retrospectively the operative records
during the period January 2009–January 2012. All patients who underwent a
diagnostic laparoscopy were identified. The endpoints of our study were the
indications, findings and definitive procedures carried out at the time of
laparoscopy.
Results: A total of 65 procedures were performed in 57 females and 8 males.
The ages ranged from 15 to 81 yrs, with a median of 31 yrs. The vast majority
were performed as emergency procedures to investigate acute abdominal pain.
In 11 cases laparoscopy found no abnormality, whereas in 54 cases a definitive
procedure was conducted. Of these, 30 were appendectomies, 14 had gynae-
cological pathology, 3 suturing of perforated peptic ulcer and the remaining
required other procedures (drainage of intra-abdominal collection, lavage for
biliary leak, adhesiolysis and omental biopsies for presumed metastatic dis-
ease). No conversions occurred. In 6 cases there were minor complications.
Conclusion: The main indication of diagnostic laparoscopy is the investigation of
acute abdominal pain. The low morbidity and mortality indicate that the procedure is
safe. Our results reveal high sensitivity, diagnostic and therapeutic benefit of the
procedure.
P042 – Anaesthesiology
ANAESTESIA IN URGENT VIDEOLAPAROSCOPIC
APPENDECTOMY: IS IT A PROBLEM FOR
ANESTIOLOGIST, SURGEON OR FOR PATIENT?
S.V. Satsuta, R.V. Bondarev
State Medical University, LUGANSK, Ukraine
Aims: Granting of own results of research of efficiency of application pro-
longed epidural blockade (EB) at anesthesiology maintenance of laparoscopic
appendectomy (LA).
Methods: It is spent prospective; randomized research at 90 patients with
acute destructive appendicitis, including the complicated peritonitis among
the patients who had have LA. The age of patients has made from 19 till 62
years. Mesentery and stump of vermiform process are ligated. Artery ap-
pendicularis is clipped during mesentery crossing. In case of a peritonitis an
abdominal cavity is sanitized by means of an antiseptic solution, drained of
tubular drainages. Risk of anesthesia for all patients corresponded to the II
class to the ASA scale, and was due to the basic pathology. 35 patients (I
group) were operated in the conditions of the general balanced combined
intravenous anesthesia with artificial ventilation of lungs and at 55 patients
(II group) in conditions of prolonged EB at level Thvll- Thlx with artificial
ventilation of lungs. Used a ‘step-by-step’ induction EB of the 0.5% solution
of bupivacain entered in small volumes of 2–3 ml with an interval 10–15
min under the constant control the arterial blood pressure and heart rate.
Essential fluctuations of haemodynamics and the oxygen status at patients
during anesthesia it was not marked. Average anaesthesia duration was equal
to 45 min.
Results: The analysis of results has shown, that at patients of II group, resto-
ration of function of intestines occurred on the average on 4–6 hours earlier,
provided optimum intra- and postoperative analgesia, did not demand
appointment of opioids and also allowed to carry out painful manipulations
(bandagings, removal of drainages etc.).
Conclusions: Prolonged EB is an optimum component of anesthesiology
maintenance and postoperative intensive therapy after LA.
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P043 – Basic and Technical Research
STRESS MONITORING SYSTEM WITH CONTINUOUS
PERSPIRATION MEASURING DURING LAPAROSCOPIC
SURGERY
F. Michitaka1, N. Sakakibara2, S. Kondo2, C. Tanaka1, N. Ohashi1,
G. Nakayama1, M. Koike1, Y. Kodera1
1
Graduate School of Medicine, Nagoya university, NAGOYA, Japan,
2
K&S Company, KARIYA, Japan
Background: During laparoscopic operation, we often feel irritated because of various
restriction of surgical view and instruments probably more than during open surgery. Such
irritation might have a harmful influence on surgical outcome. Therefore, there is possibility
that monitoring and analysis of mental status including irritation contributes to improve-
ment of quality or safety of the operation. We measured heart rate and perspiration volume
of the surgeon momentarily during the operation as pilot study to search an indicator of
phycological status. We found momentary perspiration related to some surgical events. In
this paper, we show the result of continuous perspiration measurement of the first and added
two cases.
Cases and Methods: The temperature and perspiration of the sole of surgeon’s foot were
continuously measured with continuously transpiration and perspiration measuring instru-
ment SS-100 (K&S Corporation, Kariya, Japan) during laparoscopic gastrectomy for gastric
cancer at Nagoya University Hospital. The bioinstrumentaion data was collated with video
record of the operation to investigate the influence of operative event.
Results: As measured data were unstable without understandable reason in 1 case, so
the data of two cases with reliable data were analyzed. The volume of perspiration of
surgeon’s sole fluctuated although the temperature of the soul was relatively stable.
Generally fluctuation of perspiration was within 3% up and down, however some-
times larger increases more than 10% were observed. 14 times large rises were
shown in 2 cases. Collating with operation video, 11 rises of 14 were coincided with
events which potentially irritate the surgeon.
Conclusion: It suggested that continuous monitoring of perspiration is available to estimate
the stress of surgeon, although further analysis of more cases is necessary.
P044 – Basic and Technical Research
ANASTOMOSIS WITHOUT DOG-EAR USING THE
COMPRESSION ANASTOMOSIS RING IN LAPAROSCOPIC
ANTERIOR RESECTION
H.B. Lee, S.N. Yoon, C.S. Chung, D.K. Lee
Hansol hospital, SEOUL, Korea
Purpose: To evaluate clinical outcome of the anastomosis without dog-ear using the
compression anastomosis ring (CARTM 27) in laparoscopic anterior resection.
Method: Between March 2010 and February, 2011 a non-randomized prospective
study of patients undergoing an elective laparoscopic anterior resection, followed by
an anastomosis using the CARTM 27. Before creating anastomosis, we added con-
verging suture at both ends of distal colonic stump to remove out linear staple line in
dog-earless group. Clinicopathological features and perioperative surgical outcomes
were reviewed between dog-ear (Group A = 24 patients; 17 female) and dog-earless
(Group B = 20 patients; 15 female) group.
Results: There were no statistically significant differences between the two groups in
terms of gender p = 0.66), age (A = 58.8 yr, B = 59.2 yr, p = 0.54), BMI (A = 26.9
kg/m2, B = 25.2 kg/m2; p = 0.39) and location of lesion from the anal verge (A = 16.9
cm, B = 17.5 cm, p = 0.46). The pathologic stage (I: II: III, A = 4: 14: 6, B = 4: 12: 4,
p = 0.38), operation time (A = 140.5 min, B = 143 min, p = 0.55) was similar to both
groups. There was no open conversion, perioperative mortality at two groups. There
was also no stenosis at endoscopic follow-up after a median follow up of 6 months in
all patients. One patient of group A was developed anastomosis leak at post-oper-
ative day #4. She was received diverting ileostomy and improved.
Conclusion: Dog-earless CARTM 27 anastomosis in laparoscopic anterior resection
revealed acceptable outcomes in surgical procedure such as operation time, con-
version rate. It was also safe and easy to eliminate staple cross line known as risk
factor of anastomotic leaks.
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Surg Endosc (2013) 27:S53–S166
P045 – Basic and Technical Research
COMPARING CONVENTIONAL AND SINGLE-PORT
LAPAROSCOPIC APPENDECTOMIES: A RANDOMIZED
PROSPECTIVE TRAIL
L.C. Kao, P.F. Yang, W.C. Fan
Kaohsiung Municipal Ta-Tung Hospital, KAOHSIUNG CITY,
Taiwan
Background: Laparoscopic appendectomy is becoming popular and is performed by
three-port approach generally. For cosmetic reasons, single-port laparoscopic
appendectomy is managed.
Methods: From January 2011, we collected totally 67 patients of acute appendicitis.
Randomly, they were separated to two arms: 33 in conventional three-port and 34 in
single-port laparoscopic appendectomies, respectively. None of them was converted
to open appendectomy. The three ports of the conventional way are located on
umbilical, suprapubic, and left lateral margin of the rectus abdominis muscle. For the
single-port approach, we applied the commercial device (LAGIS TRL4-20,
approved by Taiwan Department of Health). After setting the device, we made some
necessary dissection and retrieved the appendix extracorporeally to ligate it.
Result: Between these two arms, there is no difference in basic character. We can get
better outcome on operative time (75 versus 50 minutes) and surgical site infection
rates (5.4% versus 2.3%). About hospital stay length and post-operative pain, we do
not see statistics difference.
Conclusion: According to the trail, we conclude that single-port laparoscopic
appendectomy is a safe procedure. And we can also get some benefit on less oper-
ative time and less wound pain. Single-port laparoscopic appendectomy could be
considered a standard procedure to treat acute appendicitis.
P046 – Basic and Technical Research
TECHNICAL BASES OF GASTRIC PLICATION VERSUS
SLEEVE GASTRECTOMY IN EXPERIMENTAL BARIATRIC
SURGERY: JUSTIFICATION
A. Cabrera, F. Sabench, M. Hernández, M. Vives, M. Parı́s,
A. Sánchez, S. Blanco, D. Del Castillo
Rovira i Virgili University. U. Hospital of sant Joan. IISPV,
REUS, Spain
Aim: Advances in bariatric and metabolic surgery involve further studies in exper-
imental animals and the development of new surgical techniques. Gastric plication
(GP) is an emerging technique of bariatric surgery that does not involve resection of
the fundus. Long-term effects weight and metabolic effects are still unknown. The
aim of this paper is the description of the surgical technique in experimental animals
and the protocol used for the comparison of anthropometric and metabolic data after
the sleeve gastrectomy (SG).
Methods: Sprague-Dawley rats M 7 weeks old (12PG+12SG+6 sham group). High
fat (Cafeteria) diet for 4 weeks. Prior to surgery: puncture and cannulation of the
external jugular vein under microscopic control for the extraction of blood (3 cc).
Daily monitoring of weight and intake. Weekly control of blood glucose by coc-
cygeal vein puncture. Surgery: Midline laparotomy (4 cm). Greater curvature
dissection and ligation of vasa recta (silk 5/0). GP: caudocranial longitudinal
invaginating suture of the gastric greater curvature of the rumen by using tutor
(semirigid pipette 1 cm-diameter) SG: linear longitudinal gastrectomy with partial
resection of the rumen and double continuous suture (polypropylene 4/0). Liver
biopsy is performed on all animals intraoperatively for the quantification of hepatic
steatosis. (Brunt Scale).
Results: Intervention time: 27 min (GP) and 45 min (SG). Mortality 0%. Postop-
eratively, the weight and daily intake is weekly calculated, as well as the blood
glucose. Sacrifice takes place 4 weeks after surgery with blood collection by intra-
cardiac puncture together with liver and gastric wall biopsies.
Conclusions: GP is a relatively faster and less laborious technique than SG. This fact,
at the clinician, may be a factor working in its favor, but by weight and metabolic
implications, in particular, hormonal implications (ghrelin) are still to be determined.
Failure to perform the resection of the fundus (the main producer of ghrelin) may not
regulate the sensation of satiety in morbidly obese patients undergoing GP surgery.
On the other hand, invagination of the fundus may avoid the stimulus of food on
ghrelin-producing cells and produce the same metabolic effect on intake level.
Biochemical and hormonal analysis will complete the study.
Surg Endosc (2013) 27:S53–S166
P047 – Basic and Technical Research
MEASURING TISSUE OXIMETRY AS A METHOD
FOR EVALUATING ACUTE TISSUE RESPONSE
TO COMPRESSION
R.D. Segan, S.L. Carter, A. Miesse, D. Bronson, M. Godek
Covidien, NORTH HAVEN, CT, United States of America
Aim: Iompression affects oxygen levels in tissue; this study aims to develop a
method evaluating the change in tissue oxygenation as tissue is compressed and
released. During surgery, tissue is compressed for various reasons, including
grasping, manipulation, and stapling. Excessive compression during surgery may
irreparably damage tissue causing ischemia and necrosis. However, appropriate
tissue compression is necessary for tissue apposition during surgical repair. The
effect of perfusion and %StO2 levels on healing and successful anastomosis has been
reported. The balance between the compressive forces needed to prevent bleeding or
leakage and allowing adequate blood flow necessary to enable healing is unknown.
Methods: Uncompressed tissue thickness measurements were taken along the greater
curvature of porcine stomach. Each location was compressed and released, using a
modified circular stapler, in a stepped fashion holding at each step for a minimum of
15 seconds for data collection. A modified anvil allowed a T-Stat Tissue Oximeter
Endoscopic 2-mm probe (CTH-060-END,Spectros, CA) to be placed on the tissue
and the percent oxygen saturation (%StO2) was measured. %StO2 was measured as
a function of time and gap (distance between anvil and cartridge face) and tissue
strain (change in thickness).
Results: The gap, perfusion (%StO2), and strain were correlated and graphed as a
function of time. The exaggerated dwell time at each step enabled visualization of
%StO2 changes in the tissue. During release, reperfusion to levels equivalent to
baseline occurred in all of the samples evaluated (n = 33). The %StO2 decreased
with the gap, indicating that as tissue strain increased (amount of compression), the
blood flow to the area was compromised. The reperfusion of all tissue samples to
%StO2 equivalent to baseline indicates that the applied compression did not illicit an
acute negative effect.
Conclusions: This method measured tissue oxygen levels under compression.
Measuring the %StO2 during clamping may be valuable for evaluation of tissue
health at acute time points and may correlate to healing and tissue viability in
chronic studies. Future studies will characterize the tissue response to the rate and
force per anatomical location and the impact of stapling.
P048 – Basic and Technical Research
LAPAROSCOPIC METHOD OF ADHESIONS PREVENTION
V.M. Demidov, S.M. Demidov
National Medical University, ODESSA, Ukraine
Aims: After operation period characterizes by the possible numerous complication
development especially in the case of the intraabdominal surgical interventions. The
importance of our clinical observation lies in the range that we manage to provide
the prophylaxis of the after operational adhesions formation in patients during the
abdominal operation.
Methods: 37 patients with acute pancreatitis (AP) and acute cholecystitis (ACh) were
operated laparoscopically during the last 3 years. According to their decision, 14
patients received intraabdominal Sandostatin (Novartis Pharma Stein AG, Switzer-
land) and thioctacid (thioctic or alpha-lipoic acid, Pliva, Croatia) infusions assuming
their antiinflammative activities. The rest of the patients (group N2) were operated
traditionally without the prophylactic antiadhesive procedures. Theses patients were
followed 5–9 days in the hospital, 3, 6 and 12 months during the after operational
period. Pain intensity and localization as well as abdominal cavity organs ultrasound
investigation were performed.
Results: The average pain syndrome intensity 6 hrs after the operation in both
groups’ patients was equal to 30.0 ± 4.6 and 35.1 ± 5.6 points, correspondently, that
have no statistical difference. 24 hrs after the operation these data were differed
insignificantly (20.6 ± 4.7 and 29.6 ± 4.7 points, correspondently; P [ 0.05). The
visceral pain subjective expression 48 hrs and 5 days after the operation in the 1st
group patients was 2.4 times less comparing the same index in the 2nd group patient.
Analogous observation in these patients 3, 6 and 12 month’s after the operations
revealed the expressed (in 3 till 7 times) less pain expression in the patients of these
two groups. Performed ultrasound investigation 6 and 12 month’s after the opera-
tions showed less cases of the after operational adhesions formation in patients with
intraoperational antiadhesive treatment.
Conclusions: Thus, we report that it is reasonable to provide the prophylactic efforts
aimed to prevent the adhesions formation during the laparoscopic operations on the
abdominal cavity organs.
S65
P049 – Clinical Practice and Evaluation
A FEASIBLE TECHNIQUE FOR INTRAOPERATIVE
ENDOSCOPY OF GASTROINTESTINAL BLEEDING:
CLOTHED ENDOSCOPY
T. Sezer, H. Yildirim, O. Unalp, T. Yoldas, O. Firat, S. Ersin,
A. Guler, C. Hoscoskun
Ege University School of Medicine, IZMIR, Turkey
Background: To review our experience with intraoperative endoscopy in evaluating
occult bleeding.
Materials and Methods: Materials in this technique are an endoscopic camera cover
which is used in laparoscopic surgery and an endoscopic camera. After camera is
clothed by endoscopic cover at back table, an enterotomy or gastrotomy with 2
centimeters length is applied. The proximal part of cover is opened and entered to the
gastrotomy or enterotomy. Then, endoscopy is pushed into the organ without any
contamination and scrolled into the endoscopic cover by using a forceps. At the end
of exploration camera can easily be taken out of area just pulling together with
endoscopic cover. The technique also gives this opportunity to surgeon.
Conclusion: Clothed intraoperative enteroscopy is safe and effective in localizing
origin of upper gastrointestinal bleeding, providing complete visualization of the
small-bowel mucosa without threating sterility. It is a feasible diagnostic way in
selected patients with occult gastrointestinal bleeding.
P050 – Clinical Practice and Evaluation
LONG-TERM OUTCOMES OF ROUX-EN-Y AND
BILLROTH-I RECONSTRUCTION AFTER LAPAROSCOPIC
DISTAL GASTRECTOMY
K. Motoyama, M. Inokuchi, K. Kato, K. Kojima, K. Sugihara
Tokyo Medical and Dental University, TOKYO, Japan
Aims: Laparoscopic distal gastrectomy (LDG) is an established procedure for the
treatment of early gastric cancer. Roux-en-Y (R-Y) or Billroth-I (B-I) reconstruction
is generally performed after LDG in Japan. The aim of this retrospective cohort study
was to compare the effectiveness of R-Y and B-I reconstruction and thereby
determine which has better clinical outcomes.
Methods: We analyzed data from 172 patients with gastric cancer who underwent
LDG. Reconstruction was done by R-Y in 83 patients and B-I in 89. All patients
were followed up for 5 years. Evaluated variables included symptoms, nutri-
tional status, endoscopic findings, gallstone formation, and later gastrointestinal
complications.
Results: Scores for the amount of residue in the gastric stump, remnant gastritis, and
bile reflux, calculated according to the ‘residue, gastritis bile’ (RGB) scoring system,
were significantly lower in the R-Y group (score 0 vs 1 and more; p = 0.027,\0.001,
and \0.001, respectively). The proportion of patients with reflux esophagitis was
significantly lower in the R-Y group (p \ 0.001). Relative values (postoperative 5
years/preoperative) of body weight, serum albumin levels, and total cholesterol
levels were similar in the groups (p = 0.59. 0.56, and 0.34, respectively). Gallstone
formation did not differ between the groups (p = 0.57). As for later complications,
the incidence of gastrointestinal ulcer was 4.5% in the B-I group, and that of ileus
was 3.6% in the R-Y group, but differences between the groups were not significant
(p = 0.12, 0.11, respectively).
Conclusions: As compared with B-I, R-Y was associated with lower long-term
incidences of bile reflux into the gastric remnant and reflux esophagitis.
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S66
P052 – Clinical Practice and Evaluation
A PROSPECTIVE RANDOMIZED TRIAL COMPARING
TOTALLY LAPAROSCOPIC DISTAL GASTRECTOMY
WITH LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY
IN EARLY GASTRIC CANCER
J.H. Lee
Ewha Womans University, SEOUL, Korea
Aim: To compare the short-term outcomes of laparoscopy-assisted distal gastrec-
tomy (LADG) with totally laparoscopic distal gastrectomy (TLDG) to provide the
basis for standardization of the laparoscopic gastrectomy in early gastric cancer.
Methods: In this prospective study, 45 patients with early gastric cancer were ran-
domized to have either TLDG or LADG with Billroth II anastomosis.
Clinicopathologic characteristics, operative details, postoperative course and quality
of life were compared.
Results: TLDG was performed in 22 patients and LADG was performed in 23
patinets. Estimated blood loss was less in TLDG group and in TLDA group, oper-
ative time was longer than in LADG group. The longest length of wound after skin
closure was significantly longer in TLDG group. Postoperative pain score was not
significantly different from day 0 to day 7 between two groups. Also, lesser opioid
consumption added to intravenous PCA in TLDG group was not statistically sig-
nificant. The first flatus was observed at 3.1 ± 1.0 days in TLDG group and at 2.8 ±
0.9 days in LADG group. The length of postoperative hospital stay was slightly
longer in TLDG group than in LADG group. Test of pulmonary function were
performed on preoperative day and postoperative day 4. Forced vital capacity and
forced expiratory volume in 1 second decreased slightly less after TLDG than
LADG. Scores for physical function presented more healthy level of functioning in
TLDG groups (P = 0.034). Whereas there were no significant differences in scores
for global health scales and other functional scales between two groups. Scores for
pain and discomfort, emotional problem, restriction of eating and body image pre-
sented lower level of problems in TLDG groups than in LADG groups.
Conclusion: This study suggests that TLDG was safe and feasible as LADG in early
gastric cancer. The statistically significant beneficial effect of TLDG were smaller
wound below umbilicus compared with epigastric wound after LADG and more
healthy physical function of quality of life. Our study is ongoing to overcome the
limitation of small sample size.
P053 – Clinical Practice and Evaluation
STEP-BY-STEP INTRODUCTION OF REDUCED-PORT
LAPAROSCOPIC RIGHT HEMICOLECTOMY USING
MINILAP
Y. Sumi, K. Kanemitsu, K. Yamashita, N. Urakawa, D. Kuroda
Kobe University, KOBE, Japan
Background: Reduced-port surgery is currently being introduced following the
development of small-diameter forceps. After a survey concerning attitudes to such
surgery found that staff at our institution were all enthusiastically interested in it,
since January 2011 our Department has been gradually introducing reduced-port
surgery consisting of 3 ports + 1 puncture employing MiniLap (Stryker Co., San
Jose, California, USA) for right-side colon cancer. We compared operation time,
blood loss, and complications at different stages during this introductory period.
Methods: We reduced the number of ports from the conventional 5 step-by-step. Port
reduction was started by omission of the right upper abdomen port. Because we
experienced no problems with 4-port surgery, the remaining port of the right lower
abdomen was then replaced with a MiniLap (clutch) achieving 3-port + 1 puncture
surgery. To date, we have performed 5-port, 4-port, and 3-port + 1 puncture surgeries
in 10, 4, and 3 cases, respectively.
Results: The BMI was 19.7, 21.4 and 22.5 for the 3-, 4- and 5-port groups,
respectively. The mean operation time was 225 minutes (range 182–229 minutes) for
the 3-port group (3 cases) and 228 minutes (range 165–289 minutes) for the 4-port
group (4 cases). The mean blood loss was 30 g for the 3-port group and 15 g for the
4-port group. The 5-port group had a mean operation time of 260 minutes (range
184–319 minutes) and a mean blood loss of 47.4 g. There were no significant
differences in any parameter or postoperative complication between the groups.
Conclusions: It was found that right-side colon cancer could be excised by 3-port + 1
puncture surgery as safely as with 4-port or 5-port approach. Additionally, it would
seem to be important that reduced-port surgery should be phased into laparoscopic
surgery when it is introduced.
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Surg Endosc (2013) 27:S53–S166
P054 – Clinical Practice and Evaluation
LONG-TERM (OVER 5 YEARS) OUTCOMES AFTER
LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY
FOR GASTRIC CANCER
M. Inokuchi, K. Kato, K. Motoyama, N. Ogawa, Y. Yanaka,
K. Kojima
Tokyo Medical and Dental University, TOKYO, Japan
The purpose of this retrospective study is to reveal the feasibility of laparoscopy-
assisted distal gastrectomy (LADG) for gastric cancer through long-term outcomes.
239 patients with gastric adenocarcinoma underwent radical LADG between 1999
and 2006, were analyzed. Indication for LAG was early gastric cancer diagnosed
preoperatively, however, LAG was performed with enough informed consent when
the patient with advanced gastric cancer hoped. There were 167 men and 72 women,
with a median age of 64 years (range: 27–92). One hundred seventy-six patients
(74%) underwent D1+ lymphadectomy, and 63 (27%) were D2. Median tumor size
was 30 mm (range: 4–120 mm). One hundred two (43%), 99(41%), 20(8%), 12(5%),
and 6(3%) patients were T1a, T1b, T2, T3, and T4 in terms of pathological depth of
invasion classified by UICC. Two hundred five (86%), 23 (10%), 5 (2%), and 6 (3%)
patients were N0, N1, N2, and N3 in pathological N stage. One hundred eighty-six
(78%), 27 (11%), 5 (2%), 13 (5%), 4 (2%), 3 (1%), and 1 (0.4%) were stage IA, IB,
IIA, IIB, IIIA, IIIB, and IIIC. Tumor recurrence occurred in eleven patients,
including four patients with peritoneal dissemination, 3 with lymphnode metastasis,
2 with liver metastasis, and 1 with local disease. One (0.5%) patients were stage IA,
1 (4%) were IB, 5 (28%) were II, and 4 (50%) were III. Sixteen (7%) patients died
from other disease. Postoperative late abdominal complications were observed in 12
patients (5%), including 4 patients with gastrointestinal ulcer, 2 with ileus, 1 with
cholangitis, 1 with pancreatitis, 1 with stomal stenosis, 1 with stomal bleeding, and 1
with incisional hernia. LADG was feasible treatment for gastric cancer through long-
term outcomes, although it remains controversial for advanced cancer.
P055 – Clinical Practice and Evaluation
COLORECTAL RESECTION IN NONAGENARIANS:
EFFECTIVENESS OF THE LAPAROSCOPIC SURGERY
T. Soma, M. Sugano, T. Ito, G. Kiguchi, T. Tanaka, T. Nishikawa,
Y. Hattori
Obama Municipal Hospital, OBAMA CITY – FUKUI
PREFECTURE, Japan
Aims: The number and proportion of old and very old people in the general popu-
lation have been increasing. Thus, the incidence of colorectal carcinoma inevitably
increases. However, laparoscopic colorectal resection in the nonagenarians are not
well documented.
Methods: Consecutive patients aged 90 and above who had elective colorectal
resection (laparoscopic surgery or laparotomy) from September 2009 to October
2011 were included. Data concerning anamnesis, American Society of Anesthesi-
ology score, details of operations, and postoperative events were collected.
Comparisons between results of laparoscopic surgery and open surgery were made.
Results: Eleven patients underwent attempted colorectal resection. Eight patients had
laparoscopic colectomy and three had open surgery during the study period. No
patients undergoing laparoscopic surgery required conversion to an open procedure
and no complications related to laparoscopy occurred. Median operative time was
longer (247 minutes versus 183 minutes), but blood loss was less (88 mL versus 315
mL) in the laparoscopic group. No patient died in the laparoscopic group and two
died in the open group. Laparoscopic resection was associated with earlier return of
bowel function, then earlier resumption of solid diet (2.75 days versus 6 days).
Conclusions: Laparoscopic treatment for the very old patients may have great
advantage, in so far as postoperative management copes intensively with previous
illness. We conclude that laparoscopic colectomy may be particularly indicated in
nonagenarians.
Surg Endosc (2013) 27:S53–S166
P056 – Clinical Practice and Evaluation
SINGLE-INCISION TRANSUMBILICAL LAPARO-
ENDOSCOPIC GASTRIC SUBMUCOSAL TUMOR
RESECTION USING LASER-SUPPORTED
DIAPHANOSCOPY
M. Patrzyk
Universitätsmedizin Greifswald, GREIFSWALD, Germany
Background: Rendezvous surgery involves the simultaneous use of two techniques: lapa-
roscopy and endoscopy. Both techniques allowed precise location and excision of
submucosal tumor. Precise tumor location avoided incision of the tumor or excessive
excision of healthy gastric tissue. Single port is the next step to minimize operations trauma.
The surgery becoming essentially scarless if the incision is hidden within the umbilicus. In
this prospective single centre study we evaluated the single port approach of excision of the
submucosal tumors using tissue sparing laser-supported diaphanoscopy for localisation.
Materials and Methods: In this study we have evaluated 9 patients suffering from
submucosal gastric tumors and treated by laser-guided laparoscopic resection during
a laparoscopic-endoscopic rendezvous procedure using single port technique
between 2011 and 2012. Patients included 3 males and 6 females (mean 69 years,
range 55–89 years). Patients’ histories, surgical and demographic data were pro-
spectively collected and analysed.
Results: Excision of the submucosal tumors was carried out in 9 cases in a single port
technique. Mean surgical time of all procedures was 110 minutes (41–217 minutes).
Estimated blood loss (\50 ml per operation) was negligible. All procedures were suc-
cessfully completed. There was no conversion to laparotomy or standard laparoscopy.
Histopathological examination confirmed 6 cases of GIST and 2 cases of lipoma and 1 case
of leiomyoma. Specimen size ranged from 15 mm to 60 mm in the greatest diameter.
Tumor size ranged from 10 mm to 45 mm in the greatest diameter. The mean length of
hospital stay was 5 days.
Conclusions: Single port technique is an option for the resection of the submucosal tumors.
Compared to the standard laparoscopic approach it requires only one incision decreasing
the risks compared with those of several trocars. At the same time the patient benefits from
the better cosmetic result. This novel laparoscopic approach combining with the laser-
supported diaphanoscopy make minimal invasive surgery more minimal invasive and offers
new perspectives in the rendezvous surgery. However, this method can be more time
consuming and requires an experienced laparoscopic surgeon.
P057 – Clinical Practice and Evaluation
LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR
SUPERIOR MESENTERIC ARTERY (WILKIE’S)
SYNDROME
R. Galleano, A. Franceschi, M. Ciciliot, S. Di Giorgi, F. Falchero
S. Maria di Misericordia, ALBENGA, Italy
Wilkie’s syndrome (SMAS) is a rare condition, characterized by compression of the
transverse portion of the duodenum between the aorta and the superior mesenteric
artery. This can result in chronic and intermittent, or acute complete/partial duodenal
obstruction. A case of SMAS with complete occlusion of the duodenum is described.
An 82-year-old man who had a history of longstanding epigastric pain, postprandial
discomfort and early satiety was admitted from the emergency department. Main
symptoms were acute abdominal pain and vomit (bilious/partially digested food)
associated to elevated serum amylase. Patient was malnourished and dehydrated. Plain
abdomen X-ray showed a dilated stomach with no sign of small or large bowel
obstruction. Medical treatment was started and NGT inserted. CT scan showed enlarged
oesophagus, very distended stomach and duodenum up to his passage through the
aortomesenteric angle, NGT in oesophagus. Upper GI endoscopy allowed aspiration of
3.8 l of fluid, positioning of NGT in the stomach and showed oedematous mucosa
without obstructing lesion. SMAS diagnosis was made. Conservative management was
not helpful so laparoscopic duodenojejunostomy was planned. Patient was placed in
lithotomy position with surgeon between his legs, cameramen on his left and scrub
nurse on his right. Monitor was at the head of the patient and a 30 scope was inserted
with an open technique just below the umbilicus. Two other ports were inserted on the
transverse umbilical line lateral to the rectus sheath, a 12-mm for the right hand and a
5-mm for the left hand. A fourth port was placed in the left subcostal space and
cameramen used it to elevate transverse mesocolon. Dissection of peritoneum over the
second/third part of duodenum expose the site were a side to side mechanical anas-
tomosis (45-mm white cartridge stapler) was carried out with the second loop of
jejunum. A double row suture was used to close the remaining enterotomy. Postoper-
ative period was complicated by systemic mycosis. Patient was able to tolerate food six
days after the operation and was discharged a week later. Laparoscopic duodenojeju-
nostomy can be considered a safe and appropriate treatment for SMAS also in fragile
patients that fail conservative therapy.
S67
P058 – Clinical Practice and Evaluation
POSTOPERATIVE OUTCOMES AND COMPLICATIONS
AFTER LAPAROSCOPY-ASSISTED PYLORUS-
PRESERVING GASTRECTOMY FOR EARLY
GASTRIC CANCER
N. Hiki, S. Nunobe, X. Jiang
Cancer Institute Hospital, TOKYO, Japan
Objective: Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was
introduced as a function-preserving and minimally invasive operation for early
gastric cancer (EGC) in Japan. This study investigated the postoperative outcomes,
complications, and associated risk factors of the procedure.
Methods: From January 2005 to December 2009, 307 patients with EGC diagnosed
before surgery underwent LAPPG. The postoperative outcomes and complications
were assessed in this study. Postoperative complications were classified according to
the Clavien-Dindo classification of surgical complications, and risk factors related to
complications were analyzed.
Results: The mean operation time for LAPPG was 229.4 ± 47.5 minutes and esti-
mated blood loss was 49.1 ± 62.0 mL. The mean total number of dissected lymph
nodes was 31.6 ± 10.4, with nodal involvement observed in 25 patients (8.5%). The
preoperative diagnostic accuracy of EGC was 93.2%. Complications developed in 53
patients (17.3%), and major complications, classified as grades greater than Clavien-
Dindo classification IIIa, were observed in 4 patients (1.3%). The most frequent
complication was gastric stasis, occurring in 19 patients (6.2%). Body mass index
(BMI) and surgical experience of LAPPG were identified as significant risk factors
of postoperative complications. Body mass index was related to severity of the
complications. The patients’ serum total protein and albumin did not change sig-
nificantly after surgery.
Conclusions: Laparoscopy-assisted pylorus-preserving gastrectomy is a safe opera-
tion with excellent postoperative outcomes in terms of minimized major
complications based on the Clavien-Dindo classification in patients with EGC in the
middle third of the stomach. To prevent postoperative complications, surgeons need
to ensure an extra leaning period for LAPPG, and LAPPG should be performed
cautiously in patients with high BMI.
P059 – Clinical Practice and Evaluation
LAPAROSCOPY-ASSISTED SUBTOTAL GASTRECTOMY
WITH VERY SMALL REMNANT STOMACH FOR
SELECTED EARLY GASTRIC CANCER IN THE UPPER
STOMACH
S. Nunobe, X. Jiang, N. Hiki
Cancer Institute Ariake Hospital, TOKYO, Japan
Total gastrectomy or proximal gastrectomy is usually performed either as an open
procedure or laparoscopically for the treatment of early gastric cancer (EGC) in the
upper stomach. However, quality of life after either total or proximal gastrectomy is
not so satisfactory. The authors report a novel surgical procedure, laparoscopy-
assisted subtotal gastrectomy (LAsTG), by which a very small remnant stomach is
preserved, for the surgery of selected EGCs in the upper stomach. Twenty-three
patients with EGC in the upper stomach underwent LAsTG. After lymph node
dissection and mobilization of the stomach, the stomach was transected about 2 cm
proximal to the tumor and a very small remnant stomach was preserved. An anvil
was inserted transorally into the remnant stomach by using the OrVil system. The
reconstruction method was Roux-en-Y, and hemidouble-stapling gastrojejunostomy
with a circular stapler was performed intracorporeally. There were no intraoperative
complications or conversions to open surgery. Mean operation time and blood loss
were 266.7 min and 54.6 ml, respectively. The overall incidence of early postop-
erative complications was 17.4%, and two patients underwent reoperation because of
duodenal stump leakage and stenosis of the Y-anastomosis, respectively. During the
follow-up period, two patients experienced gastrojejunostomy stenosis and both were
treated successfully by endoscopic balloon dilation. LAsTG may be performed in
selected patients with EGC in the upper stomach. With the described method, a very
small remnant stomach can be preserved.
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S68
P060 – Clinical Practice and Evaluation
ASSESSMENT OF ANATOMY ABOUT ACCESSORY LEFT
HEPATIC ARTERY AND METHOD OF APPROACH FOR
LAPAROSCOPIC-ASSISTED GASTRECTOMY
M. Kano, A. Nakamitsu, Y. Imamura, M. Sasaki, M. Koyama,
A. Oshita, H. Nakamura, K. Toge, H. Taogoshi, T. Yamaguchi,
Y. Fukuda
Hiroshima General Hospital, HATSUKAICHI, HIROSHIMA, Japan
Aim: Accessory left hepatic artery (ALHA) is observed in about 10% of the whole.
A contrast-enhanced CT scan is obtained to perform gastrectomy safely and cor-
rectly. In this study, we evaluated assessment of anatomy of ALHA before
laparoscopic-assisted gastrectomy (LAG), and method of approach in LAG.
Methods: The study involved 30 patients scheduled for LAG from 2009.
Results: ALHA was found in five patients of 30. Only 1 in them was showed in
operation. Two patients were kept ALHA, three were resected. Temporarily, ele-
vation of GOT/GPT score was recognized, but it was relieved naturally. The careful
point about approach was, before suprapancreatic lymphnode dissection, to confirm
of ALHA on lesser omentum from left edge of proper hepatic artery to esophagus.
And to leave a nerve sheath open continually from left gastric artery to ALHA.
Conclusion: By resection of ALHA, it may be caused fatal liver damage. It is
difficult to decide range of lymphnode dissection because there is not a Merkmal. It
is useful to assessment of anatomy by 3D-CT before LAG to perform resection of
gastric cancer safely and correctly.
P061 – Clinical Practice and Evaluation
DIAGNOSTIC YIELD AND SAFETY OF COLONOSCOPY IN
OCTOGENARIANS IN A DISTRICT GENERAL HOSPITAL
K.M. Khatri, K.J. Perryman, S. Enefer, M. Sayegh
Western Sussex Hospitals NHS Trust, Worthing Hospital,
WORTHING, United Kingdom
Objectives: According to the British Society of Gastroenterology (BSG) guidelines,
colonoscopy in elderly patients is less likely to be successful and is not without risks.
We aimed to analyse the yield of colonoscopy, the completion rate and the com-
plications in patients eighty years or above.
Methods: All patients who underwent colonoscopy from November 2008 to
November 2011 in a District General Hospital were included. Data was extracted
from a prospectively collected endoscopy database Data related to endoscopy find-
ings, histology, completion rate and complications encountered was collected and
analysed.
Results: Nine hundred and sixty-eight patients underwent 1030 colonoscopies in the
3 year period. Average age of the cohort was 84 (81–97) years and female to male
ratio was 1.23 (570:460). Three hundred and nine (30 %) were reported normal.
Significant pathology was identified in 34.3 % including malignancy 7.2 % (75/
1030), polyps 25.2 % (260/1030), and inflammatory bowel disease 1.9 % (20/1030).
Diverticular disease was the most prevalent benign pathology encountered (45.6 %).
The completion rate was 85 %. There were 39 complications overall. Twenty nine
patients poorly tolerated colonoscopy, 7 patients had hypotension requiring intra-
venous fluid resuscitation, 1 patient had sedation related complication, 1 patient had
bleeding following polypectomy (treated using clips) and 1 patient had mild chest
pain.
Conclusion: Our results demonstrate that colonoscopy amongst Octogenarian has a
high diagnostic yield and a relatively low complication rate. This procedure could be
offered to octogenarian safely, depending on relative cancer risk and co-morbidity.
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Surg Endosc (2013) 27:S53–S166
P063 – Clinical Practice and Evaluation
THE OUTCOME OF ESOPHAGOJEJUNOSTOMY WITH
DIRECT INSERTION AND TRANS-ORAL INSERTION OF
ANVIL HEAD AFTER LAPAROSCOPY-ASSISTED TOTAL
GASTRECTOMY
K. Kawai, T. Yumiba, Y. Akamaru, M. Fujii, Y. Morimoto,
K. Yasumasa, E. Kono, T. Konishi, Y. Tanaka, A. Kasashima,
Y. Taniguchi, Y. Okubo, R. Matsuura, Y. Yamasaki
Osaka Kosei-Nenkin Hospital, OSAKA, Japan
Aims: Laparoscopy-assisted total gastrectomy(LATG) has become popular gradually
because of its low surgical invasiveness. However, the technical difficulty especially
of esophagojejunostomy makes this operative procedure restricted to some facilities
and it is still controversial which technique for esophagojejunostomy is better.
Methods: We had introduced LATG since March 2008 mainly for the patients with
early gastric cancer. At the beginning of the introduction of LATG, we performed
esophagojejunostomy with direct insertion of anvil head using purse-string suture
instrument (PSI) through the surgical incision of 7 cm at upper midline abdomen in
12 patients (the PSI group). At September 2009, we changed the technique for
esophagojejunostomy to double stapling technique (DST) using trans-oral insertion
of anvil head, and we performed esophagojejunostomy of this method in 8 patients
until December 2011(the trans-oral group).
Results: The operation time of the PSI group was 313 ± 67 min (mean±SD) and that
of the trans-oral group was 342 ± 60 min. The intraoperative bleeding volume of the
PSI group was 100 ± 115 ml and that of the trans-oral group was 66 ± 69 ml. As to
postoperative complications, the anastastomotic leakage occurred in 1 patient of the
PSI group (8.3%), and 2 patients of the trans-oral group (25%). The anastomotic
stricture requiring endoscopic balloon dilatation occurred in 1 patient of the PSI
group (8.3%), and 3 patients of the trans-oral group (37.5%). Compared with the PSI
group, the trans-oral group had no significant difference in the operation time, the
intraoperative bleeding volume, the occurrence of the anastastomotic leakage and the
anastomotic stricture requiring endoscopic balloon dilatation.
Conclusion: There is no significant difference in both intraoperative and postoper-
ative complications between the PSI group and the trans-oral group in LATG.
P064 – Clinical Practice and Evaluation
LAPAROSCOPY-ASSISTED RADICAL GASTRECTOMY
WITH D2 LYMPHADENECTOMY FOR ADVANCED
GASTRIC CANCER: A MULTICENTER RETROSPECTIVE
ANALYSIS FROM CHINA
T. Mou, G. Li, Y.F. Hu
Nanfang Hospital, GUANGZHOU, China
Aims: Laparoscopy-assisted radical gastrectomy (LAG) has been increasing rapidly for the
treatment of gastric cancer. However in China, most gastric cancer cases are diagnosed at
an advanced stage, the application of LAG for advanced gastric cancer (AGC) remains
controversial. The aim of this study was to evaluate the safety, technical feasibility and
oncologic efficacy of LAG with D2 lymphadenectomy for AGC in a large-scale multicenter
level in China.
Methods: A total of 1985 patients with gastric cancers underwent LAG with D2 lym-
phadenectomy between January, 2002 and January, 2010 in 26 hospitals from China.
Among these patients, 1926 were confirmed with AGC and analyzed retrospectively.
RESULTS: There were 948 men and 378 women, with a mean age of 57.90 ± 11.61 years.
Total gastrectomy was performed in 495 patients, distal gastrectomy in 719, proximal
gastrectomy in 12. The mean tumor size was 44.41 ± 22.28 mm and there were 258 grade
T2 (19.5%), 271 grade T3 (20.4%), 764 grade T4a (57.6%) and 33 grade T4b (2.5%)
lesions. The mean number of retrieved and metastatic lymph nodes were 21.12 ± 11.24 and
4.88 ± 6.58, respectively. 86 (6.5%) patients required conversion to open procedure during
operation. The mean operating time was 255.26 ± 101.31 min and estimated blood loss was
188.68 ± 103.85 ml. Postoperatively, time to first flatus and liquid diet were 4.18 ± 1.70
days and 5.76 ± 2.10 days, respectively and hospital stay was 13.70 ± 7.48 days. There
were 9 intra-operative morbidities (0.7%) and 146 postoperative morbidities (11.0%) within
30 days from operation. Three patients died after operation (0.02%), two died from lung
infection and respiratory failure and one died from postoperative anastomotic leakage and
intra-abdominal bleeding. The estimated 3-year cumulative survival rate was 69.4%. Tumor
recurred in 144 patients (10.9%) during the follow-up period (median 12 months; range
2–69).
Conclusion: laparoscopy-assisted radical gastrectomy with D2 lymphadenectomy is safe
and feasible for treatment of advanced gastric cancer, but further prospective randomized
controlled trial comparing it with open radical gastrectomy will be needed.
Surg Endosc (2013) 27:S53–S166
P065 – Clinical Practice and Evaluation
ESTIMATION OF ENDOSCOPIC PROCEDURES
WORKLOAD USING NASA-TLX
E. Dabizzi1, G. Miranda2, M. Casmiro2, E. Miranda3, R. Naspetti1,
G. Cavassi2
1
Azienda Ospedaliero-Universitaria Careggi, FIRENZE, Italy,
2
Faentia Consulting s.r.l., FAENZA, Italy, 3Casentino Hospital,
AREZZO, Italy
Background: Several studies have provided reliable evidence of an increased
frequency of musculoskeletal disorders among operators performing endo-
scopic procedures. Little is known, however, about the cognitive hazards which
can result from the physical separation between visual and physical aspects of
endoscopic manoeuvres; this factor compels the operators to blend the view on
the display and the indirect mechanical feedback, to obtain a correct manip-
ulation of the tissues. Other variables within the operating field (e.g. the use of
multiple monitors, instruments/devices exchanging, visual discomfort caused
by the use of 2-dimensional video images coming from endoscope) may
contribute to the occurrence of cognitive hazards. Therefore, a comprehensive
evaluation of endoscopic procedures hazards should include a special attention
for cognitive risk.
Aim of the Study: We have planned a case-control study; the overall endo-
scopic workload will be estimated by means of the NASA Task Load Index
(NASA-TLX), which is a validated multi-dimensional rating test providing an
overall workload score. The NASA-TLX is based on a weighted average of
ratings on six subscales (mental, physical and temporal demands, own per-
formance, effort and frustration).
Patients and Methods: The study is currently on-going. The case-control analysis
will compare the overall workload between expert endoscopists and trainees; for
each of these two groups a comparison will be performed between therapeutic and
diagnostic procedures (these latter representing the control group), so that four
groups of operators will be enrolled (ten subjects in each group). NASA-TLX will be
administered at the end of each procedure by a trained physician.
Analysis: A matched analysis of the overall workload score will be performed
between (1) all cases and controls, and (2) between each of the two subgroups
of cases and controls. Enrollment of cases and controls was started on January
9, 2012 and will be completed as March 1, 2012.
P066 – Clinical Practice and Evaluation
LAPAROSCOPIC TOTAL GASTRECTOMY IN GASTRIC
CANCER: OUR EXPERIENCE IN 92 CASES
P. Angelini, F. Andreoli, L. Miranda, A. Settembre, F. Corcione
Monaldi hospital, NAPLES, Italy
Aims: Laparoscopic total gastrectomy (TG) is seldom used for gastric cancer
because the complex vascularization and lymphatic drainage makes the lym-
phadenectomy difficult and the complicated esophagojejunal anastomosis
requiring special skills, and because many alternative technologies are avail-
able to perform these operations. Our aim was to demonstrate the feasibility
and accuracy of laparoscopic TG in gastric oncologic surgery with D2
lymphadenectomy.
Method: We report the techniques used in 88 TG and 4 degastroresections over
[12 years (January 1999–June 2011). The median patient age was 64 years,
and the male/female ratio was 1.49/1. A D2 lymphadenectomy was performed
in 87 cases and only 5 patients had a D1 limited lymphadenectomy.
Results: The study shows the retrospective analysis of intra- and peri-operative
mortality and morbidity. In only 4 of 96 cases approached by laparoscopy, a con-
version to laparotomy was needed. There were 2 (2.17%) perioperative deaths during
92 procedures and few complications. Histological data show 79 advanced gastric
cancers (AGC), 11 early gastric cancers (EGC), and 2 gastric diffused lymphomas.
The five-year Kaplan-Meier overall survival in patients with EGC and AGC was
100% and 58%, respectively.
Conclusion: The results demonstrate the feasibility of an oncologically-correct,
minimally-invasive TG. We would like to promote comparisons between dif-
ferent institutions to achieve better standardization of surgical indications and
techniques for a laparoscopic approach to gastric cancer.
S69
P067 – Clinical Practice and Evaluation
IMPROVING PATIENT SAFETY IN THE IMMEDIATE
POST-OP COMMUNICATION IN LAPAROSCOPIC
SURGERY
S.K. Sarker, S. Yao, N. Muhibullah
Safety Innovations Unit Worcestershire, DROITWICH,
United Kingdom
Aims: Patient safety in surgery is of paramount importance, it has been shown that
good communication improves this. The present study aims to improve information
transfer and communication for immediate post-op patients in general surgery.
Methods: After panel discussion and interview questionnaires, 16 specific post-op
instruction criteria were identified. We then retrospectively assessed 40 post-op
general surgical day and inpatient cases using the post-op instructions in the oper-
ation sheet as a standard for immediate post-op surgical communication to compare
if any of the 16 criteria were instructed. After this we devised a sticky label with the
16 criteria to be stuck on at the end of the operation sheet. We then prospectively
assessed 60 post-op general surgical day and inpatient cases using the post-op
communication label to determine if there was an improvement in communication
transfer in the immediate post-op period.
Results: In total 100 post-op general surgical patients were assessed for immediate
post-op information from the operation note. There were 45 female and 55 male
patients with a mean age of 61. There were 70 day cases and 30 inpatients. Prior to
the introduction of the sticky label post-op instruction, 62% of the 16 criteria were
completed. After its introduction this increased to 97%.
Conclusions: Introducing a simple post-op sticky label to the operation note
improved written communication for post-op surgical patients. In the era of shift
system for all health care professionals it is essential for good communication
regarding management of patients. Our study demonstrates that a simple measure
can improve this and therefore patient safety.
P068 – Clinical Practice and Evaluation
ROLE OF STAGING LAPAROSCOPY IN PATIENTS WITH
INTRAABDOMINAL MALIGNANCIES
K.S. Burmich, A.I. Dronov, I.A. Kovalskaya, I.L. Nastashenko,
S.V. Zemskov
Bogomolets National Medical Unirvesity, KYIV, Ukraine
Role of staging laparoscopy in patients with intraabdominal malignancies is widely
accepted. However, in Ukraine its usage has been limited. Staging laparoscopy may
allow avoidance of unnecessary laparotomy in patients with metastatic or locally
advanced unresectable disease. Laparoscopy is associated with decreased postop-
erative pain, a shorter hospital stay.
The aim of this study was to evaluate diagnostic laparoscopy as first step procedure
in surgical treatment of gastrointestinal, gynecological cancers and mesothelioma.
Materials and Methods: The clinical study was based on the analysis 32 cases, where
the diagnostic laparoscopy as a TNM staging method was applied. Staging was
performed with frozen section biopsy of suspicious lesions.
Results: sttaging laparoscopy in our study was performed in: 7 gastric cancer cases, 6
pancreatic cancer cases, 1 colorectal cancer liver metastasis, 1 melanoma liver
metastasis, 2 hepatocellular cancer, 3 gallbladder cancer, 10 ovarian cancer, 2
mesothelioma. Laparoscopy detected 23 unresectable cases (71.9%), among them 19
peritoneal carcinosis undetectable at previous CT scan and 4 locally advanced. In all
these patients, we avoided an unnecessary laparotomy.
Conclusion: laparoscopy has been shown to be sensitive in detecting intraabdominal
metastases in cancer of different locations, thus helping to avoid unwanted lapa-
rotomy and providing a higher quality of life to cancer patients who undergo further
non-surgical palliation.
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S70
P069 – Clinical Practice and Evaluation
WHAT DID WE LEARN IN LAPAROSCOPIC COLORECTAL
SURGERY? (LOW BUDGET LAPAROSCOPIC SURGERY)
T. Youssef, E.F. Ebied, M.A. Nada, A. Al Anwar, S. Raslan,
A.A.A. Abou Zeid
Ain Shams University, CAIRO, Egypt
Background: Laparoscopic colectomy for colorectal disease technically is feasible
but needs a very long learning curve. Despite the obvious benefits, acceptance of the
laparoscopic approach for malignant disease has been gradual. It is a technically
more challenging surgical procedure; could this, with other environmental factors,
represent a compromise in oncological safety?
Patients and Methods: This study is a prospective study to see the early outcome and
how to build a learning curve aiming to standardization of the technique of lapa-
roscopic colorectal surgery in a developing country like Egypt with the least budget.
This Study was conducted from January 2008 to July 2011. In Ain Shams University
Hospitals (Demerdash) Surgical Department, after putting a protocol for standardi-
zation of the technique and fixing a team for the cases with rotatory training program
including dry labs and animal labs. Regular meetings were done to evaluate our work
after every case, tips and tricks from our own experience were recorded to modify
our standardized technique.
Results: 65 patients had differant laparoscopic colorectal procedures, either bengin
or malignant. Average operative time was 120 minutes. The average post-operative
stay in the hospital was 5 to 7 days for the resection cases and 1 day for the rectal
prolapse and sigmoid volvulas cases. Convergence was in the form of 8 cases had
planned convergence, 6 cases had unplanned convergence, one case had postoper-
ative leakage treated by covering iliostomy 4 case of perineal wound infection one
case of burst of the suprapubic incision all treated conservatively, no local recurrence
of the malignant cases.
Conclusion: Laparoscopic colectomy has been shown to be associated with many
advantages. However, these benefits come at the cost of slightly prolonged operative
time and associated expense whiche we can overcome some of the cost without
affecting the adequacy of surgery. In addition, surgeons who perform these opera-
tions need more advanced laparoscopic skills and training programs to do it
efficiently and safly.
P070 – Clinical Practice and Evaluation
TELEPHONE FOLLOW-UP IN ELECTIVE VERSUS
EMERGENCY SURGERY
N.G. Patel
Hinchingbrooke Hospital, LONDON, United Kingdom
Aim: Follow-up after surgical procedures is essential to allow assessment of patient
recovery. Telephone follow-up has been shown to be safe and effective for elective day case
surgery, though its use for emergency surgery is uncertain. This study aims to evaluate the
use of telephone follow-up in elective versus emergency surgery.
Methods: A prospective study of telephone follow-up interviews conducted by a
fully trained Surgical Care Practitioner (SCP) using a standardised proforma. 635
appointments were made including 521 elective and 114 emergency procedures
between 1/9/07–12/11/08. Cases deemed safe for telephone follow-up were selected
at time of discharge by the operating surgeon. The data collected were: Patient
demographics, BMI, operation, type (elective or emergency), surgeon (consultant or
trainee), peri and post-operative events, patient perception of discharge advice, need
to contact another service (GP/NHS direct), antibiotics required post-discharge, time
to follow-up, follow-up acceptable to patient, patient discharged at first telephone
follow-up, further telephone or clinic follow-up arranged.
Results: Of elective patients 87% were happy with their discharge from hospital compared
with 59% of emergency cases (p \ 0.0001), the main complaint being adequacy of dis-
charge information. A total of 86 patients did not answer on their first appointment (9.0%
elective and 37.7% emergency, p \ 0.0001). Of these 15 did not answer on their second
appointment and were therefore discharged (0.9% elective, 9.4% emergency, \0.0001). 43
patients (6.9%) required a second call and 48 patients (7.8%) required a hospital
appointment, with no difference between emergency and elective cases. The most common
reasons requiring further follow-up, was ongoing pain.
Conclusion: This study demonstrates that telephone clinics are a safe and acceptable tool
for follow-up of elective day surgical cases. It has however identified reduced patient
satisfaction and contact rates in the emergency group. This may relate to communication
pathway differences between the two groups because of different nursing staff/ward
locations for each group. Overall this study identified a high patient satisfaction with the
telephone follow-up process allowing a 92% reduction in follow-up outpatient clinic
appointments. However, further work needs to be done before it is effective for emergency
surgery patients.
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Surg Endosc (2013) 27:S53–S166
P071 – Clinical Practice and Evaluation
THE IMPACT OF PROLONGED OPERATIVE TIME AND
MAJOR BLOOD LOSS ON THE OUTCOME OF ENHANCED
RECOVERY AFTER COMPLEX LAPAROSCOPIC
COLORECTAL SURGERY
E.R. Carlisle1, O.J. Harrison1, N.J. Smart1, P. White2, A. Brigic1,
J. Reid1, A.S. Allison1, J.B. Okrim1, N.K. Francis1
1
Yeovil District Hospital, YEOVIL, United Kingdom; 2University
of the West of England, BRISTOL, United Kingdom
Aims: The combination of laparoscopy and enhanced recovery has demonstrated a consid-
erable reduction in the length of hospital stay after colorectal surgery. However, laparoscopic
surgery for complex cases may increase operative time and blood loss. Hence, the aim of the
present study was to investigate the impact of prolonged surgery and operative blood loss on
the outcome of enhanced recovery after complex laparoscopic colorectal surgery.
Method: Data was collated from patients who underwent elective laparoscopic colorectal
resection on the Enhanced Recovery After Surgery (ERAS) pathway in Yeovil District
Hospital between 2002 and 2009. All patients were cared for within an Enhanced Recovery
Programme. Operative and postoperative outcomes were collected and delayed discharge
was defined as patients who stayed beyond the mean in this series (= 8 days). Univariate
analysis was carried out with a p value set at 0.05.
Results: 385 patient records were reviewed including 152 patients (39%) who
underwent laparoscopic pelvic surgery after chemoradiotherapy, ileal pouch for-
mation and re-do pelvic surgery. Median operative time was 180 minutes and median
blood loss was 100 ml. Conversion rate was 14%, but this was not associated with
delayed discharge.
Median length of stay was 6 days (mean of 8 days) but 122 patients (31%) stayed longer
than one week despite only 7.5% requiring return to theatre (including 1.6% due to anas-
tomotic leak). Operative time and blood loss correlated with length of stay in a stepwise
fashion. Delayed discharge was associated with an operative time of five hours or longer
(OR = 2.02, 95% CI 1.05 to 3.90, p = 0.027), and blood loss of more than 500 ml (OR =
3.114, 95% CI 1.501 to 6.462, p = 0.002).
Conclusion: Prolonged operative time of more than 5 hours and increased intra-operative
blood loss of more than 500 ml increase the likelihood of delayed discharge for patients
undergoing complex laparoscopic colorectal resections within an enhanced recovery
programme.
P072 – Clinical Practice and Evaluation
THE LEARNING CURVE FOR LAPAROSCOPIC TOTALLY
EXTRAPERITONEALHERNIORRHAPHY BY MOVING
AVERAGE
S.E. Lee, Y.M. Ra, J.W. Lim, J.I. Moon, I.S. Choi, W.J. Choi,
D.S. Yoon, H.S. Min
Konyang University Hospital, DAEJEON, Korea
Aim: Laparoscopic Totally Extraperitoneal (TEP) herniorrhaphy has been recog-
nized as one of the treatment for inguinal hernia. The objective of this study was to
clarify the learning curve for TEP herniorrhpahy using moving average method.
Methods: 90 patients underwent TEP herniorrhaphy by single surgeon between
March 2009 and March 2011. We analyzed medical records include the demographic
data, operating time, hospital stay, post-operative complications.
Results: The mean operating time of the first 30 cases that we called learning period
was 66.3 minutes. After the results decreased to 52.8 minutes in the 60 cases in
experienced period (p = 0.015). This represents operating time becomes stabilize and
then decreases as the numbers of case increase. The hospital stay, pain control,
complication rate were shorter in experienced period, however, there was not sig-
nificant statistically.
Conclusion: We suggest that the learning curve for TEP herniorrhaphy would be 30
cases. The operating time for TEP herniorrhaphy stabilizes after 40 cases in moving
average.
Surg Endosc (2013) 27:S53–S166
P073 – Clinical Practice and Evaluation
CASE REPORT: EXTRAMURAL TYPE
GASTROINTESTINAL STROMAL TUMOR (GIST)
WITH PERFORMING BY SINGLE INCISION
LAPAROSCOPIC SURGERY (SILS)
T. Aoki
Kinki Central Hospital, ITAMI, Japan
Introduction: Nowadays single incision laparoscopic surgery (SILS) is being per-
formed for a variety of diseases. We report here a case of gastrointestinal stromal
tumor (GIST) which is operated by SILS.
Case Report: Woman in her sixties was presented to department of gastroenterology.
Ultrasonogram (USG) and computed tomography (CT) were performed and gastric
submucosal tumor was pointed out. During follow-up, she desired to be operated and
was referred to our department. CT was performed again, and 3-cm projected
(extramural) tumor located on the anterior wall of gastric antrum was revealed, and
also about 2-cm submucosal tumor was diagnosed by gastrointestinal endoscopy
(GIS).
Progress: A laparoscopic port was made by open method (3-cm) via an umbilicus,
and pneumoperitoneum was established by using laparoscopic protector and gloves.
We observed into the peritoneum, and identified about 3-cm pedunculated (stalked)
polyp like tumor in diameter on the anterior wall of gastric antrum. There is no
peritoneal dissemination and liver metastasis. Because of pedunculated polyp like,
we inserted a mini-loop retractor via left subcostal plane, holding pedunculated part
to retract the tumor, and performed gastric partial gastrectomy (including tumor) by
using Endo-GIA duet 60. We retrieved resected portion by sac to prevent tumor cell
dissemination (spread). The immunochemistry of the resected specimen was c-kit
(±), CD34 (+), s-100(–), aSMA (–), Desmin (–). Therefore, we confirmed the
diagnosis as GIST.
Conclusion: We consider that SILS is extremely beneficial operative method for
extramural type GIST such as our case.
P074 – Clinical Practice and Evaluation
COMPARISON OF LAPAROSCOPIC GASTRECTOMY
FOR ADVANCED GASTRIC CANCER BETWEEN TWO
HIGH-VOLUME SPECIALIZED INSTITUTIONS IN CHINA
AND KOREA
Y.F. Hu1, W.J. Hyung2, G.X. Li1, H.I. Kim2, T.I. Son2,
N.K. Okumura3, S.H. Noh2
1 Background: In an aging society, a patient has not only gastric cancer but also
Nanfang Hospital Southern Medical University, GUANGZHOU,
China; 2Yonsei University College of Medicine, SEOUL, Korea;
3
Gifu University, GIFU, Japan
Aims: The application of laparoscopic gastrectomy (LG) with regional lymphade-
nectomy for advanced gastric cancer (AGC) is still controversial. The purpose of this
study is to clarify whether there are differences in surgical and oncologic outcomes
after LG for the treatment of locally AGC between two high-volume specialized
institutions in China and Korea, attempting to learn how to improve management
protocol from each other.
Methods: From June 2003 to August 2011, both 248 patients in China (Group C) and
189 in Korea (Group K) underwent LG for AGC. The demographic, clinicopatho-
logic characteristics, surgical and oncologic outcomes of these patients in the two
groups were compared.
Results: The mean operation time in the group C was longer than that in the group K
(221.1 ± 64.0 min vs. 177.8 ± 59.4 min, P \ 0.001), but no significant difference
was observed in estimated blood loss (125.3 ± 118.9 ml vs. 140.1 ± 186.5 ml, P =
0.407). The mean number of retrieved lymph nodes were 22.4 ± 10.7 in the group C
and 39.9 ± 14.3 in the group K (P \ 0.001). The indicators associated with early
recovery such as the time to first flatus, liquid diet, semi-liquid diet, and length of
hospital stay were significantly shorter in the group K than in the group C, respec-
tively (P \0.001 for each). Postoperative complication occurred in 24 Chinese
patients (9.7%) and 24 Korean patients (12.7%) (P = 0.317), without mortality in
both groups. Stratified analyses showed a similar short-term oncologic outcome
according to TNM stage between the two groups.
Conclusions: For experienced surgeons, laparoscopic gastrectomy with regional
lymphadenectomy is a technically feasible procedure with satisfactory short-term
oncologic outcomes for advanced gastric cancer. Postoperative recovery course
could be improved by using enhanced recovery protocol in laparoscopic surgery.
However, longer follow-up results are still needed to draw a solid conclusion in
terms of long-term oncologic security.
S71
P075 – Clinical Practice and Evaluation
COMPLICATIONS AFTER LAPAROSCOPIC HIATAL
HERNIA OPERATIONS
J. Piatkowski, M. Jackowski
Nicolaus Copernicus University, Collegium Medicum in Bygdoszcz,
TORUN, Poland
Aim: The aim of the study was the evaluation of complications after laparoscopic
treatment for hiatal hernia in Surgical Clinic in Torun
Methods: Between January 2005 and June 2011 178 patients (103 males and 75
females) with hiatal hernia and symptoms of GERD were treated in our Clinic. In
every case we did endoscopy and radiological examination of upper gastrointestinal
tract. Some patients because of nonspecific symptoms have done CT scans of chest
and upper abdomen.
Results: In every case we performed laparoscopic hernioplasty (crural repair) and
fundoplication. In most cases (172) we performed Nissen-Rossetti procedure, in 4
cases Toupet and in 2 cases Dor procedure. In 4 cases we have to convert to open
procedure (becouse of massive adhesions after previous surgery). The average
operating time was 72 minutes (55–140). Mean postoperative hospital stay was 3
days (2–5). In every patients we have obtained good postoperative result.
There was no serious intraoperative complications. We have 4 cases of pneumo-
thorax – treated conservatively and 1 oesophagus perforation – closed by sutures.
Dysphagia occured in 20 patients (11.2%). In 16 cases yielded after 2 months but in
4 cases lasted till 6 months. Trocar site hernias occured in 3 cases (1.68%) – at obese
patients. Gastric cardia stenosis we noticed in 4 cases. Recurrent hiatal herniation we
observed in 6 patients (3.2%). We performed 10 reoperations in 9 patients: 3 becouse
of trocar site hernias, 4 becouse of recurrent hiatal herniation and 2 becouse of
gastric cardia stenosis. In all cases we noticed good result of operation.
Conclusions: Laparoscopic treatment is simple and effective method of operation for
patients with GERD symptoms caused by hiatal hernia. The number of complica-
tions is lower compared with open surgery.
P076 – Clinical Practice and Evaluation
LAPAROSCOPIC GASTRECTOMY IN GASTRIC CANCER
PATIENTS COEXISTENT WITH CARDIOVASCULAR
DISEASES
T. Kaetsu, K. Matsuda, Y. Kimura, A. Ohta
Kikuna memorial hospital, YOKOHAMA, Japan
several disease. In this particular case, coexistence with cardiovascular diseases has a
major impact on surgical indication and outcome. An assessment of the outcome for
gastric cancer patients who underwent laparoscopic gastrectomy coexistent with
cardiovascular diseases was made.
Patients and Methods: Between July 2006 and June 2011, 15 patients who underwent
gastrectomy for gastric cancer coexistent with cardiovascular disease were studied
retrospectively. Gastrectomy was performed by laparoscopic surgery in seven
patients (group A) and ordinary open surgery was made in eight patients (group B).
In this study, cardiac function (ejection fraction: EF), the stage of gastric cancer,
operating methods, postoperative complications, hospital stay and mobility were
compared between two groups.
Results: The mean age of patients were similar between two groups. All the patients
were male regardless of operating methods. According to the TNM classification, all
patients were classified on stage I 5, II 2 in group A, stage I 3, II 2, III 2 and IV 1 in
group B respectively. Cardiac function, postoperative complications and postoper-
ative hospital stay were not different between two groups. In regard to operating
methods, distal and total gastrectomy was performed in 4 patients of the group B
respectively. In contrast to group A, we underwent distal gastrectomy in all patients.
Conclusion: Even though our data were given form retrospective and restricted
study, it is unlikely that laparoscopic gastrectomy affects the postoperative state in
the patient with cardiovascular disease.
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S72
P077 – Clinical Practice and Evaluation
SINGLE-INCISION LAPAROSCOPIC LEFT COLECTOMY
COMPARED WITH CONVENTIONAL LAPAROSCOPY
FOR MALIGNANCY: ASSESSMENT OF PERIOPERATIVE
OUTCOMES
M.J. Kim
Samsung Medical Center, Seuol, Korea
Aims: Laparoscopic colectomy for malignancy is currently the standard operative
technique over open colectomy. Single-incision laparoscopic surgery is an advance in
minimally invasive operative techniques and is going to be an alternative of the treat-
ment options for colorectal disease, including malignancy. The study aimed to compare
single-incision laparoscopic (SIL) left colectomy with conventional laparoscopy (CL)
in patients with colon cancer especially focused on perioperative outcomes.
Methods: Between April 2010 and November 2011, 39 patients who underwent pri-
mary laparoscopic left colectomy for malignancy at Samsung Medical Center were
recruited to participate in this study. Of these, 18 patients had received SIL colectomy.
Results: There were no significant differences in general characteristics for SIL and
CL left colectomy groups (age, sex, BMI, ASA score, previous abdominal operation
and diagnosis). Perioperative complications showed no significant difference
between SIL and CL groups (22.2% and 23.8%, respectively; p = 1.000). Length of
hospital stay and time to drink water didn’t reveal any significant differences for both
groups. But, flatus came out more faster in CL left colectomy group (3 ± 1 and 2 ± 1
days, respectively: p = 0.027). Mean harvested lymph nodes were 14 ± 6 and 19 ± 8
for SIL and CL left colectomy (p = 0.024). There were no differences in tumor size,
cell type, stage, proximal and distal resection margins for both groups.
Conclusions: Single-incision laparoscopic left colectomy for cancer is safe and can
provide equivalent perioperative outcome and recovery compared with conventional
laparoscopic left colectomy. More efforts to achieve appropriate oncologic resection
are needed.
P078 – Clinical Practice and Evaluation
THE EVALUATION OF LAPAROSCOPY ASSISTED
COLECTOMY FOR TRANSVERSE COLON CANCER
Y. Hirasaki, M. Fukunaga, Y. Lee, K. Nagakari, M. Sugano,
Y. Iida, G. Katsuno, M. Ouchi, Y. Ito
JAPAN/Juntendo Urayasu Hospital, Juntendo University,
URAYASU, Japan
Background: Laparoscopy assisted colectomy (LAC) is a minimally invasive sur-
gical technique that is gaining wider acceptance for the treatment of colon cancer.
However, LAC for transverse colon cancer is technically difficult, so the indication
for LAC is still controversial. The aim of this study is to assess the feasibility and
safety of LAC for transverse colon cancer.
Method: Between May 1996 and December 2010, we performed 1290 LAC for
colorectal cancer. We compared operative and oncologic findings between the two
groups of patients undergoing either LAC for transverse colon cancer (T-LAC group,
n = 108) or the other colon cancer (Other LAC group, n = 533). Excluded cases were
as follows; descending colon cancer cases, stoma created cases, synchronous
resection cases of two cancer site or other organ.
Result: The patients in both groups were comparable in age, sex, cancer invasion
depth, and cancer stage. In the T-LAC group, there were 57 cases of transverse
colectomy, 24 of extended rt. hemi-colectomy, 19 of rt. hemi-colectomy, 4 of
extended lt. hemi-colectomy and 4 of lt. hemi-colectomy. Of them, 4 patients were in
stage 0, 35 in Stage I, 40 in Stage II and 29 in Stage III. The mean operative time was
longer (215 vs. 184 min) in the T-LAC group than the Other LAC group. The mean
estimated blood loss was same (109 vs. 90 ml) in both groups. Time to liquid diet
(2.6 vs. 2.2 days), and hospital stay (15 vs. 13 days) were similar in both groups.
Overall Complications were observed in 17 patients (15.8%) in the T-LAC group.
The 5-year overall and disease-free survival rates for patients with stage II were
93.3% and 91.3% in the T-LAC group and 96.1% and 91.8% in the Other-LAC
group, respectively. The 5-year overall and disease-free survival rates for patients
with stage III disease were 80.2% and 82.1% in the T-LAC group and 84.3% and
84.2% in the Other-LAC group, respectively. No significant differences were found
in terms of overall survival, disease-free survival between the two groups.
Conclusion: LAC is a safe, oncologically feasible and acceptable procedure for the
treatment of transverse colon cancer.
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P079 – Clinical Practice and Evaluation
LAPAROSCOPIC APPENDECTOMY – STUDY REGARDING
SURGEONS PREFERENCE AND EXPERIENCE
I.O. Avram1, M.F. Avram1, D. Koukoulas2, F. Horhat1, F. Cadariu1,
S. Olariu1
1
University of Medicine and Pharmacy, TIMISOARA, Romania;
2
Emergency Hospital Lugoj, LUGOJ, Romania
Aims: To evaluate the correlation between the surgeons perception of laparoscopic
appendectomy, their personal experience and their opinion regarding laparoscopic
appendectomy.
Material and methods: We asked 40 surgeons form 4 hospitals to complete a survey
containing 50 questions related to their surgical experience, their knowledge of literature
and their opinion on laparoscopic appendectomy. We analyzed the data in order to identify
patterns or significant correlations between their answers and the type of appendectomy
they usually perform.
Results: Although out of 40 surgeons only 19 (47.5%) were in favor of laparoscopic
appendectomy, only 9 (22.5%) perform it on a regular basis, while 4 (10%) perform it only
in selected cases while the other 6 were unable to perform it due to technical difficulties.
We found that significant factors in favor of laparoscopic appendectomy were: surgeons age
(\45 years), surgeons percentage of laparoscopic procedures performed, more than 5
articles/studies on laparoscopic appendectomy read in the last 2 years.
In favor of open appendectomy were the surgeons with a low percentage of surgical
procedures performed laparoscopically, high volume of surgical procedures/month, no
knowledge of recent medical literature, limited laparoscopical experience.
Conclusions: Laparoscopic appendectomy is performed mainly by young surgeons with
extensive experience in laparoscopic surgery. Experienced consultants still prefer to per-
form classical appendectomy while most surgical residents are clearly in favor of the
laparoscopic technique.
P080 – Clinical Practice and Evaluation
EVALUATION OF THE LEARNING CURVE FOR
LAPAROSCOPIC APPENDECTOMY IN A LOW-BUDGET
HOSPITAL
I.O. Avram1, D. Koukoulas2, F. Horhat1, F. Cadariu1, M.F. Avram1,
S. Olariu1
1
University of Medicine and Pharmacy, TIMISOARA, Romania,
2
Emergency Hospital Lugoj, LUGOJ, Romania
Introduction: The evolution of laparoscopic surgery in a low-budget hospital is often
hindered by financial burdens and lack of disposable instruments like pre-formed
Roeder loops and staplers. Surgeons often need to use improvised techniques, in
order to overcome these obstacles. Another problem is that the general anesthesia
which is needed for laparoscopic surgery is 15 times more expensive than the spinal
anesthesia used for classical appendectomy.
Aim of the study: We tried to evaluate the duration, conversion rate, outcome and
complication rate and total costs of laparoscopic appendectomy, during and after the
learning period and to compare the results with a control group of patients where
classical appendectomy was performed.
Material and methods: We studied 2 groups of patients having laparoscopic
appendectomy performed by the same operating team: group A (the first 25 cases
performed laparoscopically) and group B (25 consecutive cases, performed after
overcoming the learning curve) were studied. All patients were operated in the same
low-budget hospital which Results were compared between group A and B, but also
with a control group C (25 patients where classical appendectomy was performed).
We also tried to evaluate the impact of different modifications of the original 3-port
Hasson technique on the outcomes (use of different ‘home-made’ knot pushers,
intracorporeal knotting).
Results: As expected there was a significant difference in the duration of surgery
between the study groups; the time difference however was not significant if we
compare only the last 5 cases from group A where we used intracorporeal knotting.
Rate of complicated appendicitis was significantly higher in group B and the control
group compared to group B, with similar complication and conversion rates. Post-
operative complications were more frequent in group C.
Conclusions: ‘Home-made’ knot pushers increase significantly the duration of lap-
aroscopic appendectomy. Intracorporeal knotting seems to be the best option in order
to obtain good results without increasing the costs of appendectomy, allowing us to
reduce the duration of the surgical procedure and the complications rate, while the
increased cost of general anesthesia is compensated by the shorter hospital stay and
the recede need for medication as compared to classic surgery.
Surg Endosc (2013) 27:S53–S166
P081 – Clinical Practice and Evaluation
EARLY LAPAROSCOPIC INTERVENTIONS IN PATIENTS
WITH CONSERVATIVELY RESOLVED ADHESIVE
INTESTINAL IMPASSABILITY
V.I. Bondarev, A.L. Chybisov, S.S. Selivanov
State Medical University, LUGANSK, Ukraine
Aims: To outline the indications for early laparoscopic interventions use in patients
with conservatively resolved adhesive intestinal impassability.
Methods: 14 patients were included into main group at whom the intestinal
impassability clinical signs were resolved conservatively. These patients after the
complete diagnostics were operated laparoscopically. The following events were
evaluated as the reasons of intestinal impassability: a) postoperative intestinal
junctions with an uterus as the result of gynecologic interventions (n = 4), b) local
junction in right abdominal area with an involvement of small intestine’ loops,
caecum, parietal peritoneum, single gut adhesions in the form of ‘double-barreled
gun’ [in patients with appendectomy in anamnesis] (n = 7), c) small intestine’ loops,
large intestine and epiploon deformations by plural adhesions [in patients with a
median laparotomy in anamnesis] (n = 3). The first incision (trocar) place has been
defined according to ultrasonic investigations data. Laparoscopic adhesiolysis was
performed using monocoagulative method with the help of bipolar clip.
Results: There were no complications during the operations and during the post-
operative period. Conversions were performed in 3 patients because of the intensive
adhesions – these patients had median laparotomy in anamnesis. Early laparoscopic
interventions in patients with conservatively resolved adhesive intestinal impass-
ability should be performed in the presence of local adhesive process with a
postoperative hem of a parietal peritoneum, individual junctions of a gut as ‘double-
barreled gun’ as well as anamnesis data about acute adhesive intestinal impass-
ability. The intensive adhesions and intestinal loops conglomerates are considered to
be a contraindication to laparoscopic adhesiolysis.
Conclusions: One could assume that it’s impossible to eliminate conservatively the
adhesive intestinal impassability morphological background. Thus, the patients that
were conservatively treated because of the adhesive intestinal impassability should
be admitted to laparoscopic adhesiolysis with the aim of its relapse prevention.
P082 – Clinical Practice and Evaluation
THE COMPARATIVE EFFICACY OF THE VENTRAL
HERNIA LAPAROSCOPIC TREATMENT USING PTFE
MESH WITH NITINOL RING
V.Ye. Vansovich, D.N. Osadchiy
National Medical University, ODESSA, Ukraine
Aims: To evaluate the clinical efficacy of the ventral hernias laparoscopic treatment
using the polypropylene/ePTFE composite mesh with a novel internal nitinol ring.
Methods: 11 patients who underwent ventral hernia repair with a PTFE composite
self-expanding mesh with nitinol between June 2011 and December 2011 were
compared with 17 consecutive patients who underwent the same procedure with a
‘Proseed’ mesh during the same time interval. Using a 3- or 2-trocar technique, the
polypropylene meshes were underlayed by 3 to 5 cm beyond the edges of the hernia
defect and fixed to the abdominal wall with 2 rows of titanium staples. The standard
technique was the sublay mesh-plasty with the retromuscular positioning of the
mesh. The two groups were equal in BMI, age, gender and hernia size. Patients were
routinely seen back in the surgical department.
Results: There were no cases of complications among the majority of patients with
ventral hernias who were laparoscopically treated using both types of polypropylene
meshes. Only patients with ‘Proseed’ meshes had wound infection (n = 1), transient
partial small bowel obstruction which resolved without operative management (n =
1) and seroma (n = 1). There were no conversions to an open procedure. It was
observed the significantly shorter duration of the surgical intervention in case of self-
expanded PTFE composite mesh using with an internal nitinol ring (operative time
was 48 min, range from 34 to 68 min) compared with the same time of operation
with ‘Proseed’ mesh using (operative time was 69 min, range from 43 to 101 min).
We used 2-trocar technique in all 11 patients with ventral hernias in case of self-
expanded PTFE mesh with nitinol using with the subsequent minimization of the
operative time, insufflated carboxyperitoneum amount and its possible negative
influence on the organism. We used 3-trocar technique in 15 out of 17 patients with
ventral hernias while using ‘Proseed’ mesh. 1 patient who was operated using
‘Proseed’ mesh had hernia recurrence.
Conclusions: The data obtained show comparatively safe, long effective and more
clinically efficacious the laparoscopic surgical intervention with self-expanded PTFE
mesh with nitinol.
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P083 – Clinical Practice and Evaluation
PAIN SYNDROME EXPRESSION DECREASING
IN PATIENTS WITH ABDOMINAL ADHESIONS
V.Ye. Vansovich, D.V. Novikov
National Medical University, ODESSA, Ukraine
Aims: To determine the clinical efficacy of the pain syndrome expression liquidation or
minimization in patients after the laparoscopic adhesiolysis (LAL). The background of the
work is that secondary adhesion-dependent abdominal pain is a common complaint of the
patients but in the majority of the cases surgeons do not perform any surgical interventions
until the patient won’t suffer from an intestinal obstruction.
Methods: 17 patients underwent LAL interventions last year. All patients were examined
clinically. We used the following indications for the LAL: open surgical interventions on
the abdominal and pelvic organs in the anamnesis, episodes of intestinal obstructions, acute
pain during physical work and emotional stress as well as failure in conservative treatment.
We evaluated the expression of the pain syndrome using the visual analog scale of pain that
represents a 100 mm-long horizontal line, which may contain word descriptors at each end.
The back side of the line shows the point expressions of the pain on which patients
indicated according to its subjective feeling. The time of pain syndrome determination was
1, 7 days postoperative period in-department, 3 and 6 month’s during out-department time.
Results: There were no episodes of intestinal obstruction, pain reoccurrence and no
repeated surgical interventions in patients who were operated using LAL. The
average expression of the pain syndrome in the patients with adhesions was equal to
6.7 (range from 5 to 8 points). 1 day after the LAL this index was insignificantly less
5.6 (range from 4 to 6 points, P \ 0.05). on the 7th days of the postoperative period
the investigated data was equal to 2.1 (range from 1 to 4 points) that was signifi-
cantly less compared to the initial data of the pain syndrome subjective expression (P
\ 0.05). The forthcoming evaluation of the pain syndrome showed averagely 0.6
(range 0 to 2 points) 6 month’ s after the LAL.
Conclusions: The lysis of adhesions during LAL results in adhesion-related pain subjective
expression. Additionally to clinical manifestation of the primary disease laparascopic ad-
hesiolysis significantly improves patients’ clinical condition and their quality of life.
P084 – Clinical Practice and Evaluation
MANAGEMENT OF ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY-RELATED
PERFORATIONS
J.Y. Jeon, I.G. Kim
Hallym University Sacred Heart Hospital, ANYANG, Korea
The purpose of this study is to analyze the treatment strategies of patients with
endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. This
is a retrospective study.We experienced 13 perforations associated with ERCP. We
reviewed the medical records and classified ERCP-related perforations according to
mechanism of injury in terms of perforating device. Injury by endoscopic tip or
insertion tube was classified as type I, injury by cannulation catheter or sphincter-
otomy knife as type II, and injury by guidewire as type III. Of four type I injuries,
Type I injuries require immediate surgical management after EPCP or immediate
endoscopic closure during ERCP whenever possible. Type II injuries require surgical
or conservative treatment according to intra- and retro-peritoneal dirty fluid col-
lection findings following radiologic evaluation. Type III injuries almost always
improve after conservative treatment with endoscopic nasobiliary drainage.one case
was managed by conservative management after primary closure with a hemoclip
during ERCP. The other three patients underwent surgical treatments such as pri-
mary closure or pancreatico-duodenectomy. Of five type II injuries, two patients
underwent conservative management and the other three cases were managed by
surgical treatment such as duodenojejunostomy, duodenal diverticulization and
pancreatico-duodenectomy. Of four type III injuries, three patients were managed
conservatively and the remaining patient was managed by T-tube choledochostomy.
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S74
P085 – Clinical Practice and Evaluation
DOUBLE STAPLING METHODS USING LINEAR STAPLERS
IN TOTALLY INTRACORPOREAL ROUX-EN-Y
RECONSTRUCTION AFTER LAPAROSCOPIC DISTAL
GASTRECTOMY
J.Y. An, Y.M. Kim, J.H. Cheong, W.J. Hyung, S.H. Noh
Yonsei University College of Medicine, SEOUL, Korea
Backgrounds: Roux-en-Y reconstruction in laparoscopic distal gastrectomy is a more
complicated procedure than B-I or B-II reconstruction regardless of its benefits.
Methods: We performed totally intracorporeal laparoscopic distal gastrectomy with
Roux-en-Y reconstruction in 12 patients. All anastomotic procedures were per-
formed using linear staplers. The clinicopathological and surgical outcomes were
evaluated.
Results: In all patients, totally laparoscopic intracorporeal Roux-en-Y gastrectomy
using linear staplers were performed without any complications. The mean operation
time was 212.1 min and the mean anastomotic time was 23.0 min. The mean time to
the first flatus was 3 days, and diet was started on postoperative day 3 or 4. All
patients tolerated soft diet without any discomfort and the mean hospital stay was 8.1
days. There was no postoperative complication.
Conclusion: Totally intracorporeal Roux-en-Y reconstruction using linear staplers is
a simple, fast, and safe procedure.
P086 – Day Surgery
CHOLEDOCHOLITHAISIS PREDICTION IN MODERN
GALLBLADDER SURGERY
G. Simutis, V. Beiša, K. Strupas
Vilnius university Medical faculty, VILNIUS, Lithuania
Aim: Accurate preoperative prediction of choledocholithiasis before laparoscopic
cholecystectomy (LC) is important in order to choose optimal treatment strategy and
reduce patient management risk and cost. The aim of our study was to revaluate our
original predictive score of choledocholithiasis (PSC) based on two preoperative risk
factors and modify assessment degree of probability for choledocholithiasis.
Methods: We retrospectively reviewed every LC and the related endoscopic retro-
grade cholangiography (ERC) or intraoperative biliary investigations performed in
our center between January 2007 and December 2009. A strategy to assign risk of
choledocholithiasis was based on value of PSC (PSC = A/30 + B 9 0.4; A – total
bilirubin (lmol/l) and B – common bile duct (CBD) diameter (mm) on ultrasound).
Patients at high probability of choledocholithiasis (PSC = 4.7) typically preoperative
ERC was undertaken, in patients who have a low probability of choledocholithiasis
(PSC \ 4.7) – intraoperative cholangiography.
Results: A total of 309 patients undergoing LC were investigated for choledocho-
lithiasis during study period. CBD stones were detected in 156 patients with PSC =
4.7 and in 27 patients with PSC \ 4.7. The sensitivity and specificity of PSC were
0.85 and 0.53 respectively and accuracy 72.12%. PPV was 0.73, while the NPV was
0.71.
Patient distribution in rank order according to predicted probability of choledo-
cholithiasis and value of PSC in diagram form delineated graph and graph equation
was estimated. Likelihood of intermediate probability of choledocholithiasis
expected in patients with PSC value 3.2 – 5.2 was calculated using graph equation.
Investigation of these patients with more reliable and noninvasive procedures for
detecting or excluding CBD stones can enhance prognostic efficiency of PSC:
sensitivity 97.8, specificity 59.5 and accuracy 82.2%.
Conclusions: The application of modified PSC likely allow the development of more
effective preoperative strategies for patients undergoing LC. PSC will demonstrate
an ability to predict choledocholithaisis with a sensitivity of 97.8%.
123
Surg Endosc (2013) 27:S53–S166
P087 – Day Surgery
THE METHOD OF EXTERNAL DRAINAGE OF CYSTIC
TRANSFORMATION OF THE BILE DUCTS
D.V. Fokin1, V.A. Dudarev2, I.V. Kirgizov3
1
Public Health Services Municipal Authority City Clinical Hospital
20 of a name, KRASNOYARSK, Russia; 2Krasnoyarsk State Medical
University of a name of professor V.F.Vojno-Jasenetsky,
KRASNOYARSK, Russia; 31st MSMU After I.M. Sechenov,
MOSCOW, Russia
Inputting of new technologies into the pediatric practice leads to the considerable
improvements of children’s anomaly development of cholecyst and bile-excreting ducts
diagnosis. However the problems of early diagnosis and treatment on time are actual things
nowadays because it is depend on the surgical treatment of these diseases results.
Aim: formation of the condition for unimpeded flux of bile into the bowels, decrease biliary
and pancreatic hypertension, liquidation of inflammation process and prevention of
malignant transformation of modified ducts.
Materials and methods: indication for operation of external drainage was defined among
17th children with the mechanical jaundice and hepatic deficiency also with the sponta-
neous perforation of choledoch cyst with gall peritonitis among 8th patients. This
complication we observed among 3th newborns, 4th 3–4 months old babies and 1th child
three years old. Long lasting mechanical jaundice which is non-capable to conservative
therapy and significant disorder of coagulant system was observed among 4th 3–4 months
old babies and 4th 1.5–5 years old children. Radical cure for these patients was counter-
indicative because of their grave condition. External drainage of the bile-excreting ducts
was made on the first stage of the treatment. For the adequate support of bile outflow a
cholecystectomy was formed or if there was coarse deformation of isthmus-ductal area of
the gall bladder and with abnormality of the patency the dilated duct was drained. The drain
tube with the diameter not smaller 4–5 mm was outputted on the skin through the additional
puncture and fixed.
Conclusion: We have found out that the operation of external drainage it the compulsory
measure for the handle of critical situation. It is important that after external drainage on the
background of giant bile loss especially among newborns and infants the symptoms of
major abnormality of acidic-basic and electrolytic balances were appeared. For the cor-
rection of these problems the substitute systemic therapy besides the bile is given through
the stoma is inputting through gastric tube.
P088 – Different Endoscopic Approaches
LENGTH OF THE WOUND AND POSTOPERATIVE SCAR
AFTER USING SINGLE PORT LAPAROSCOPIC
CHOLECYSTECTOMY
O.B. Ospanov, R.E. Khassenov
National Researsh Medical Center, ASTANA, Kazakhstan
Aim: To compare length of the wound and used the resulting postoperative scar for
the standard and single port laparoscopic cholecystectomy.
Methods: In our study from January 2010 to November 2011 included 60 patients
who underwent laparoscopic cholecystectomy. The criterion for inclusion was
cholelithiasis. The criterion for exclusion was conversion of laparoscopic surgery in
the open surgery.
All patients were randomly assigned into two groups. The first group were included
30 patients who had laparoscopic cholecystectomy was performed transumbilical
from a single access device using X-CONE. The second group included 30 patients
who had a standard multi port laparoscopic cholecystectomy with four trocars. Mean
age groups were the following: in the first group 42.6 ± 12.0 years in the second –
45.0 ± 13.1 year. Both group did not differ in mean values of sex and body mass
index. Measuring the length of the wounds was performed using a flexible metric
device at the end of the operation after the skin sutures. The length of the scar was
measured at 1 month after surgery. Results for all patients were compared using the
Student’s t-test.
Results: The average length of the cut in the first group was 23.7 ± 3.5 mm vs.
47.4.1 ± 5.0 mm in the second group. These differences were statistically significant
(P \ 0.001). If add up all diameters two 10 mm and two 5 mm trocars for second
group, should have been enough for the total cut of 30 mm. But in practice it turned
out that the trocars cuts for longer involuntarily obtained in 1–2 mm, and for par-
umbilical access because of its use for removal of the gall bladder out section
reaches values of 12 to 21 mm.
One month after surgery the shortest length of postoperative scar was in the first group:
21.07 ± 4.2 mm vs. 45.07 ± 4.9 mm – the total length of the second group (P\0.001).
Conclusion: After using single port laparoscopic cholecystectomy total length of the
wound and postoperative scar significantly less than after using a standard multi port
laparoscopic cholecystectomy.
Surg Endosc (2013) 27:S53–S166
P089 – Different Endoscopic Approaches
DEVELOPMENT AND APPLICATION OF AN EFFECTIVE
ACCESS DEVICE FOR SINGLE-INCISION LAPAROSCOPIC
COLECTOMY
T. Takagi, Y Nakase, K Fukumoto, T. Miyagaki
Nishijin Hospital, KYOTO, Japan
We previously developed and reported an effective access port (EZ Access: Hakko,
Japan) for single-incision laparoscopic surgery for the removal of smaller organs
such as the gallbladder or appendix. In this paper, we report the development of an
access device which is optimal both technically and oncologically for conducting
reduced port surgery including single-incision laparoscopic surgery for gastrointes-
tinal tract malignancies, as well as evaluate our short-term experience of single-
incision laparoscopic colectomy (SILC) and Plus one port SILC involving 14
patients using this device.
Device and methods: The multi-channel port consists of the following components: a
silicone rubber protector which protects the edges of the incision, a 107-mm
diameter disk-shaped device to cover the protector, and trocars to insert through the
disk-shaped device which can be used for conventional laparoscopic surgery. The
disk-shaped device is made of silicone rubber, which allows easy insertion using any
number of trocars at any desired location, facilitating a multi-channel approach for
not only single-incision laparoscopic surgery but also reduced port surgery.
We conducted SILC and Plus one port SILC involving 14 patients with colon cancer
using this device to compare with standard laparoscopic colectomy, which requires a
subumbilical incision and another 4–5 small incisions to allow the insertion of
operating ports, in respect of the duration of surgery, blood loss, intra- and post-
operative complications, and cost-effectiveness.
Results: Comparing with conventional laparoscopic colectomy, the duration of
surgery was slightly longer for SILC, whereas it showed almost no difference for
Plus one port SILC. The blood loss was similar among all three procedures. No intra-
and post-operative complications, additional trocars, or shift to open surgery were
observed. This device is made of silicone rubber and requires less trocars than
conventional laparoscopic surgery, resulting in cost-effectiveness.
Conclusion: This device is considered effective for conducting SILC and Plus one
port SILC.
P090 – Different Endoscopic Approaches
ENDOSCOPIC SUBMUCOSAL DISSECTION BY
PERFORMED BY A ENDOSCOPIC SURGEON
H. Ohara
Fujieda Memorial Hospital, FUJIEDA, Japan
Introduction: In our institution, a gastrointestinal surgeon perform endoscopic sub-
mucosal dissection (ESD). Since 2004, with the application of the laparoscopic
surgery technique, we have performed 120 cases of ESD with good results. This
method, including the selection of devices, will be discussed.
Methods and Procedures: These 120 cases are as follows: 4 esophageal carcinoma, 1
esophageal SMT, 30 gastric adenocarcinoma, 24 gastric adenoma (called ATP), 3
gastric SMT, 1 gastric carcinoid, 15 colon adenocarcinoma, 28 colon adenoma
(called LST), 6 rectal carcinoid, and 8 other diseases. In the early period, we used
only an endoscopic Hook knife, which is smaller than a laparoscopic hook knife in
LC but similar shape. By using this Hook knife, we could perform ESD under the
direct vision. As gaining our experience, we were able to recognize the submucosal
vessel anatomy, we used IT knife2, too. Recently, we used SB knife (similar shape to
laparoscopic LCS), as a result we were able to safely perform ESD on the patient
with large intestine diseases.
Results: There were 7 perforation cases, four of which had to undergo open surgery
(Postoperative course were uneventful). However, there were no bleeding cases. The
average treatment time of the first third (40 cases), the middle third (40 cases), the
latter third (40 cases) were 102.1 min, 78.0 min, 73.5 min, respectively. The curative
resection rate of those were 77.5%, 84.2%, 97.5%, respectively. Furthermore, in the
latter third, we have no perforation cases. The technical progression was validated.
Conclusion: Not only the laparoscopic surgery skill but also new devices such as SB
knife (same to the device of LCS in laparoscopic surgery) have attributed to our ESD
good results.
S75
P091 – Different Endoscopic Approaches
LAPAROSCOPIC MANAGEMENT OF GASTROINTESTINAL
STROMAL TUMOURS
E. Tarcoveanu, A. Vasilescu, R. Moldovanu, C. Lupascu, G. Dimofte,
C. Bradea, D. Ferariu
University of Medicine, St. Spiridon Hospital, IASI, Romania
Gastrointestinal stromal tumours (GISTs) represent the most common non-epithelial
tumour of the digestive tract. Laparoscopic approach may be considered ideal for the
resection of these tumours. Their particular biological behaviour allows for a cura-
tive resection even without large resection margins and extensive
lymphadenectomies.
Method: Over a period of five years, nine patients benefited from laparoscopic
resections (seven patients with primary gastric GIST and two patients with small
bowel GIST). Pathological features were analyzed including tumour size, surgical
margin status, immunohistochemical staining profile, and tumour mitotic index. All
cases were confirmed GISTs by immunohistochemical staining.
Results: The mean age of the patients was 62.4 years (range 48–71 years). Of these
patients, five initially presented to hospital with acute gastrointestinal haemorrhage
(four cases) or occult bleeding (one case). Gastric or small bowel tumours were
identified during subsequent investigation. A presumptive diagnosis of gastric GIST
was made in gastric lesions based on endoscopic, ultrasonic, and CT scan charac-
teristics. Small bowel tumours were identified and presumed to be GIST based on
information gathered from video capsule endoscopy, enteroscopy and CT scan.
Complete resection was obtained with laparoscopic approach in seven cases, while in
two cases resection was laparoscopically assisted, with added oncology safety
margins as preoperative definitive diagnosis was not available. Tumours varied in
dimension from 2.5 cm to 9 cm and their malignant risk score using Fletcher criteria
was low in three cases, intermediate in three cases and high in two cases. Mean
postoperative stay was 3.8 days and there were no morbidity and not postoperative
mortality. After a mean follow-up of 38.5 months (range 5 to 77 months) all patients
are symptom free and free of recurrent disease.
Conclusions: A selective approach to laparoscopic resection of gastro-intestinal
GISTs allows safe resections and very good results, on the condition that a clear
diagnosis of GIST has been established on preoperative assessment. The laparo-
scopic feasible and safe considering the biological particularities of GIST, and it
carries no additional risks.
P092 – Different Endoscopic Approaches
THE EXCISION OF A LOWER RECTAL TUMOR BY
TRANSANAL ENDOSCOPIC SURGERY WITH SILS
H. Katoh, S. Kouichirou, H. Chikashi, U. Tsuneyuki, W. Toru,
H. Osamu
Yokohama Sakae Kyousai Hospital, YOKOHAMA-CITY, Japan
Transanal excisions of rectal tumors can be performed by open direct excision,
transanal endoscopic surgery, or transanal minimally invasive surgery.
Many devices for laparoscopic abdominal surgery have recently been developed;
single incision laparoscopic surgery port (SILSTMport, Covidien, Mansfield, MA) is
one such device. We report a case of a 69-year-old man with a lower rectal tumor
excised by transanal endoscopic surgery with the SILSTMport.
The tumor was a polyp of the Is type and measured 3 cm in diameter. The tumor was
located above the second Houston’s valve (sited on Ra/b) and 10 cm from the anal
verge.
The patient was preoperatively diagnosed with a semicircular adenoma on the left
side of the rectum. The patient is positioned in the operating room depending on the
anatomic location of the tumor. Therefore, we placed the patient in the prone jack-
knife position and administered general anesthesia. SILSTMport was gently intro-
duced into the anal canal, and the breached skin was sewn up. CO2 gas was
insufflated into the bowel canal at 5–10 mmH2O.
We lifted the tumor using a submucosal saline solution injection, and initiated
transanal excision from the same side by LCS. After the tumor excision procedure
proceeded to 5–10 mm, the tumor was excised using Endo GIA stapler (30 mm,
white).
The patient was discharged from our hospital at postoperative day 5 without any
complications. Pathological findings indicated the presence of a carcinoma within
the adenoma with margins free from the carcinoma. Thus, transanal tumor resection
with SILSTMport is an effective procedure that can be easily performed. We suggest
that it can be useful for transanal endoscopic resection.
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P093 – Different Endoscopic Approaches
THE SCARLESS LAP CCE, OR HOW TO MIMICK
SINGLE-PORT ESTHETICS WITHOUT FANCY TOOLS
A.B.S. de Gheldere, P.W.M. Vanclooster, J. Fierens
Heilig Hart Ziekenhuis, LIER, Belgium
Single-port laparoscopic surgery is on the rise. So far however, the only proven
advantage of single-port surgery is superior esthetic results. The major drawbacks
are reduced ergonomy and extra costs, the latter probably limiting it’s implemen-
tation in a lot of centers.
We propose an approach for lap. CCE offering an esthetic result comparable to
single-port Lap CCE using regular instruments.
Key points in the technique are highlighted:
– the optimal use of the natural umbilical scar offering access to two trocars.
– strategic placement of the ancillary trocars in either existing skin creases,
existing scars or in a suprapubic position.
– the use of traction stitches on the gallbladder fundus to retract the gallbladder if
needed without extra scar.
– The eventual use of a Verres needle as liver retractor if needed.
– The use of long instruments to cope with the suboptimal ergonomics of this
approach.
Since july 2009, all lap CCE deemed feasible by this approach were performed by
the first author this way. In the initial experience, less than 50 % of the lap CCE were
performed this way (31/79 in 2010), while nearly all lap CCE are started this way
nowadays. Conversion threshold however is low, namely in case of obesity, unclear
anatomy, dense adhesions or less than optimal exposure. Approach and technique are
highlighted by numerous pictures and video fragments. We believe that this
approach can emulate the esthetic results achieved by single-port lap CCE with
comparable or better ergonomics and a cost not exceeding ‘classic’ lap CCE.
P094 – Different Endoscopic Approaches
A NEW WAY OF ACCESS TO THORACIC CAVITY WITH
OPEN ABDOMINAL SURGERY -TRANSDIAPHRAGMATIC
APPROACH-
M. Ishizaki, H. Sato, H. Torigoe, H. Kawai, S. Kinoshita, N. Waki,
H. Nishi, M. Mano
Okayama Rosai Hospital, OKAYAMA CITY, Japan
Aims: We developed a new thoracoscopic approach to the thoracic cavity when
abdominal open operation is done simultaneously. This approach enables to make
the postoperative thoracic pain minimum, so it is very attractive for the patients who
have thoracic and abdominal disease simultaneously.
Methods: 54-year-old gentleman came to our division for double gastric cancers.
Then he was found to have a giant bulla in the right upper lobe. He was scheduled for
open total gastrectomy, and we decided to resect the bulla in the right upper lobe
simultaneously through right diaphragm. Only one port for the thoracoscopy was
added through the intercostal space on the lateral thoracic wall, and other manipu-
lation was made through right diaphragm. This is so called ‘transdiaphragmatic
approach’. First we resected bulla in the right upper lobe, and then we resected his
stomach totally with lymphnodes dissection. Post-operative course was very smooth
with little pain in the thoracic wall, and discharged on the 12th day after surgery.
Conclusion: Transdiaphragmatic approach is a new and attractive method for the
patients who have abdominal and thoracic disease simultaneously.
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Surg Endosc (2013) 27:S53–S166
P095 – Different Endoscopic Approaches
MINIMALLY INVASIVE TENSOR FASCIA LATA HARVEST
FOR USE IN SUSPENSION PROCEDURES
A. Rebecca, S. Gnagi, J. Lackey, W. Casey
Mayo Clinic, PHOENIX, United States of America
Aim: To evaluate the use of minimally invasive tensor fascia lata (TFL) harvest for
use in suspension procedures. Many uses are noted including but not limited to
urethroplasty, static suspension in facial paralysis, parastomal hernia repair pub-
ovaginal slings, dural patch repair and tendon repairs. Our patient suffered from oral
incompetence secondary to scleroderma and had failed other modes of treatment. We
proposed a minimally invasive fascial harvest for static facial sling.
Method: Tensor fascia lata harvest from the leg was achieved under direct visuali-
zation utilizing the vasoview hemopro endoscopic harvesting system (Maquet). The
entire length of the tendon was easily visualized, mobilized and accessed through
two incisions 1 cm and 3 cm in length. A tendon graft 2 cm wide by 32 cm long was
obtained without difficulty and used for a static facial sling. Result: The patient
achieved excellent oral competence with the TFL sling. There were no notable
complications or complaints of pain at the donor site.
Conclusion: Endoscopic harvest of tensor fascia lata results in a better overall result
due to limited incisions, decreased pain and complication at the donor site and direct
visualization of the tissue to be harvested. The length and width of the TFL graft is
easily altered to fit the need of the patient and surgeon. This technique is easily
adapted to multiple surgical specialties.
P096 – Different Endoscopic Approaches
DIAGNOSTIC LAPAROSCOPY THROUGH THE DEEP
INGUINAL RING DURING INGUINAL HERNIA REPAIR:
A LITERATURE BASED REVIEW
N. Ladwa, M. Sajid, M.K. Baig, P. Sains
Worthing Hospital, WORTHING, United Kingdom
Objective: The objective of this article is to systematically review the published
literature on the role of diagnostic laparoscopy through the deep inguinal ring during
inguinal hernia repair.
Methods: Standard electronic databases were searched reporting articles on the role
of diagnostic laparoscopy through the deep inguinal ring during inguinal hernia
repair. We included all types of published studies in any language and on patients of
any age and gender.
Results: Twenty-eight articles on 5834 patients undergoing diagnostic laparoscopy
through the deep inguinal ring during inguinal hernia repair were retrieved from the
electronic databases. There was one randomized, controlled trial, 5 case reports and
24 case series. Seven articles were reported to assess the bowel viability following
spontaneous reduction of strangulated hernia in adults. Overall, the laparoscopy
group had a reduced operative time, reduced length of hospital stay, lower com-
plication rates and earlier return to normal activities.
Twenty-one articles were reported to assess the contralateral deep ring in paediatric
patients. Laparoscopy success rate was reported in more than 95 % patients. Con-
tralateral patent processus vaginalis indicative of inguinal hernia was found in more
than 48 % children undergoing diagnostic laparoscopy through deep inguinal ring.
There was no major morbidity reported in any group.
Conclusion: Diagnostic laparoscopy through the deep inguinal ring during inguinal
hernia repair may be performed safely when indicated. Routine use of deep ring
laparoscopy is an established practice in children. There is still insufficient evidence
to recommend the routine use in adults. A major randomized, controlled trial is
required to validate these findings.
Surg Endosc (2013) 27:S53–S166
P097 – Different Endoscopic Approaches
MINIMALLY INVASIVE RIGHT COLECTOMY FOR
CANCER: INTRA VERSUS EXTRACORPOREAL
ANASTOMOSIS. A MULTI-INSTITUTIONAL EXPERIENCE
W.L. Petz1, M. Montorsi2, E. Opocher3, L. Casali1, S. Bona2,
A. Pisani Ceretti3, P.P. Bianchi1
1
European Institute of Oncology, MILANO, Italy; 2Istituto Clinico
Humanitas. School of Medicine. University of Milan, MILANO,
Italy; 3Ospedale San Paolo. School of Medicine. University of Milan,
MILANO, Italy
Background: The technique of minimally-invasive right colectomy is not still defined as the
role of intra corporeal (IA) or extra corporeal (EA) anastomosis. Aim of this retrospective
study is to evaluate oncological safety and short term clinical outcomes of two groups of
patients who underwent minimally invasive (laparoscopic or robotic) right colectomy for
cancer with IA and EA.
Methods: From March 2001 to December 2011, 228 patients underwent minimally-invasive
right colectomy for adenocarcinoma in three different Hospitals, 111 with IA (11 robotic)
and 117 with EA (2 robotic). The data were retrospectively analyzed from a prospective
data base.
Results: Patients in the two groups were comparable in terms of mean age (66 ± 13 years in
IA group, 69 ± 11 EA group) and mean body mass index (26 ± 4 and 25 ± 3 kg/m2
respectively). Mean surgical time was 243 ± 57 minutes in IA and 202 ± 62 minutes in EA
group (p: 0.0001), blood losses were negligible in both groups. Length of laparotomy was
4.5 cm in IA and 6.3 cm in EA group (p: 0.001), first bowel movements were observed after
2 ± 1 days in IA and after 3 ± 1 days in EA (p:0.0014), mean hospital stay was 7 ± 6 days
in IA and 9 ± 6 days in EA group (p: 0.06). Mean number of harvested lymph nodes per
patient was 25 ± 9 in IA and 22 ± 10 in EA group (p: 0.01). In all the patients, resection
margins were negative. Overall major complications rate was 7% in both groups, incisional
hernias occurred in 2% of the patients in both groups and infection of minilaparotomy in
3% of the patients in IA and 6% of the patients in EA. Small bowel obstruction verified in
2% of the patients in IA and in 3% of the patients in EA.
Conclusions: Intracorporeal anastomosis in robotic or laparoscopic right colectomy seems
to produce better results than the extracorporeal technique. The robotic assistance, facili-
tating fine surgical gesture as intracorporeal suturing, may contribute to expand the use
of IA.
P098 – Different Endoscopic Approaches
LAPAROENDOSCOPIC SINGLE SITE SURGERY WITH
NEW INSTRUMENTS
R. Torres Peña, J. Barreras González, J. Ruiz Torres, O. Campillo
Dono, J.B. Olivé González
Centro Nacional de Cirugı́a de Mı́nimo Acceso, HAVANA, Cuba
Aims: Several techniques of Laparo-endoscopic Single Site (LESS) surgery have been
described. This paper shows the preliminary results of a clinical trial (phase I) based on a
new modality of LESS surgery using new designed instruments. The study was aimed at
determining the technical feasibility and safety of the proposed procedures.
Methods: For this study, conducted from January 2010 to December 2011, several proto-
types of improved laparoscopic instruments were devised. The procedures were based on
the use of one working channel laparoscope in order to avoid the conflict between the
surgeon and the assistant; and the use of a retraction system (TORCAM device) based on
1.2-mm wires specially designed in order to achieve enough triangulation for a safe dis-
section. The proposed LESS-techniques, including cholecystectomies, hysterectomies and
hepatic cyst fenestrations were performed by two surgeons. Surgical outcomes were pro-
spectively recorded.
Results: Forty-five LESS procedures including cholecystectomies (27), hysterectomies (16)
and hepatic cyst fenestration (2) were performed in 42 selected patients. LESS-cholecys-
tectomy was evaluated in 27 cases of non-complicated symptomatic gallbladder diseases.
The mean age was 36 years (range, 17–57) and the sample included 23 women. The mean
BMI was 24.4 (range, 21.9 to 27.5); the mean operative time was 62 minutes (range,
41–80). LESS-hysterectomy was proposed in 16 benign uterus diseases. The mean age was
47 years (range, 35–76); mean weight of uterus was 230 g (range, 138–300); intraoperative
bleeding was 75 ml (range, 20–400). The mean operative time was 115 minutes (range,
75–160). All LESS procedures were successfully performed. No conversion to open surgery
or additional trocars were necessary. Two minor complications were reported: a disruption
of the gallbladder during the umbilical extraction with no consequences on the follow-up;
and a vaginal vault abscess. The cosmetic result was considered optimal in all patients at
one month.
Conclusions: In light of the advantages related to the quality of triangulation and ergonomic
conflict, among others, the proposed LESS procedures are recommended as innovative
techniques that have proven feasible and safe in selected patients. Nevertheless further
randomized clinical trial (phase II) is needed.
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P099 – Different Endoscopic Approaches
BLASTOMATIC MECHANICAL JAUNDICE: DIAGNOSIS
AND TREATMENT
I.V. Sarian
Institute of General and Emergency Surgery, KHARKOV, Ukraine
Introduction: When surgical treatment of liver and extrahepatic biliary tract most
difficult may be recognized by those who are accompanied by persistent obstruction
of main bile duct, followed by the development of mechanical jaundice (MJ).
Problems of diagnosis and differential diagnosis of bile duct obturation reasons not
lost their relevance at this time.
Materials and methods: Analyzed 215 patients with treatment blastomatic MJ aged 43
to 91 years in the last 7 years. Of these, 119 men and 96 women (1:1.2).
Neoplastic nature of the disease was caused by cancer head of pancreas (pancreas), a
large duodenal papilla, gall bladder, common bile duct, porta hepatis and metastases in
liver cancer.
Results and discussion: Acute jaundice was observed in 93 (43.3%), jaundice, which
was delayed in 59 (27.4%), chronic – in 63 (29.3%) patients. The average level of total
bilirubin was 237.7 ± 136.2 mmol/l (from 88 to 523).
The accumulated experience in treating patients with MJ allowed us to develop and
implement a new algorithm for diagnosis and treatment of this pathology, which
includes, in addition to standard clinical and laboratory study of the above methods of
instrumental studies, most of which if necessary can be converted from diagnostic
medical procedures.
Conclusions: Minimally invasive endoscopic through the skin through the liver and
laparotomic (mini access) relief interventions are an effective way to restore the
outflow of bile with obstruction of biliary system against cancer. These techniques
allow you to quickly and effectively eliminate the MJ and cholangitis, make it
possible to perform surgery in the most favorable conditions, especially in chronic
jaundice in a planned manner and in elderly patients and with severe co-morbidities
can be an alternative to surgical treatment.
In acute jaundice and compensated the patient can perform radical surgery without
prior decompression of biliary tract.
P100 – Different Endoscopic Approaches
HYBRID TRANSVAGINAL NOTES CHOLECYSTECTOMY.
WHY NOTES WHEN WE HAVE LAPAROSCOPY?
V. Syrovatka, J. Rohac, P. Vozeh
Hospital Melnik, Melnicka zdravotni a.s., MELNIK, Czech Republic
Background: In the past decade there seems to be nothing more exciting in surgery
than NOTES. An innovating philosophy offering a promise of less pain, no visible
scars, reduction of hernia risk and wound infection. But is it worth the effort when
we have laparoscopic cholecystectomy (LC)? We tried to find out.
Methods: Hybrid transumbilical 5 mm laparoscopic access and posterior colpotomy
is used. Laparoscopic port inserted through umbilical scar is used for a 5 mm camera,
dissector, coagulation hook, clip applier and to monitor intraabdominal pressure.
Transvaginal access is used for an endoscope and grasper. Cholecystectomy is
carried out in a conventional laparoscopic manner and gallbladder is extracted
through posterior colpotomy. Entire procedure is carefully monitored from its
beginning to the end in turns by a five millimeter laparoscopic camera and an
endoscope. Colpotomy is closed from vagina using absorbable suture.
Results: Forty patients with symptomatic gallstone disease or polyps were op-erated on
by hybrid transvaginal NOTES cholecystectomy. Mean age was 44.8 years. Mean BMI
was 27.6. Mean operation time was 58 minutes. All patients were discharged on second
post op day the latest. Pain control was achieved usually by a single dose of a non-
opioid analgesic. There was one conversion to a laparoscopy due to cholecystitis. We
had no complications due to the vagina access, neither to the cholecystectomy itself.
Conclusion: Hybrid transvaginal NOTES cholecystectomy can be successfully per-
formed with common instruments and in a traditional laparoscopic way. It is a
feasible, safe and repeatable procedure, so far without any intra or postoperative
complications in our group.
It brings great benefits as short hospitalization, minimal pain, fast recovery and early
return to a normal way of life. We also cannot forget the excellent cosmetic result, an
aspect that may be of great importance to a certain part of our patients. We are
confident that hybrid transvaginal NOTES cholecystectomy is as safe as standard LC
but it adds benefits, which LC cannot provide. Hybrid transvaginal NOTES chole-
cystectomy may certainly be a matter of choice for a certain part of patients
otherwise requiring laparoscopic cholecystectomy.
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P101 – Different Endoscopic Approaches
‘LAPAROSCOPIC VERSUS OPEN TOTAL GASTRECTOMY
IN PATIENTS WITH GASTRIC CANCER’
L. Haverkamp, J.P. Ruurda, P.C. van der Sluis, R. van Hillegersberg
UMC Utrecht, UTRECHT, The Netherlands
Aims: To compare laparoscopic total gastrectomy (LTG) with open total gastrectomy
(OTG) with respect to morbidity, mortality, oncologic outcome, and functional recovery.
Methods: From 2000 until 2012 a total of 49 consecutive patients with gastric cancer
underwent LTG or OTG at the University Medical Center Utrecht. A retrospective
database was constructed and analyzed with the use of SPSS in an intention to treat
model. Data are presented in medians with range between brackets.
Results: A total of 27 (55%) patients underwent OTG, compared with 22 (45%) patients
who received LTG. Conversion from LTG to OTG occurred in 8 (36%) patients. Reasons
for conversion were tumor ingrowths in surrounding structures (6 patients), arterial bleeding
(1 patient), and venous bleeding (1 patient). The median duration of OTG was 240 (225)
minutes, whereas the duration of LTG was 303 (273) minutes (p = 0.01). Blood loss for
OTG was 613 (2900), compared with 250 (2670) for LTG (p = 0.01). In the OTG group 2
(7%) patients died during hospital stay, compared with 0 (0%) patients in the LTG group (p
= 0.18). Complications were comparable between both groups, except for sepsis and ate-
lectasis. In the OTG group 9 (33%) patients developed sepsis, whereas only 1 (5%) patient
in the LTG group suffered from sepsis. Atelactasis was seen in 18 (67%) OTG patients and
8 (36%) LTG patients (p = 0.04). Reoperation was required in 11 (41%) OTG patients,
compared with 2 (9%) LTG patients (p \ 0.01). Functional recovery was faster in LTG
patients. Hospital stay was 25 (181) days in the OTG group, compared with 13 (16) days in
the LTG group (p \ 0.01). Intensive care stay was 6 (57) days for OTG patients, whereas
LTG patients spend 0 (8) days at the intensive care (p \ 0.01). Radicality of resection was
similar in both groups. R0 resection was achieved in 22 (81%) OTG patients and 18 (82%)
LTG patients (p = 0.98). Interestingly, the lymph node yield was 15 (31) in the OTG group
and 26 (48) in the LTG group (p = 0.01).
Conclusion: Bloodloss, functional recovery, morbidity, and lymph node yield were
improved for LTG compared with OTG, at the cost of a longer surgical duration.
P102 – Different Endoscopic Approaches
CHEAPER DOES NOT NECESSARILY MEAN INFERIOR
S.R. Magill, S. Brown, H. Koh, M. Vella, P. Finn, L. Chisholm,
A. Renwick
Royal Alexandra Hospital, PAISLEY, United Kingdom
Introduction: When the country is facing greater austerity measures, greater emphasis is
made of getting value for money. A recent service change at one of our sites meant we were
able to objectively quantify the quality of service provision given such an austere shift. One
site (Site 2) began solely utilising the equipment from a cheaper manufacturer for endos-
copy and colonoscopy. We prospectively evaluated the completion rates, use of sedation
and comfort scoring for all colonoscopies performed by three colorectal surgeons between
two sites. Endoscopists all favoured the more expensive equipment and thought that service
quality may be affected. Site 1 used the equipment which was valued by them as being
100% more expensive than that used in Site 2.
Methods/ Results: Data for 836 endoscopies, performed by three different surgeons, was
prospectively collected. Overall completion rates was 89.9% at site 1 (n = 490) and 92.2%
at site 2 (n = 346). There was no a significant difference (p = 0.182). Completion rates for
each consultant between the sites also showed no significant differences.
The mean dose of Midazolam between the sites showed no significant difference in the
overall comparison (3.576 mg vs. 3.512 mg, p = 0.413), however statistically significant
lower doses were observed in 2 of the consultants’ Midazolam use at site 2 (3.23 mg vs 2.79
mg, p = 0.00 (n = 346/129) and 3.19 mg vs 2.95 mg, p = 0.022(n = 22/90)). The use of
analgesics showed no statistical differences between the sites (49.57 mg vs 49.07 mg, p =
0.22).
Comfort score comparison showed no statistical differences overall (p = 0.969). However
for two of the consultants evaluated the comfort scoring at site 2 was significantly better (p
= 0.029 and p = 0.002).
Conclusion; Since the introduction of cheaper endoscopic equipment at one of the
sites, completion rates, use of sedation and comfort scores have been comparable
between the sites. Therefore we conclude that the quality of service provision is not
diminished by the type of equipment utilised for endoscopic tasks.
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Surg Endosc (2013) 27:S53–S166
P103 – Different Endoscopic Approaches
RARE DISEASE IN A PATIENT ADDMITED FOR
GALLBLADER STONE
A.R. Stoian1, M. Popescu2, V. Strambu3, E.V. Radu1, G.A. Manea1,
M.A. Sandu1, V.T. Grigorean1
1
‘‘Bagdasar-Arseni’’Emergency Hospital, BUCHAREST, Romania;
2
District Emergency Hospital, PITESTI, Romania; 3Clinical
Nephrolody Hospital ‘‘Carol Davila’’, BUCHAREST, Romania
Introduction: Sometimes gallbladder stones may induce in a patient different
symptoms which may vary from classical clinical symptoms to atypical presenta-
tions – such as those in biliary ileus (gallstone ileus).
Aims: A 50 years old male, known with appendectomy, presented in our clinic with
right upper abdominal and right lower abdominal pain, nausea, vomiting, anorexia
and the absence of intestinal transit for gas symptoms that appeared for about 72
hours before admission. The abdominal US revealed a very large gallbladder, with
thick walls, containing multiple stones of app 0.8–1.2 cm and distended small bowel
loops in the upper and lower right abdomen. The plain abdominal X-ray showed
multiple hidro-aeric levels and important intestinal distension. Blood works revealed
leukocytosis, neutrophilia, monocytosis, lymphopenia, trombocytosis and increased
inflammatory markers.
Methods: Our patient underwent a laparoscopic surgery; intraoperatory was dis-
covered an incisional hernia in the lower right quadrant, acute colecystitis with an
intense adherent process surrounding the gallbladder and a small bowel invagination
that contained a tumour – on the terminal portion of the ileon. The cholecystectomy
and the enterectomy were made in this laparoscopic approach, and the mechanical
anastomosis of the small bowel was made by opening the defect of the incisional
hernia from the lower right quadrant, with it’s surgical correction.
Results: The postoperative evolution of the patient was favourable; he presented
intestinal transit in the 5th postoperative day, had good food tolerance. He was
dismissed in the 7th postoperative day. The pathological result shown a GIST tumour
of the small bowel.
Conclusions: Even in the cases that presented with atypical symptoms the laparos-
copy it’s useful both for the diagnosis and for the surgical treatment. The
laparoscopic approach it’s preferred to the classic surgery in terms of short hospi-
talisation, lower costs and overall recovery of the patient.
P104 – Different Endoscopic Approaches
LAPAROSCOPIC IMPLANTATION OF DISTAL
PERITONEAL VENTRICULO-PERITONEAL SHUNT
CATHETER. A COMPARATIVE STUDY
A. Mahajna, O. Cohen-Inbar, E. Cochran, U. Hadelsberg, M. Zaaroor
Rambam Health Care Campus, The Technion- Israel I, HAIFA, Israel
Background: Ventriculo-peritoneal shunts (VPS) are a common treatment for
hydrocephalus. Placement of the distal abdominal catheter can be difficult in the
setting of advanced age, previous shunt or abdominal surgeries, obesity, chronic
illnesses etc. at our institute, part of the procedures are performed using a multi-
disciplinary team of a neurosurgeon and a laparoscopic surgeon. We evaluated the
influence on prognosis of a laparoscopically assisted VPS placement using a single-
port technique as compared to the conventional mini-laparotomy approach.
Methods: A retrospective review of all patients admitted and operated at our institute
for hydrocephalus or shunt dysfunction during 2006–2010 was performed, forming a
cohort of 302 patients, 48 with single trocar laparoscopy. Neurosurgeons and lapa-
roscopic surgeons logged the presenting symptoms, past medical history, chronic
illnesses and past surgical procedures. Surgical procedure and findings were logged
as well. Outcome data was collected at several time points after the surgical
intervention.
Results: The laparoscopic patients group was significantly much older, had more
chronic illnesses and had significantly more prior abdominal and shunt operations.
And still, this group had the same outcome as the open minilaparotomy group,
expressed in several independent outcome parameters.
Conclusions: Elderly patients or those suffering less optimally controlled chronic
illnesses and obesity, as well as those patients who underwent previous abdominal or
shunt operations may benefit from the laparoscopic single port technique for distal
catheter placement during VPS procedure. This is shown to reduce the surgical
complications and equals the outcome parameters to those of the young, otherwise
healthy patients.
Surg Endosc (2013) 27:S53–S166
P105 – Different Endoscopic Approaches
ONE-PORT LAPAROSCOPIC COMMON BILE DUCT
EXPLORATION WITH T-TUBE CHOLEDOCHOSTOMY FOR
MANAGEMENT OF CHOLEDOCHOLITHIASIS: ONE CASE
REPORT.
A. Smirnoff1, G. Goudard1, L. De Poncheville2, E. Drapier2,
N. Kagan1
1
Hospital, LA ROCHELLE, France; 2Clinique du Mail,
LA ROCHELLE, France
We describe here a case of common bile duct stone in an elderly woman operated
using the single-port method. This procedure involved cholecystectomy, choledo-
chotomy, the choledoscopic removal of ductal calculi and T-tube choledochostomy
using conventional methods with standard laparoscopic instruments. There were no
complications and no residual stones. The operating time was 101 min and the
overall hospital stay lasted 6 days. Laparoscopic common bile duct exploration using
the single-port method is technically demanding but this concept could be applied in
the future for other frail patients with poor parietal healing potential.
P106 – Different Endoscopic Approaches
SINGLE PORT LAPAROSCOPIC LOOP ILEOSTOMY FOR
ANASTOMOTIC DEHISCENCE AFTER COLORECTAL
SURGERY
S.W. Chung, S.Y. Lee, S.H. Yun, Y.A. Park, Y.B. Cho, H.C. Kim,
W.Y. Lee, H.K. Chun
Samsung Medical Center, SEOUL, Korea
Aims: The aims of this study was to describe a novel technique of single port laparoscopic
loop ileostomy for fecal diversion and to report our experience with six patients who
underwent this procedure for anastomotic dehiscence after colorectal surgery.
Methods: We conducted a retrospective study performed by experienced laparoscopic
surgeons at a single institution. From October 2011 to November 2011, 6 patients under-
went single port laparoscopic loop ileostomy for anastomotic dehiscence after anterior
resection for colorectal cancers. Fecal diversion was performed in lithotomy position. The 2
to 3 cm round incision was performed in the right lower quadrant at the predetermined
ileostomy site. All cases, we used custom made single glove port. A wound retractor was
placed on the edge of the abdominal incision and covered with a surgical glove. After
setting the pneumoperitoneum to 12 mmHg we approached anastomosis site and peritoneal
lavage was performed. The bowel is grasped with a laparoscopic grasper and delivered
through the ileostomy incision, taking care to maintain proper orientation. At this point, the
port is removed and ileostomy is matured in usual fashion.
Results: All patients were male. Median patients age was 53.0 years (range 45–69). The
initial surgeries were as follows; open low AR with liver resection (1), hand assisted
laparoscopic AR(1), SPL AR(1), SPL low AR (2), multiport laparoscopic low
AR(1).Median level of anastomosis was 7.0 cm (range 4–17). Median duration between
initial surgery and reoperation was 5.0 days (range 2–6). There was no conversion to open
procedures. The median operative time was 118.0 minutes (range 81–142).. Median day of
first soft diet was 4 days (range 3–10). Length of postoperative hospital stay was 9.5 days
(range 8–13), and only one patient developed a mild paralytic ileus. There was neither
wound complication, complications associated with ileostomy, reoperation nor postopera-
tive death.
Conclusions: Single port laparoscopic loop ileostomy for anastomotic dehiscence after
colorectal surgery is a feasible alternative to standard laparoscopy for fecal diversion. With
this procedure, It may offer better cosmetic outcomes, reduce incisional pain, reduce wound
complication.
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P107 – Different Endoscopic Approaches
TRANS-AXILLARY RETRO-MAMMARY (TARM)
APPROACHED VIDEO-ASSISTED BREAST SURGERY
(VABS) NEEDS NO INJURY ON THE WHOLE BREAST
WITH GOOD ESTHETIC OUTCOMES
K. Yamashita, S. Haga, K. Shimizu
Nippon Medical School, TOKYO, Japan
Background: The breast conserving surgery and the sentinel node (SN) biopsy became to be
recognized as the standard treatment for early breast cancers. We have reported about
cosmetic effectiveness and lower infestation of the video-assisted breast surgery (VABS)
for the breast diseases. 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 evaluated the aesthetic results and the curability of this
surgical method.
Methods: We have performed VABS on 300 patients since December, 2001. The newly
devised trans-axillary retromammary approach (TARM) was performed on 120 patients of
early breast cancer, stage I and II. After endoscopic sentinel node biopsy, we elongated the
axillary skin incision to 2.5 cm. We dissected major pectoral muscle fascia to detach
retromammary tissue under the tumor. We cut the proximal side of the gland vertically, and
dissect skin flap over the tumor. Then we cut each sides vertically and removed it through
the axillary port. The breast reconstruction was done by filling absorbable fiber cotton
(oxidized cellulose). The postoperative aesthetic results were evaluated by ABNSW.
Results: The skin incision was made only in the axilla. We do not use the special disposable
apparatus. The operative cost is very low. It could be applied for any tumors even in the
medial or caudal side of the breast. All surgical margins were negative. There was no
significant difference in operational infestation. The reconstruction by filling absorbable
fiber needs no excessive detachment of the skin beyond the surgical margin of mammary
gland. The breast shape could be maintained easily. The postoperative esthetic results were
excellent and good. The sensory disturbance was minimal, observed only in the detached
area within the surgical margin. All patients were satisfied with this operation.
Conclusions: TARM approach of VABS needs no injury on whole breast with single
incision in the axilla.
P108 – Different Endoscopic Approaches
MODERN OPPORTUNITIES OF ENDOVIDEOSURGICAL
TECNOLOGIES IN THE TREATMENT OF ACUTE
CHOLECYSTICS WHICH IS COMPLICATED BY
MECHANICAL JAUDICE
D.V. Fokin1, V.A. Dudarev2, I.V. Kirgizov3
1
Public health services municipal authority city clinical hospital #20
of a name, KRASNOYARSK, Russia; 2Krasnoyarsk state medical
university of a name of professor V.F.Vojno-Jasenetsky,
KRASNOYARSK, Russia; 31st MSMU after I.M. Sechenov,
MOSCOW, Russia
Aim: Estimate possibilities of endovideosurgical technologies in the treatment of
acute cholecystics which is complicated by mechanical jaundice.
Materials and Methods: In the period from 2006 to 2008 years there were 425
patients with the acute cholecystics,59 patients (11,7%) have had symptoms of bile
hypertension. Diagnosis was fitted by using clinical data and minimum lab obser-
vation and ultrasonic scanning (US) of hepatopancreatoduodenal area (HPDA)
organs. After that we tried to make the endoscopic retrograde cholangiopancrea-
tography (ERCP) for all patients. We have managed to make ERCP to 50th (84.75%)
patients. Among 9th (2.1%) patients the trials of ERCP were unsuccessful.
Results of the investigation: The reasons of bile hypertension were managed to disposed by
endoscopic papillotomy (EPT) among 39th (66.1) patients. After successful EPT the positive
dynamic of the acute cholecystics was reached among 30th (50.8%) patients. For all patients in the
planning regimen were made laparoscopic cholecystectomy (LCT). The operation was made in a
harry for 12th (20.3%) patients because of positive dynamic for acute cholecystics absence. For the
fifth patients of them was managed to make LCT. The reasons of conversion among the rest 3 d
patients were difficulties during the LCT connected to evident infiltrate in a gallbladder neck. The
reasons of bile hypertension were not disposed by using EPT among 7th (14%) patients. It can be
explained by high strictures of choledoch and incapability of major duodenal papilla (MDP) full
dissection because of anatomy peculiarities. LCT was made for all of them. The bile hypertension
symptoms were not found in all cases. It can be explained by decreasing of inflammation infiltrate
in the choledoch area. During LCT the conversion was made for all of them because of incapability
to continua operation endoscopy because of evident inflame infiltrate into the gallbladder neck and
choledoch areas.
Conclusion: ERCP and EPT for acute cholecystics which is complicated by mechanical jaundice
allow to get full regression of disease in the major cases and to make LCT in the planning order. If
the positive dynamic is absent this tactic allows making minimal invasive surgical intervention.
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P109 – Different Endoscopic Approaches
INTRALUMINAL OPERATIVE TREATMENT OF GERD
IN CHILDREN BY MEANS OF A TOOL-SEWING
ATTACHMENT-COMPLEX FOR GASTROSCOPES ESOFIX
D.V. Fokin1, I.V. Kirgizov2, M.M. Lochmatov3, A.A. Gusev3,
T.A. Prudnikova3, D.V. Fokin1
1
Public health services municipal authority city clinical hospital #20
of a name, KRASNOYARSK, Russia; 21st MSMU after I.M.
Sechenov, MOSCOW, Russia; 3Federal state budgetary establishment
- Centre of science of health of children-, MOSCOW, Russia
Aim: to estimate efficacy of carrying out transoral intraluminal fundoplication in pediatrics.
Fundoplication is carried out by means of attachment-complex EsofiX suitable to any
modification of gastroscope, from 7.6 mm to 10.6 mm. in diameter. Optimum conditions for
the procedure are conditions of operating room, with videoendoscope equipment and
additional delivering of CO2 through biopsy channel of endoscope.
Materials and methods: TIF was carried out for the first time in Russia in the patient A, 16
years old. From the age of 4 he was observed in clinic with the diagnosis: gastroesophageal
reflux disease, a reflux-esophagitis, insufficiency of cardia, hyperacidity, continuously
progressing flow, resistance to conservative therapy. On EGDS erosive esophagitis,
insufficiency of cardia, gastro-esophageal prolapse, duodeno-gastral reflux came to light.
On 24 hour pH-metry before operation was revealed that pH \4 it = 23 at norm 4.5;
quantity of acid refluxes with pH \4.0 = 168 at norm 46.9; number of refluxes [ 5 mines –
7 at norm 3.5. Index De Meester 47.91 at norm \14.72.
Results: TIF was carried out by means of attachment-complex EsofiX. In 3 months after
operation, at control inspection on EGDS cardia closes completely, at inverse inspection
dense fit of mucosa of the generated LES to endoscope is marked. Results of the 24 hour
pH-metry after operation: the general pH\4 = 3 – normal; quantity of acid refluxes with pH
\4.0:: 7 (N), number of refluxes[ 5 mines = 1 (N). Index De Meester 9.85 (N) At carrying
out of water-syphon test no refluxes were observed. At control examination in 3 months
after operation no signs of the gastroesophageal reflux disease were revealed.
Conclusion: The newest procedure – transoral intraluminal fundoplication (TIF) by means
of attachment-complex EsofiX has proved to be as a highly effective method of treatment of
GERD.
P110 – Different Endoscopic Approaches
LAPAROSCOPIC RIGHT HEMICOLECTOMY USING THE
NEW S2 OCTOPORT DEVICE. SINGLE CENTER
EXPERIENCE
J. Cintas-Catena, J. Valdés-Hernández, L.C. Capitan-Morales,
J.C. Gómez-Rosado, J. Galan-Alvarez, J. Guerrero-Garcia,
F. Oliva-Mompeán
HUV Macarena, SEVILLA, Spain
Introduction: Laparoscopic right hemicolectomy has become a widely safe and
feasible technic, with al least similar oncologic outcomes than open approach, in the
treatment of right colon neoplasias with the advantages of the minimal invasive
surgery.
Technic: We used the S2 Octoport device in the right hypochondrium in addition to
an usual laparoscopic aproach. This device allows to start the surgery with the
assistance incision and without Veres needle and open pneumoperitoneum. In
addition to replacing one of the commonly used trocars and obviates the need for
extraction bags in oncological surgery.
Conclusion: The use of S2 Octoport device allows us to perform a safe colon cancer
surgery. There have been no major complications in our surgical series. The average
age of patients was 67 years. The average stay was 5 days. In all specimen there were
at least 12 lymphatic nodes. The cost analysis is similar by using the device, com-
pared with the cost of conventional laparoscopic surgery, minimizing the risk of
closed access to the abdominal cavity. No surgical infection or other wound com-
plication were seen.
123
Surg Endosc (2013) 27:S53–S166
P111 – Different Endoscopic Approaches
REDUCED PORT SURGERY FOR COLORECTAL
CANCER WITH SPECIAL REFERENCE TO A NOVEL
INTRA-ABDOMINAL ANCHOR SYSTEM
J.I. Tanaka, T. Omoto, Y. Takehara, K. Nakahara, D. Takayanagi,
M. Chiyo, Y. Wada, S. Mukai, E. Hidaka, S. Endo, F. Ishida, S. Kudo
Showa University Northern Yokohama Hospital, YOKOHAMA,
Japan
Objective: Technical difficulties of reduced port surgery (RPS) including single port sur-
gery (SPS) include inadequate retraction of tissues as well as inadequate triangular
formation. To overcome these difficulties we applied intra-abdominal anchor system for
RPS for colorectal cancer.
Methods: The EndoGrabTM (Virtual Ports, Israel) contains grasping forceps and posi-
tioning forceps, and it can be introduced into the abdomen through a 5-mm port. The
grasping forceps is attached the colon or mesocolon and the positioning forceps is anchored
to the any peritoneal surface reducing two ports of assistant surgeon. Therefore, retraction is
versatile, and retracting direction can be changed repeatedly during the surgery. Also during
the surgical procedure in the pelvic space, uterus or the bottom peritoneum can be retracted
by EndoGrab in order to obtain sufficient operative field.
Results: RPS colorectal resections in 25 patients were successfully performed with this
anchoring device. This intra-abdominal retractor device could be able to achieve superior
retraction and successfully to fix the colon or rectum toward to the peritoneal wall. There
were no significant injuries to the peritoneal wall and no pain noted after removal of the
device. Operative time for the procedure was reduced along the learning curve as we gained
familiarity with the technique and the device. Postoperative hospital stay is not longer than
that of conventional laparoscopic surgery.
Conclusion: The performance of RPS procedures for colorectal cancer with a novel intra-
abdominal anchor system not only yield the better cosmetic results and better cost per-
formance but also is most versatile method of tissue retraction during the procedures.
P112 – Different Endoscopic Approaches
LAPARO-ENDOSCOPIC SINGLE-SITE CHOLECYSTECTOMY:
PROSPECTIVE ANALYSIS OF THE REPRODUCIBILITY
BY STAFF AN RESIDENTS OF A STANDARDIZED
TECHNIQUE
S. Morales-Conde, J. Cañete, M. Socas, A. Barranco, I. Alarcón,
V. Gómez, J.M.H. Cadet, F.J. Padillo
University Hospital Virgen del Rocio, SEVILLA, Spain
Background: Following reports of Laparo-Endoscopic Single-Site (LESS) cholecystectomy
concerns have been raised over the level difficulty and a potential increase in complications
when moving away from conventional gold standard multi port laparoscopy due to
incomplete exposure and larger umbilical incisions. With continued development of tech-
nique and technology it has now become possible to replicate this standardized gold
standard through a LESS approach. First experiences with a newly developed technique and
instrument are reported.
Aim: The aim of this study is evaluate a standardized surgical technique for single port
cholecystectomy (SPC), to evaluate if this technique can be reproduced by an expert
surgeon in laparoscopy with no previuos experience in single port surgery compared with
surgeons who does not know the standardized technique and use the literature and videos
published by different companies to perform a SPC and to evaluate if this technique can be
reproduced by a resident with no previuos experience in single port surgery compared with
a resident who does not know the standardized.
Methods: Twenty-five patients presenting with cholelytiasis without signs of inflammation
were operated on using all surgical steps considered appropriate for the conventional 4 port
laparoscopic approach, but applied through a single access device. Operation centered
outcomes are presented. Five surgeons, two of them last year resident, are selected in to be
included in the study. Each surgons performed 5 SPC.
Results: There were no per- or postoperative complications. Mean operating time was 41
minutes. No conversion to regular laparoscopy was required, and the critical view of safety
was achieved in all cases. Mean skin incision length was 2.2 cm. The mean operating time
of the expert who doesn’t know the standardized technique and the resident was higher than
expert and resident that who know it.
Conclusions: How we can see in our results, this technique can be reproduced by surgeons
with no previuos experience in single port surgery and by Resident, but the operating time
and the stress of the surgery is less when we know a standardized technique and when there
is a master who show it us.
Surg Endosc (2013) 27:S53–S166 S81

P113 – Different Endoscopic Approaches P115 – Education

INTRODUCER PEG (IPEG): A SAFE TECHNIQUE FOR PRACTICE OF REPROCESSING AND SPECIFIC
ENTERAL ACCESSING IN ADVANCED OROPHARYNGEAL EXPERIENCES WITH INSPECTION SINCE 2003
AND ESOPHAGEAL MALIGNANCY CASES T.W. Fengler, A.R. Hartwig
S. Udomsawaengsup, K. Thanavachirasin, W. Utanwutipong, Cleanical Investigation & Application, BERLIN, Germany
S. Pungpapong, C. Tharavej, P. Navicharern Reprocessing of medical devices follows the law, considers recommendations, knows
Chulalongkorn University, BANGKOK, Thailand normation and has a common practice. Therefore, it is indispensable to control the daily
work. We present our experiences with cases of inspection by county. Before the visit,
Background: Nutrition supplement is a key to optimize advanced cancer cases to achieve
during the visit and after presentation of the catalogue of deficiencies it is recommended to
loco-regional and systemic treatment. Normal route of ingestion is limited in oropharyngeal
communicate precisely and free of emotions. Not everything can be solved in a moment,
and esophageal cancers. Conventional Percutaneous Endoscopic Gastrostomy (PEG) might
therefore it is crucial to clarify the priorities for improvement and change. Short but precise
not be able to introduce and intra-luminal cancer might be migrated along the tract. We
documentation as a part of the quality management are the main preconditions for a
have introduced a simple technique in placing a PEG tube directly under the endoscopic
successful management of inspection by third parties. Examples of our CSSD coaching are
guidance.
given in our lecture.
Methods: After a complete diagnostic endoscopy, a 5-mm trocar is introduced directly into
the gastric lumen using a safe track technique. A gastrostomy catheter is then inserted under
endoscopic monitoring through a trocar into the gastric lumen.
Results: From January 2009 to December 2011, there were 12 patients aged 29–68
year old underwent the introducer PEG. Five of them were advanced nasopharyngeal
cancers, three were esophageal cancers. There were cancers of tonsil, buccal mucosa
+ mid esophageal cancer, lung with hilar nodal metastasis. The youngest was
29-year-old man with osteosarcoma of right maxilla. Introducer PEGs were suc-
cessfully done in all cases without any procedural related complications. The feeding
started on the first day after the placement.
Conclusion: The introducer PEG (iPeg) is a safe and effective technique for enteral access.
It should be applied for patients with advanced oropharyngeal and esophageal cancers. The
iPeg could also be an alternative option to a regular PEG placement.

P114 – Different Endoscopic Approaches P116 – Education

IRREVERSIBLE ELECTROPORATION – PRELIMINARY YOUTH IS THE BEST TIME TO START TEACHING

RESULTS OF NON-THERMAL ABLATION THERAPY ENDOSCOPIC SKILLS
J. Stefka, V. Janik, R. Gürlich, Z. Otava, Z. Klezl, M. Kubecová S.A. Yeo, K.H. Ng, K.W. Eu, C.L. Tang
Faculty hospital of Královské Vinohrady, PRAGUE, Czech Republic SingHealth, SINGAPORE, Singapore
Background: Irreversible electroporation (IRE) using the NanoKnife System is minimally Aims: To compare the ability of learning endoscopic skills in young participants versus an
invasive, non-thermal tumor ablation therapy used as an alternative to surgery. Using high older group on a validated endoscopic simulator.
voltage (3000 V) pulsating direct current of 20–50 A in a microsecond electrical pulses to Methods: A group of 12 first year medical students is compared against a group of 12
cause cells death by permanent opening nano-sized pores in the membranes of the paramedical workers. Both groups are naı̈ve to endoscopy. A standardized briefing and
malignant cells. The electrical pulses are delivered through 2–5 needle electrodes places demonstration are performed for both groups prior to commencement of the study. Both
into and around the tumor’s ablation area. groups perform 10 oesophago-gastro-duodenoscopies (OGD) each for case 1 consecutively,
Method: Our initially experience with irreversible electroporation therapy includes treat- and 10 colonoscopies each for case 1 consecutively on the GI Mentor endoscopic sim-
ment of primary and secondary malignant tumors of different target organs – lung, liver, ulator. The results in both groups are compared.
pancreas and kidney. Fifteen patients (11 female, 4 male) were treated by NanoKnife Results: There were 12 participants in each arm. In the young group all the participants
between July to December 2011. Eleven patients were treated percutaneously, using CT were 20 years of age, with 9 participants having history of video game playing (75%) and
guidance, 4 patients were treated using (Ultrasound guidance?) laparoscopy. All procedures musical instrument use (75%) respectively. The older group has a mean age of 45.8 years
were performed under general anesthesia. Inclusion criteria included one or two tumors of (range 40–54 years) with 3(25%) participants from this group having history of video game
the target organs lung, liver, pancreas and kidney in which conventional therapy was not use and 1(8.3%) with previous musical instrument use.
possible or had been unsuccessful. All patients underwent clinical examination,biochem- In both the OGD and colonoscopy group, the average time to complete the scopes were
istry and a contrast enhanced Computed Tomography (CT) or Nuclear Magnetic Resonation similar in both groups (p = 0.61 for OGD and p = 0.89 for colonoscopy). However, mean
(NMR) examination before procedure. A post-procedure CT was obtained immediately mucosa examined (p = 0.04 for OGD and p = 0.001 for colonoscopy) and efficiency of
after percutaneously performed or 1 day after surgically performed IRE procedure to procedure (p = 0.014 for OGD and p = 0.002 for colonoscopy) were much better in the
confirmed if the entire region of the tumor had been ablated. The following CT examination young group compared to the older group. History of video game use and musical
was performed 1 and 6 month after IRE procedure. Group of primary malignancy included instrument use do not seem to have any significance.
2 patients with renal cell carcinoma 2 patients with pancreatic carcinoma and 2 patient with
lung’s carcinoma. The metastatic group included 7 patients with liver metastasis of the
colorectal carcinoma, 1 patient with liver metastasis of prostatic cancer and 1 patient with
liver metastasis of mammary carcinoma. After procedure were patients observed 48 hours
on Intensive Care Unit and after that discharged home.
Results: The IRE procedures of all patients were successfully performed and well tolerated.
A total 17 tumors were treated in the 15 patients. The number of IRE procedures per tumor
ranged from 2–8. The tumors treated ranged in size from 1.1 9 1.6 mm to 72 9 51 mm
(average 9.6 cm Meanwhile 10 patients had at least 1 month CT or NMR follow up. Tumor
necrosis with no residual enhancement was evidenced in 6 patients, tumor necrosis with
residual enhancement of occurred in 2 patients. A new lesions represents progression of the
primary malignancy were revealed in 2 patients. There was no evidence of adjacent organ
damage related to the IRE. One patients died 14 days after IRE for pulmonary embolization
which event was not directly related to IRE. Post-procedural CT examination revealed
pleural effusion in 9 patients treated percutaneously under CT guidance. Another patient
with two pulmonary lesions developed pneumothorax which was solved by three days
pleural drainage. We did not find out post-ablation symptoms related to the ablation pro-
cedure. No patients required prolonged pain relief after discharge.
Conclusions: IRE therapy offers safety, minimally invasive, non-thermal treatment of
malignant tumors, useful for patients who are not candidates for surgery.

123
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P117 – Education
A NOVEL REUSABLE AND COST EFFECTIVE TRAINING
MODEL FOR LEARNING LAPAROSCOPIC TOTALLY
EXTRA-PERITONEAL HERNIA REPAIR
B. Tang1, M. McMillian1, S. Kazmi2, I. Tait2
1
University of Dundee, DUNDEE, United Kingdom; 2Ninewells
Hospital and Medical School, DUNDEE, United Kingdom
Aim: To develop and evaluate a novel reusable and cost effective synthetic training
model for surgeons to learn totally extra-peritoneal (TEP) laparoscopic hernia repair.
Materials and methods: a model representing lower abdomen was designed with a
life-like abdominal wall, pelvis, and the related anatomy seen from extra-peritoneal
space. Different synthetic materials were selected, shaped, and coloured to simulate
the core anatomical structures such as inguinal ligament, internal inguinal ring, direct
hernia space, inferior epigastric vessel, iliac vessels, vas deferens, peritoneum of the
lower abdomen. Standard lapasoscopic equipment, instruments, and mesh were used
for the simulated TEP hernia repair practice on the model. A specific 1 (poor) to 5
(very useful) Likert-like scale questionnaire was used to collect feedback from the
surgeons for the evaluation of the quality of the model.
Results: 10 models were made in house and each one was used repeatedly. The cost
to make one model was about £150, which was very cost effective compared with
one bought at a price of £900 from the market. 98 surgical trainees have practiced
laparoscopic TEP hernia repair using this model over last two years. The overall
score for the model was 3.8 on a scale of 1 (poor) to 5 (very useful). For the feedback
on specific components of the model, port position, representation of the anatomical
structure, usefulness for identification of the important structure related the proce-
dure, instrument handling, and handling the mesh and orientation was scored at 3.95,
4.10, 4.15, 3.9, and 4.25 respectively.
Conclusion: a novel model allows an easier understanding and appreciation of a
complex anatomical region. It provides an opportunity to rehearse the essential steps
and techniques of totally extra-peritoneal (TEP) laparoscopic hernia repair. It is more
cost effective compared with one bought commercially.
P118 – Education
THE ACADEMIC CONTRIBUTION OF THE UNITED
KINGDOM IN THE FIELD OF ADVANCED MINIMAL
ACCESS SURGERY AND ENDOSCOPIC TECHNIQUES
A.H. Engledow, A. Murray, A. Razik, G. Conn, J. Mccullough
University College Hospital, LONDON, United Kingdom
Aims: The United Kingdom (UK) considers itself to be at the forefront of modern
healthcare. However the clinical uptake of minimal access surgery and advanced
endoscopic techniques has lagged behind that of comparable countries in Europe, the
United States of America (USA) and the Far East. The academic output of the UK is
assessed to see if the UK is on a par academically with these comparable countries.
Methods: Surgical Endoscopy (SE) is the highest ranked minimal access journal with
a ranking of 15 out of 187 general surgical journals currently published. It is the
journal associated with both the European (EAES) and American (SAGES) minimal
access societies. The impact factor in 2010 was 3.46. All publications in SE from
01/01 2006 to 01/01/2011 were reviewed and the nationality of the publishing
institution was recorded. This was used as a surrogate marker of academic activity in
the field of minimal access surgery.
Results: There were 2848 articles in total. In terms of numbers of articles published
the USA was ranked first followed by Japan, Italy and Germany with 883 (31%), 202
(7.1%), 194 (6.8%) and 189 (6.6%) published articles respectively. The UK was in
fact 5th with 183 (6.4%) published articles.
Conclusions: Using SE publications as a surrogate for high quality minimal access
surgery publications the UK is performing well when compared to comparable
countries. This is now mirrored by the increased clinical uptake of advanced minimal
access and endoscopic techniques in the UK.
123
Surg Endosc (2013) 27:S53–S166
P119 – Education
SKILLS DEVELOPMENT AFTER AN INTENSIVE BASIC
LAPAROSCOPIC TRAINING COURSE FOR GENERAL
SURGEONS, UROLOGISTS AND GYNAECOLOGISTS
F.M. Sanchez Margallo, S. Enciso Sanz, M.A. Sánchez Hurtado,
I. Dı́az-Güemes
Minimally Invasive Surgery Centre Jesus Uson, CACERES, Spain
Aims: Our objectives are to assess the surgical skills development through a intensive
hands-on course in laparoscopic surgery and to compare the skills enhancement among
different specialties: gynaecology, urology and general surgery.
Methods: Fifteen novice surgeons enrolled the study: five gynaecologists, five
urologists and five general surgeons. They attended an intensive basic course con-
sisting of simulator (1 day) and animal training (2 days). Different in vivo surgical
techniques were practiced depending on each specialty. Before and after the course,
all attendants carried out the following tasks on LAPMentorTM virtual simulator:
hand-eye coordination (1), hand-hand coordination (2) and object transference (3).
Different metrics were registered in order to analyse their skills dexterity: time,
number of movements, path length and speed of movements. Before and after
measurements were statistically analysed using the Wilcoxon test and data among
specialties was compared with Kruskal-Wallis test, applying U-Mann Whitney test
for further comparisons.
Results: After the course, surgeons performed all tasks faster (1: p = 0.003; 2: p = 0.003; 3: p =
0.008). Number of movements was reduced in task 1 (right instrument, p = 0.044), task 2 (right
instrument, p = 0.012; left instrument, p = 0.006) and task 3 (right instrument, p = 0.041). Path
length of the left instrument only decreased in task 2 (p = 0.006). Speed of movements was
increased in task 1 (right instrument, p = 0.049), task 2 (right instrument, p = 0.003; left
instrument, p = 0.004) and task 3 (right instrument, p = 0.013). Basal measurements among
specialties only showed a higher speed of movements by gynaecologists for task 2 (left
instrument, p = 0.039). After the course, general surgeons significantly reduced the path length
of the right instrument in task 2 compared to gynaecologists (p = 0.016). Moreover, in task 3 a
higher speed of the right instrument was observed for gynaecologists and general surgeons
compared to urologists (p = 0.032) and a higher speed of the left instrument was also observed
for general surgeons compared to urologists (p = 0.032).
Conclusion(s): Intensive basic training courses in laparoscopic surgery improve basic
surgical skills in novice surgeons. Gynaecologists and general surgeons seem to have a
higher development of skills, although further research is required to confirm it.
P120 – Education
PIG MODEL FOR TRAINING IN LAPAROSCOPIC
VENTRAL MESH RECTOPEXY
S.M.P. Lansen-Koch1, B. Tang2, M. McMillan2, G. Ross2, D. Ziyaie1,
K. Campbell1
1
Ninewells Hospital, DUNDEE, United Kingdom; 2School
of Medicine, University of Dundee, DUNDEE, United Kingdom
Aims: Rectopexy through an abdominal approach is the preferred surgical method in
otherwise fit patients with rectal prolapse. Whilst posterior rectal mobilisation and fixation
has been the traditional method of choice, in more recent time ventral mesh rectopexy
(VMR) has been gaining increasing popularity. This is largely due to avoidance of inad-
vertent neurological damage in the posterior rectopexy and the resulting post-operative
constipation in as many as 50% of the cases. Moreover laparoscopic rectopexy is proven to
be superior to the open technique with lower morbidity and shorter hospital stay.
It is acknowledged that formal laparoscopic training is essential in minimising complica-
tions following uptake of independent practice. Training on animal models and use of
virtual reality stimulators are the first steps taken in any form of laparoscopic training.
Anatomical variations, difference in tissue depth and thickness in the animal model and
lack of sufficiently developed virtual reality stimulators for advanced laparoscopic colo-
rectal training could pose limitations in providing a realistic challenge. We have assessed
use of pig model in overcoming some of these challenges mainly demonstrating comparable
pelvic anatomy, practice in fine tissue dissection and intracorporial suturing technique.
Methods: The model was used and assessed in 4 courses ran in 2010 and 2011 in an
intensive four day laparoscopic colorectal training programme designed for senior colo-
rectal trainees and consultants. Candidates were given an initial power-point presentation
on VMR that included literature review and operative video presentations followed by the
instruction video on the animal model. The participants in pairs performed the procedure in
the wet lab on two separate female pig models alternating as the main operator and the
cameraman. Participants were asked to rate the model in a questionnaire.
Results: Using the Likert scale (1 = not answered 2 = strongly disagree, 3 disagree, 4 =
agree, 5 = strongly agree), total of 76 participants responded to the questionnaire. Thirty
(39%) strongly agreed, 27 (36%) agreed, 19 (25%) did not answer the question. There were
no participants who disagreed.
Conclusions: The pig model can provide a highly realistic training model for laparoscopic
ventral mesh rectopexy.
Surg Endosc (2013) 27:S53–S166 S83

P121 – Education P123 – Education

THE MODERN APPROACH TO TRAINING CALOT’S TRIANGLE. A COMMON MISCONCEPTION OF

OF A CHILDREN’S SURGERY ENDO – AND BASIC ANATOMY
LAPAROSCOPIC IN THE RUSSIAN FEDERATION D. Veeramootoo, A. Bond, W.F.A. Miles, K.K. Singh
D.V. Fokin1, A.A. Gusev2, I.V. Kirgizov3, S.V. Minaev4 Worthing Hospital, WORTHING, United Kingdom
1
Public health services municipal authority city clinical hospital ?20 Aims: Dissection of the Calot’s Triangle (CT) is regarded as the key component to a safe lapa-
of a name, KRASNOYARSK, Russia; 2Federal state budgetary roscopic cholecystectomy. Yet, Jean Francois Calot in his doctoral thesis of 1891, named the
establishment -Centre of science of health of children-, MOSCOW, boundaries of his triangle as: the cystic duct, the common hepatic duct and the cystic artery. This
study aimed to review the medical literature on the description of CT.
Russia; 31st MSMU after I.M. Sechenov, MOSCOW, Russia; Methods: A focussed search was undertaken to evaluate the following: basic anatomy textbooks,
4
Ivanovo state medical academy, IVANOVO, Russia surgical textbooks and pubmed (articles about CT published in 2011).
Results: Two commonly used textbooks (Last’s and Gray’s anatomy) inaccurately described the
Aim: for the purpose of development endo- and laparoscopic treatment methods in pediatric inferior border of the liver as one boundary of CT instead of the cystic artery. Similarly, the ‘oxford
surgery in the Russian, in our clinic was established the newest integrated videoendoscopic surgical handbook of clinical surgery’ and ‘essential general surgical operations by Churchill Livingstone’
complex named \OR-1[ by ‘Karl Shtortz’ & laparoscopic surgical simulators by Simbionix-LAP made the same error. From sourced pubmed data, 17 peer reviewed articles were published in 2011
Mentor allowing to carry out complete training of experts. describing CT. Only one correctly described the boundaries. 4 were inaccurate and 6 did not
Actuality: Considering the sizes and territorial remoteness of some regions of our country, exit provide an anatomical description of the triangle but simply referred to it. Of the remaining 6: 4
training cycles are possible not always, therefore introduction of the given operational complex and were not accessible, 1 was in Serbian and 1 was a multimedia article.
the use of the laparoscopic simulator during the training cycles allows to rise training of all experts Conclusion: The cystohepatic triangle is a common misnomer for the Calot’s Triangle, which is a
on qualitatively new high update level. content of the aforementioned triangle. Recognition of this misconception will aid teaching and
Materials and methods: Thanks to HD technologies,\OR-1[ allows to receive high definition and training towards performing a safe laparoscopic cholecystectomy
detailed images. The equipment allows to move by desktop pressing of several buttons, adjusting
and changing modes of devices, optimizing visualization of images on monitors, carrying out
digital record, simultaneous transmission of sound (an explanation of the operating surgeon) allow
conduct high quality training, operation and directly respond to questions.
Also we have few laparoscopic surgical simulators – LAP Mentor system – because dif-
ficult to provide the necessary at once training in the operating room. The LAP Mentor
provides a safe and motivating learning environment, as well as providing a complete
educational solution integrated into training programs.
Results: Carrying out on line translations from the operational limits to a local network or through
the Internet allowed to spend us for the past 2.5 years–23 training cycles for more than 270 regional
experts in pediatric surgery. Most of the students were also trained on simulators (43). However, on
our observations, training courses is more effective in groups no more than 5–6 persons as at
intrernet training and during training on simulators.
Conclusions: Perfectioning of methods of integration in operating systems, able to broadcast
qualitative HD signal in the worldwide web, as well using the LAP Mentor with tactile experience
when using the surgical tools allows you to experience of tissue resistance during surgery simu-
lation, allows to develop new systems of qualitative vocational training that, undoubtedly, gives the
positively affects on the general professional level of profile experts.

P122 – Education P124 – Emergency Surgery

OESOPHAGO-GASTRODUODENOSCOPY YIELD IN SURGICAL MANAGEMENT OF DUODENAL

PATIENTS WITH COELIAC DISEASE PRESENTING PERFORATIONS AFTER ERCP: THE CRUCIAL ROLE OF
WITH IRON DEFICIENCY ANAEMIA: A RE-AUDIT A RETROPERITONEAL APPROACH
K.M. Khatri1, K.J. Perryman1, S. Enefer1, A. Todd2, M. Sayegh1 F. Rosa, S. Alfieri, C. Cina, A.P. Tortorelli, A. Tringali,
1 G. Costamagna, G.B. Doglietto
Western Sussex Hospitals NHS Trust, Worthing Hospital,
WORTHING, United Kingdom; 2Western Sussex Hospitals Catholic University, ROME, Italy
NHS Trust, WORTHING, United Kingdom Introduction: Evidence-based strategies are lacking regarding the appropriate management of
duodenal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP)
Objectives: In our previous audit it was shown that the majority of patients with iron-deficiency
combined with endoscopic sphincterotomy (ES).
anaemia (IDA) suspected of having coeliac disease (CD) underwent oesophago-gastroduodeno-
The aim of this study was to investigate clinicoradiologic findings and treatment outcomes in
scopy (OGD) and duodenal biopsy as a routine procedure, but only 0.2% patients had serum coeliac
patients with ERCP-related perforation and to suggest useful treatment modalities for the
screening prior to OGD. It was suggested that routine duodenal biopsy could be avoided by routine
perforations.
serum coeliac screening, as recommended by the British Society of Gastroenterology (BSG). The
Methods and procedures: A retrospective review of ERCP-related perforations to the duodenum
purpose of this current study was to complete the audit cycle.
observed at the Digestive Surgery Department of the Catholic University of Rome was conducted
Methods: Data related to histology and serum coeliac screen of all patients with IDA undergoing
to identify their optimal management and clinical outcome. Charts were reviewed for the following
OGD in a District General Hospital from January 1st to October 31st 2011 were evaluated. Data
data: ERCP indication, clinical presentation, diagnostic methods, time to diagnosis and treatment,
were extracted from Gastrointestinal reporting tool and analysed in Microsoft Excel
type of injury, management, length of hospital stay, and clinical outcome.
spreadsheet.
Results: From January 1999 to December 2010, 30 duodenal perforations after ERCP were
Results: A total of 732 patients with IDA were referred for OGD. There were 282 male and 450
observed. Seven patients underwent ERCP/ES at another institution and eleven patients underwent
female patients with a mean age of 69.1 years. Duodenal biopsy was performed in 610 patients
an endoscopic procedure at the Digestive Endoscopy Unit of Gemelli Hospital, Catholic University
(83.3 %) at the time of OGD; CD was confirmed histopathologically in 17 patients (2.8%).
of Rome.
Duodenal biopsy was normal in 593 patients (97.2 %). A total of 122 patients (16.7 %) had serum
Eleven patients were treated conservatively just with aspirative naso-duodenal and naso-biliary
coeliac screening prior to OGD; 7 cases (5.7%) were positive.
tubes, three other patients received percutaneous drainages of retroperitoneal abscesses. Sixteen
Conclusion: Completing the audit cycle it was found that the majority (83.3 %) of patients with
patients underwent surgery: ten received a posterior approach, four both an anterior and posterior
suspected CD presenting with IDA continue to undergo OGD and duodenal biopsy as a routine
approach and two an anterior approach. The overall mortality rate was 16.6% (5 of 30 patients).
procedure. CD was confirmed histopathologically in 2.8% of cases (compared with 2.52% previ-
Conclusion: Clinical and radiographic features can be used to determine which type of surgical or
ously). Of note, 16.7% of patients had serum coeliac screening prior to OGD, compared with 0.2%
conservative treatment of ERCP-related duodenal perforations, whereas intraoperative findings can
previously. Whilst this represents an improvement in practice the need for wider use of coeliac
determine the final outcome and morbidity or mortality. The interval between the perforation and
screening appears to remain.
the operation is of great significance. The mortality rate increases dramatically with late surgical
management. Moreover, our data confirm that the technique of posterior laparostomy offers the
advantage of creating a wide and open cavity, permitting continuous gravitational drainage and
avoiding septic contamination of the peritoneal cavity.

123
S84
P125 – Emergency Surgery
ACUTE APPENDICITIS: EXPERIENCE AND RESULTS
IN AN EMERGENCY ROOM SERVICE OF A SPECIALIZED
CENTER
J. Sampson, M. Valentini, C. Ginestà, R. Soliva, X. Morales,
J.C. Garcı́a-Valdecasas, G. Benarroch
Hospital Clı́nic of Barcelona, BARCELONA, Spain
Introduction: Acute appendicitis continues to be the most frequent cause of acute surgical
abdomen. Since 2004, the emergency room service has provided the assistance of four
surgeons on week days from eight in the morning until ten at night. These surgeons have
been exclusively dedicated to this pathology. On holidays and at night time schedule, the
assistance is provided by hospital surgeons including four emergency room doctors. Since
our hospital has been able to acquire a profound specialization in emergency services, we
thought it would be interesting to analyze the results obtained in the treatment of acute
appendicitis and to compare it with the results previously published.
Objective: A descriptive and prospective study of the treatment, evolution and complication
of the cases of acute appendicitis treated in the emergency room service of our center.
Material and methods: We made a prospective study in the period between January 1st,
2010 and June 30th, 2011, including all the patients with a diagnosis oriented to acute
appendicitis who were admitted into the emergency room service. The variables evaluated
were demographic data of the patients, history and physical exploration, image testing,
treatment applied, evolution and pathological anatomy. The statistical analysis was done
with the SPSS program 14 (SPSS Inc., Chicago, IL).
Results: 376 patients were admitted for suspected appendicitis. 375 (99.7%) underwent
urgent appendectomy. Overall 369 (98.4%) of all appendectomies were performed lapa-
roscopically, 88% of the patients underwent surgery within the first 12 hours of admittance.
76.8% (288) of the surgeries were performed by surgeons with exclusive dedication to the
emergency pathology. The overall conversion rate was 4 (1%). The mean operating time
was 53 ± 18.2 (15–135) min. The intraoperative complications were 2 (0.5%) The post-
operative complications appeared in 27 cases (7.2%) out of which 8 (2.1%) were
intraabdominal abscesses
Histological finding revealed complicated appendicitis in 183 (49.1%) of the patients. The
mean postoperative length of hospital stay was 2.9 days.
Conclusions: In our center the laparoscopic approach is the first choice for the
treatment of acute appendicitis, proving to be a safe and effective procedure, com-
parable with results previously published.
P126 – Emergency Surgery
ACUTE CHOLECYSTITIS: RESULTS IN A UNIT
SPECIALIZED IN EMERGENCY SURGICAL PATHOLOGY
G. Diaz Del Gobbo, C. Ginesta, R. Soliva, A. Martinez, M. Valentini,
X. Morales, O. Vidal, G. Benarroch, J.C. Garcı́a-Valdecasas
Hospital Clinic i Provincial, BARCELONA, Spain
Aim: Analyze the outcome of the treatment of acute cholecystitis (AC) in a surgical
department dedicated to emergency pathology, from January 1, 2010 to March 31, 2011.
Methods: All cases of AC were identified in the database of the emergency department, and
organized prospectively. Patients with cholangitis, pancreatitis or choledocholithiasis were
excluded. To evaluate the differences between the therapeutic decision, the series was
divided into two groups: early surgical treatment (EST) and medical treatment (MT). To
analyze the treatment outcome, the patients were separated into three groups: (EST), sur-
gical after medical failure (SAMF) and only medical (OMT).
Results: 181 diagnoses of CA. Of these EST was performed in 128 cases (70.7%) vs MT 53
(29.2%). 10 needed surgery (SAMF). Differences of distribution were found in the vari-
ables: age (62.1 vs. 76.7), medical records (1.61 vs 3.06), polypharmacy (21.1% vs. 27%),
antiaggregation (7.8% vs. 18.9%), ASA = 3 (28.9% vs. 67.9%), complicated cholecystitis
(63.5% vs. 81.1%). 17% of patients with MT had TB[ 3 mg/dl Vs 7.1% of cases of EST.
98.55% of laparoscopic approach in the 138 surgical patients. The conversion rate was
1.4%. Mean operating time was 91.27 min. 16.7% (23 cases) of intraoperative complica-
tions, hemorrhage was the most frequent (82.6%). Postoperative complications related to
the procedure were 7.2% (10 patients). The bile leaks were treated conservatively. The
overall mortality was 3.3% (6 cases). The result of PA 73 (52%) acute, worsened chronic 34
(24.6%) gangrenous (41 cases) 29.7%. We found 4 cases of xanthogranulomatous and 1
case of adenocarcinoma. The median postoperative stay was 3.17 days. The hospital stay in
surgical patients was 5.6 days (0.5 to 42.97) and the OMT was 8.3 days (2–50).
Conclusions: We present a series of patients with high comorbidity, and high local com-
plexity, in which cholecystectomy was completed in all surgical cases; increasing the rate
of patients who were offered a definitive treatment, without decreasing the laparoscopic
approach, having a conversion rate equal to the elective surgery. We believe that one
important factor in achieving these results is derived from the high degree of specialization
of the surgical team.
123
Surg Endosc (2013) 27:S53–S166
P128 – Emergency Surgery
LAPAROSCOPIC REPAIR OF BILATERAL ACUTE
RUPTURED DIAPHRAGMATIC HERNIA AND RECURRENT
VENTRAL HERNIA IN A SINGLE PATIENT
V. Golash
Sultan Qaboos Hospital, SALALAH, Oman
Aims: to validate the use of laparoscopy in the diagnosis, management and treatment
of ruptured diaphragmatic hernia in acute settings in a hemodynamically stable
patient. Laparoscopy avoided the major thoraco-abdominal surgery.
Methods: a 31 year old patient was admitted with the history of acute onset severe
abdominal pain, vomiting and difficulty in breathing. She had undergone laparo-
scopic repair of a large ventral hernia one month prior to her admission. X-ray chest
and CT scan revealed herniation of small intestine, colon, spleen and pancreas in the
chest through a large defect in left diaphragm. Port position for laparoscopy was
same as for hiatus hernia repair. The rupture in left diaphragm was 10.5 cm. The
hernial contents were reduced. An intercostal tube drain was inserted under lapa-
roscopic view. The defect was large and not suitable for primary suture and the
hernia was repaired using a 15x15 prolene mesh. She presented again six months
after her left ruptured diaphragmatic hernia repair with severe respiratory distress. A
thoracoabdominal CT revealed ruptured right diaphragmatic hernia this time with
herniation of small intestine and colon. On Laparoscopy a ruptured right diaphrag-
matic hernia of 12 cm was seen in posterior superior aspect. The small and large
intestine were reduced. The diaphragmatic defect was repaired with nylon sutures
and further reinforced with dual mesh.
Results: There were no conversion to open and no intraoperative or postoperative
complications. There has been no recurrence in one year.
Conclusions laparoscopic repair of acute rupture diaphragmatic hernia is feasible in a
hemodynamically stable patient. It provides good visibility, easy reduction of her-
niated organs and if necessary thorax exploration. We successfully repaired bilateral
ruptured diaphragmatic hernia with mesh and recurrent ventral hernia in a single
patient by laparoscopy
P129 – Emergency Surgery
USE OF ENDOVIDEOSURGICAL METHOD IN THE
DIAGNOSTICS AND TREATMENT OF ACUTE
APPENDICITIS AND ITS COMPLICATIONS
A.P. Ukhanov, D.V. Zakharov, A. Ignatjev, S.V. Kovalev,
E.V. Novozhilov, S.R. Chakhmakhchev
Central municipal clinical hospital, VELIKIY NOVGOROD, Russia
Aim: Improvemment of results of surgical treatment of patients with acute appen-
dicitis by using endovideosurgical technology.
Materials and methods: 385 patients with acute appendicitis were operated on
laparoscopically.
On morphological form the patients were distributed as follows: catarral appendicitis
was found out in 45 (11,7 %), phlegmonous appendicitis in 255 (66.2 %), gangre-
nous appendicitis in 65 (16.9 %), gangrenous perforated appendicitis in 20 (5.2 %)
patients. In 131 patients acute appendicitis was complicated by peritonitis including
local peritonitis in 80 (20.8 %) cases, diffuse peritonitis in 31 (8.6 %), periappen-
dicular abscess in 20 (5.2 %) patients.
Results: In 25 (6.5 %) cases there was conversion to laparotomy. Postoperative
complications were observed in 21 (5.5 %) patients, including intraabdominal
abscess in 5 (1.3 %), a postoperative peritonitis in 2 (0.5 %), suppurations of wounds
in 8 (2.1 %) cases, paralytic ileus in 3 (0.8 %), thrombophlebitis of lower extremities
in 2 (0.5 %), pneumonia in 1 (0.3 %) patient. Mean length of stay was 6.5 ± 0.3
days. There were no cases of postoperative mortality.
Comparison of results of laparoscopic appendectomy with traditional interventions
has showed that in group of 543 patients with typical appendectomy postoperative
complications were in 42 cases (7.7 %) and, average length of stay was 9.4 ± 0.4
days (p \ 0.05).
Conclusion: Thus, introduction of videoendosurgical technology in the treatment of
acute appendicitis and its complications is very feasible intervention, allows to
reduce postoperative morbidity, diminish duration of hospital stay.
Surg Endosc (2013) 27:S53–S166
P130 – Emergency Surgery
LAPAROSCOPIC TREATMENT OF COLORECTAL
EMERGENCY
R. Galleano, M. Ciciliot, A. Franceschi, L. Reggiani, F. Falchero
S. Maria di Misericordia, ALBENGA, Italy
Laparoscopy is an accepted technique for elective treatment of colorectal diseases
but few data exist on management of colorectal emergency. A review of a single
centre practice has been carried out.
In the last ten years laparoscopy has been used as first diagnostic/therapeutic tool in a
variety of colorectal surgical emergency: A) a 96 years old patient that had a ret-
roperitoneal perforation of the rectum secondary to an enema was submitted to
diagnostic laparoscopy that showed minimal pelvic peritonitis with a retroperitoneal
pelvic haematoma and, consequently, a laparoscopic sigmoid loop colostomy was
completed; B) three patients underwent laparoscopic exploration and suture of iat-
rogenic endoscopic perforation of the left colon; C) two patients with acute abdomen
due to foreign body perforation of the gut were diagnosed and treated by laparoscopy
with the extraction of a toothpick from a Meckel diverticulum that was resected and
the extraction of a chicken bone perforating the sigma wall that was sutured; D)
thirteen patients presented with acute abdomen due to diverticulitis has been
explored laparoscopically and ten of them received laparoscopic peritoneal lavage
with complete remission of symptoms and delayed elective laparoscopic sigmoid
resection, the remaining three were converted to laparotomy because of fecal peri-
tonitis or necrotic sigmoid colon; E) a patient with suspected acute appendicitis was
found to be affected by right colon cancer and laparoscopic urgent right colectomy
was carried out. In all described cases there were no major complication, no wound
infection, and no re-operation. Two patients after peritoneal lavage for acute div-
erticulitis had pulmonary infection. Laparoscopy in the emergency setting identifies
the source of intra-abdominal pathology and estimates its severity. Whether the
therapeutic procedure is laparoscopic or open is decided by the surgeon depending
on findings, patient’s condition, complexity of the procedure to be completed.
Possible advantages of laparoscopy are reduced pain, shorter hospital stay, quicker
recovery, decreased wound complications. In selected cases laparoscopic treatment
of colonic emergency seems to be a viable alternative to open approach. Inability to
locate source of abdominal pathology, doubt regarding safety of the procedure,
faecal peritonitis or hemodynamic instability should prompt conversion to open
surgery.
P131 – Emergency Surgery
HAS LAPAROSCOPY REDUCED THE RATE OF NEGATIVE
APPENDICECTOY IN OUR INSTITUTE?
M. Salama, A. Zaidi, T. Taha, A.R.H. Nasr, I. Ahmed
Our lady of lourdes hospital, DROUGHEDA, Ireland
Introduction: Despite the recent advances in imaging techniques, the diagnosis of acute
appendicitis still poses a challenge to even the most experienced surgeon. Ultrasound, C.T
scan and blood tests may help, but are not absolutely diagnostic for acute appendicitis. The
risk of morbidity and mortality increases with perforated and gangrenous appendicitis. To
minimise these risks, surgeons tend to err on the side of over diagnosis of acute appendicitis
and many accept this as a safer surgical practice. There is no consensus on what to do when
surgeons come across an apparently normal looking appendix during laparoscopy. This is
reflected in the high incidence of negative appendicectomies even in the laparoscopic era.
Aim: To study the impact of laparoscopy in our institute in reducing the rate of negative
appendicectomies.
Methods: The hospital records of all patients who had emergency appendicectomy
during the period of two years from January 2009 to December 2010 were analysed.
Cases of elective interval appendicectomy were excluded from our study. The
presence of Neutrophils involving the layers of the wall of the appendix was con-
sidered to be diagnostic for acute appendicitis.
Results: A total of 650 patients (335 females and 315 males) had emergency appendicec-
tomy during the two years study period. Most surgeons had removed the appendix at
laparoscopy even if it looked normal. Histology showed no evidence of acute appendicitis
in 105 out of 650 patients (14.4%) which is not different from what we had during the pre-
laparoscopic era. Of these 105 who did not have acute appendicitis, 26 showed lymphoid
hyperplasia, 2 torsion of appendices epiploica, 2 endometriosis of the appendix, 8 ente-
robius vermicularis and 7 faecalith in the lumen of the appendix. 8 had tumours (Carcinoid
4, Mucinous cyst adenoma 1, Adenocarcinoma 2, and Ovarian tumour 1).
Conclusions: The most important determinant of the diagnostic accuracy is the experience
of the clinical examiner. Imaging techniques and blood tests may be helpful in doubtful
cases. In combination with the above, a definite consensus on the fate of normal looking
appendix at laparoscopy is necessary to reduce the rate of unnecessary appendicectomy and
its associated morbidity.
S85
P132 – Emergency Surgery
COMPARISON OF HOSPITAL COSTS AND CLINICAL
DATA BETWEEN LAPAROSCOPIC APPENDECTOMY AND
OPEN APPENDECTOMY IN A DEVELOPING COUNTRY
B. Mantoglu, M. Okuducu, A.B. Karip, H. Altun, E. Onur,
A. Baskent, U. Akyuz, O. Bat, O. Aras, K. Memisoglu
Fatih Sultan Mehmet EA Hospital, ISTANBUL, Turkey
Acute appendicitis is the most frequent surgical procedure that requires emergency
surgery in general surgical practice. Laparoscopic appendectomy (LA) is an alter-
native to open technique and performed by many surgeons. The advantages and
disadvantages of laparoscopic access is not yet clear, so there is no consensus about
the ideal technique in Turkey. In this study, our aim was to compare LA and open
appendectomy (OA) in terms of hospital costs and clinical outcomes.
The present study was designed as prospective randomized study. Sixty-three
patients with a presumed diagnosis of acute appendicitis were investigated. Inclusion
criteria were patients who were between 13 and 65 years of age, who have ASA I-III
scores and who had no prior abdominal surgery. Acute appendicitis was diagnosed
by physical examination and laboratory findings. The patients were randomized into
two groups of LA group and OA group according to admitting day. Patients who
were admitted on odd days were treated with LA and the others with OA. Collected
clinical data included demographic data, hospital stay, operation time, complication,
return to work and pain scores. Hospital costs were calculated for both groups.
In this study, the level of pain scores, hospital stay and return to work found sig-
nificantly less in LA group compared to OA group. Operation time was not
significant between two groups. Higher BMI values prolonged the operation time for
LA and OA. The mean hospital costs were not statistically significant between two
groups. With the advantages of this minimally invasive method, LA should be the
procedure of choice in the treatment of acute appendicitis. Discouraging side of this
operation is the hospital cost in developing countries, but with the usage of reusable
laparoscopic sets and self made loops, the hospital costs can be reduced to the level
of OA.
P133 – Emergency Surgery
LAPAROSCOPIC TREATMENT OF COLORECTAL
ANASTOMOTIC LEAKAGE AFTER RECTAL CANCER
RESECTION
G. Pernazza, I. Monsellato, G. Alfano, A. D’Annibale
San Giovanni Addolorata Hospital, ROME, Italy
Anastomotic leakage is one of the most important complications after rectal cancer
resection. Leakage rate after open surgery is 2.8–12% and postoperative mortality
after anastomotic leakage is 7–14%. Massive anastomotic leakage and peritonitis
requires generally prompt reintervention by laparotomy. Laparoscopic reintervention
after primary laparoscopic surgery might be beneficial, while an open approach
might lose the advantages of minimally-invasive approach. We reported our personal
experience of treating three anastomotic leakages occurred in 98 left colectomies/
LAR (low anterior resection) for colorectal malignancy. There were 47 colorectal
anastomosis with the upper rectum; 18 colorectal anastomosis with the medium
rectum and 33 colorectal anastomosis with the lower rectum. Diverting stoma were
always performed in the latter cases, while in the first case only in presence of risk
factors. We experienced three anastomotic leakages with partial dehiscence after
ULAR (ultra-low anterior resection). A massive peritonitis was observed but there
were neither adhesions nor distension of the colon or small bowel, so the abdominal
cavity was easily explored. An accurate lavage of the abdominal cavity was carried
out easily, in all the anatomical recesses, according to the international guidelines.
Four drainage tubes were placed in the pelvic cavity. The anastomosis was saved,
thanks also to the presence of a functioning diverting stoma. Mean operative time
was 110 min. Postoperative course was uneventful and mean length of stay was 4 ±
3. Although further study would be necessary, laparoscopic redo could be a choice
for anastomotic leakages after laparoscopic LAR.
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S86
P134 – Emergency Surgery
LAPAROSCOPIC RESOLUTION IN FOUR CASES OF
STRANGULATING OBSTRUCTION IN THE FEMALE
PELVIS
Y. Shimizu, Y. Yoshikawa, N. Hatanaka, H. Tominaga,
M. Tanemura, A. Nishitani, T. Irei, K. Hiraoka, M. Inoue, J. Moon,
T. Kinoshita, M. Park, M. Wakahara, N. Honmyou, W. Kamiike
NHO Kure medical center, HIROSHIMA, Japan
Introduction: Laparoscopic surgery is increasing in number but is not so commonly used for the
treatment of intestinal obstruction. Specifically, limited space due to dilated intestine, emergent
situation, in most cases; and various mechanisms of obstruction make laparoscopic resolution
difficult. We report on four cases of strangulating obstruction that originated in the female pelvis
and were successfully treated by laparoscopy.
Patients: Average age was 51.8 years old and all patients presented with abdominal pain and one
also reported nausea. Three reported no previous abdominal operations; however, one patient
underwent two caesarean sections. Although physical examinations revealed only mild tenderness
in the abdomen and laboratory findings were not contributory, abdominal CT revealed signs of
closed-loop obstruction of the small bowel in the pelvis that resulted in our decision for an
emergent operation. Laparoscopy revealed the cause of strangulating obstruction in all four cases;
broad ligament hernia in one patient, and fibrous adhesion to the uterus, the fatty appendices of
rectum, and fimbria of the fallopian tube in the other three cases. Average operation time was 59.8
minutes and blood loss was minimal. The case of broad ligament hernia was converted to open
surgery with 5 cm mini-laparotomy because of bleeding from the mesentery, although bowel
resection was not necessary. The postoperative course was uneventful in all cases.
Discussion: The causes of bowel obstruction without a history of laparotomy were considered as
follows, 1. Inflammatory adhesion: Inflammatory reaction often takes place, especially around the
female genitals. 2. Internal hernia: Intrapiploic hernia, broad ligament hernia, obturator hernia, etc.
In general, early diagnosis of strangulating obstruction is difficult. Based on our experience, closed-
loop obstruction of the small bowel on CT findings are very informative to identified the focus of
obstruction. We presumed that early diagnosis made the operation easier because of less intestinal
distension and preserved working space, and prevented unnecessary bowel resection.
Conclusion: We had four cases of strangulating obstruction that were diagnosed early by precise
evaluation of CT findings and successfully treated by laparoscopy. In female, it was also suggested
that inflammatory adhesion around the female genitals may induce strangulating obstruction.
P135 – Emergency Surgery
LAPAROSCOPIC SURGERY FOR PREGNANCY
O.B. Kutovyy1, V.A. Pelekh2, N.K. Ruban2, N.V. Yenotova2,
M.O Kutovyy2, V.V. Pimakhov1, O.V. Meleshko3
1
Dnepropetrovs’k medical academy, DNEPROPETROVS’K,
Ukraine ; 2Dnepropetrovs’k regional clinical hospital of I.I.
Mechnikov, DNEPROPETROVS’K, Ukraine ; 3SMSD - 6,
DNEPROPETROVS’K, Ukraine
Aims: The purpose of article is to evaluate the results of the laparoscopic operations on pregnant
women.
Materials and methods: The indications for the procedure were acute catarrhal appendicitis (4
cases), phlegmonous appendicitis (11 cases), gangrenous appendicitis (2 cases), acute phlegmonous
cholecystitis (7 cases), acute strangulate bowel (1 case). Women aged between 18 to 39 years old,
with the pregnancy terms between 10 to 31 weeks.
Results and their explanation: Appendectomy with extracorporeal ligation of appendix has been
conducted on 7 pregnant women, intracorporeal ligation has been conducted on 6 pregnant women.
One patient has suffered from bowel obstruction caused by thread-like adhesion, which had con-
nected intestinal mesenteries root and uterine fundus compressing small intestine in the border
between jejunum and ileum. Intestinal wall was cleared after dissection of adhesion by mono-polar
electrode. There was no need for any additional manipulation.
There has been no difference whatsoever in the laparoscopy cholecystectomy techniques used.
Postoperative period has run smoothly for all patients. There has been no danger of miscarriage or
any other complications observed after the procedure. Pregnancy for 19 patients has resulted in
physiological birth through the natu-ral birth canal at the terms between 37 and 41 weeks. All the
new-borns has been assessed according to Apgar scale receiving between 6 and 9 points. There has
been no indication of any intrauterine growth retardation or hypoxic disorders. The caesarean
section has been given to only one patient at the term of 40 weeks after she endured appendectomy.
Prolonged infertility in the past following in-vitro fertilization were indications for the operation.
At present, five of the patients are still pregnant. There has been no pathology observed according
to ultrasound tests.
Conclusions: Based on our experience, we have not observed any significant negative impact of
laparoscopic surgery using carboxyperitoneum on further course of pregnancy, birth and the
development of the new-borns. However, considering the benefits of videoendoscopic surgery these
methods could be more widely used at the various stages of pregnancy, providing the rules and the
techniques of performing the procedure are carefully observed.
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Surg Endosc (2013) 27:S53–S166
P136 – Emergency Surgery
MUCINOUS CYSTADENOMA OF THE APPENDIX:
SURGICAL APPROACH (LAPAROSCOPIC VS OPEN)
I Taronna
Centro Medico Loira, CARACAS, Venezuela
Aims: We report an unusual case of acute appendicitis caused by a mucinous cystadenoma of the
appendiceal base in the cecum that obstructing the lumen of the appendix, treated by laparoscopic
right hemicolectomy.
Methods: An otherwise healthy, 42-year-old woman with a 4 day history of right lower quadrant
abdominal pain with peritoneal rebound. An abdominal ultrasound was normal, CT reported altered
peri-caecal fat. Diagnostic laparoscopy was performed by palpation instrument evidencing a tumor
in the cecum and saccular dilatation of the appendix. The patient underwent a laparoscopic right
hemicolectomy, there was no pathologist for frozen biopsy.
Results: The patient was discharged on the fifth postoperative day without complications. The
pathology specimen reported an appendix tumor, Mucinous cystadenoma of the appendiceal base,
without atypia and acute appendicitis. No lymph node involvement. The tumor was 3 cm and
bulges into the cecum without alteration of the cecum mucosa, with obstruction of the appendiceal
lumen. The follow-up at one year, the patient was asymptomatic.
Conclusions: The appendiceal mucinous cystadenoma is unusual, 0.3% of acute appendicitis. If the
base of the appendix is not compromised, laparoscopic appendectomy can be made with biopsy by
frozen sections of the appendix, to rule out a mucinous cystadenocarcinoma, which would extend to
a right hemicolectomy surgery. If the appendiceal base is compromised and we to palpate a tumor
in the cecum, is safe to perform a laparoscopic right hemicolectomy without frozen sections.
P137 – Emergency Surgery
MINIMALLY INVASIVE APPROACH IN THE TREATMENT
OF COMPLICATED APPENDICITIS
A.V. Sazhin, S.V. Mosin, A.A. Kodjoglyan, B.K. Laypanov,
H.T. Mirzoyan, A.R. Yuldoshev
Russian National Research Medical University named after NI
Pirogov, MOSCOW, Russia
Materials and methods: From 2005 to 2011 the results of 1530 laparoscopic appendectomy (LA)
were analyzed. Complicated appendicitis was in 391 patients (25.5%). During the laparoscopic
operation in 34(8.7%) cases an appendicular mass was found, in 40(10.2%) – appendicular abscess,
76(5.16%) patients had widespread peritonitis and 238(60.8%) patients – perforated appendix.
Patients with appendicular mass were treated conservatively. However, in 9(2.3%) cases it was
transformed into abscess and resolved by ultrasound guidance.
In 26(6.6%) cases of appendicular abscess was diagnosed during laparoscopic mobilization, in
25(1.6%) of this laparoscopic appendectomy was successfully carried out. In 1 patient (0.2%) LA
was dangerous, then followed draining of abscess by laparoscopy. Interval LA was performed 6
month later.
Widespread peritonitis with bowel paresis revealed in 14(3.6%) patients, which required general
laparotomy and nasointestinal decompression. In 65(16.6%) patients with widespread peritonitis
without bowel paresis was performed completely laparoscopic appendectomy with washing and
draining of abdominal cavity.Perforated appendix occurred in 78(19.9%) cases. We use intracor-
poral purse-string suture to immersion of the stump.
Results: In 37(9.7%) cases a postoperative inflammatory mass in the right iliac region was found,
which had regressed with anti-inflammatory therapy over the next 5–6 days. In 3(0.7%) cases it was
transformed into abscess and resolved by ultrasound draining. Another 3(0.7%) cases occurred
failure appendicular stump, which required reoperation. All patients recovered. In 12(0.8%)
patients with purulent peritonitis after LA an ileus was observed during next 3 days, which was
resolved by conservative treatment, and 2(0.5%) patients required second look procedures. In
5(0.3%) we observed wound infection. The overall complication rate was 54(13.8%). Conversion
to open surgery was in 63(16.1%) cases. The postoperative period was 6.9 ± 0.3 days. There was
no mortality with complicated appendicitis.
Conclusions: We propose that laparoscopic appendectomy is a safe method of choice in compli-
cated appendicitis.
Surg Endosc (2013) 27:S53–S166
P138 – Emergency Surgery
THE ROLE OF LAPAROSCOPY IN INTESTINAL
PERFORATION DUE TO BLUNT ABDOMINAL TRAUMA
A.E. Nicolau, M. Craciun, A. Kitkani, R. Zota
Spitalul Clinic de Urgenta Bucuresti, BUCHAREST, Romania
The intestinal perforations due to blunt abdominal trauma (BAT) are often difficult to diag-
nose clinically and imagistically within the first hours from the accident, especially in the case
of multiple trauma patients. The initially missed intestinal lesions in the case of nonoperative
therapy result in a high morbidity and mortality. The clinical examination is irrelevant in more
than 50% cases, but there are indirect CT signs that are hallmark for CT scans: ‘peritoneal fluid
in the absence of solid organs injuries’. Diagnostic laparoscopy (DL) performed in the case of
a stable patient is a seldom used option. We present five cases of BAT with suspicion of
intestinal lesions. Three patients presented the ‘belt sign’. The clinical examination was
equivocal due to the associated traumatic lesions (cerebral, thoracic and pelvic) and the CT
scan done only in three cases (technical causes) presented only indirect signs. The diagnostic
laparoscopy showed the intestinal perforations in all cases. Also, the laparoscopy allowed us to
perform a complete abdominal lavage. Through a minilaparotomy (5–7 cm) we performed an
exteriorisation of the perforated intestinal loop, followed by a laparoscopic assisted segmental
bowel resection in three cases, and an enterorrhaphy in two cases. There were no missed
injuries. We had one abdominal wound infection.
We consider that in selected cases of BAT when we have suspicion of intestinal injuries,
DL is a useful diagnostic tool with therapeutic potential which can reduce the incidence of
missed lesions and unnecessary laparotomies.
P139 – Emergency Surgery
LAPAROSCOPIC MANAGEMENT OF DIFFUSE,
SEVERE PERITONITIS SECONDARY TO ENDOSCOPIC
MAL-POSITIONING OF A CYSTOGASTROSTOMIC
‘PIGTAIL’ DRAIN
R. Costi1, A.B.F. Kassi2, F. Marchesi1, S. Cecchini1, B. Randone3,
L. Sarli1, V. Violi1, L. Roncoroni1
1
Università degli Studi di Parma, PARMA, Italy; 2Hôpital Cochin,
PARIS, France; 3Hopital d’Eaubonne, EAUBONNE, France
Aims: Traditionally, pancreatic pseudocysts are treated by surgical derivation into the GI
tract. Cystogastrostomy and cystojejunostomy are alternatively used based on pseudocyst
location in the pancreas. The recent spread of mini-invasive techniques has allowed per-
forming cystogastrostomy by endoscopic positioning of a drain through the gastric wall into
the pseudocyst without general anesthesia and low morbidity. The appropriate management
of the complications of these procedure remains undefined also owing to their low fre-
quency. Here we present the first reported case of laparoscopic management of acute
peritonitis due to drain mal-positioning outside the pancreatic pseudocyst.
Methods: A 56-year-old man, with a history of compensated alcoholic cirrhosis (Child A)
and pancreatic pseudocyst following a self-limited Balthazar D (one peri-pancreatic body
collection), Ranson 1 (age [55) alcoholic acute pancreatitis, underwent a second endo-
scopic cystogastrostomy by placement of two ‘pigtail’ drains, eight weeks after the first
unsuccessful endoscopic attempt. Six hours after the second procedure the patient devel-
oped tachycardia and epigastric tenderness. CT scan showed massive pneumoperitoneum
and free fluid (Fig. 1). The 3D reconstruction (Fig. 2) clearly identified two pigtail drains
passing through the gastric wall but not reaching the pancreatic pseudocyst, thus allowing
deducing that acute peritonitis was likely due to gastric juice extravasation. Emergency
laparoscopy confirmed the presence of acute peritonitis and free, whitish fluid. After
dividing the gastro-colic ligament division, the two ‘pigtail’ drains were found to be passing
through the gastric wall but not in the pancreatic pseudocyst (Fig. 3). Both drains were then
removed and the posterior gastric wall was sutured laparoscopically (Fig. 4). A drain was
left in place. The procedure lasted 65 minutes, mostly needed for peritoneal lavage.
Results: The outcome was uneventful and the patient was discharged on postoperative day
5. At 7 months follow-up visit, the patient’s examination remained unremarkable.
Conclusions: Onset of unexplained abdominal pain after endoscopic cystogastrostomy should
prompt CT-scan. In the case of diffuse acute peritonitis by mal-positioning of a cystogastros-
tomy drain, the laparoscopic management (drain removal, gastric wall suture and lavage)
showed to be rapid, effective and safe, and should be considered as the first-line treatment option.
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P140 – Emergency Surgery
18 YEARS EXPERIENCE OF URGENT LAPAROSCOPIC
INTERVENTIONS FOR ACUTE SURGICAL DISEASES
OF ABDOMINAL CAVITY IN A SINGLE CENTER
M.E. Timofeev, S.G. Shapovalyanz, E.D. Fedorov, R.V. Plahov,
A.N. Bachurin
Russian State Medical University, MOSCOW, Russia
Objectives: to report clinical results of using Laparoscopic Intervention (LI) in urgent
abdominal surgery
Methods: 11075 urgent LI’s (6970 (62.9 %) – diagnostic, 4105 (37.1 %) – therapeutic) were
performed. Main indications were: acute appendicitis, acute adhesive small bowel obstruction
(AASBO), perforative ulcer, general peritonitis (GP) of different etiologies, torsion and necrosis
of epiploic appendices (EA).
Results: In 1396 pts. with acute appendicitis laparoscopic appendectomy (LA) was
performed: zero intraoperative complications (IC), 15 postoperative complications
(PC) and 2(0.14%) lethal cases. LI was performed in 363 pts. with AASBO,
65(17.9%) pts had had early postoperative AASBO and 36(9.9%) pts had no oper-
ative history. Laparoscopic adhesiolysis, using standard and ultrasonic scissors,
ligation and clipping was performed in 183(50.4%) patients. There were 2 IC, 17 PC
(surgical – 12, general – 5) and 3 (0.8%) lethal cases. LI were performed in 220 pts.
for perforative duodenal ulcer with 2 IC and 3 PC, without lethal outcomes.
From I. 2000 to XII. 2011 overall 175 pts. with GP underwent LI to eliminate the cause of
peritonitis and/or to clean abdominal cavity. In 95 pts. both, elimination of the cause of
peritonitis and sanitation of abdominal cavity were performed laparoscopically (34 repairs
of perforating ulcer, 24 appendectomies and 3 cholecystectomies). In 50 pts. elimination
was performed via local surgical access followed by laparoscopic sanitation LS. In 30 pts.
all steps of the operation were performed via median laparotomy with programmed LS
afterwards. With no IC, PC were revealed in 16 (9.1%) pts. and there were 8(4.5%) lethal
cases. 76 pts. with torsion and infarction of (EA) of the colon were operated with LI. There
were no IC and no PC.
Conclusion: Urgent LI had proved to be highly effective, with decreased lethality and compli-
cations rate, minimal pain syndrome, fast restoration of small bowel peristalsis, prompt return to
work and good cosmetic effect. Effective LI practice subject to surgical tactics: careful indications
and counter indications count, technical excellence and respect to the classical surgery rules.
P141 – Emergency Surgery
A NEW KNOT PUSHER USED IN LAPAROSCOPIC
APPENDECTOMY; KARMAN CANNULA
B. Mantoglu1, B. Kaya2, H. Altun2, A.B. Karip2, M.T. Aydin2,
K. Memisoglu2
1
Afsin State Hospital K. Maras, KAHRAMANMARAS, Turkey;
2
FSM Egt.Ars Hastanesi Genel Cerrahi Klinigi, ISTANBUL, Turkey
Introduction: Acute appendicitis is a common surgical condition. Appendectomy is one of
the most frequently performed operation worldwide. Several prospective randomized trials
comparing open appendectomy and laparoscopic appendectomy have been published up to
date. There is still no consensus about which procedure must be chosen. The choice of the
procedure is still surgeon dependent. Laparoscopic appendectomy is more device needed
procedure than conventional appendectomy. The Karman cannula is a soft, flexible cannula
(or curette) popularized by Harvey Karman in the early 1970s and specially used in
gynecological operations. We used this device as a knot pushing instrument in laparoscopic
appendectomy.
Material and Methods: Between March 2011 and September 2011, we performed 42 lap-
aroscopic appendectomies. Under general anesthesia, after 1 cm infra-umbilical incision,
pneumoperitoneum was performed with Veres needle and 10 mm trochar introduced into
the abdomen. A 10 mm, 30 degrees laparoscope was inserted and other trocars (5 mm trocar
at suprapubic area and 12 mm trocar at 7 cm right to the umbilicus) were inserted. Meso-
appendix was ligated and divided with harmonic scalpel (Ethicon). A Karman cannula was
taken and a hole was made with a needle at the top of the cannula. Two extracorporeal loops
were prepared with Vicryl 0/suture and pushed the knot with the help of Karman cannula
No: 8 to the base of the appendix. After appendectomy, appendix was taken out from
abdominal cavity with endo-bag.
Results: There were 24 men and 18 women in this study. The mean age was 31.8 years. The
average operation time was 38.9 minutes. The histopathological diagnosis was phleg-
monous appendicitis in 26 patients, catarrhal in 5 patients and gangrenous in 11 patients.
All patients were discharged at first operative day. There were no postoperative surgical
complications.
Conclusion: Several methods have been described to ligate the base of the appendix such as
extracorporeal knots, intracorporeal knots, and ligation with clips. In this study, we used
Karman cannula as a knot pusher in 42 patients successfully. Karman cannula can be used
safely in laparoscopic appendectomies.
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P142 – Emergency Surgery
A CHEAP, SAFE AND EASY TECHNIQUE IN
LAPAROSCOPIC APPENDECTOMY
T. Sezer, H. Yildirim, O. Unalp, L. Yeniay, O. Firat, S. Ersin,
A. Guler, C. Hoscoskun
Ege University School of Medicine, IZMIR, Turkey
Aims: Laparoscopic appendectomy is becoming the preferred technique for treating acute
appendicitis. Despite of its shown advantages, laparoscopic operation costs are reported to be
higher. This study was undertaken to assess another feasible and economical way of laparoscopic
appendectomy.
Methods: In this technique, we have used pre-tied loops to ligate the appendix base instead of
endoscopic stapler and a glove finger instead of endocatch to extract appendix. A retrospective
review was performed of 29 patients who were treated laparoscopically with this technique for
appendicitis.
Results: The average operative time was 75 minutes (range 55–110 minutes). Pathological evidence
of appendicitis was present in all the patients. Mean age of patients was 31.4 years.
The average length of hospital stay was 2.5 days (range 2–4 days). No complication
occured during surgery and wound infection is the unique complication for one
patient as far as postoperative complications are concerned.
Conclusion: The findings suggest that laparoscopic appendectomy with this technique is feasible in
patients with appendicitis and diminishes laparoscopic operation costs significantly.
P143 – Emergency Surgery
ACUTE CHOLECYSTITIS: EARLY LAPAROSCOPIC
SURGERY VS ANTIBIOTIC THERAPY AND DELAYED
ELECTIVE CHOLECYSTECTOMY
G. Lezoche1, R. Campagnacci2, M. Baldarelli2, R. Ghiselli2,
A.M. Paganini3, M. Rimini2, A. Piccioli2, C. Romiti2, M. Haxiu2,
M. Guerrieri2
1 Method: Between October 2008 and December 2011 the surgical teams in our clinic proposed the
University ‘‘Politecnica delle Marche’’, ANCONA, Italy;
2
Department of General Surgery, University ‘‘Politecnica delle
Marche’’, ANCONA, Italy; 3Department of Surgery, II Clinica
Chirurgica, Sapienza University of Rome, ROME, Italy
Aim: The definition of the best time-point for laparoscopic cholecystectomy (LC) is controversial.
Aim of this study was to compare early and delayed LC in patients with acute cholecystitis.
Methods: From January 2005 to July 2011, patients with acute cholecystitis who underwent lap-
aroscopic cholecystectomy were retrospectively analysed on the basis of a prospectively collected
database. Patients were divided according to the time of LC since appearance of the first symptoms:
‘early group’ underwent surgery within 72 hours and ‘delayed group’ more than 72 hours since
onset of symptoms. The choice between the two policies was left up to the attending surgeon who
was on call at the time of the patient’s admission. The two groups were compared in terms of intra
and postoperative complications, conversion and length of postoperative stay.
Results: During this 6-years period, a total of 53 patients underwent LC for acute cholecystitis.
Twenty four patients underwent surgery within 72 hours since occurrence of symptoms (‘early
surgery’) and twenty nine patients were treated with intravenous antibiotics first, with surgery
delayed (on average, 16 weeks) (‘delayed surgery’). Mortality was nil in both groups. There was no
biliary injury during LC. In the ‘early surgery’ group one patient developed a subhepatic fluid
collection and in the ‘delayed surgery’ group one patient developed umbilical wound infection (p =
n.s.). Conversion to open surgery occurred in two cases, one in each group (p = n.s.). Mean
operative time was 96 min (range, 62.5–117.5) for the ‘early group’ and 99 min (range 68.7–125.5)
for the ‘delayed group’ (p = n.s.). The mean postoperative hospital stay was two days in both
groups (p = n.s.).
Conclusions: Although the number of patients is limited, the present cohort shows no advantage in
delaying LC for acute cholecystitis and it requires a double hospitalisation, with increasing costs.
Based on this study, early LC for the management of acute cholecystitis is suggested.
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Surg Endosc (2013) 27:S53–S166
P144 – Emergency Surgery
EVALUATION OF THE EFFECT LAPAROSCOPIC
ASSISTANT DEVASCULARIZATION OPERATION
COMBINED WITH SPLENIC ARTERY BLOOD REDACTION
IN PORTAL HYPERTENSION CASES
M. Tutchenko1, D. Rudyk1, O. Shavlovskyi1, R. Romanov2
1
Bogomolets National Medical University, KYIV, Ukraine; 2City
clinikal emergency hospital, KYIV, Ukraine
Mortality rate in case of variceal hemorrhage is still high and depends on liver failure. In Child-
Pugh grade C die 75% patients, grade B – 50–60%, grade A – 30%. Summary: experience of
laparoscopic-assistent treatment of 26 patients with portal hypertension complications was
summarized.
Aim: To investigate the effect of laparoscopic – assistant splenic artery blood redaction combined
with upper part gastric and low part esophagus devascularization (a.,v. gastric sinistra, aa., vv.
gastricae brevis, a. gastroepiploica sinistra ligation), esophagus transection, and fundoplication
procedures in liver cirrhosis patients.
Methods and materials: 26 laparoscopic-assisted operations were performed in 26 patients for
esophageal variceal hemorrhage (26), hypersplenism (24), and ascites (22). Liver function indi-
cators were measured on 26 liver cirrhosis patients (10 in Child-Pugh grade B and 16 in grade C).
The ages ranged from 16–70 years (mean 48 ± 12.8 years) in 15 male and 11 female patients.
Results: We have one recurrent variceal hemorrhage after operation throughout follow-up period.
In 19 of 24 patients with hypersplenism the platelet values were increased by 2–3 times compared
to baseline levels since next day after operation and remained normal or subnormal. In 15 of 24
patients with hypersplenism, hematologic indexes returned to and remained normal throughout
follow-up. Mortality rate consisted 2 (7.6%).
Laparoscopic splenic artery ligation resulted in decrease of ascites in 11 patients and complete
resolution in 7 patients. In addition 8 of 10 (80%) Child-Pugh grade B patients progressed to grade
A and 9 of 16 (56.2%) Child-Pugh grade C patients progressed to grade B 1–2 month after
operation.
Conclusion: Laparoscopic-assisted splenic artery reduction combined with upper part gastric
devascularization, esophageal transection and fundoplication procedures are an effective methods
to reduce recurrent bleeding from esophageal varices due to portal hypertension and may be
considered as an alternative option for the patients who are unable to undergo safe liver trans-
plantation, transjugular intrahepatic portosystemic shunt or surgical shunt placement.
P145 – Emergency Surgery
LAPAROSCOPIC APPENDECTOMY
A. Maghiar, D.H. Ciurtin, M. Sfirlea, P.R. Sookha, G. Dejeu,
C. Macovei
Spitalul Pelican Oradea, ORADEA, Romania
Aim: Performing the most common of all the surgical operation using the 3 port laparoscopic
technique or single port (SILS) technique.
laparoscopic approach to all patients admitted with acute appendicitis. We had 194 patients with acute
appendicitis and 190 agreed to the laparoscopic approach.
Our technique involves us making the first incision just supra-umbilical and using a 5 mm trocar for the 5
mm optics. After performing an exploratory laparoscopy we introduce 2 further trocars, one 5 mm in the
left iliac fossa and one 10 mm trocar supra-pubic. We dissect the appendicular artery using the mono-
polar cautery, the bipolar cautery or the LigaSure Advance, and use endoloops to close the appendicular
stump. We extract the appendix using endobags, using the supra-pubic trocar incision for the extraction.
Results: We attempted laparoscopic appendectomy in all 190 patients that agreed to this, and we
performed the operation in 188 of the cases (40 performed by residents), we had 2 conversions to
classic surgery due to retro-cecal, sub-serous appendix, which made the dissection using lapa-
roscopy impossible. During 2011 we started using the Dapri curved grasper from Karl Storz and we
proposed the SILS approach to 8 patients, 5 agreed and we performed the SILS appendectomy to
all of them. We had no major complications. The mean hospital stay was 48 hours ± 10 hours, and
mean surgery duration was 25 min ± 10 min.
Conclusions: In our experience laparoscopic appendectomy is a very feasible operation, safe and
fast in experienced hands, with fast postoperative recovery for the patient, minimal postoperative
pain and need for antalgic drugs, excellent cosmetic results. SILS appendectomy is also feasible in
very experienced surgeons, but it needs more study before it can be recommended as standard
technique.
Surg Endosc (2013) 27:S53–S166
P146 – Emergency Surgery
SAFE LAPAROSCOPIC DISSECTION OF THE
MESOAPPENDIX
G. Vasic1, V. Zivanovic1, D. Vasic2, B. Djuric1, B. Dakovic1,
D. Radovanovic1
1
UCHC ‘Dr Dragisa Misovic-Dedinje’, BELGRADE, Serbia; 2PHC
‘Rakovica’, BELGRADE, Serbia
Aim: Describing our original method of dissecting mesoappendix with the ultra-
sound-activated scalpel (UAS) during laparoscopic appendectomy.
Methods: Our changed appendix dissection approach was applied on 67 patients,
ages from 16 up to 79, with various degree of appendicitis. It is required UAS
activation level 1. Dissection direction goes appendix top to the bottom, heading
along its wall, between the mesoa and the wall, separating the appendix from the
mesoappendix. When peritoneum is released, lower caliber a.appendicularis bran-
ches are next UAS treated. Approaching is safer and is easier to identify appendix
wall and basis, no matter the inflammation degree. It makes easier putting two endo-
loops around appendix bases without mesoa disturbance. Endo-loops are going
safely securing the stump of the appendix. Appendix extracting maneuver is much
easier going trough 12 mm umbilical port, without mesoa that surrounds appendix.
This is methodological significant improvement, comparing to standard approach
where mesoa is treated directly on appendix basis.
Results: The average dissecting time is 2 to 11 minutes. Appendicle branches
bleeding were not recorded during, or after the operation. Cekum or appendix wall
injuries were avoided. Endo-loops positioning is much easier and shorter. Appendix
extraction time trough umbilical port is shorter and easier. Intra abdominal abscess
formation or umbilical wound infection were not recorded.
Conclusions: Our original, precise UAS incision technique for laparoscopic appen-
dectomy appears to be safe in respect of stability, sterility and tissue changes.
Vascular elements treatment, precise appendix basis approach, quicker and easier
extraction maneuver and endo-loops positioning are major advantages of appendix
extraction through umbilical trocar.
P147 – Emergency Surgery
INTRA-ABDOMINAL COLLECTIONS IN LAPAROSCOPIC
VS OPEN APPENDICECTOMY: THE WAY IS FORWARD
A. Bond, D. Wilson, N. Ladwa, M.K. Baig, P. Sains
Worthing Hospital, WORTHING, United Kingdom
Aims: A recent Cochrane review suggests an almost two fold increased risk of intra-
abdominal collection with laparoscopic appendicectomy when compared with the
open technique. The aim of this study is to show that in a District General Hospital
where laparoscopic appendicectomy is routine, there is no increased risk of intra-
abdominal collection.
Methods: A retrospective study of all patients having laparoscopic and open
appendicectomy between April 2009 and September 2011 was performed. Patients
were identified using coding records. Postoperative radiology was reviewed in all
patients to identify those with collections. Histology of the appendix was also
reviewed.
Results: 516 patients had an appendicectomy. 242 (47%) were open and 274 (53%)
were laparoscopic. 26/516 patients (5%) were found to have collections postopera-
tively. The groups were matched for age but laparoscopic appendicectomy was more
likely to be performed on females. There were equal numbers of perforated/necrotic
appendixes in each group. There was no significant difference between number of
patients with intra-abdominal collection in laparoscopic or open procedure.
Conclusion: The laparoscopic approach to appendicectomy is a safe and effective
method where the skills and resources are available and does not increase the chance
of developing a postoperative intra-abdominal collection. The presence of a perfo-
rated or necrotic appendix on histological examination remains a significant risk
factor for the development of intra-abdominal collections.
S89
P148 – Emergency Surgery
LAPAROSCOPIC MANAGEMENT OF PYOGENIC LIVER
ABSCESS WITH COMBINED APPENDICECTOMY
L.M. Arthur, K. Shalli
Wishaw General Hospital, WISHAW, United Kingdom
Aims: Pyogenic liver abscess is a recognised complication of acute appendicitis
often associated with significant mortality rates. The mainstay of management of
liver abscesses today is longterm intravenous antibiotic therapy with or without
percutaneous radiologically guided abscess drainage. Here we present a case of a
patient who underwent successful laparoscopic management of pyogenic liver
abscess combined with appendicectomy in the same procedure. We also aim to
highlight the advantage of laparoscopic over open appendicectomy in allowing
careful diagnostic exploration and washout of the peritoneal cavity.
Methods: We present the case of a 22 year old gentleman visiting the UK from his
home in India. He presented with a one week history of right sided abdominal pain
and fever associated with significantly elevated inflammatory markers. At theatre
laparoscopy identified dual pathology of acute appendicitis and secondary pyogenic
liver abscess.
Results: Successful drainage of the liver abscess was achieved laparoscopically. This
was combined with laparoscopic appendicectomy in the same procedure with thor-
ough peritoneal lavage. Microbiology of the pus from the liver abscess revealed no
growth on culture. Histology of the appendix confirmed acute appendicitis. Length
of hospital stay was 6 days. Intraoperative images are available displaying the liver
abscess cavity during and post drainage.
Conclusions: Laparoscopy allowed thorough inspection of the peritoneal cavity and
identification of the liver abscess which may not have been identified with the
traditional open appendicectomy approach. Laparoscopy also obviated the need for
full laparotomy and its associated morbidity to achieve abscess drainage. Surgical
drainage of pyogenic liver abscess is traditionally reserved for cases who have failed
to respond to conservative measures. We have demonstrated laparoscopic drainage
of liver abscess with combined appendicectomy is a feasible management option for
this condition; allowing shortened length of hospital stay.
P149 – Emergency Surgery
RELAPAROSCOPY IN TREATMENT OF
INTRAABDOMINAL COMPLICATIONS IN EARLY
POSTOPERATIVE PERIOD
D. Yaroshuk, M.I. Tutchenko
National Medical University, KIEV, Ukraine
Aim: Explore the possibility of relaparoscopy in patients with intraabdominal
complications in the early postoperative period.
Introduction: In the period from 2009 to 2012 for acute surgical pathology laparo-
scopically operated 535 patients. In 5 (0.9 %) of them due to complications in early
postoperative period relaparoscopy was performed. All patients had stable haemo-
dynamics and had no contraindications to carboperitoneum.
Materials and Methods: In 2 (0.37 %) of patients with acute gangrenous cholecystitis
occurred intraabdominal bleeding. At the first source was the artery in the bed of the
gallbladder is not identified in its dissection. Remove blood clots and bipolar
coagulation was sufficient for the successful completion of relaparoscopy. The
second – tension subcapsular hematoma of extensive diaphragmatic surface of the
right lobe of the liver, the volume of 270 ml, not to treat by punctures under
ultrasound guidance. When relaparoscopy made the dissection, partial evacuation of
hematoma and drainage. Tense hematoma and its extension to the subdiaphragmatic
surface of the superior vena cava implied bleeding from large venous trunks.
In 1 (0.18%) patients after suturing perforated duodenal ulcer with a diameter of 1.2
cm by the end of the first day after surgery diagnosis of leakage. Relaparoscopy with
excision and duodenoplasty led to recovery and discharge on the 7th day.
In 1 (0.18%) patients after dissection of adhesions due to strangulated small bowel
obstruction relapsed on the 5th day. Relaparoscopy with dissection of adhesions gave
a positive result.
In 1 (0.18%) patients operated on for gangrenous appendicitis, on the 2nd day after
surgery revealed failure of the stump. When relaparoscopy performed suturing the
caecum with interrupted sutures, sanitation and drainage of the abdominal cavity.
Discharged from hospital on the 12th day.
Results: Trocar wound suppuration was observed in the case of gangrenous
appendicitis. Urgent application of relaparoscopy led to recovery in all patients.
Conclusions: Relaparoscopy can be operation of choice in patients with complica-
tions in early postoperative period.
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P150 – Endocrine Surgery
LAPAROSCOPIC ADRENALECTOMY. CUBAN
EXPERIENCE
R. Torres Peña1, S. Turcios Tristá2, L. León Chiong3, J. Nodal
Ortega1
1
Centro Nacional de Cirugı́a de Mı́nimo Acceso, HAVANA, Cuba;
2
Instituto Nacional de Endocrinologı́a, HAVANA, Cuba; 3Hospital
Universitario Manuel Fajardo, HAVANA, Cuba
Aims: Laparoscopic adrenalectomy (LA) has emerged as the standard treatment for
most patients with benign functioning and non-functioning adrenal diseases. This
study aimed at evaluating the results of LA at the National Center for Minimal
Access Surgery in Havana.
Methods: Between February 2001 and September 2011, 41 LAs were carried out in
37 patients (28 women). The left adrenal was removed from 18 patients, the right
adrenal from 13 patients, and both adrenals from 5 patients. The preoperative
diagnosis was documented at the National Institute of Endocrinology and the pre-
scription for LA was assumed at the National Center for Minimal Access Surgery,
based on a multicenter and multidisciplinary approach and follow-up. Parameters
related to the diagnosis, tumor size and side, operative details, complications and
others are statistically analyzed.
Results: Seventy-six percent of LAs was performed in patients with functioning
disease: endogenous hypercortisolism (25), primary hyperaldosteronism (3), and
pheochromocytoma (3). Less common indications were incidentalomas (10),
resulting in non-functioning adenomas, myelolipoma, ganglioneuroma, and others.
According to our protocol of treatment, in 5 patients with endogenous hypercorti-
solism, LA was bilateral but in two steps according to their clinical condition (3/7
patients with ACTH-dependent disease, 1/1 patient with ectopic ACTH syndrome
and 1/6 patients with ACTH-independent macronodular adrenal hyperplasia). The
mean patient age was 41 years (range, 21–65); the mean operative time was 210 min
(range, 90–60); the mean blood loss was 84 ml (range, 10–400); the mean tumor size
was 4.6 cm (range, 0.9–8.5). There were two conversions statistically correlated with
the tumor size greater than 5 cm (p = 0.046). There weren’t intraoperative com-
plications, and wound sepsis was reported in two patients. Mortality was zero.
Conclusions: The multicenter approach based on the laparoscopic and endocrine
experiences of two large Cuban institutions allows results comparable with others
published from large referral centers.
P151 – Endocrine Surgery
ROBOTIC ADRENALECTOMY: TECHNICAL ASPECTS
AND EARLY RESULTS
A. D’Annibale, G. Lucandri, I. Monsellato, M. De Angelis,
G. Pernazza, G. Alfano, P. Mazzocchi, V. Pende
San Giovanni Addolorata Hospital, ROME, Italy
Introduction: The chapter of adrenal surgery is undergoing continuous evolution;
robotic technology may give a further contribute to extend indications for a mini-
mally-invasive approach to adrenalectomy. Herein we report our experience on
robotic-assisted unilateral transperitoneal adrenalectomy: aspects on indications,
technique and early outcome are emphasized.
Material and Methods: Thirty robotic procedures have been performed at our
Departments over a decade period; presence of bilateral lesions and involvement of
vascular structures were the only contraindications for a mini-invasive approach.
Several patients presented significant co-morbidities: BMI [ 35 kg/m2 (20%), ASA
score III–IV (58.7%), moderate to severe impaired respiratory function (36.6%);
40% of patients have been previously submitted to abdominal surgery. Data on
length of operation and robotic use have been carefully collected.
Results: Two patients presented intraoperative complications (6.6%) and only 1
patient required conversion to open procedure (3.3%); any patient needed intraop-
erative transfusions. Hospital morbidity was 10% while no mortality was recorded.
Mean length of hospital stay was 5.2 ± 2.2 days. Mean size of resected adrenal mass
was 5.1 ± 2.4 cm. A significant trend in reduction of operative times was reported.
Conclusions: Robotic adrenalectomy is a safe and feasible procedure. Thanks to the
application of robotic technology, some subpopulations of patients with clinical or
oncological contraindications to laparoscopic treatment may be regained and
addressed to a mini-invasive treatment.
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P152 – Endocrine Surgery
SINGLE-PORT LAPAROSCOPIC ADRENALECTOMY
FOR BENIGN ADRENAL TUMORS: INITIAL EXPERIENCE
A. Sasaki, S. Baba, T. Obuchi, A. Umemura, S. Nishizuka,
Y. Kimura, H. Nitta, K. Otsuka, K. Koeda, M. Mizuno,
G. Wakabayashi
Iwate Medical University, MORIOKA, Japan
Background: Single-port laparoscopic surgery is now a procedure of great interest
worldwide. The aim of the present study was to evaluate the safety and feasibility of
single-port laparoscopic adrenalectomy (SPLA) for benign adrenal tumors.
Methods: Between January 2010 and December 2012, 12 consecutive patients (six
men and six women) underwent SPLAs for benign adrenal tumors. The median age
of the patients was 53 years (range, 39–74). Indications for SPLA were 10 aldo-
sterone-producing adenomas and two non-functioning tumors. A 2.5 cm incision was
made on the umbilicus, and a multi-channel port (SILSTM port) was inserted. A
5-mm flexible laparoscope, articulating instrument, and tissue sealing system were
the primary tools used in the operation. The right liver lobe was evaluated by means
of a percutaneous instrument (MiniLapTM).
Results: All surgeries were successfully completed without any intraoperative
complications. An additional 5-mm port was required in two patients with body mass
index greater than 30 kg/m2. This port was for the liver retraction in the right-sided
tumors. The median operating time was 120 min (range, 90–180) and the median
blood loss was 5 ml (range, 1–35). There were no significant differences in operating
time between the left-sided and right-sided tumors. No tumor rupture or spillage
occurred during any of the procedures. The median tumor size was 2.2 cm (range,
1–3.5). The median hospital stay was 3 days (range, 3–5). The postoperative course
was uneventful with no morbidity within one month of follow-up.
Conclusions: SPLA is a safe and technically feasible procedure for patients with
benign adrenal tumors when performed by a surgeon experienced in laparoscopic
and adrenal surgery. However, more surgical experience using this technique is
required to confirm our initial impressions.
P153 – Endocrine Surgery
EXPERIENCE OF ENDOVIDEOSURGERY OF AN ADRENAL
GLANDS DISEASE
O. Gulko, M. Nytchytaylo, O. Lytvynenko, V. Chornyi, I. Lukecha
National Institute of Surgery and Transplantology, KYIV, Ukraine
Laparoscopy plays an important role in adrenal gland surgery. A great number of
adrenal’s pathologies will benefits of this kind of surgery. Since then, this approach
has become the gold standard for benign disorders.
Methods: Between 2002–2011, 63 patients (44 female and 19 male) with adrenal
disorders have been operated in our clinic. The average age of the patients was 47.4
years (20–69 years). Our experience of endoscopic interferences on adrenals
includes 63 operations: 38(60.3%)- left-side adrenalectomies and 25 (39.7%) – right-
side. The study includes 10(16.0%) patients operated for pheochromocytomas,
17(26.8%) patients with nonfunctional adenomas, 3(4.8%) with adrenocortical car-
cinoma, 11(17.5%) with Cushing adenomas, 13(20.7%) with Conn adenoma,
4(6.3%) with fibroma, 5(7.9%) with adrenal metastases. The lateral transperitoneal
access has been used. The trocars, as a rule, were placed directly under a rib arc.
Quantity of trocars was 4–5.
Results: There were not conversions to open surgery. The duration of the operation
time has compounded: right-side 63.7 ± 17.1 minutes, left-side – 111.6+11,8 min-
utes, the intraoperational hemorrhage – 121.3 + 9.2 ml, the duration of postoperative
stay in a hospital – 3.6+1,4 days. The complications – 1 (1.58%) cause of haemo-
peritoneum after left-side adrenalectomy.
Conclusions: Thus, the laparoscopic adrenalectomy is to be less invasive method of
operations on adrenals ensuring efficiency of treatment, small operational trauma and
fast postoperative rehabilitation.
Surg Endosc (2013) 27:S53–S166
P155 – Endocrine Surgery
SPECIFIC COMPLICATIONS DURING
RETROPERITONEOSCOPIC SURGERY FOR
PHEOCHROMOCYTOMA
G. Todorov1, P. Tzaneva1, Ts. Lukanova2
1
University Hospital ‘‘Alexandroska’’, SOFIA, Bulgaria; 2Military
Hospital, SOFIA, Bulgaria
Aims: The aim of this study is to accentuate on specific complications during ret-
roperitoneoscopic removal of pheochromocytomas.
Methods: For the period of 2002–2012 forty-six pheochromocytomas were removed
retroperitoneoscopically in our clinic. We present two cases, complicated with
unilateral pulmonary oedema and severe left ventrical dyskinesia, described in lit-
erature as reversible Takotsubo cardiomyopathy.
Results: The rate of perioperative complications for the whole series of pheochro-
mocytoma cases was 8.6 % with mortality rate of 0%.
Conclusions: Perioperative management of patients with pheochromocytoma is a
great challenge for the surgical team and the anaestesiologist, requiring adequate
monitoring and support of vital functions. Operative treatment should be done only
in highly specialized clinics with experienced teams in both endocrine and laparo-
scopic surgery.
P156 – Endocrine Surgery
COMPARISON OF STANDARD AND NEW APPROACH FOR
TRANSPERITONEAL LEFT ADRENALECTOMY
V.V. Grubnik, O.S. Burlak, V.V. Ilyashenko
Odessa national medical university, ODESSA, Ukraine
Background: Sometimes laparoscopic left adrenalectomy is technically difficult
because of need to dissect splenic ligaments and due to proximity of splenic flexure
of colon tail of pancreas.
Aim of study was to compare standard technique and new approach to left adrenal
gland via the lesser sac.
Methods: from 2007 to 2011, a total of 32 left laparoscopic adrenalectomies were
performed (incidentalomas – 17, pheochromocytoma – 10, aldosteroma – 4,
metastasis of lung tumour – 1). Among them, 21 patients were operated transperi-
toneally. Standard approach was used in 10 patients (group A), novel approach was
used in 11 patients (group B). It is performed by transection of gastrosplenic liga-
ment, posterior leaf of parietal peritoneum and retoperitoneal access to the gland.
There were no statistically significant differences between groups in terms of pre-
operative data including adrenal gland size.
Results: There were no intraoperative complications in both groups. Mean blood loss
was 90 ml (range, 15–450) in group A, and 24 ml (range, 10–40) in group B (p [
0.05). Postoperative complications were in 3 cases in group A and were absent in
group B (p \ 0.05). Mean hospital stay was 6.2 days (range, 3–14) in group A and
4.6 days (range, 3–6) in group B (p \ 0.05).
Conclusion: Our ppreliminary results show some benefits of new transperitoneal
approach for left laparoscopic adrenalectomy. Further prospective randomized study
should be performed to show the best approach.
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P157 – Endocrine Surgery
TOTALLY ENDOSCOPIC PARATHYROIDECTOMY IN
BELGIUM: FIRST SHORT AND MID-TERM RESULTS
S. Van Slycke1, J.P. Gillardin2, N. Brusselaers3, H. Vermeersch3,
H. Maes1
1
OLV Aalst, AALST, Belgium; 2OLV Clinic Aalst, AALST,
Belgium; 3University Hospital Ghent, GHENT, Belgium
Times are changing, and undoubtedly it is the progress of imaging studies that has
modified the surgical management of patients with primary hyperparathyroidism and
helped the development of new surgical techniques. Today, the development and the
reported efficacy of non-invasive techniques have tempted many endocrinologists
and many surgeons to also order some of these new non-invasive techniques on
patients undergoing first-time parathyroidectomy. Moreover, more than half the
surgeons performing parathyroid surgery now consider that bilateral parathyroid
exploration is no longer the only option in all patients with primary hyperparathy-
roidism. Patients presenting with solitary adenoma must be considered as candidates
for new limited surgical procedures. This emphasises the current role of preoperative
localization studies in the surgical management of patients with primary hyper-
parathyroidism. We describe the first experience in Belgium concerning totally
endoscopic parathyroidectomy, a technique offered to all patients who present with
a unilateral posteriorly localised parathyroid adenoma, confirmed by concordant
results on ultrasonography and scintigraphy/SPECT-CT.
P158 – Endocrine Surgery
THE USE OF LAPAROSCOPIC GASTRIC CORRUGATION
(PLACATION) FOR TREATMENT OF DIABETES MILLITUS
TYPE I. OUR EXPERIENCE
R.Y. Havrysh1, Y.I. Havrysh2, M.P. Pavlovskyy1, O.V. Lukavetskyy1,
N.I. Boyko1, I.V. Kravchuk2
1
Lviv Medical University, LVIV, Ukraine; 2Lviv Regional Hospital,
LVIV, Ukraine
Aim: To analyse the results of our treatment of patients with type I diabetes.
Method: We know that bariatric operations cause a sharp increase in production of
an incretin hormone, which leads to proliferation of ß-cells of the pancreas. Diabetes
mellitus type I in some of the patients is autoimmune genesis, and therefore any of
the bariatric operations that lead to the formation of new ß-cells will be failed.
However, in patients with low level of antibodies to the insulin and ß-cells, bariatric
operations are supposed to be effective for type I diabetes treatment.
Result: from September 2011 to January 2012 we operated 3 patients with diabetes
mellitus of type I – 1 man and 2 women. Age of patients – from 25 to 39 years. The
disease lasts from 5 to 9 years, the patients were taking daily dose of insulin – 25, 60,
87 units. BMI of all of the patients is less than 35. One patient had ketoacidosis coma
in 2008. We did not found antibodies to the insulin and ß-cells in any of the patients.
We performed laparoscopic gastric corrugation in all of the patients. The operations
lasted from 80 to 110 min. There were no intra- and postoperative complications. No
mortality. The next day after the surgery we reduced the dose of insulin to half. After
three weeks the dose of insulin was reduced to zero. After the operation we were
observing the episodes of hypoglycemia and increase of acetone in the urine in one
patient during one week. The pH of blood did not change. A month after the surgery
in 2 patients the level of Glycated hemoglobin was higher than normal, but three
months after the operation – in all patients the level of Glycated hemoglobin was
normalized.
Conclusion: Laparoscopic gastric corrugation in patients with diabetes mellitus type
I is effective and safe. The mechanism of influence of the operations on the endo-
crine function of the pancreas requires further deep studing. Also it requires attention
during the postoperative period, when there is a risk of hypoglycemia.
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P159 – Endocrine Surgery
CARCINOID TUMORS OF THE APPENDIX
N.I. Boyko, Y. Havrysh, V. Khomyak, R. Kemin, A. Revura
Lviv Medical University, LVIV, Ukraine
Introduction: Carcinoid tumors most frequently (70 %) develop in the gastrointes-
tinal tract. Carcinoid tumors grow slowly, have a great potential for malignancy
transformation and only in 30% of patients the tumor is benign.
Aim: To improve the results of diagnosis and surgical treatment of the patients with
carcinoid tumors of the gastrointestinal tract, by studying the clinical course of the
disease, hormone and morphological characteristics, surgical treatment.
Methods: We analyzed the results of diagnosis and treatment of 25 patients with
carcinoid tumors of appendix for last 27 years (1984–2010). Age of the patients was
19–68 years. We have used US, MRI, enzyme immunoassay of hormones and
immunohistochemical analysis.
Results: Urgently 22 patients were admitted to surgical department with clinical
signs of acute appendicitis and one patient with bowel obstruction, routinely were
admitted two patients with chronic recurrent appendicitis. Carcinoid syndrome we
observed in one case. Laparoscopic appendectomy was performed in 7 patients.
Results of histological examination: in 24 patients – benign tumor, in 1 – malignant.
Tumors sizes were 15–26 mm. In one case right hemicolectomy was performed for
carcinoid tumor of appendix causing bowel obstruction. In this patient after 16
months was diagnosed 16 9 81 mm tumor in the pelvis, she was performed hys-
terectomy with ovaries. Histological conclusion – carcinoid metastasis in the ovaries.
After 8 months she was diagnosed metastases in the liver. In other patients we didn’t
find distant or local metastasis after 2 year.
Conclusions: In 4% of patients was observed hormonally active carcinoid tumors of
appendix. If carcinoid tumor of the appendix was less than 20 mm in diameter
without invasion into the mesentery and absent metastases in the regional lymph
nodes, patient should be performed appendectomy and resection of the appendix
mesentery, in other cases – right hemicolectomy should be done.
P160 – Flexible Surgery
FLEXIBLE-SINGLE-INCISION-SURGERY IN COLECTOMY
AND CHOLECYSTECTOMY
J.F. Noguera, A. Cuadrado, J.M. Olea, R. Morales, J.C. Garcı́a
Hospital Son Llàtzer, PALMA, Spain
Introduction: The development of NOTES surgery has led to other new techniques,
such as single-port surgery. The use of the flexible endoscope for single-incision
surgery paves the way for further refinement of both surgical methods.
Objective: The aim of the presentation is to describe a new, single-incision surgical
technique, namely flexible-single-incision-surgery to perform cholecystectomy and
colectomy.
Material and Methods. Lecture with video sequences showing the assessment of the
safety and effectiveness of endoscopic colectomy and cholecystectomy using the
new technique. This technique consists of a single periumbilical incision measuring
25 mm through which a flexible endoscope is introduced, and of two parallel entry
ports measuring 3 to 5 mm that provide access to non-articulated laparoscopic
instruments.
Results: The technique was applied in a clinical series of more than 20 cholecys-
tectomies and 3 right colectomies with no need to convert to conventional
laparoscopy. No general or surgical wound complications were noted. Surgical time
was no longer than usual for single-port surgery. The intervention cost far less than
single-port surgery owing to the use of instruments from the inventory and to the fact
that no single-port device had to be put in place.
Conclusions: Flexible single-incision surgery is a new single-site surgical technique
allowing for further refinement of NOTES and of single-incision surgery and
offering the same level of patient safety, at minimal cost.
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P161 – Flexible Surgery
SILS TECHNOLOGY IN SURGERY AND GYNECOLOGY
K.V. Puchkov1, Y.E. Andreeva1, D.K. Puchkov2
1
Swiss University Clinic, MOSCOW, Russia; 2Ryazan State Medical
University, RYAZAN, Russia
Introduction: SILS port is now occupied a strong position as a minimally invasive
treatment of cholelithiasis, as well as perform gynecological operations. Numerous
advantages of this method, which include: the ability to perform this operation in
patients of any age and sex, available technical facilities are pushing an increasing
number of surgeons to develop this area of surgery. The only limiting factor is the
specificity of training, which significantly prolongs the time of surgery in the period
of development.
Objective: To evaluate the results of the SILS port in the surgery of cholelithiasis,
diseases of the colon and gynecology.
Patients and Methods: Authors, for the period from 2010 to 2011, performed 115
operations, using the technology S-port. The structure of operations: surgery – 61
cholecystectomy, resection of the sigmoid colon 4 (stage I-II of a cancer), 1 total
proctocolectomy with ileoanal anastomosis; gynecology – 28 supravaginal ampu-
tation of the uterus, 21 hysterectomy. Our clinic has the experience of performing
simultaneous operations: 14 supravaginal amputation of the uterus and a cholecys-
tectomy; cholecystectomy and resection of the sigmoid colon.
Results: To evaluate the effectiveness of SILS port in surgery and gynecology, we
took a common standard – the operating time. We conducted studies postulating the
fact that even after 10–15 operations the operating time was close the corresponding
averages for the use of traditional laparoscopic techniques.
Conclusion: These data suggest the possibility of performing such operations, using
minimally invasive techniques S-port.
P162 – Flexible Surgery
LAPAROSCOPIC DISTAL GASTRECTOMY USING DUAL
PORTS METHOD
H. Kashiwagi, K. Kumagai, E. Monma, M. Nozue
Shonai Amarume Hospital, YAMAGATA, Japan
Aim: Despite the rapid development of laparoscopic surgery in last decade, lapa-
roscopic gastrectomy for gastric malignancy is still controversial in the world. One
of the reasons is the complexity of this procedure. Although recent trend of lapa-
roscopic 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 SILS. We
report the laparoscopic distal gastrectomy (LADG) using dual ports method with
SILS-port and surgical nylon ligature.
Method: Seven 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 71.6 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 for
lifting up the gastric wall and it can visualize the surgical field between stomach and
other neighbour organs. The 12 mm-port (Ethicon, Japan) was inserted from left
lower abdomen for the usage of the surgical instrument by the right hand of a
surgeon. Result: Mean operation time and blood loss were 267.1 ± 46.5 min. and
48.6 ± 66.1 g, respectively. All patients were transferred to the general unit from the
high care unit on day 1 after the surgery and started to the oral intakes gradually.
Mean hospital stay after surgery was 8.3 ± 1.5 days. No major complications
occurred in the post-surgery period.
Conclusion: Recent trend of laparoscopic procedure has been toward minimizing the
number of incisions. Although benefits of this type of surgery, called reduced port
surgery, compared to conventional laparoscopic surgery have not been established,
some advantages are expected. Cosmetic benefit is the definitive advantage of
reduced port surgery. Less postoperative pain may be an advantage, also. In addition,
tissue trauma and port-related complications such as organ damage, adhesions,
bleeding, wound infection and hernias can be decreased.
Surg Endosc (2013) 27:S53–S166
P163 – Flexible Surgery
MINIMAL ACCESS THERAPY AND OPERATIVE
ENDOSCOPY: HEALTH AND ECONOMIC IMPACT
A DEVELOPING SUB-SAHARA AFRICA – ONE YEAR
EXPERIENCE
S. Tabiri, K. Segoe
School of Medical and Health Sciences, University for Development
Studies, TAMALE, Ghana
Aims: There has been controversy concern the benefit of minimal access therapy in
the developing Sub-Saharan African countries. The purpose of this study was to
evaluate the health and economic impact flexible gastrointestinal endoscopy in the
developing Sub-Sahara West Africa country (Ghana).
Method: Endoscopy diagnostic and therapeutic interventions were performed at the
Minimal Access Therapy and Operative Endoscopy (MATOE) Unit of Tamale
Teaching Hospital from September 2010 to September 2011. Operative time, hos-
pital stay and generation of initial capital investment were analyzed.
Result: 688 (male 355 – 51.6%, female 333 – 48.4%) patients were treated with
mean age of 40.6 years ±17.1 SD. 671 (97.5%) patients are on National Health
Insurance. Main indications for endoscopy include: epigastric pain occurs in 56.4%;
Haematemesis – 14.2%; abdominal pain/retrosternal pain/heartburns – 18.1%; dys-
phagia – 4.7%. Diagnostic procedures performed include upper gastrointestinal (GI)
endoscopy in 667 (96.9%) patients, colonoscopy in 19 (2.8%) patients, and sig-
moidoscopy in 2 (0.3%) patients. The following operative endoscopic procedures:
biopsy for histopathology/ helicobacter pylori in 518 (75.3%) patients; sclerotherapy
for bleeding oesophageal varices – 24; balloon dilation for oesophageal strictures –
18; haemostasis upper GI bleeding using adrenaline injection – 7; polypectomy – 7;
foreign body removal – 5; percutaneous endoscopic gastrostomy – 5 (0.5%); En-
doclips for upper GI bleeding – 1 were performed. Operative time 17.02 minutes ±
8.09 SD, hospital stay after procedure was 0.14 ± 0.52. In one year, hospital
investment 166445.4 Ghana Cedis (104028 US dollars) was recovered.
Conclusion: Minimal access therapy and operative endoscopy has significant health
and economic impact in the developing country. Flexible and interventional
endoscopy can contribute significantly to the financial productivity of hospitals.
P164 – Gastroduodenal Diseases
MINIMAL INVSIVE TREATMENT OF GASTRIC STROMAL
TUMORS
A. Balint, B. Rózsa, M. Máté, B. Brenner, A. Kalocsai
Saint Emeric District Hospital, BUDAPEST, Hungary
Introduction: The gastrointestinal stromal tumors (GISTs) are rare mesenchymal
neoplasms of the gastrointestinal tract with a considerable life-threatening potency. It
can occur throughout the gastrointestinal tract but the most frequent location is the
stomach (50%). Its dignity varies from very low risk to very high risk. For primary
resectable GIST in the absence of metastasis, surgery is the first line treatment. In
such cases the excision of the tumor with free margin is sufficient. The patients
having solitaire tumors with the size = 5 cm are good candidates for laparoscopic
removal. Our aim was to evaluate the efficacy and safety of laparoscopic surgery of
gastric GISTs.
Material and methods: Between January 2007 and January 2011, 19 patients had
undergone surgery because of GIST. In 14 of 19 patients the location was stomach,
in 3 of 19 small intestines, in 1 patient the rectum and in 1 the retropreitoneum. 11 of
14 gastric GIST patients (7 M and 4 F with median age 62.3 ranges 30 to 80) were
suitable for laparoscopic wedge resection. The average time of procedure was 78 ±
32 min. There was no mortality and serious morbidity in the postop period. The
postop hospital stay was 5.6 ± 1.9 days. Although the data concerning the efficacy of
adjuvant tyrosine kinase treatment are controversial, our patients except the ones
with very low risk tumor (2 pts), were treated for one year with imatinibe. Up to now
there is no confirmed recurrence in this subset of patients, but they require thorough
oncologic follow up.
Conclusions: In our practice the solitaire gastric GISTs with size = 5 cm were
suitable for laparoscopic gastric wedge resection. The intervention proved to be
effective and safe.
S93
P165 – Gynaecology
ECONOMICAL LAPAROSCOPIC SURGERY USING
THE ABDOMINAL WALL LIFTING (AWL) METHOD
A. Okuda, R. Oi, S. Abe
Tokyo metoropolitan Ohtsuka Hospital, TOKYO, Japan
Aims: All Japanese have health insurance. The cost of expendable operative
equipment, such as disposable trocars, is included in fixed surgical expense, and
hospitals cannot claim these expenses separately. Gasless laparoscopic surgery using
the abdominal wall lifting (AWL) method is generally simple and economical,
because the AWL method allows for the use of laparotomy instruments and fewer
trocar than the pneumoperitoneum (P) method. Since 2011, we started using the
AWL method, and here, we introduce our method and report the cost-effectiveness.
Methods: This is a retrospective analysis of 11 laparoscopic unilateral ovarian
cystectomy procedures (LC) performed in 2011. The two groups consisted of
patients who underwent operation for the diagnosis of benign ovarian cyst (dermoid
cyst, mucinous cyst, endometrial cyst). One group consisted of 6 LC performed
using the AWL method, and the other group comprised 5 LC performed using the P
method in 2011. The mean cost of the expendable operative equipment, amount of
bleeding, and operative time were analyzed.
Results: The mean cost of the expendable operative equipment per case for LC using
the AWL method (22.183 yen) was 63% less expensive than that using the P method
(60,000 yen).
The mean number of used disposable trocars was 1 in the AML method and 3.6 in
the P method. There were no significant differences in the amount of bleeding (1 g/0
g) and operative time (72 min/95 min). In both methods, no conversion to open
surgery occurred.
Conclusion: LC using the AWL method was less expensive than that using the P
method. This is mainly due to the use of fewer trocars and the use of electric scalpel
for laparotomy in the AWL method. If LC using the AWL method instead of the P
method is performed, considerable savings can be achieved without compromising
patient safety.
P166 – Gynaecology
UTILITY OF SINGLE INCISION LAPAROSCOPIC
SURGERY(SILS) BY A SMALL SUPRA-PELVIC INCISION
IN OVARIAN CYSTECTOMY
M. Yamada, M. Watanabe, K. Kazemoto, T. Igarashi, J. Suzuki,
K. Akiyama
Metropolitan Hiroo hospital, TOKYO, Japan
Aim: Laparoscopic surgery is often performed in gynecology area. The number of
Single incision laparoscopic surgery (SILS) is increasing, as the needs of as mini-
mally invasive surgery are growing. Training system for SILS has not been
established, because of its complicated procedure and specific equipment. We
introduce a SILS procedure by a small supra-pelvic incision for benign ovarian
tumors with good mobility. Furthermore, its utility as an educational procedure is
discussed.
Methods: Patients who had benign ovarian tumors without adhesion were selected.
We approached to abdominal cavity by 2 cm transverse incision on supra-pelvic, and
covered the incision site with a wrap-disc which is available as an aeroperitonia port.
Results: We used two endoscopic graspers and one endoscope at one time through
the aeroperitonia port and performed ovarian cystectomy by Extracavitary proce-
dure. The incisional wound was only one and its length was 2 cm.
Conclusions: The working space in abdomen with this procedure is considerably
restricted in comparison with typical SILS procedure by an umbilical incision.
Therefore, only ovarian tumors with good mobility are target. The incisional wound
is available as an extended incisional wound, if operations convert to open approach.
Also, this approach is a simpler operative procedure for less-experienced operators.
This supra-pelvic incision procedure is useful as a minimal invasive and a port-
reduced surgery.
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P167 – Gynaecology
LAPAROSCOPIC CONSTRUCTION OF A NEOVAGINA
USING SIGMOID COLON VIA A SINGLE UMBILICAL
INCISION: A CASE REPORT
M. Sekimoto, I. Takemasa, J. Nishimura, T. Mizushima, M. Ikeda,
H. Yamamoto, T. Tanigawa, Y. Doki, K. Hosakawa, M. Mori
Osaka University, OSAKA, Japan
We herein report a case of single incisional laparoscopic construction of neovagina
using sigmoid colon. A 47-year-old woman visited our hospital for construction of a
vagina. She had a female-like perineum, but only a shallow hollow was present in the
perineum. Magnetic resonance imaging revealed a male-like pelvis containing a
prostate. The laparoscopic procedures were performed via three 5 mm trocars in the
umbilicus. The sigmoid colon and rectum were mobilized, and one of the trocars was
replaced with a 12-mm trocar, through which an endostapler was inserted to transect the
sigmoid colon. Then a 2-cm laparotomy was made in the umbilicus. The sigmoid colon
was exteriorized and the distal end of sigmoid colon was harvested as the neovagina.
Simultaneously, another team incised the perineum to create a tunnel to pass the
neovagina. The exteriorized sigmoid colon and conduit were returned to the peritoneal
cavity, and the umbilical incision was covered with a surgical glove. Trocars were
inserted through the cut fingertips of the glove. Following colorectal anastomosis, the
peritoneal reflection was dissected, and then the conduit was pulled down to the per-
ineum and was anastomosed. The patient was uneventfully discharged on the ninth day.
One month after surgery, the scar was almost completely hidden within the umbilicus.
Six months after surgery, neither erosions nor strictures were observed. The patient
expressed satisfaction with the operative result. In conclusion, single-incision lapa-
roscopic surgery that utilizes the sigmoid colon to construct a neovagina is feasible, and
results in excellent cosmesis and patient satisfaction.
P168 – Gynaecology
A COMPARATIVE STUDY BETWEEN LAPAROSCOPIC
SACROCOLPOPEXY AND TRANSVAGINAL APPROACH
FOR GENITAL PROLAPSE
R.A. Stoica1, T. Enache2
1
Sf.Ioan, BUCHAREST, Romania; 2Panait Sarbu, BUCHAREST,
Romania
Aims: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of
urinary, bowel and sexual symptoms may be associated with prolapse. Our goal was
to determine the effects of the many different surgeries in the management of pelvic
organ prolapse.
Methods: Fifty consecutive patients with symptomatic severe vaginal vault or uterus
prolapse were enrolled. The transvaginal approach was performed with a mesh
interposition between sacrospinous ligament complex and vaginal apex. The mesh
was extended to anterior and posterior vaginal wall for the repair of concurrent
cystocele and rectocele. The sacrocolpopexy was performed laparoscopic with a
mesh interposition between promontorium and anterior and posterior vaginal wall.
The surgical results and complications were evaluated. The prolapse evaluation was
performed according to International Continence Society ordinal stages of pelvic
organ prolapse.
Results: The mean age was 58 years. The mean follow-up was 1 year (range 0.5–2
years). Only the two procedures were performed for all patients. The average time
for transvaginal approach was 80 min and for the laparoscopic sacrocolpopexy was
172 min. The average blood loss for transvaginal approach was 75 ml, and for
laparoscopic sacrocolpopexy was 10 ml. No major complication. The concurrent
surgeries included total hysterectomies, and tension-free vaginal tape procedures. No
recurrence of prolapse was observed. However, five patients developed stage I
prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor
postoperative complications were observed.
Conclusion: laparoscopic sacrocolpopexy and alloplastic transvaginal approach are
safe and effective procedures for the correction of genital prolapse. A long-term
follow-up is necessary to detect any late complication. The addition of a continence
procedure to a prolapse repair operation may reduce the incidence of postoperative
urinary incontinence but this benefit needs to be balanced against possible differ-
ences in costs and adverse effects. Adequately powered randomized controlled
clinical trials are urgently needed.
Acknowledgement: This paper is supported by the Sectoral Operational Programme
Human Resources Development (SOP HRD) 2007–2013, financed from the Euro-
pean Social Fund and by the Romanian Government under the contract number
POSDRU/107/1.5/S/82839.
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Surg Endosc (2013) 27:S53–S166
P169 – Gynaecology
COMBINED TRANSANAL AND LAPAROSCOPIC
APPROACH FOR THE TREATMENT OF DEEP
ENDOMETRIOSIS INFILTRATING THE RECTUM.
V, Bridoux, H. Roman, M. Vassilieff, B. Kianifard, L. Marpeau,
F. Michot, J.J. Tuech
Hospital Charles Nicolle, ROUEN, France
Background: Two surgical approaches are employed in the treatment of deep infil-
trating endometriosis of the rectum (DIER): colorectal resection and nodule excision.
In 2009, we introduced a new technique for transanal full thickness disc excision of
endometriotic nodules infiltrating the low and middle rectum, using the Contour()
Transtar(TM) stapler (Ethicon Endo-Surgery inc., Cincinnati, OH, USA). The aim of
this retrospective study was to describe the technique and to present data on the
feasibility of this technique.
Methods: From April 2009 to October 2010, all patients presenting with DIER and
undergoing full thickness excision using the Contour() Transtar(TM) stapler were
enrolled in the study. Pre-, intra- and post-operative data were collected and reported.
Results: Six nulliparous women were managed using this technique during the study
period. The rectal wall discs removed measured from 40 9 45 to 60 9 50 mm. In
two cases, microscopic foci were noted on one of the margins but in four cases the
limits were clear. Operating time varied from 180 to 450 min. Four women were
completely free of post-operative digestive complaints.
Conclusions: Despite the small numbers in this series, our data suggest that the new
technique of transanal rectal disc excision using the contour stapler may be applied in
patients with infiltrating endometrial nodules of the rectum up to 10 cm from the anal
margin and up to 5 cm in diameter. This new procedure promises to be a useful addition to
the surgeon’s armamentarium in a multidisciplinary approach to deep pelvic endometriosis.
P170 – Gynaecology
DIGESTIVE FUNCTIONAL OUTCOMES OF THE SURGICAL
MANAGEMENT OF DEEP ENDOMETRIOSIS
INFILTRATING THE RECTUM: RADICAL VERSUS
SYMPTOM GUIDED APPROACH?
V, Bridoux, H. Roman, M. Vassilieff, B. Kianifard, L. Marpeau,
F. Michot, L. Schwarz, J.J. Tuech
Hospital Charles Nicolle, ROUEN, France
Deep infiltrating endometriosis of the rectum (DIER) may be managed according to
2 surgical approaches: radical or carcinologic (based on colorectal resection) and
conservative or symptomatic (rectal shaving and nodules full thickness excision).
Our team followed the radical approach until November 2007, then adopted the
preserving approach.
The goal of this study was to assess whether or not digestive functional outcomes
depend on the surgical approach.
All the women treated for endométriose deep posterior with rectal infiltration since
March 2005 were contacted to answer questionnaire, including scores KESS, FIQL,
GIQLI and BRISTOL. The data were compared according to the approach adopted at
the time of the surgery (group of women operated before and after November 2007
whatever the type of intervention).
86 women were included, respectively 25 and 61 in each group. The rate of multiple
digestive nodules (23 vs 40%, P = 0.36), the height of the lowest rectal nodule (12
cms vs 11 cm, P = 0.44), and the diameter of the largest rectal nodule (32 vs 31 mm,
P = 0.81) were comparable. The rates of colorectal resections, disc resections and
shaving were respectively 72.4, 24%, and 21.5, 74 %. The postoperative follow-up
was respectively of 52 months (28 to 69) and 21 months (12 to 34). No deep
recurrence requiring new surgery was recorded. A statistically significant increase in
the overall KESS score was recorded in women managed during the period of radical
approach (14.5 ± 7.2vs 9.3 ± 6.3, P = 0.002) corresponding to a higher degree of
constipation.
A statistically significant increase in the overall GIQLI score was recorded in women
managed during the period of radical approach (92 ± 27 vs 107 ± 22, P = 0.02). The
difference between the FIQL score was not statistically significant except for the
depression.
The adoption of the conservative approach allowed to divide by 3 the rate of
colorectal resections, without impairement on postoperative pain and recurrence, but
with significant improvement in constipation scores and quality of life.
Surg Endosc (2013) 27:S53–S166
P171 – Gynaecology
LAPAROSCOPIC TREATMENT OF TUBE-PERITONEAL
INFERTILITY AFTER PREVIOUS OPERATION DUE TO
EXTRAUTERINE PREGNANCY
O.S. Holub
Rivne Regional Hospital, RIVNE, Ukraine
Background: It is revealed that infertility develops in 45–60% of cases after
surgical treatment of ectopic pregnancy.
Aim: To estimate role of laparoscopy in diagnostics and management of tube-
peritoneal infertility after surgical treatment of extrauterine pregnancy.
Methods: To discover genesis of sterility we have conducted diagnostic lapa-
roscopy for 51 patients with previous unilateral tubectomy by means of
laparoscopy (first group) and for 39 ones by way of laparotomy (second group).
Diagnostic laparoscopy was made in interval 7–20 months from moment of
surgical interference.
Results: All 90 patients had adhesive process of different degree with
involvement of womb, uterine tubes, intestines, omentum. Patients of the
second group had more extensive pathological condition of internal sexual
organs than patients of the first group. In the first group there was conducted:
salpingoovariolysis – 24 (47.0%) cases, salpingostomy of contralateral tube –
12 (23.4%) cases. In the second group – salpingoovariolysis – 32 (82.1%)
cases, salpingostomy of contralateral tube – 14 (35.9%) cases. To prevent new
adhesions formation we provided peritoneal lavage via drain tube with fol-
lowing solution: dexamethasone 5 mg, reopolyglucinum 200 ml, dioxydinum
10 ml. In some cases we conducted recurrent laparoscopy in 5–7 days fol-
lowing diagnostic-surgical laparoscopy (14 women of first group and 12
women of second group).
Conclusion: Laparoscopy prevents large defects formation in peritoneum and
ensures minimal tissue trauma that leads to reducing an intensity and duration
of catabolic reactions, as well as immune depression that allows reduce
adhesive process. Recurrent laparoscopy can be recommended for diagnostics
and treatment of tube-peritoneal infertility after previous operation due to
extrauterine pregnancy.
P172 – Gynaecology
LAPAROSCOPIC RECTAL RESECTION OF DEEP
INFILTRATING ENDOMETRIOSIS
F. Jelenc, M. Ribic Pucelj, R. Juvan, V. Salamun
UMC, LJUBLJANA, Slovenia
Purpose: Deep infiltrating endometriosis with colorectal involvement is a
complex disorder often requiring segmental bowel resection. Complete
removal of all visible lesions is considered the adequate treatment of infil-
trating endometriosis in order to reduce recurrence. In this article, we describe
our experience with laparoscopic management of deep infiltrating endometri-
osis with involvement of the rectum.
Methods: A retrospective analysis of data from patients with deep infiltrating
endometriosis with rectal involvement, who underwent a laparoscopic surgery
in the years 2002 to 2009 at the Department of Obstetrics and Gynecology, was
made.
Result: Between 2002 and 2009, a laparoscopic partial rectal resection was
performed in 52 patients and laparoscopic disk resection was performed in 4
cases with deep infiltrating endometriosis. The mean age of patients was 34.4
years (range 22–62 years). Preoperative symptoms included dysmenorrhea,
dyspareunia, chronic pelvic pain and infertility. The laparoscopic procedure
was converted to formal laparotomy in 3 patients (5.4%). The mean duration of
surgery was 145 minutes. Postoperative complications included 3 cases of
anastomotic leakage with rectovaginal fistula in two cases and intraabdominal
bleeding in one case. The mean hospital stay was 7 days. Postoperatively, nine
patients had a normal delivery, two of them after IVF treatment.
Conclusion: Laparoscopic rectal resection for deep infiltrating endometriosis is
a relatively safe procedure, when performed by surgeon and gynecologist with
sufficient experience in laparoscopic colorectal surgery.
S95
P174 – Intestinal, Colorectal and Anal Disorders
SINGLE INCISION LAPAROSCOPIC COLECTOMY
IN DIFFICULT SITUATIONS
J.F. Noguera, J.M. Olea, A. Cuadrado, J.C. Garcı́a, R. Morales
Hospital Son Llàtzer, PALMA, Spain
Introduction: Single Incision Laparoscopic Surgery (SILS) is a feasible
approach por colon cancer. Some situatins like the location in esplenic flexure
or the presence of a wall stent may be a problem for this approach.
Aim: To report the differences between a typical SILS sigmoidectomy and an
unusual SILS approach for a colonic adenocarcinoma in the splenic flexure of
the large bowel treated with subtotal colectomy or a transverse colectomy with
a colonic wall stent in situ.
Results: Satisfactory results with a SILS approach for the subtotal colectomy
and for transverse colectomy with colonic wall stent are presented.
Conclusion: This is a feasible and reproducible minimally invasive approach
for these situations. Subtotal/total colectomy may be difficult but not
impossible.
P175 – Intestinal, Colorectal and Anal Disorders
SINGLE INCISION LAPAROSCOPIC COLON RESECTION
Yu.A. Shelygin, S.A. Frolov, S.I. Achkasov, O.I. Sushkov,
D.G. Shakhmatov
State Scientific Center of Coloproctology, MOSCOW, Russia
Aim: To compare single incision laparoscopic colon resection with multiport
laparoscopic (ML) operation.
Patients and methods: Since May 2010 till December 2011 35 patients were
operated using SILS technique (main group). In control group 70 patients were
includes who underwent multiport laparoscopic procedures at the same period.
All patients were operated due to benign or malignant colon tumor. There was
no difference between both groups in terms of age, gender and BMI. We
performed 15 SILS and 24 ML right hemicolectomies, 19 SILS and 44 ML left
colon resections and 2 transverse colon resection in each group.
Results: The mean operation time was longer in main group than in control
(159.8 min vs 127.1 min). Bloodloss was negligible in both groups. The total
incision length of abdominal wall was significantly less in SILS group (3.9 cm
vs 9.5 cm). The minor complications were observed in 1(3.7%) and 2(4.3%)
patients in main and control group, respectively. Conservative treatment was
effective in all three cases. In one patient after ML right colectomy transmural
myocardial infarction occurred. And the patient died at postoperative day three.
Overall length of postoperative stay was significantly shorter in SILS group –
5.8 days in compare with ML group – 8.4 days.
Conclusion: Preliminary results show that SILS technique provides better
cosmetically result than multiport method. Subsequent accumulation of expe-
rience in SILS and prospective studies are needed to demonstrate the benefits
of SILS compared to conventional laparoscopic approach.
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P176 – Intestinal, Colorectal and Anal Disorders P178 – Intestinal, Colorectal and Anal Disorders

TRANSVAGINAL SINGLE-INCISION LAPAROSCOPIC LAPAROSCOPIC TREATMENT OF DIVERTICULITIS.

COLON RESECTION HAVE WE LEARNED SOMETHING?
Yu.A. Shelygin, S.A. Frolov, S.I. Achkasov, O.I. Sushkov, M.E. Franklin
D.G. Shakhmatov Texas Endosurgery Institute, SAN ANTONIO, United States
State Scientific Center of Coloproctology, MOSCOW, Russia of America
First experience of transvaginal single-port laparoscopic surgery for colon cancer is * History
presented. Female patient of 54 years old underwent screening colonoscopy which
revealed 3 cm tumour of sigmoid. Endoscopic excision was not made due to focal – 50’s: Lavagae and drainage
adenocarcinoma diagnosed by biopsy. The patient had no previous surgery, BMI – – 60’s: Resection after second episode, 2 stages
23.5 kg/m2 and there was no any significant comorbidity. Therefore decision to (Hartmann’s + Resection)
perform transvaginal laparoscopic sigmoid resection was made. – 70’s: No changes
The procedure was performed at April, 7 2011 in lithotomy position under combined – 80’s: First lap cholecystectomy
anesthesia. Laparoscopic revision was made using 5 mm trocar inserted through
posterior vaginal vault. Then SILS port (Covidien, USA) was placed into 3 cm
– 90’s: First Lap colon resection
incision, pneumoperitoneum was reestablished. Sigmoid mobilization was per- *Prevalence
formed using 5 mm laparoscopic instruments including harmonic scalpel and
‘Ligasure’. Sigmoid colon at the level of the upper rectum was transected by – 5–10% over 45 years
endoscopic stapler device Echelon (Ethicon Endo-Surgery, USA) and the specimen – 40% 60 years
was extracted via vagina. Proximal colon transection was performed extracorpore-
– 80% over 85 years
ally at the level 10 cm above the tumour following insertion of a circular stapler
anvil. Intracorporal anastomosis was created with circular stapler CDH-29. The *Modified Hinchey Classification
pelvis was drained through colpotomy wound. There was no necessity for transab-
dominal ports. – I: Pericolic abscess
Operation time was 270 min, bloodloss was negligible. The patient had uncompli- – IIA: Distant abscess amenable to percutaneous drainage
cated postoperative period and was discharged at postoperative day 6. Morphological
– IIB: Complex abscess associated with fistula
examination revealed adenocarcinoma invading submucosal layer (pT1N0M0).
Transvaginal single-incision laparoscopic colectomy seems to be feasible option for – III: Generalized purulent peritonitis
treating colonic adenoma and early stage cancer. Further experience is necessary to – IV: Fecal peritonitis
assess advantages and limitations of this technique.
*Laparoscopic or open resection of diverticular disease may be quite challenging
*When to perform surgery? *** all can be performed laparoscopically ***

– Drainage of abscess not ammendable to CT Drainage

– Necessary colonic resection
– Large un-resolving phlegmon
– Complications of diverticulitis (not responding to medical management)
P177 – Intestinal, Colorectal and Anal Disorders *Chances of converting to open colectomy

LAPAROSCOPIC-ASSISTED REVERSAL OF HARTMANN’S
PROCEDURE
S.I. Achkasov, O.I. Sushkov, D.G. Shakhmatov, M.B. Rinchinov
State Scientific Center of Coloproctology, MOSCOW, Russia
Aim: To assess the efficacy of the Laparoscopic assisted Hartmann’s reversal
(LAHR) in patients with the end stoma in comparison with the conventional reversal
Materials and methods: During 2008–2011 y.y. 40 patients who underwent LAHR
were included in main group and 45 patients after open reversal of Hartmann’s
procedure were included in control group. All patients had length of rectal stump 10
cm or more. The two groups were similar in terms of gender, age, indications for
Hartmann’s procedure and previous attempts to reversal. Also there is no difference
in BMI, stump length, expressiveness and extend of adhesions and distance between
anastomosed colon parts. It should be noted that there was no total adhesiolysis in
LAHR group.
Results: Mean operative time was significantly shorter in the LAHR group in
compare with the open one (179.5 vs. 266.9 min). Bloodloss was less in the main
group (64.7 vs. 181.8 ml). Postoperative wound length was substantially smaller in
laparoscopic group (9.5 vs. 36.5). Preventive ileostomy was performed in 11 and 3
cases in open and LAHR group, respectively. There was no conversions in laparo-
scopic group. Postoperative course was statistically better in main group in terms of
time to first peristalsis, flatus, bowel movement, expresivness of postoperative pain
and self-service. Complication rate was similar – 3 (7.5%) and 3 (6.6%) in LAHR
and open group, respectively. Length of stay was shorter in the main group (8.8 vs.
12.8 days).
Conclusion: Laparoscopic-assisted Hartmann’s reversal is a technical feasible
operation and it is accompanied with the reduction of the operative time and blood
loss. LAHR promotes faster rehabilitation, lower postoperative pain and results of
this surgery are not worse than after conventional technique. Division of adhesive
process in the left lateral canal and small pelvis only does not lead to postoperative
adhesive ileus.
– 4.8% rate in Hinchey I-II, 18.2% rate of conversion for cases of complicated
diverticulitis (Hinchey III-IV)
– Causes of conversion: Hemorrhage in mesentery, fibrosis, severe inflammation,
adhesions, anatomy not defined
– Placement of diversion (ileo-colostomy)
– Examination and lavage of peritoneal cavity
Conclusions:
– Laparoscopic colon surgery is a valid alternative for the treatment of acute and
chronic diverticulitis.
– There is documented success with both laparoscopic colectomy as well as
laparoscopic peritoneal lavage and drainage.
– The applicability of laparoscopic colonic surgery will remain directly dependent
upon the individual surgeon’s laparoscopic skills.
– In experienced hands, laparoscopic sigmoid colectomy for diverticulitis is as
good or better than open colectomy.
– The most common indication for surgery in our practice is patient with chronic
refractory disease which summarily interferes with the lifestyle of the patient.
– Patients with complicated, perforated (localized) diverticulitis rarely require
urgent surgery.
– The presence of diverticulitis does not necessary means that surgery is needed
immediately or ultimately.
– Close followup and patient education…. mandatory!!
– Large number of patients, even with perforation can be treated without
resection.

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P179 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC MANAGEMENT OF BOWEL
OBSTRUCTION, THE ALL INCLUSIVE APPROACH,
IMPROVES OUTCOMES
M.E. Franklin
Texas Endosurgery Institute, SAN ANTONIO,
United States of America
Background: Multiple series on laparoscopic management of Bowel obstruction have
been published. Most are limited to likely cases of adhesive Small Bowel
Obstruction and exclude patients with hernias and/or Colon Obstruction. We present
our series on the ‘all inclusive approach’ to laparoscopic treatment of bowel
obstruction.
Methods: From 1991 to 2010, 448 patients underwent laparoscopy for Bowel
Obstruction. Results: Laparoscopic management was successful in 74.5%. There
were 62 enterotomies (13.8%). Mean length of stay was 10.4 days. Mortality was
1.7%. Significant differences were found between the Laparoscopic and Converted
patients in enterotomies (6.4% vs 40%), Mean ASA score (2.47 vs. 2.94), Blood loss
(49.183 vs. 177.35 cc), Length of surgery (94 vs. 166 min.), length of stay 9.485 and
14.714 (p value 0.008) and in the Nonenterotomy and Enterotomy length of surgery
(94 vs. 149 min.) and Blood loss (64 vs. 127 cc). Linear regression showed a relation
between ASA score and Length of Stay (p value 0.0001).
Conclusion: Bowel Obstruction can be managed by laparoscopy in 74.5% of cases.
Conversion is associated with a significant increase in blood loss, operating time, a
greater number of enterotomies and increased length of stay, with the latter being
related to patient co-morbidities.
P180 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC COLORECTAL SURGERY IN PATIENTS
WITH DIVERTICULAR DISEASE
N. Naguib, L. Satharley, S. Winstanley, M. AbdelDayem,
A.G. Masoud
Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom
Aim: Benign colorectal surgery is recommended for training in laparoscopic colo-
rectal resection (LCR), one of the commonest is Diverticular disease. We evaluate
whether Diverticular disease is suitable to obtain experience in LCR.
Methods: Retrospective study of elective LCR performed 2002–2011. The study
compares LCR for Diverticular disease (study group-S) with LCR for other
pathology (control group-C). Groups were compared according to demographic
characteristics, conversion rate, operative time, hospital stay, morbidity and mor-
tality. Statistical analysis was performed using Fisher’s exact test, Student ‘t’ test and
Mann Whitney U-test.
Results: The study included 194LCR out of which 22(11.3%) were in group-S. The
overall conversion rate in LCR was 11.9% (23/194). Conversion rate in S-group was
27.3% (6/22) versus 9.9% (17/172) in C-group, p = 0.017 (C.I. 1.1804–9.9039).
The mean operating time (MOT) in all LCR was 226.5 minutes (60–544). The
operating time was stratified for procedure type for groups S and C (n = 22 and 103,
respectively). MOT was significantly higher in S-group (250 minutes) compared to
196 minutes in C-group, p = 0.0004. The median length of hospital stay in all LCR
was 4 days (1–52). This was 6 days in S-group and 4 days in C-group, p = 0.12.
The incidence of enterotomy in S-group [2/22(9.1%)] was higher than in C-group
1/172 (0.6%), p = 0.034. There was one right-side ureteric injury and one superficial
urinary bladder injury in group-S, but none in group-C (p = 0.113). Other morbidities
and mortality rates were not statistically different between the two groups.
In another subgroup analysis among the S group to study the effect of the learning
curve, we compared the LCP done for Diverticular disease in the 1st half (50:50) (7/
97 LCP), with those done in the 2nd half (15/97 LCP) of the study. There was a
significantly higher conversion rate 4/7 (57%) in the first part compared to 2/15
(13.3%), p = 0.05. The mean operative time was not significantly different between
both subgroups; 235 & 257 minutes respectively, p = 0.34. There was no significant
difference between both subgroups in morbidity or wound infection.
Conclusion: LCR for Diverticular disease are technically challenging and should be
attempted later in the learning curve.
S97
P181 – Intestinal, Colorectal and Anal Disorders
SHORT TERM OUTCOMES OF LAPAROSCOPIC
COLORECTAL SURGERY IN PATIENTS WITH PERIOUS
ABDOMINAL OPERATIONS. 10 YEARS EXPERIENCE
N. Naguib, A. Saklani, P. Shah, P. Mekhail, M. AbdelDayem,
M. Alsheikh, A.G. Masoud
Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom
Aim: to assess the effect of previous abdominal surgery (PAS) on laparoscopic colorectal
surgery (LCP).
Methods: This is a follow up study for the effect of previous abdominal surgery on the
outcome of laparoscopic colorectal surgery. Our initial results in 2009 showed that previous
abdominal operations results in increased operative time during LCP. In this study we re-
evaluate the outcomes from a prospectively collected database of LCP for 10 years between
2001 and 2011. Patients were divided into two groups; Group-A; patients with no PAS and
Group-B; patients with PAS. Data collected includes prior abdominal operations, type of
LCP, time for surgery and conversions. Morbidity, mortality and ward stay in both groups
were compared. Statistical analysis was performed using Fisher’s exact and student ‘t’ tests.
Results: 182 patients underwent LCP, 113 in Group-A and 68 in Group-B. 29 cases were
performed in the first 5 years, 10 had previous abdominal surgery. 152LCP were performed
in the last 5 years, 58 of them had previous abdominal surgery, p = 0.8. Mean operative
time in Group-A and Group-B was 216.5 minutes (60–520) and 233.2 minutes (114–544)
respectively (p = 0.17). In the first 90 cases, the mean operative time was significantly lower
for Group-A (203 minutes) than in Group-B (236.5 minute), p = 0.02. The rate of con-
version was 10.6 % (12/113) in Group-A and 13.2% (9/68) in Group-B, (p = 0.6). 2 patients
in Group-B had small bowel enterotomies (1 missed) compared to none in Group-A.
Morbidities were comparable in both groups. Median hospital stay was 4.5 and 4 days in
both groups respectively (p = 0.9). There were 3 mortalities in Group-A (one surgical-
related). One surgical-related mortality occurred in Group-B.
Conclusion: Short-term outcomes of laparoscopic colorectal surgery in patients with pre-
vious abdominal surgery are acceptable. There is no significant difference in conversion
rate, hospital stay, morbidity or mortality. Difference in the operative time is significant
only in the early part of the learning curve.
P182 – Intestinal, Colorectal and Anal Disorders
SHORT TIME OUTCOMES OF SINGLE PORT SURGERY
FOR SIGMOID COLON CANCER
M. Fukunaga
Juntendo University Urayasu Hospital, URAYASU, Japan
Background: Single port surgery has been developed with the aims of offering
additional benefits compared to traditional multiport laparoscopic surgery. We herein
analyze our short time outcomes of our initial experiences for transumbilical single
port surgery (SPS) for sigmoid colon cancer.
Methods: Between April 2009 and December 2011, 101 patients underwent SPS for
sigmoid colon cancer. Most common procedure was SPS performed in 33 patients
(33%). The umbilical incision was performed, and platform is placed within the
umbilicus. Laparoscope was inserted from the median trocar. We utilized laparo-
scopic coagulating shears during operation. The surgeon operated endoscopic
instruments bimanually with other 2 trocars. Procedures were mostly carried out
using medial to lateral approach. The origin of the inferior mesenteric artery was
initially dissected with lymph node dissection (D2 or D3), and the mesentery and
diseased segment of the bowel were mobilized. The bowel was transected with a
laparoscopic linear stapler via umbilical trocar and anastomosis was created using
double stapling technique intracorporeally. We were strictly adherent to oncologic
principles.
Results: We retrospectively reviewed our series of 33 patients underwent SPS for
colon cancer. We have never experienced intraoperative complications. No patient
required additional instruments, no conversion to open surgery. Postoperatively,
there was no mortality and major postoperative complications such as leakage.
Wound infection was observed in one patients.
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P183 – Intestinal, Colorectal and Anal Disorders
ANALYSIS OF THE BENEFIT OF NEOADJUVANT
TREATMENT FOR ‘INTERMEDIATE RISK’ RECTAL
CANCER IN BOTH LAPAROSCOPIC AND OPEN SURGERY
N.C. Tanner, N. Naguib, S. Winstanley, M. Al-Dayem, A.G. Masoud
Prince Charles Hospital, CARDIFF, United Kingdom
Aims: The optimal use of neoadjuvant chemoradiotherapy for rectal cancer remains contentious,
especially for the management of ‘intermediate’ risk patients.
Methods: A prospectively maintained database of all patients who had surgery for rectal cancer
since 2001 was analysed. Patients underwent extensive follow up with 6 monthly clinical assess-
ment, CT scans and CEA levels. Patients were divided into 4 groups: Group 1 – pT1/pT2, N0 (‘low
risk’). Group 2 – pT3 and/or node positive disease (‘intermediate’ risk patients). Group 3 –
preoperative threatened/involved margin and/or resectable metastatic disease (‘high risk’). Group 4
– patients with metastatic disease which is not suitable for metastectomy (‘palliative’) were
excluded. Our unit reserves radiochemotherapy for ‘high risk’ rectal cancers.
Results: A total of 122 consecutive patients with rectal cancer and minimum follow up of 6 months
were identified. 83 had a lower rectal tumour [below the peritoneal reflection], & 39 upper rectal
cancer [below the sacral promontory and above peritoneal reflection]). The median age at surgery
was 68 years (range 44–92 years). 59 patients (48.4%) had a laparoscopic resection with a con-
version rate of 10.2%.
There was a bias towards laparoscopic surgery in group 1 and to open surgery in group 3, but the
‘intermediate risk’’ group is comparable.
Laparoscopic = 22.28 and 7 for groups 1, 2 and 3 respectively
Open cases = 14.33 and 16 for groups 1, 2 and 3 respectively
Six patients have developed local recurrence (three patients in group 2 and three in group 3). All
local recurrences occurred in lower rectal cancers. Six patients had a post-operative positive CRM,
and 2 have developed local recurrence (at 11 months in group 2 & 18 months in group 3). Follow-
up for the remaining CRM positive patients is 20, 27, 31 & 44 months.
Local recurrence in the laparoscopic group was 0/23, 1/28(3.6%), 0/8 for groups 1, 2 and 3;
Local recurrence following open surgery was 0/14, 2/33(6%) and 3/16 for groups 1, 2 and 3
respectively.
There is no significant difference between laparoscopic and open surgery for the development of
local recurrence in the ‘intermediate risk’ group. P-value = 1.0.
Conclusion: According to our data, the risk of local recurrence in ‘intermediate risk’
rectal cancer when neoadjuvant chemoradiation is not used, is comparable for both
laparoscopic and open surgery. We do not recommend the use of neoadjuvant
therapy in early rectal cancer or for tumours above the peritoneal reflection. The
value of neoadjuvant treatment in reducing local recurrence is between 3.6%-6% for
‘intermediate risk’ patients, at best.
P184 – Intestinal, Colorectal and Anal Disorders
SINGLE INCISION LAPAROSCOPIC TOTAL COLECTOMY
DUE TO CECUM AND DISTAL SIGMOID COLON CANCER
K.Y. Hahn1, S.H. Kim2
1
Seongnam Central Hospital, SEONGNAM, Korea; 2Anam Hospital,
Korea University, SEOUL, Korea
Aim: Single incision laparoscopic cholecystectomy and appendectomy were common procedure
these days. Also, single incision laparoscopic colectomy for colon cancer is increasing recently. There
are many factors to overcome for performing single incision laparoscopic colectomy. First of all very
narrow working space, fightings between the laparoscopic tools, reverse triangle of laparoscopic
instruments and limitation of intracorporeal suture. To get over these difficulties and prove the
oncologic safety of this method, we carried out this single incision colectomy for colon cancer.
Method: Seventy-three years old male patients visited our hospital because of low abdominal pain and
distension. He took a medicine for 3 yrs due to hypertension. In colonoscopy and barium enema study
revealed obstructing mass in distal sigmoid colon and another irregular shape ulcero-fungating mass in
cecum. We planned the single incision laparoscopic total colectomy and ileo-rectal anastomosis.
Results: The operation time was 245 minutes and blood loss was 200 cc. The gas and stool passed
postoperative 2nd and 3rd day respectively. There was no post-operative complications. The
pathologic report manifested that tumor extended into subserosa layer without lymph nodes
metastasis (0/63). Proximal and distal margin were 20 cm and 7 cm individually. The patient was
received 12th cycle of chemotherapy (FOLFOX4). He is being followed up without recurrence.
Conclusion: Compared to conventional laparoscopic surgery, overcome and adapt the reverse
triangle in single incision laparoscopic surgery are quite hard process. Especially, colonic
obstruction with bowel dilatations might be jeopardize the operation. Handling of bowels by two
ports within single incision is very difficult procedure. To make optimal dissection plan with one
assist hand is also another barrier during this operation. But in my experience, through sufficient
conventional laparoscopic colon surgery, we can perform the single incision laparoscopic colec-
tomy without complication. By virtue of this single incision surgery, we can actualize very small
surgical wound (4–5 cm) with high cosmetic outcome. There is no oncologic difference in single
incision colectomy in dissection, high ligation of vessels, hepatic and splenic flexure mobilization
and bowel cutting by endo-cutter. To confirm the operative stability and oncologic safety, large
scale prospective randomized studies are warranted.
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Surg Endosc (2013) 27:S53–S166
P185 – Intestinal, Colorectal and Anal Disorders
AN EARLY PREDICTION MODEL FOR DEVIATION AND
FAILURE OF ENHANCED RECOVERY AFTER SURGERY
(ERAS) FOLLOWING LAPAROSCOPIC COLORECTAL
SURGERY
J.D. Foster1, N.J. Smart1, P. White2, A.S. Allison1, J.B. Ockrim1,
R.H. Kennedy3, N.K. Francis1
1
Yeovil District Hospital, YEOVIL, United Kingdom; 2University of
the West of England, BRISTOL, United Kingdom;
3
St Mark’s Hospital, HARROW, United Kingdom
Aims: Enhanced Recovery After Surgery (ERAS) programmes are well established, but deviation
from the postoperative elements may result in delayed discharge. Early identification of patients
deviating from the postoperative pathway may enable remedial action to be taken. The aims of this
study were to investigate factors associated with delayed discharge and to produce a predictive
scoring system for ERAS failure.
Methods: Retrospective review of case notes of patients who underwent elective laparoscopic
colorectal resection and ERAS at a single centre between 2002 and 2009. Univariate and multi-
variate analyses were performed and binary logistic regression was used to model a predictive
scoring system.
Results: 385 patient records were reviewed. Median length of stay was 6 days. 122 patients (31%)
stayed longer than one week (delayed discharge). 159 (41%) deviated in one or two postoperative
ERAS factors. Patient demographic factors were not predictive of delayed discharge. Prolonged
length of stay was associated with an operation time greater than 5 hours, blood loss in excess of
500 ml and the formation of a stoma. Deviation from ERAS factors at the end of the first post-
operative day, including continued intravenous fluids, lack of functioning epidural, inability to
mobilise, vomiting requiring nasogastric tube insertion and re-insertion of urinary catheter, were
strongly associated with delayed discharge. The following five element predictive scoring system
for ERAS failure and delayed discharge was formulated: (2 9 IV Fluids Required) + (2 9 Re-
catheterised) + (2 9 Stoma) + (3 9 Failure to Mobilise) + (4 9 Vomiting Requiring Nasogastric
Tube) – 5 = Score.
The variables take the values of 1 or 0 (where 1 = Yes; 0 = No). If the value obtained from
evaluating the formula is negative (or zero) then a stay of up to seven days can be predicted. If the
formula is positive then length of stay greater than one week can be predicted.
The model has good predictive properties and the area under the ROC amounts to 0.807.
Conclusions: Enhanced recovery failure and delayed discharge after laparoscopic
colorectal surgery can be predicted by the early deviation from postoperative factors
of an ERAS programme.
P186 – Intestinal, Colorectal and Anal Disorders
LONGTERM OUTCOMES IN OPEN VERSUS
LAPAROSCOPIC COLORECTAL CANCER SURGERY
S.L. Winstanley, P. Shah, A. Watkins, N. Tanner, L. Satherley,
N. Naguib, M. Abdel Dayem, A. Masoud
Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom
Aim: The data for long term disease free survival (DFS) for laparoscopic colorectal cancer surgery
in the UK is limited due to previous NICE restrictions. This study shows overall survival and DFS
for open and laparoscopic colorectal cancer resections, for a single surgeon in a district general
hospital.
Method: A prospective database of consecutive patients who have undergone colorectal cancer
surgery has been maintained since 2001. Patients underwent extensive follow up with 6 monthly
clinical assessment, imaging and CEA levels. For accurate calculation of 3-year DFS, patients with
less than 3.5-year follow up were excluded. Patients with distant metastasis (Dukes’ D) were also
excluded. Chi square test was used for statistical analysis.
Results: There were 286 colorectal cancer resections performed to date of which 50.7% were
laparoscopic. For the purpose of this study, we included 151 resections performed between June
2001 and December 2008, of which 27.8% (42/151) were laparoscopic. 46.2% of study population
was ASA grade = 3. There were 43.9% of patients with ASA grade = 3 in laparoscopic group and
47.2% in the open group.
The overall 3-year and 5-year survival for ASA grades\3 were significantly better than ASA grade
= 3 (p = 0.003 and p = 0.003 respectively). The overall 3-year and 5-year survival was 76.8% and
61.7% respectively. The 3-year survival for the laparoscopic group and open group was 80.9% vs.
75.2% respectively. This was not statistically significant (p = 0.30).
The overall 3-year DFS was 91.8%. In the laparoscopic group, 3-year DFS for Dukes’ A, B and C
cancers was 100%, 93.75% and 66.67% respectively, whereas for the open group was 93.33%,
95.23% and 95% respectively. This was not statistically significant (p = ns).
Conclusions: Long term outcomes in laparoscopic resection are comparable to open resection in
terms of overall 3 year survival and 3-year disease free survival.
Surg Endosc (2013) 27:S53–S166
P187 – Intestinal, Colorectal and Anal Disorders
ALTERATIONS OF PLASMA RNA OXIDATION AFTER
COLECTOMY FOR COLORECTAL CANCER
K. Tsimogiannis1, G. Pappas-Gogos1, C. Tellis2, A. Tselepis2,
E. Tsimoyiannis1
1
G.Hatzikosta General Hospital of Ioannina, IOANNINA, Greece;
2
University of Ioannina, IOANNINA, Greece
Background: Although lipid peroxidation, protein oxidation and DNA damage have been
studied in patients with colorectal cancer (CRC), studies on oxidative RNA damage are still
limited to neurodegenerative diseases, atherosclerosis, hereditary hemocromatosis and
disorders associated with aging. The aim of this study was to investigate oxidative RNA
damage in patients with CRC, the impact of surgery, and the relation between measured
parameters and stage of the disease.
Material and Methods: 40 patients with colorectal cancer and 30 healthy subjects were
included in the present study. Patients were classified according to the clinical stage (0, I, II,
and III). Blood samples were collected the day before surgery and 24 h after the operation.
Analysis of RNA oxidation was carried out by determination of 8-hydroxyguanosine (8-
OHG) levels in plasma samples.
Results: Preoperative values of 8-OHG were found significantly increased, compared to
controls (Controls 32.97 ± 7.39 ng/ml, Preoperative 40.47 ± 9.79 ng/ml, p = 0.002). Post-
operatively 8-OHG levels decreased almost to those of controls (Preoperative 40.47 ± 9.79
ng/ml, Postoperative 37.30 ± 10.83 ng/ml, p = 0.40), (Controls 32.97 ± 7.39 ng/ml, Post-
operative 37.30 ± 10.83 ng/ml, p = 0.09). Multiple comparisons showed significant
differences between controls and stages II and III (Controls 32.97 ± 7.39 ng/ml, Stage II 43.45
± 5.14 ng/ml, Stage III 50.57 ± 6.24 ng/ml, p\0.0001 and p\0.0001), stage 0 and stages II
and III (Stage 0 29.46 ± 4.47 ng/ml, Stage II 43.45 ± 5.14 ng/ml, Stage III 50.57 ± 6.24 ng/ml,
p\0.0001 and p\0.0001), stage I and stages II and III (Stage I 32.30 ± 4.21 ng/ml, Stage II
43.45 ± 5.14 ng/ml, Stage III 50.57 ± 6.24 ng/ml, p = 0.008 and p \ 0.0001). Multinomial
regression showed a relative risk of patients with significant increased of 8-OHG, to have stage
II (OR: 1, 36, p = 0.001) or stage III disease (OR: 2.42, p\0.0001).
Conclusion: This study has shown that oxidative RNA damage is higher in patients with
colorectal cancer. Advanced stages of the disease showed increased levels of plasma
8-OHG, while patients in early stages exhibit low or normal 8-OHG levels. Finally,
resection of the cancer leads to reduced 8-OHG levels to normal values.
P188 – Intestinal, Colorectal and Anal Disorders
A CASE OF LAPAROSCOPIC TOTAL GASTRECTOMY FOR
A 12-CM-DIAMETER GIANT MALIGNANT GASTRIC GIST
G. Kiguchi1, T. Ito2, Y. Kamada2, T. Tanaka2, T. Nishikawa2,
M. Sugano2, T. Soma2, Y. Hattori2
1
Mitsubishi Kyoto Hospital, KYOTO, Japan; 2Sugita Genpaku
Memorial Obama Municipal Hospital, OBAMA, Japan
Introduction: Laparoscopic partial gastric resection is widely accepted as a treatment for
small gastric submucosal tumors. However, it cannot be applied easily to big tumors.
Methods: A 62-year-old woman was admitted to our hospital because of dizziness due to
melena and severe anemia (Hb: 3.2). The emergent upper gastrointestinal endoscopy
revealed a giant tumor with surface necrosis and bleeding at the greater curvature of the
upper body of the stomach. Malignant gastric GIST was diagnosed by a pathologic
examination. Abdominal CT disclosed a 12-cm-diameter tumor. Moreover, the pancreatic
body and the splenic hilum was seemed to be involved by the tumor, and there were
multiple liver metastases. Resection of the gastric tumor was necessary for control of
bleeding and risk of perforation before chemotherapy with Imatinib.
Results: Total gastrectomy without distal pancreatectomy and splenectomy was performed
successfully under laparoscopy. We could get a excellent view of back side of the huge
tumor and preserve the pancreatic body and the spleen because of no invasion to those
lesions. In operation, for the giant tumor we couldn’t help dissecting around the tumor in
the narrow space but retroperitoneal distal pancreatic mobilization was very helpful. Since
post operation 21 day, we could start a chemotherapy with Imatinib and the liver metastases
have been well controlled for more than 1 year.
Conclusions: Laparoscopic total gastrectomy was feasible in treatment of a case with a
giant gastric malignant GIST, and contribute patients’ early recovery and less wound
related complication.
S99
P189 – Intestinal, Colorectal and Anal Disorders
SINGLE INCISION LAPAROSCOPIC ILEOCECAL
RESECTION BY E-Z ACCESSTM
H. Bando, M. Kotake
Ishikawa Prefectural Central Hospital, KANAZAWA, Japan
Introduction: Single incision laparoscopic surgery has been developed for better cosmetic
wound. We have been trying this technique for laparoscopic ileocecal resection since
November 2010. The characteristic points of our operation are: 1. To use E-Z access
(Hakko, Nagano, Japan) at 3 cm umbilical wound as platform, 2. To use assistant’s pre-
bending instrument for keeping countertraction of dissected tissue.
Method: At first, 3 cm-incision was made at umbilicus. Lap-protector (Hakko, Nagano,
Japan) was fitted into the small incision, and capped by E-Z access. Because E-Z access is
consisted of silicone, the trocars can be inserted into E-Z access freely. We usually needled
one 12 mm, two 5 mm trocars and an assistant’s pre-bending instrument. In the case of
cancer, D3 lymph node dissection was performed. The retroperitoneal tissue was dissected
sharply by monopolar electric knife through medial-to-lateral approach. We usually tran-
sected the ileum by Endostapler. This procedure made good operative field of
retroperitoneum like opening door. Reconstruction was performed by functional end-to-end
anastomosis.
Results: This operation was underwent for 13 cancers, 2 diverticular disease. The mean
operative time of our operation was 30 minutes longer than conventional surgery. But blood
loss was equal between two operations, and there was no intraoperative and perioperative
complications.
Conclusion: We think that the assistant’s instrument is necessary to keep countertraction for
sharp dissection. Our technique is feasible for laparoscopic ileocecal resection.
P190 – Intestinal, Colorectal and Anal Disorders
SIMULTANEOUS RESECTION OF COLORECTAL CANCER
BY LAPAROSCOPIC APPROACH AND PULMONARY
LESION
S. Yamamoto, S. Fujita, A. Akasu, Y. Moriya, H. Sakurai,
S. Watanabe, H. Asamura
National Cancer Center Hospital, TOKYO, Japan
Aims: Laparoscopic approaches have become increasingly used in patients with colorectal
cancer and, recently, the feasibility of simultaneous laparoscopic resection of colorectal
cancer and synchronous metastatic liver tumor has been reported. However, simultaneous
resection of colorectal cancer by a laparoscopic approach and a pulmonary lesion has not
been reported, and its feasibility remains unknown. The aim of the present study was to
determine the feasibility of simultaneous resection of colorectal cancer by a laparoscopic
approach and a pulmonary lesion.
Methods: Between June 2001 and December 2011, 1133 patients with colorectal cancer
underwent laparoscopic surgery at our institution. Of those, four patients underwent simulta-
neous laparoscopic resection of colorectal cancer and resection of a pulmonary lesion. The
surgical outcomes are reviewed.
Results: All procedures were completed laparoscopically. There were 4 male patients with a
mean age of 65 (range: 53–74) and a mean BMI of 27.8 (range: 24.9–29.7), and all the
patients were classified as ASA II. Preoperative cardiac function was within the normal
range; however, one patient had mild obstructive lung disturbance. All patients underwent
laparoscopic colon resection followed by pulmonary resection. Surgical procedures inclu-
ded right hemi-colectomy and wide wedge resection of the right lower lobe, right hemi-
colectomy and left upper segmentectomy, anterior resection and right upper lobectomy, and
partial resection of the transverse colon and wide wedge resection of the left upper lobe.
The mean duration of the operation was 390 min (range: 327–432 min) and the mean
estimated blood loss during surgery was 133 ml (range: 93–200 ml); no patients required
intraoperative transfusion. Liquid and solid foods were started on the 1 and 3 postoperative
days, respectively, and all patients were discharged on postoperative day 8. Regarding
postoperative complications, two patients had atelectasis, which was treated conservatively.
The final pathological diagnosis of the pulmonary lesion was metastatic colorectal cancer in
2, primary lung cancer in 1, and inflammatory granulation tissue in 1.
Conclusion: The indication for and order of the procedures are still controversial; however,
simultaneous resection of colorectal cancer by laparoscopic approach and a pulmonary
lesion in selected patients is a feasible and safe procedure.
123
S100
P191 – Intestinal, Colorectal and Anal Disorders
SINGLE-INCISION LAPAROSCOPIC SURGERY FOR
COLON CANCER: SINGLE INSTITUTIONAL 50 INITIAL
EXPERIENCES.
Y. Hirano, M. Hattori, K. Douden, S. Shimizu, Y. Nishida, Y. Sato,
K. Maeda, Y. Hashizume
Fukui Prefectural Hospital, FUKUI, Japan
Aim: Single-incision laparoscopic surgery (SILS) has recently been developed with
the aim to further reduce the invasiveness of conventional laparoscopy. In the present
study, our initial experiences with SILS for colon cancer are reviewed, and its
outcomes are evaluated.
Methods: Our initial experience of SILS for colon cancer is presented. Fifty patients
(21 women) were treated with the SILS procedure between August 2010 and Sep-
tember 2011. The abdomen was approached through a 2.5 cm transumbilical
incision. Almost all the procedures were performed with standard laparoscopic
instruments, and the operative procedures were similar to those employed in the
standard laparoscopic colectomy.
Results: Two patients were converted to laparotomy, and 0ne patient required an
additional port insertion. Of these 47 patients, 18 patients underwent right hemi-
colectomy, 12 underwent ileo-colectomy, 12 underwent sigmoidectomy, 3
underwent partial resection of the transverse colon, and 2 underwent left hemicol-
ectomy with SILS procedure. The mean skin incision was 2.93 cm. The mean
operative time and blood loss were 223.1 min and 66.6 mL, respectively. The mean
number of harvested lymph nodes was 26.4. Intra- or postoperative complications
only occurred in one patient, who suffered from surgical site infection. The patients
were discharged after a mean period of 11.1 postoperative days.
Conclusions: Our initial experiences suggested that SILC is feasible and safe for
colorectal cancer patients. However, further studies need to be undertaken to prove
that it has non-cosmetic advantages over conventional laparoscopic colectomy.
P192 – Intestinal, Colorectal and Anal Disorders
THE BENEFIT OF PREOPERATIVE MDCT ANGIOGRAPHY
FOR RADICAL RIGHT COLECTOMY FOR CANCER
M. Spasojevic1, S. Kiil1, J.M. Naesgaard1, B. Stimec2, S. Wayessa3,
A.E. Faerden3, T. Oresland3, D. Ignjatovic3
1
Vestfold Hospital Trust, TONSBERG, Norway; 2University of
Geneva, GENEVA, Switzerland; 3Akershus University Hospital,
OSLO, Norway
Background: The complex anatomical relations of the superior mesenteric vein (SMV) and artery
(SMA) and their branches perpetuate the current practice of vascular division on the right side of
the SMV.
Aim: To map relations of SMV and SMA branches in patients operated with D3 right colectomy,
and correlate radiology results with the operation.
Methods: CTs were analyzed with Osirix software. Relations between colic arteries and the SMV
as well as jejuno-ileal veins (JIV) to the SMA were noted. Distances between the ileocolic vein
(ICV) and the gastrocolic trunk (GTH), and between the ileocolic artery (ICA), the right colic
artery (RCA) and the middle colic artery (MCA) along the right side of the SMA were measured.
Levels of the GTH and MCA were noted. At surgery D3 dissection was performed as previously
published, the anatomical relations verified, measured and photographed.
Results: Twenty seven (9 men), median age 73 years were included. Fifteen had MDCT angiog-
raphy, 12 had standard CT. The ICA crossed the SMV anterior in 12 patients (44.4%). The MCA
crossed anterior in all patients (100%), both verified at surgery. RCA was found in 4 patients at
surgery, verified on MDCT angiography in 1, while 3 patients where the RCA was not found
preoperatively had an ordinary CT.RCA crossed the SMV posterior in 1 patient (25%), completely
correlating to the angiography. The median number of JIV crossing the SMA was 2 (range 1–3)
with mean caliber 6.9 mm ±2.3.JIV crossing anterior in 5 and posterior in 13, while 9 had crossing
both anterior and posterior. The median number of JIV crossing the SMA between MCA and ICA
was 1 (0–3). Mean distance between ICA and MCA was 27.1 ± 11.5 mm and 34.8 ± 10.5 mm
between the ICV and GTH. The MCA had a more proximal origin to the GTH in 14 patients, mean
distance between these structures was 11.4 ±7.3 mm. The median number of jejuno-ileal arteries
was 3 (1–5) with mean caliber 2.9 ± 0.9 mm.
Conclusion: The preoperative analysis of the anatomy on angiography correlates well to the actual
anatomy found at surgery, making the surgeon more secure in dissection.
123
Surg Endosc (2013) 27:S53–S166
P193 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC EXTRA-LEVATOR ABDOMINO-
PERINEAL EXCISION WITH BIOLOGIC MESH CLOSURE
OF PERINEUM WITHIN ENHANCED RECOVERY: INITIAL
RESULTS
J. Millar, S. Kipling, K. Young, N. Smart, A.E. Day, A. Allison,
J. Ockrim, N. Francis
NHS, YEOVIL, United Kingdom
Background: Extralevator abdominoperineal excision (ELAPE) is now the standard
of care for low rectal cancer because of improvements in oncological outcomes.
ELAPE involves resection of the rectum through the abdominal approach and
completion of the excision through the perineum. The aim of this study was to assess
the feasibility and outcomes of an initial series of laparoscopic ELAPE with perineal
reconstruction with biologic mesh.
Methods: 31 patients underwent ELAPE between 2006–2010. 70% of patients
received radiotherapy prior to surgery which was performed after 12 weeks. Lapa-
roscopic rectal dissection was performed down to the origins of the levator muscle
and the perineal dissection was performed in the prone position. The perineum was
reconstructed with a biological mesh (Permacol). All patients were enrolled into the
enhanced recovery programme. Data captured included operative details, length of
stay, postoperative complications and six month follow up.
Results: 22 patients were male with mean age of 68 years and mean BMI of 28. The
conversion rate was 16%. Only two cases (6%) had positive circumferential resec-
tion margins. The median length of stay was 7 days with a re-admission rate of 16%.
There were 11 major complications, including 3 perineal wound breakdowns, one
port site hernia, one postoperative bleeding requiring return to theatre. At four weeks
outpatient review, seven patients (22%) had perineal wound problems (pain/ sinus)
but only one patient (3%) had a persistent sinus at six months. There were no
perineal hernias or mortality in this series.
Conclusion: Laparoscopic ELAPE is safe and in combination with biologic mesh
closure of perineum and enhanced recovery may result in short length of stay without
compromising the histological resection margin or postoperative complications.
P194 – Intestinal, Colorectal and Anal Disorders
SIMULTANEOUS LAPAROSCOPIC RESECTION FOR
COLORECTAL CANCER AND SYNCHRONOUS LUNG
METASTASES
B.K. Ahn, S.H. Lee, M.J. Joo, K.W. Seo, K.Y. Yoon, S.U. Baek,
S.D. Park
Kosin University College of Medicine, BUSAN, Korea
Background: The laparoscopy-assisted colorectal surgery (LAC) is performed
worldwide as the standard treatment for colorectal cancer. The video-assisted tho-
racoscopic surgery (VATS) for lung metastases is a safe procedure which has fewer
complications and a reduced hospital stay when compared with an open thoracot-
omy. However, simultaneous laparoscopic resections for colorectal cancers and
VATS for synchronous lung metastases are rarely documented and its feasibility
unknown.
Purpose: The purpose of this study is to review our experience of simultaneous
laparoscopic resection for colorectal cancers and synchronous lung metastases.
Methods: From January 2004 to December 2009, a total of four cases underwent
simultaneous resection for primary colorectal cancers and VATS for synchronous
lung metastases with curative intention. For colorectal cancers, open colectomy
(Open group) was performed in 2 patients (2 male; age 65, 71 years) and laparo-
scopic colectomy (LAP group) was performed in 2 patients (2 male; age 65, 72
years). For the VATS, a 5 mm trocar was inserted at the fourth intercostals space and
two 12 mm trocar at the fifth and seventh intercostals spaces. Under observation of
the thoracic cavity via thoracoscopy, resections of lung lobe were performed using
linear-cutter stapler.
Results: In the Open group, low anterior resection was performed for colorectal
cancer in two patients. In LAP group, right hemicolectomy was performed in two
patients. In all of lung specimen, resection margin was not involved tumor cell.
Operation time was 245, 320 min in Open group and 295, 315 min in LAP group.
Blood loss was 200, 350 cc in Open group and 300, 800 cc in LAP group. Post-
operative complication was a pulmonary edema in Open group and a wound
bleeding in LAP group. There was no postoperative mortality.
Conclusion: Simultaneous laparoscopic resection for colorectal cancer and VATS for
synchronous lung metastasis is a feasible option as minimal invasive treatment.
Surg Endosc (2013) 27:S53–S166 S101

P195 – Intestinal, Colorectal and Anal Disorders P197 – Intestinal, Colorectal and Anal Disorders

SIMULTANEOUS LAPAROSCOPIC COLORECTAL REDUCED PORT SURGERY FOR RECTAL PROLAPSE

RESECTION AND NEPHRECTOMY: REPORT OF TWO
CASES
B.K. Ahn, S.H. Lee, M.J. Joo, K.W. Seo, K.Y. Yoon, S.U. Baek,
T.S. Kim
Kosin University College of Medicine, BUSAN, Korea
Simultaneous laparoscopic surgery of colorectal cancers and coexisting abdominal
disease are shown to be feasible without increasing postoperative morbidity. How-
ever, simultaneous laparoscopic colorectal resection and nephrectomy are rarely
documented and its feasibility unknown.
We report two cases of simultaneous colorectal resection for colorectal cancers and
nephrectomy. Case 1 was a 71-year-old female, who had an ascending colon cancer
and left hydronephrosis, underwent laparoscopic right hemicolectomy and left
nephrectomy. Case 2 was a 77-year-old male, who had a descending colon cancer
and left renal cell carcinoma, underwent laparoscopic left hemicolectomy and left
nephrectomy. The body mass index was 21.73 and 26.78. The operation time was
275 and 395 minutes. The blood loss was 300 and 250 cc. The postoperative hospital
stay was 8 and 10 days. In both cases, there was no postoperative morbidity and
mortality. Simultaneous laparoscopic resection for colorectal cancer and nephrec-
tomy is a feasible and safe procedure.
Y. Konishi
Hokkaido Social Insurance Hospital, SAPPORO CITY, Japan
Aims: Laparoscopic rectopexy for rectal prolapse has been highlighted because of
the potential benefits of a minimally invasive approach, including less pain, shorter
hospitalization, earlier recovery, better cosmetic result, and fewer complications,
compared with open abdominal surgery. Recently Single incision laparoscopic
surgery was reported to be less invasive than conventional laparoscopic surgery. We
report our experience of reduced port surgery for rectal prolapse with surgical out-
comes and recurrence.
Methods: Between May 2011 and July 2011, three patients with rectal prolapse
underwent laparoscopic suture and stapling rectopexy. Under general anesthesia,
patients were placed in the dorsosacral position with the Trendelenburg tilt. SILS
port was placed in the umbilicus and a pneumoperitoneum was established. Addi-
tionally, One 12-mm port was placed in right iliac fossa. The uterus was fixed to the
ventral abdominal wall using a temporary suture. The rectum was dissected down to
the pelvic floor with complete posterior mobilization of the mesorectum to the level
of the levator ani muscle. The rectum was hitched up then mesorectum was fixed to
the right of sacrum with a hernia stapler device, monitoring improvement of prolapse
from anal side. Then elevated sigmoid colon was fixed to the left abdominal wall
using a suture.
Results: Three patients were each 79, 84, 85 years old women. The median follow-up
period was 7 (range 6–8) months. The median operative time was 133 (range
105–155) minutes. Operative blood loss was little in each case. Complication was
only one wound infection. There was no recurrence of prolapse by now.
Conclusion: Reduced port surgery for rectal prolapse was seemed to be less invasive
and superior in terms of cosmetic, and surgical outcome was comparable to that of
conventional laparoscopic rectopexy. It is possible that Reduced port surgery
becomes a new surgical strategy for rectal prolapse.

P196 – Intestinal, Colorectal and Anal Disorders P198 – Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC RECTOPEXY IS EFFECTIVE IS RESECTIONAL SURGERY FOR CANCER IN

TREATMENT FOR RECTAL PROLAPSE IN THE PATIENTS
WITH CONGENITAL MENTAL RETARDATION
H. Tominaga, Y. Yoshikawa, N. Hatanaka, M. Tanemura,
Y. Shimizu, A. Nishitani, T. Irei, K. Hiraoka, M. Inoue, J. Moon,
T. Kinoshita, M. Park, M. Wakahara, N. Honmyo, W. Kamiike
National Hospital Organization Kure Medical Center • Chugoku
Cancer Center, KURE, Japan
Introduction: The rectal prolapse can be completely corrected only by surgical
treatment. Majority of patients with this disease are old age, and general performance
status is poor. Currently, many surgical options, including perineal, abdominal, and
laparoscopic approaches are available, therefore, we should decide the suitable
treatment about which type of repair is the best for patients. Nevertheless, the
ultimate goal of surgery for rectal prolapse is to prevent prolapse, to improve
associated disorder in bowel function. The patients with congenital mental retarda-
tion require special management in a number of clinical situation. Namely, there is a
widespread clinical impression that it is difficult to achieve adequate sedation after
surgery, because these patients can not accept their post operation situation,
including postoperative pain and insertion of drains. In this study, we report that
three patients with rectal prolapse, complicated with congenital mental retardation,
who were successfully treated by laparoscopic rectopexy (Table 1).
Conclusion: Laparoscopic rectopexy is generally safe for sick and frail patients,
including congenital mental retardation, with low recurrence rate and rapid post-
operative recovery.
Table 1 .
Case 1 Case 2 Case 3
COLORECTAL POLYPS NECESSARY?
N.N. Siddiqi1, D. Miskovic1, J. Khan1, A. Thorne2, A. Parvaiz1
1
Portsmouth Hospitals NHS trust, PORTSMOUTH, United Kingdom;
2
University of Portsmouth, Molecular biology, PORTSMOUTH,
United Kingdom
Background and Aims: Introduction of National bowel cancer screening in UK have
led to increase in diagnosis of colorectal polyps. Although endoscopic removal of
polyps is feasible in majority of cases, certain polyps are not suitable for such
intervention. This study aim to evaluate the outcomes of surgical resection in
patients with cancer in polyps and look at the overall and disease free survival on
patients who either had surgical resection or polypectomy alone.
Methods: Prospectively collected data from consecutive patients with cancer in
colorectal polyps from 2000–2011 were included. Patients were divided into three
groups (1: polypectomy, 2: surgical resection with lymph node negative, 3: surgical
resection with lymph node positive). Patient demographics, survival rates, stage of
tumour, postoperative mortality, local and distal recurrence rates were analyzed.
Results: 213 patients were analysed. 118 patients had surgical resections (103 L.N
negative & 15 L.N positive), 95 patients had polypectomy alone. Median age was 71
years. Local recurrence was 3.1% in polypectomy group, 1.9% in patients with
surgical resection L.N negative and 6.6% in surgical resection with L.N positive.
Five-year follow up is only available for patients who had treatment till 2006. In total
98 patients were followed up in which 89 patients has five year disease free survival.
There is no difference in survival between polypectomy and surgical resection (p =
0.341).
Conclusions: Patients with cancer in colorectal polyps with positive lymph nodes
have worse five-year survival even after surgical resection. Further research to stage
lymph node positive disease needs to be done and hence obviating the need for
resectional surgery in high-risk group.

Age at op. 26 72 65
Gender (M/F) M F M
Operative time (minutes) 222 255 196
Operative bleeding Small Small Small
Perioperative complication No No No
Hospital stay after op. (day) 8 3 30
Recurrence of prolapse No No Yes, slight

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P199 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC APPENDECTOMY FOR THE
RETROCECAL SUBHEPATIC APPENDIX: TIPS AND
TRICKS
A.M. Bakr
Cairo University, CAIRO, Egypt
Introduction: Acute appendicitis is a common surgical problem that is successfully managed with
early surgery, with low morbidity and mortality. The clinical manifestations may vary according to
the position of the appendix. Ascending retrocecal, subhepatic appendicitis may be clinically
indistinguishable from acute pathology in the right upper abdomen. Moreover, the technique of the
laparoscopic procedure needs to be altered accordingly. The aim of this study is to present our
experience with laparoscopic management of ascending retrocecal, subhepatic appendicitis.
Materials and Methods: This study involved 34 patients with acute abdominal pain. Routine
workup included a complete blood picture, ultrasound scan and computed tomography if the
ultrasound was not conclusive. The laparoscopic procedure was performed through a 3-Trocar
technique. Retrograde appendectomy was used in all but 3 patients. The mesoappendix was con-
trolled by energized devices in all cases.
Results: The pain and tenderness were notably atypical; in all patients. The pain was more towards
the upper quadrant, while maximal tenderness was most evident at the level of the umbilicus, not in
the lower abdomen. Tenderness needed a deeper palpation to be elicited. Fever was noted in 27
patients, and leucocytosis in 29 patients. US scan was diagnostic in 14 patients, inconclusive in the
rest. Those necessitated Computed tomography (CT). CT confirmed the diagnosis in all but one of
the patients. This patient was confirmed to have ascending appendicitis on laparoscopy and
underwent laparoscopic appendectomy.
One patient was converted due to difficult dissection. One patient had a postoperative collection
that necessitated ultrasound guided drainage.
Conclusion: Though appendicitis is a common surgical emergency, the variations in
its anatomical position may make the diagnosis trickier. This also applies to the
surgical management. As laparoscopic appendectomy is becoming the new gold
standard treatment of appendicitis, the technique can be applied yet it has to be
modified in cases with ascending, retro-cecal and sub-hepatic appendicitis together
with cases with a retroverted cecum. The port sites need to be altered. The use of
energized devices in the dissection is helpful and safe and the adoption of retrograde
technique a routine makes the procedure easier.
P200 – Intestinal, Colorectal and Anal Disorders
TRANSANAL ENDOSCOPIC EXCISION OF RECTAL
TUMORS USING A SINGLE-ACCESS LAPAROSCOPIC
PORT
K. Ietsugu, K. Yoshida, S. Soga, S. Tabata, K. Kiyohara
Tonami general hospital, TONAMI - TOYAMA.PREF, Japan
Background: Many lower rectal cancers are treated by surgery. Abdominal perito-
neal resection, low anterior resection and intersphincteric resection are common, but
mucosal cancers are reported to have a low rate of lymph node metastasis, so less
invasive treatments are more suitable. Transanal endoscopic microsurgery (TEM) is
a useful way to excise rectal tumors, but special instruments are required.
Aim: To show three operations for rectal tumors using a single-access laparoscopic
port (SILS port) and instruments for laparoscopic surgery. One reason for using these
instruments is that they can not be hired from agencies.
Patients and methods: Case 1: an 80-year-old woman came to our hospital because of
bloody stool. Endoscopic examination showed a laterally spreading tumor in the
lower rectum and the pathological diagnosis was cancer. Case 2: A 56-year-old man
came to our hospital because of abdominal fullness. Endoscopic examination showed
a laterally spreading tumor at lower rectum and the pathological diagnosis was
cancer. Case 3: A 40-year-old man came to our hospital because an occult blood test
of the stool was positive. Endoscopic examination showed a carcinoid tumor in the
lower rectum. The carcinoid tumor was resected endoscopically, but the vertical
surgical margin was positive, so additional transanal full thickness resection was
needed. Transanal endoscopic excision was performed for three cases using a SILS
port inserted into the anal canal and instruments for laparoscopic surgery. Under
general anesthesia, patients were positioned so that tumors were located in a 6
o’clock direction. Carbon dioxide was insufflated during surgery at 15 mmHg. A
30-degree 5-mm camera, a grasper, and laparoscopic coagulation scissors were used
to remove tumors. All tumors were excised safely.
Conclusion: This technique is useful and could be introduced into many hospitals.
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Surg Endosc (2013) 27:S53–S166
P201 – Intestinal, Colorectal and Anal Disorders
EXPERIENCE OF USING N.O.T.E.S.-TECHNOLOGY TO
TRANSANAL SURGERY
V.V. Anischenko1, A.I. Shevela2, A.A. Bass1, M.N. Kotkina1,
G.S. Gmyza2
1
Nonmunicipal health care facility Railway Hospital,
NOVOSIBIRSK, Russia; 2Institute of Chemical Biology and
Fundamental Medicine of Siberian Branch of RAS, NOVOSIBIRSK,
Russia
Extensive experience of single access surgery (more than 150 operations) with the technology NOTES,
accumulated in our hospital allowed us to work out transanal operations using SILS-port. For operations we
used SILS-port. We present two clinical cases. Case 1. Patient, a woman 34 years old, diagnosed – villous
adenoma of the rectum, which began at 4 cm from the dentate line on the left wall of the rectum, 12 cm long,
and occupied 1/3 part of the rectum.
The data of magnetic resonance imaging (MRI) and endosonography: no signs of invasion and tumor growth
within the mucosa. Position the patient on her left side. SILS-port installed with minimal devulsii anus, used
an optical system with a diameter of 5 mm. Pnevmorektum imposed. Under the mucous membrane, under
tumor was introduced indigo. Next, 5 mm away from the edge of the tumor step by step dissection of the
tumor is made under visual control using a harmonic scalpel.
Duration of surgery 50 min. The operation was bloodless and without violating the integrity of the bowel
wall. No complications. The patient was discharged 4 days. After 2 weeks, produced inspected: 1/3 of the
wound epithelialization active. Satisfactory condition.
The second case. Patient, a woman 28 years old. According to a rectal examination and MRI established
dermoid cyst. Tumor size 6 9 8 cm, located on the rear wall in the mesentery of the rectum, 5 cm proximal
to the dentate line, without invasion into the wall of the rectum.
Position the patient on his back. SILS-port installed with minimal devulsii anus, used an same optical
system. Pnevmorektum imposed. Over the tumor is dissected wall of the rectum. Stages, a single block with
dissector and harmonicscalpel produced a radical resection. The integrity of the bowel wall recovered with a
continuous suture PDS II 3.0.
Duration of surgery 70 min. The operation was bloodless.No complications. The patient was discharged on
day 7. After 7 days, produced inspected and transrectal ultrasonography. Sutures are wealthy, there is no
residual cavities. Satisfactory condition.
Conclusions. The use of SILS-port identified a number of advantages over the endoscopic or
transanal resection usingsurgical proctoscope. First, a good review and the availability ofthe
operative field straightened for the mucosa, soft port does not limit the movement and not a conflict
of tools. Secondly, a good visualization possible to perform completelybloodless dissection, with
precise accuracy and within healthy tissue.
Third, provided surgical technique has helped to keep the anatomical and functional integrity of the rectum.
And also, provided a short rehabilitation period.
P202 – Intestinal, Colorectal and Anal Disorders
MULTIPLE ABSCESS ABDOMINAL WALL IN A PATIENT
WITH RIGHT COLON DIVERTICULITIS
M. Socias1, A. Sánchez1, M. Vives1, A. Cabrera1, M.L. Piñana1,
J. Sánchez1, M. Hernández1, F. Sabench1, J. Domènech1,
D. Del Castillo1, M. Parı́s2
1
University Hospital of Sant Joan. Rovira i Virgili University. IISPV,
REUS, Spain; 2Rovira i Virgili University. University Hospital
of S. Joan. IISPV.F.of Medicine, REUS, Spain
Aim: The diverticular disease is found mainly in the descending colon and sigma and only 20% of
patients in the right colon. The occurrence of fistula is a common complication of colonic diver-
ticulitis. The most frequent are between the sigmoid colon and bladder. We report a clinical case of
a patient with atypical presentation of right diverticulitis.
Methods (Clinical case): F 76 years old patient with a history of vertiginous syndrome, type 2
Diabetes Mellitus, and laparoscopic cholecystectomy. Consults to physician for pain in right leg
and a mass at lumbar fossa and right flank of two months evolution. CT scan: Increased intra-
abdominal fat density at the right flank associated with small collections all over the abdominal
muscles, the anterior abdominal wall and back. Given the suspicion of abdominal wall abscess, the
patient was admitted in our surgical service and initiates treatment with clindamycin and
cefuroxime. Culture of abscess is positive for E. coli resistant to amoxicillin and clavulanic,
cefotaxime, cefuroxime and ciprofloxacin. We changed therapy to ertapenem. At 15 days of
evolution, the results of second culture were negative, with chronic infiltration and fibrosis at the
biopsy. Given the analytical and clinical improvement, the patient was discharged.
3 weeks later she is admitted again to the hospital with fever and increased volume of the
abdominal mass, acute inflammation, leukocytosis and neutrophilia. TC scan: thickening of the
right iliopsoas muscle with hypodense area in anterior abdominal wall. Drainage was placed. Given
the suspicion of appendicular plastron we decided surgery.
Results: Exploratory Laparoscopy: a fistula is seen in middle third of ascending
colon from the abdominal wall to the trocar hole of antique laparoscopic chole-
cystectomy. Right hemicolectomy was performed. It shows a diverticulum in the
ascending colon with diverticulitis, and xanthomatous reaction.
Evolution: After the control of infectious foci and surgery, the patient evolved correctly.
Conclusions: The ascending colon diverticulitis is a process that must be considered in processes
arising from the right side of the abdomen. Concomitant infections may cause a slow and com-
plicated clinical development.
Surg Endosc (2013) 27:S53–S166
P203 – Intestinal, Colorectal and Anal Disorders
SECONDARY INTESTINAL OBSTRUCTION TO
ENDOMETRIOSIS IN A PATIENT WITH STEINERT
MYOTONIC DYSTROPHY
E. Raga, M. Vives, J. Sanchez, S. Blanco, A. Sánchez, M.L. Piñana,
A. Cabrera, M. Hernández, F. Sabench, D. Del Castillo
University Hospital of Sant Joan. Rovira i Virgili University. IISPV,
REUS, Spain
Aim: Steinert’s disease is a hereditary myopathy in which there is generalized
muscle weakness, myotonia, and multisystem involvement. Involvement of the
muscles of the digestive tract can cause characteristic symptoms, though less fre-
quently than other systemic disorders. Dysphagia is the most common symptom
observed, and usually occurs in 25–45%. Other less common symptoms are gas-
troparesis, steatorrhea and intestinal occlusive syndrome. We report a patient
affected by Steinert myotonic dystrophy, who presented repeatedly abdominal pain
and constipation coinciding with menses.
Methods: Patient ?26 years old, affected by Steinert’s disease, subclinical hypo-
thyroidism, dysmenorrhea in treatment with oral contraceptives and depressive
syndrome. She consulted to emergency room for abdominal pain and bloating that
had been repeated in recent months coinciding with menses. Abdominal radiography
and CT were compatible with occlusive episode, resolving spontaneously within 48
hours of income. 18 months later, returns to our Hospital affected by a new episode
of pain, abdominal distension and vomiting of 4 days of duration. With radiological
suspicion of sigmoid volvulus, an urgent colonoscopy showed a stenosis at the level
of rectosigmoid at 11 cm from anus, with normal mucosa, suggesting a possible
extrinsic compression. CT and Magnetic Resonance didn’t determine the cause of
the occlusion, so it was decided to perform an exploratory laparotomy.
Results: Surgery showed endometriosis, sigmoid infiltration and bilateral ureters
dilatation with retroperitoneal infiltration and a significant fibrosis of the Denon-
villiers’ fascia, covering the rectosigmoid junction. This requires performing a total
hysterectomy, resection of the rectosigmoid junction and ureters release.
Conclusions: Endometriosis is a disease that affects 10–15% of premenopausal
women and in rare cases can cause intestinal obstruction. The presence of ectopic
endometrial tissue in the intestine affects the serosa and muscle layers, but never
penetrates the mucosa. The secondary fibrosis and adhesions are the cause of the
obstruction. Steinert’s disease is rare but the intestinal involvement is also possible.
Emphasize the importance of thorough study and careful in any young patient
without previous surgical history.
P204 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC ANTERIOR RESECTION WITH TOTAL
MESORECTAL EXCISION (TME) FOR RECTAL CANCER
F.V. Zaharie, C. Tomus, L. Mocan, R. Zaharie, D. Bartos, C. Iancu
‘‘Iuliu Hatieganu’’ University of Medicine and Pharmacy Cluj,
CLUJ NAPOCA, Romania
Background: Total mesorectal excision (TME) offers the lowest reported rates of local recurrence
and the best survival results in patients with rectal cancer; however, the laparoscopic approach
remains a challenging procedure. We present a series of ten consecutive cases in laparoscopic TME
for rectal cancer performed by a single surgical team.
Methods: A series of 10 consecutive patients undergoing laparoscopic TME for rectal cancer is
presented. A four-trocar laparoscopic approach was routinely used, including patients with prior
abdominal surgery.
Results: The average age of patients was 54.2 years (range 45–68 years). The stage of rectal cancer
according to TNM classification was: stage I in 3 patients, stage II in 3 and stage III in 4. Of the 10
patients, 7 have required complete mesorectal excision. For the other three, partial mesorectal
excision was performed (up to 5 cm below the tumor). There was no case of tumor involvement of
the distal margin. Average distal clearance was 3.6 cm (range 2.2–7) on the fixed specimen. Median
number of lymph nodes harvested was 19 (range 8–30).
Median (range) operating time and blood loss were 160 (120–240) minutes and 75 (50–100) ml.
Mean hospital stay was 5.7 days. Median time for the return of bowel function was 1.3 (range 1–2)
days. Complete patient mobilization and diet resumption was achieved on 1 day after surgery. We
have 10% morbidity rate (one case of colo-rectal anastomosis leak). There were no wound or
general complications (cardiac, neurologic or pulmonary). No patients required narcotics for
postoperative pain control; parenteral non-sterois analgesics were used. The mortality rate was null.
No patient has urinary or bladder dysfunction on discharge. Mean follow-up was 9 months (range,
6–12). There were no local or trocar site recurrences.
Conclusions: Laparoscopic total mesorectal excision is a safe and effective procedure, with low
morbidity and mortality while having all the advantages of minimally invasive.
S103
P205 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC SURGERY FOR REMNANT GASTRIC
CANCER
S. Yoshikawa
Juntendo University Urayasu Hospital, URAYASU,CHIBA, Japan
Background: Laparoscopy-assisted gastrectomy (LAG) is a less invasive surgical
technique that is gaining wider acceptance for the treatment of gastric cancer.
Remnant primary gastric cancer is defined as cancer in the remnant stomach after the
initial gastric resection. After the surgery of distal or proximal gastrectomy, there is a
risk of remnant gastric cancer. The aim of this study was to assess the feasibility of
Laparoscopic surgery for remnant gastric cancer.
Method: Between May 1996 and December 2011, we performed 474 LAG. These
cases were included 40 laparoscopy-assisted total gastrectomy(LATG) cases, and 4
patients were operated laparoscopy-assisted total remnant gastrectomy(LATrG) for
remnant gastric cancer. We examined the peri-operative results, complications and
surgical outcomes of LATrG cases. The peri-operative results were compared with
the results of 40 LATG cases.
Results: 3 patients of LATrG cases were in Stage IA, and another patient was in
Stage IB. The mean operative time was 318 minutes. The mean duration of naso-
gastric tube placement was 0.5 days, time required before passing flatus was 2.6
days, time to start of liquid intake was 5.25 days, and postoperative hospital stay was
26 days. The duration of nasogastric tube placement of LATrG was shorter than that
of LATG. There were no significant differences in the other parameters. No post-
operative complications were observed in LATrG patients. There was no cases of
cancer death or recurrence in LATrG.
Conclusion: LATrG is a safe, oncologically feasible and acceptable procedure for the
treatment of early-stage remnant gastric cancer.
P206 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC SURGERY FOR RECTAL
ADENOCARCINOMA: RETROSPECTIVE STUDY
OF A STARTING MOROCCAN UNIT EXPERIENCE
M.A. Majbar, H. Elfadili, M. Elalaoui, F. Sabbah, M. Raiss, A. Hrora,
M. Ahallat
Ibn Sina Hospital, RABAT, Morocco
Objective: To analyze data on laparoscopic surgery for rectal adenocarcinoma in our
unit of January 1, 2005, to December 31, 2009.
Material and Methods: During the above-mentioned period, 45 laparoscopic sur-
geries for rectal adenocarcinoma were performed in our unit. There were 20 males
and 25 females with a mean age of 52 years. The tumor was located in the low
rectum in 18 cases (40%), mid rectum in 8 cases (18%) and upper rectum in 19 cases
(42%). We performed 19 low anterior résection with colorectal anastomosis, 12
proctectomy with colo-anal anastomosis, 8 abdomino-perineal résection with 4 left
iliac colostomy and 4 pseudocontinent perineal colostomy and one intersphincteric
résection.
Results: Conversion rate was 11.1%. Six (13.3%) patients had stage I, 22 (50%)
stage II, and 17 (37.7%) stage III disease. The mean hospital stay was 12 days. One
(2.5%) patient died. Postoperative complications occurred in 12 (26.6%) cases.
Specific complications were as follows: suture insufficiency (3 cases), post opérative
intestinal occlusion (1 case), colostomy necrosis (1 case), pelvic abscess (1 case). In
histological specimens, 10 lymph nodes were found on the average. Recurrence rate
is 11.1% (5 patients): 4 local récurrences and one pulmonary metastasis.
Conclusions: The feasibility of laparoscopic surgery for rectal adenocarcinoma is
well established. Complication rate is similar to other authors. To evaluate disease
relapse and outcomes, observation time is not sufficient yet.
123
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P207 – Intestinal, Colorectal and Anal Disorders
TOTALLY LAPAROSCOPIC ANTERIOR RESECTION WITH
TRANSVAGINAL SPECIMEN EXTRACTION: THE
AUTHORS’ INITIAL INSTITUTIONAL EXPERIENCE
D.A. Golub1, S.V. Baydo2, A.B. Vinnitskaya2, G.B. Bernshtein2
1
Med-X-Ray International Group Zina Memorial Lissod Cancer
Hospital, KIEV, Ukraine; 2Zina Memorial Lissod Cancer Hospital,
PLIUTY VILLAGE, KIEV, Ukraine
Background: Laparoscopic surgery has made a significant impact on the practice of
colorectal surgery since first successful laparoscopic colon resection performed by
Jacobs in 1991. Most surgeons, performing totally laparoscopic anterior resection
(TLAR), use a small (5–6 sm) incision for specimen extraction.
Purpose: This report is intended to report our experience and to describe our tech-
nique in performing TLAR with transvaginal extraction of the specimen.
Methods: In 2011, 10 patients underwent TLAR, in 3 cases transvaginal approach
was used for specimen extraction. Four ports technique was used. The descending
colon, colon sigmoideum and rectum were mobilized using ultrasound scissors and
bipolar. The IMA and IMV was clipped at their origin. The rectum was transected by
stapler. Then posterior colpotomy was done with 11-mm trocar. The specimen was
extracted through vagina, the anvil was inserted and bowel was returned into
abdomen. Then anastomosis was done using circular stapler. The colpotomy was
sutured through vagina or using intracorporeally technique.
Results: All the patients were women with no prior pelvic surgery. The mean age
was 56 (52–60) years. The average operative time was 115 (100–135) minutes. No
death or complications occurred in these 3 patients. The first stool was at second p/o
day. The average length of stay was 3.4 (3–4) days. The mean specimen length was
28 cm, and the mean number of lymph nodes retrieved was 21 (18–25). The level of
postoperative pain was assessed by visual-analog pain scale. According to pre-
liminary results it was detected the tendency of decreasing pain level after
transvaginal extraction vs ‘traditional’.
Conclusion: Totally laparoscopic anterior resection with transvaginal extraction of
the specimen appears to be feasible and safe. The advantages of this approach are
better cosmetic results, less postoperative pain and faster recovery.
P208 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC MANAGEMENT IS FEASIBLE IN THE
TREATMENT OF COLOVESICAL FISTULAE – A SINGLE
CENTRE 7 YEAR EXPERIENCE
N. Ladwa, M. Sajid, T. Liston, P. Sains, M.K. Baig
Worthing Hospital, WORTHING, United Kingdom
Objective: This aim of this study is to review the results of laparoscopic surgery for the
management of colovesical fistulae in a centre with a specialist interest in minimally
invasive surgery and to propose a clear protocol to ensure prompt diagnosis and treatment
in the future.
Methods: A retrospective case note review was conducted of all patients with colovesical
fistulae who underwent laparoscopic surgery over a 7 year period. Variables collected
include patient demographics, symptoms, investigations, operative data, histology, com-
plications and length of stay.
Results: 24 patients (15 male) who underwent laparoscopic operative intervention for co-
lovesical fistula were identified. The most common symptoms were pneumaturia (79%),
faecaluria (46%) and symptoms associated with recurrent UTIs (75%). Cystoscopy was the
most accurate test to identify fistulae (87.5%) followed by CT scan (46%) and barium
enema (21%). 1 patient was unfit for major surgery and underwent palliative laparoscopic
loop colostomy. The most common cause of fistulation was diverticular disease. (92%)
Other causes included Crohns disease (4%) and colorectal cancer. (4%) Laparoscopic
anterior resection was performed in 12 (50%) patients, sigmoid colectomy in 10 (42%) and
ileocolic resection in 1 (4%) patient. 88% of patients received a defunctioning ileostomy to
protect the anastomosis. The laparoscopic to open conversion rate was 33%. (due to
multiple abscesses or extensive adhesions) The average length of colon resection was 184
± 70 mm Bladder repair was required in 25% of cases with a further 8% requiring partial
resection. There was no mortality reported peri-operatively; the anastomotic leak rate was
4% and recurrence rate was 4%. 8% of patients had wound related problems treated con-
servatively and 8% had a post-operative abdominal collection requiring drainage. Median
postoperative stay was 12.5 days (range 4–91).
Conclusion: Surgical management for colovesical fistulae is effective and safe. Laparo-
scopic resections are increasing in popularity and deliver encouraging results comparable to
open resection. It has now become the standard of care in our institution for management of
colovesical fistulae. A large multi-centre randomised controlled trial is recommended to
validate its potential benefits over open surgery.
123
Surg Endosc (2013) 27:S53–S166
P209 – Intestinal, Colorectal and Anal Disorders
LESSON FROM TWO CASES OF TRANSANAL
ENDOSCOPIC MICROSURGERY WITH SINGLE-PORT
INSTRUMENTS
D.G. Shin
Seoul Medical Center, SEOUL, Korea
Aims: To know the feasibility and safety of transanal endoscopic microsur-
gery(TEM) with single-port instruments.
Methods: From Dec 2011 to Jan 2012, we performed excisions of rectal lesion in two
patients using a SILS port (Covidien) in TEM surgery.
Case 1. Rectal carcinoid: The lesion was located 8 cm above anal verge. Initially 4
mm size polypoid lesion was endoscopically removed and the result showed rectal
carcinoid with involvement of deep and lateral resection margin. So we performed
TEM operation. Case 2. Rectal adenocarcinoma: 1.5 cm size mulberry shaped pol-
ypoid lesion was located 8 cm above anal verge. Biopsy result showed tubular
adenoma but the shaped and size was not good for endoscopic mucosal resection. So
we performed TEM operation.
Results: In all cases, it was easy to handle and resection was successful without
significant intraoperative complication. We performed five stitches to closure the
wound with chromic #3-0 suture and hemo-clip tie in all cases. Postoperative
recovery was uneventful in both cases. First case’s pathology report showed no
residual lesion in the specimen. After 3 weeks later, sigmoidoscopy study showed
that there was no suture material and small healing ulcer was seen at operation site.
In second case, pathology report showed adenocarcinoma with deep resection
margin involvement. So we performed second operation (low anterior resection) on
POD#3 days after first operation. And we found that 3 stitches (60%) are present and
two are already become loose and dropped out from the specimen. Final pathology
result showed that there was also no residual lesion in specimen and no lymph node
metastasis in 4 mesorectal lymph nodes.
Conclusion: It is necessary to discuss the pathology result carefully with pathologist
before transanal endoscopic resection operation. During TEM operation, suturing the
wound is very easy but we have to know that is it really necessary procedure.
P210 – Intestinal, Colorectal and Anal Disorders
SINGLE-INCISION LAPAROSCOPIC SURGERY FOR
COLON CANCER IN PATIENT WITH SITUS INVERSUS
TOTALIS.
S. Shimizu, Y. Hirano, M. Hattori, Y. Nishida, Y. Sato, K. Maeda,
K. Douden, Y. Hashizume
Fukui Prefectural Hospital, FUKUI, Japan
Aim: Situs inversus totalis (SIT) is a rare congenital disorder, which denotes com-
plete right-left inversion of thoracic and abdominal viscera. Surgical procedures are
considered more difficult in patients with SIT in other patients because of different
anatomic positions of organs, especially in laparoscopic surgery. Preliminary
experience with single-incision laparoscopic colectomy for colon cancer with SIT is
reported.
Method: An 87-year-old man was admitted because of a fecal occult blood. A
colonoscopy revealed cecal cancer. A colonoscopy revealed cecal tumor about 50
mm in size, and he was diagnosed as a well differentiated adenocarcinoma by colon
biopsy. An air-barium contrast enema showed the right-sided descending colon and
the left-sided ascending colon and cecum. A computed tomography showed com-
plete transposition of abdominal viscera, confirming SIT. Surgical Procedures: First,
a Lap protector was inserted through a 2.5-cm transumbilical incision. Three 5-mm
ports were placed in EZ access mounted on the Lap protector. At the observation of
laparoscopy, the cecum and ascending colon was situated at the left, and the sigmoid
colon was situated at the right.
Results: We successfully performed ileocolectomy with lymph node dissection using
a single-incision laparoscopic approach without any technical problems. The oper-
ative time was 125 min and blood loss was a negligible. Postoperative follow-up did
not reveal any umbilical wound complications and recurrences.
Conclusion. This report is the first case of colon cancer associated with SIT who
successfully treated with SILC. SILC is safe, feasible and a curative procedure for
colon cancer even in patients associated with SIT.
Surg Endosc (2013) 27:S53–S166
P211 – Intestinal, Colorectal and Anal Disorders
SINGLE-INCISION PLUS ONE PORT LAPAROSCOPIC
ANTERIOR RESECTION FOR RECTAL CANCER AS
A REDUCED PORT SURGERY
M. Hattori, Y. Hirano, Y. Nishida, S. Shimizu, Y. Sato, K. Maeda,
K. Douden, Y. Hashizume
Fukui Prefectural Hospital, FUKUI, Japan
Aim: Only limited data in the literature about single-incision laparoscopic rectal
surgery, because the laparoscopic stapler does not allow low rectal transection
without sufficient distal margins from the umbilicus port. We have developed single-
incision plus one port laparoscopic anterior resection of the rectum (SILS+1-AR) as
a reduced port surgery in which we can utilize the incision for drainage as an
additional access route for laparoscopic procedures including the transection the
lower rectum.
Methods: A Lap protector (LP) mini was inserted through a 2.5 cm transumbilical
incision, and an EZ-access was mounted to LP and three 5-mm ports were placed in
EZ-access. A 12 mm port was inserted in right lower quadrant. Almost all the
procedures were performed with usual laparoscopic instruments, and the operative
procedures were much the same as in usual laparoscopic low anterior resection of the
rectum using a flexible 5 mm scope. The rectum was transected normally using only
one endoscopic linear stapler inserted from the right lower quadrant port.
Results: We underwent modified SILS+1-AR in 16 patients with advanced rectal
cancer. One patient required an additional port insertion because of the severe dif-
ficult dissection in the deep pelvic space. The other 15 patients (93.7%) underwent a
curative anterior resection of the rectum without conversion to a multiport laparo-
scopic surgery or open surgery. We transected the lower rectum with one
laparoscopic stapler in all 15 cases. Postoperative follow-up did not reveal any
umbilical wound complications or recurrences.
Conclusions: The safety and feasibility of SILS+1-AR for advanced rectal cancer
was established in this study. However, further studies are needed to prove the
advantages of this procedure to conventional laparoscopic law anterior resection.
P212 – Intestinal, Colorectal and Anal Disorders
THE OUTCOME OF SINGLE-INCISION LAPAROSCOPIC
RIGHT COLECTOMY FOR COLON CARCINOMA IN THE
ELDERLY
Y. Nishida, Y. Hirano, M. Hattori, S. Shimizu, Y. Sato, K. Maeda,
K. Douden, Y. Hashizume
Fukui Prefectural Hospital, FUKUI, Japan
Aim: Aging of the population and a longer life expectancy have led to an increased
number of elderly patients presenting with colorectal cancer and searching for
treatment. The operative procedure used for such patients must be chosen with care,
considering both radicality and predicted hospital mortality, since elderly patients
have more preoperative risk factors. The purpose of this study was to elucidate the
feasibility of single-incision laparoscopic surgery (SILS) for these patients.
Methods: Among thirty four right colon cancer patients treated with SILS procedure
between August 2010 and September 2011, 9 (26.5%) were aged 80 or over. The
results of treatment in this elderly group were compared retrospectively with those in
10 colon younger cancer patients (aged 59–67, control group, 29.5%).
Results: The sex distribution, BMI and the tumor location were similar between the
groups. The elderly had a higher incidence of preoperative risk factors (77.7 vs
40.0%) (p = 0.17). However, operative time and estimated blood loss were similar
and postoperative complications were not occurred in both groups.
Conclusions: The rate of preoperative surgical risk factors in these elderly patients
was high while the frequency of postoperative complications was similar between
the two groups in our series. Single-incision laparoscopic approach may have con-
tributed to these low complications, and our results showed that age alone should not
be considered a reason to withhold surgical treatment from elderly patients regarding
morbidity and mortality.
S105
P213 – Intestinal, Colorectal and Anal Disorders
LONG TERM RESULTS OF LAPAROSCOPIC SURGERY
ON RECTAL CANCER IN A SINGLE INSTITUTION
M. Ouchi
Juntendo University Urayasu Hospital, CHIBA, Japan
Aims: For laparoscopic colectomy (LAC) to be recognized as the standard surgical
procedure for rectal cancer, it must be proven to have curative effectiveness com-
parable to open abdominal surgery. This study examined the long term results of
laparoscopic colectomy for rectal cancer.
Methods: The subjects consisted of 293 patients whom underwent radical surgery for
rectal cancer at our institution between June 1995 and December 2011.
The indication of LAC was mainly reserved for cases where curative resection was
possible by pelvic autonomic nerve-preserving surgery with mesorectal excision.
LAC was not performed in cases: (1) where the cancer had obviously invaded other
organs, (2) where no touch technique surgery was difficult, (3) where the operation
space could not be preserved due to a bulky tumor or narrow pelvis; and 4) where
there was a non-decompressible intestinal obstruction.
Results: There were 201 male subjects and 92 female subjects and their average age
was 63 years (range: 28–87). 163 subjects had upper rectal cancer and 130 subjects
had lower rectal cancer. 15 subjects were in stage 0 of cancer, 105 subjects in stage I,
86 subjects in stage II, 87 subjects in stage III. 233 subjects underwent anterior
resection surgery, 49 subjects underwent abdominoperineal resection, five subjects
underwent ISR, three subjects underwent Hartmann’s procedure and one subject
underwent total pelvic exenteration (TPE). The form of recurrence was most com-
monly the liver (27 subjects), the lung (24 subjects) and local (17 subjects)
(including overlap). The five-year survival rate excluding other natural causes of
death was 100% for stage 0 subjects, 98.8% for stage I subjects, 97.0% for stage II
subjects, 80.9% for stage IIIA subjects. The recurrence-free survival rate was 93.1%
for stage I subjects, 85.4% for stage II subjects, 62.5% for stage III subjects.
Conclusion: The long term results of LAC on rectal cancer are positive and it is
expected that LAC will become recognized as the standard surgical procedure in
selected patient for rectal cancer.
P214 – Intestinal, Colorectal and Anal Disorders
LAPOROSCOPIC COLORECTAL RESECTION IN
OCTAGENERIANS
A. Mahajna, R. Khoury, W. Khoury, A. Assalia, Y. Kluger
Rambam Health Care Campus, The Technion- Israel I, HAIFA, Israel
Aims: This study aimed to assess the feasibility and safety of laparoscopic colorectal
resection among octogenarians (over 80 years old), and to define any benefits in
terms of early outcome compared to open surgeries.
Method: Retrospective analysis was performed based on a prospectively maintained
database of octogenarians and non-octogenarians who underwent laparoscopic
colorectal resections from 2006 to 2011 and database of octogenarians who under-
went open colorectal resections between the same years. Diagnosis, indications of
surgery, operative data, and early postoperative complications, and mortalities are
analyzed in this report.
Results: Colorectal resection was performed for 94 patients, using laparoscopy for 20
octogenarian patients and 54 non-octogenarian patients and laparotomy colorectal
resection for 20 octogenarian patients. The mean age for the laparotomy octoge-
narians was 85.3 years and 85.2 years for the laparoscopic octogenarians whereas the
mean age for the laparoscopic non-octogenarians was 62.1 years. Colorectal
malignant disease was the most common indication for surgery in both groups of
octogenarians: for 70% of the laparoscopic octogenarians and 80% of the laparotomy
octogenarians. The conversion to open surgery happened in one patient in octo-
genarian group and in 4 patients in non-octogenarian group (p = 0.99). The patients
in the laparoscopic groups (octogenarians and non-octogenarians) had less morbidity
than the patients who underwent open surgeries (p\0.0001). The mean hospital stay
was 8.9 days in laparoscopic octogenarians and 7.6 days in non-octogenarian (p [
0.05). Moreover, the mean hospital stay was 13.1 days in laparotomy octogenarians
(P = 0.01). The mortality rate was 0% in both laparoscopic octogenarians and non-
octogenarians, however in laparotomy octogenarians it was 20% (p = 0.022).
Conclusions: Laparoscopic colorectal resection for octogenarians was effective and
safe as for non-octogenarians. Our results show that patients who underwent lapa-
roscopic colorectal resection had faster postoperative recovery, lower morbidity and
lower mortality than for octogenarians who underwent traditional laparotomy
colorectal resection.
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P215 – Intestinal, Colorectal and Anal Disorders
STENTING OF COLORECTAL CANCERS IS NOT OFFERED
TO ALL APPROPRIATE PATIENTS
J. Makey, R. Som, P. Tozer, J. Arbuckle, B. Macfarlane
West Herts Hospitals NHS Trust, WATFORD, United Kingdom
Aims: Self expanding metal stents (SEMS) provide good palliation and reduce complica-
tions in the management of obstructing colorectal cancers (CRC) in palliative and bridge to
surgery settings. We aimed to examine the utilisation and outcomes of emergency colonic
stenting in the first year following introduction of this service in our institution.
Methods: Patients with obstructing CRC and patients undergoing attempted stent placement for
presumed CRC were identified from MDT/endoscopy databases. Records and imaging were
retrospectively reviewed; demographic, disease, stenting and surgical data were collected.
Results: Thirty patients were diagnosed with obstructing CRC during the study period.
Fourteen patients underwent attempted stenting and 16 underwent primary surgery
(resection or diversion), with at least 5 suitable for stenting but not referred.
In the 14 attempted stents, obstruction was left sided in all but 1 case (transverse colon).
Eight were palliative stents and 6 were bridge to surgery.
One attempted palliative stent was abandoned due to stool and another due to difficulty in
passing the guide wire–wire perforation was suspected and the patient underwent defunc-
tioning loop ileostomy but died 4 months later. A third patient suffered a procedure related
perforation and underwent emergency subtotal colectomy and remains well. Of the 5
remaining successful palliative stents, 2 patients re-obstructed and died (6 weeks and 4
months post stenting); three patients’ stents remain patent.
Six bridge to surgery patients were successfully stented. One had a stent related
perforation at day 5 and died a day later. Four of the remaining 5 patients underwent
laparoscopic resections and the fifth, an open resection. This latter died from
widespread metastatic disease 4 months later.
Conclusions: Only around 1/4 of patients with obstructing CRC appropriate for
stenting were offered the procedure despite availability of the service and recom-
mendation by national bodies. Complication rates including perforation are
significant and careful consideration needs to be given to stenting as a bridge to
surgery, especially in young patients. This data represents our initial experience. A
further review of practice and outcomes is planned in a year’s time when cumulative
experience may mean results compare more favourably with the published literature.
P216 – Intestinal, Colorectal and Anal Disorders
SINGLE INCISION LAPAROSCOPIC APPROACH IS
FEASIBLE IN THE ADOLESCENT POPULATION WITH
ULCERATIVE COLITIS
N.A Chatzizacharias, M. Brennan, R. Heuschkel, F. Torrente,
R.J Davies
Addenbrooke’s Hospital, CAMBRIDGE, United Kingdom
Aims: Single incision laparoscopic surgery (SILS) has been increasingly used for
colorectal procedures. SILS has been associated with improved cosmesis and
enhanced recovery due to less postoperative pain. SILS subtotal colectomy and
ileostomy has the potential advantage of no risk of wound infection or incisional
hernia formation. However, compared to the traditional laparoscopic approach, SILS
has the disadvantage of difficult instrumentation due to the lack of space and tri-
angulation. To our knowledge, this is the first report of a SILS subtotal colectomy
and ileostomy in an adolescent with ulcerative colitis.
Case report: A 13-year old female patient with ulcerative colitis resistant to maximal
medical therapy underwent a single incision laparoscopic subtotal colectomy and
ileostomy. Both the procedure and the postoperative recovery were uneventful and
the patient was discharged on day 6. Follow-up at 8 weeks after surgery identified no
early complications with a 4 kg weight gain.
Conclusions: SILS is an appropriate treatment option for adolescents with ulcerative
colitis, provided appropriate laparoscopic surgical expertise is available and strict
patient selection is employed.
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Surg Endosc (2013) 27:S53–S166
P217 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC REPAIR OF PARASTOMAL ERNIA WITH
A NEW TYPE OF MESH
R. Galleano, A. Franceschi, M. Ciciliot, S. Di Giorgi, L. Reggiani,
F. Falchero
S. Maria di Misericordia, ALBENGA, Italy
Prevalence of parastomal hernia can exceed 50% in patients with colostomy. Repair
represents a surgical problem with high complication and failure rate. Controversial
exists on best technique but mesh repair appears to provide best results. The lapa-
roscopic use of a specially designed mesh to repair or prevent parastomal hernia is
described. Dynamesh IPST is made by polyvinylidenefluoride with a small amount
of polypropylene on the parietal site. It has some elasticity in both directions and it is
specially designed with a central hole and a funnel arising. Since January 2010 three
patients with symptomatic parastomal hernia received a laparoscopic repair with the
implant of this mesh. Surgical procedure entails insertion of three trocars in the right
abdomen. A 30 scope is used throughout the procedure. Complete adhesiolysis of
the abdominal wall and of the hernia’s contents is carried out. Mesh is incised in the
flat part and in the funnel to open it completely and is inserted into the abdomen
through a port. The funnel part is positioned around the colon and the flat part against
the abdominal wall. Two non-absorbable suture close the funnel around the colon
and four trans-parietal suture plus some absorbable tacks fix the mesh to the
abdominal wall. Mean hospital stay was 6 days (range 5–8). There were no infec-
tions and no complications. Mean follow-up is 12 months (range 9–15). There were
no recurrences and all three patients were able to easily use irrigation to void the
bowel. At present none of the open or laparoscopic mesh repair has proved to be
superior. Laparoscopy has however the potential to reduce infections and abdominal
wall complication due to the fact that no incisions are made near the stoma and there
are no manipulations of colostomy. Laparoscopic repair of parastomal hernia with
Dynamesh IPST seems to be safe and effective in this initial experience. More
studies and longer follow-up are needed to confirm these results.
P218 – Intestinal, Colorectal and Anal Disorders
CLINICAL OUTCOME OF DEVIATING COLOSTOMY AS
BRIDGE TO ELECTIVE SURGERY FOR PATIENTS WITH
AN ACUTE LEFT-SIDED COLONIC OBSTRUCTION
N.R. Cools Paulino Pereira, L. Goense, B.J.M. Van de Wall,
E.C.J. Consten, I.A.M.J. Broeders, W.A. Draaisma
Meander Medical Centre, AMERSFOORT, The Netherlands
Objective: Primary resection is regarded the golden standard for patients with an
acute left-sided colonic obstruction. These emergency procedures are notorious for
their high morbidity and mortality. The possibility of a stent at the site of obstruction
or the construction of a deviating colostomy is anticipated to avoid an operation in
the acute phase. Because stent placement is accompanied with high complication
rates, deviating colostomy as a bridge to elective resection remains an attractive
solution for patients with acute LSCO. This study aims to investigate the clinical
outcome of patients with acute LSCO who underwent deviating colostomy as bridge
to elective surgery (BES).
Methods: Consecutive patients presenting with LSCO receiving a deviating colos-
tomy as BES between 2003 and 2011 were retrospectively analysed. Colostomy-
related and overall morbidity (scored according to the Clavien-Dindo classification)
and mortality were measured. This study was conducted at a large teaching hospital
in the Netherlands.
Results: In total, 97 patients presented with an acute LSCO receiving a deviating
colostomy as BES. Major complications, related to the construction of the deviating
colostomy, occurred in one patient. This resulted in a mortality of 1%. The clinical
condition could be optimalised in all patients after surgery. Subsequently, 49 patients
(50.5%) were given a palliative treatment due to disseminated and/or irresectable
disease as observed at additional radiological examination. The remainder 48
patients (49.5%) were eligible for elective resection at a median time interval of 38.5
days (24–97). One patient (2.1%) deceased after elective left-sided colon resection
due to intra-abdominal bleeding. Severe morbidity graded IIIa or higher occurred in
one patient (2.1%).
Conclusion: By avoiding primary resection in the acute phase for LSCO, a deviating
colostomy as BES is a safe strategy for treating these patients. Optimalisation of the
clinical condition and analysis of the obstructing tumor are distinct advantages of
this step-up approach, leaving resection of the affected colonic segment preserved
for patients with resectable disease only.
Surg Endosc (2013) 27:S53–S166 S107

P219 – Intestinal, Colorectal and Anal Disorders P221 – Intestinal, Colorectal and Anal Disorders

ACUTE RESECTION VERSUS ‘‘BRIDGE TO SURGERY’’ SIGNIFICANCE OF DEFECOGRAPHY AND THE ROLE
WITH COLONIC STENTING OR DEVIATING COLOSTOMY OF RECTOCELE IN CONSTIPATED PATIENTS
FOR ACUTE LEFT SIDED COLONIC OBSTRUCTION; M.A. Bozkurt, E. Dilege, M.U. Kalayci, M. Dogan, H. Alis
A SYSTEMATIC REVIEW Bakirköy Dr. Sadi Konuk Education and Research Hospital,
L. Goense, N.R. Paulino Pereira, B.J.M. Van de wall, E.C.J. Consten, ISTANBUL, Turkey
I.A.M.J. Broeders, W.A. Draaisma Chronic constipation is a major medical problem. We have investigated this problem
Meander Medical center, AMERSFOORT, The Netherlands in 250 patients who have been admitted to our general surgery outpatient clinic with
Objective: Several treatment modalities can be offered for patients with acute left complaint of constipation using Rome III criteria and diagnostic defecogarphy. Out
sided colonic obstruction (LSCO), although consensus on the optimal treatment is of 250 patients who were evaluated with defecography only 24 had normal findings.
lacking. This study aims to compare the mortality and morbidity rates of primary 136 patients were found to have rectocele. We propose that rectocele is an important
resection versus a ‘bridge-to-surgery’ approach by colonic stenting or deviating etiology of constipation, and defecography should be considered early in the diag-
colostomy followed by elective resection by means of a systematic review of the nosis of rectocele.
literature.
Methods: Pubmed and Embase were used to find all relevant literature on the out-
comes of patients with acute LSCO who underwent either acute resection or a step-
up approach by initial colonic stent placement or colostomy construction, followed
by elective resection. Procedure related morbidity and mortality were set as primary
endpoints of this review.
Results: Twelve comparative studies were eligible for analysis, of which 4 were
randomized controlled trials. A total of 344 patients, with a mean age of 72.4 were
included in the acute resection group, 217 patients with a mean age of 72.3, in the
stent group and 152 patients with a mean age of 68.3 in the colostomy group. Mean
mortality rate for patients who underwent acute resection with or without primary
anastomosis was 13.8% (3.3–24.1%). Overall mortality for patients initially treated
with a colonic stent and followed by elective resection was 7.4 % (2.9–11.1), overall
mortality for patients who first underwent colostomy followed by elective resection
was 9.8% (0–14.7%). Major morbidity occurred in 26.8% (12.5–45.1%) of patients
treated with acute resection versus 25.3% (5.9–53%) in the patients treated with
initial colonic stent and 23.4% (10.5–27.6) in patients treated with initial colostomy.
Discrimination between mortality and morbidity rates occurring during initial stent
or colostomy placement and elective resection proved unfeasible.
Conclusion: Primary resection for patients with acute LSCO seems to be accom-
panied by higher morbidity and mortality rates than a step-up approach with initial
colonic stent placement or deviating colostomy. Based on two randomized trials,
colonic stents should be discouraged, although promising results have been pub-
lished in other retrospective cohort studies. No high-level studies exist on the initial
treatment with a deviating colostomy. Therefore, future comparative studies are
warranted on the optimal treatment of patients with acute LSCO.

P220 – Intestinal, Colorectal and Anal Disorders P222 – Intestinal, Colorectal and Anal Disorders

ETIOLOGY OF CONSTIPATION IN PATIENTS ADMITTED IS COLONIC TRANSIT TIME MEASUREMENT VALUABLE

TO THE OUTPATIENT CLINICS WITH CHRONIC IN THE EVALUATION OF CONSTIPATION?
CONSTIPATION M.A. Bozkurt, O. Könes, E. Gemici, H. Alis
M.A. Bozkurt, M.U. Kalayci, M. Gönenç, H. Yirgin, H. Alis Bakirköy Dr. Sadi Konuk Education and Research Hospital,
Bakirköy Dr.Sadi Konuk Education and Research Hospital, ISTANBUL, Turkey
ISTANBUL, Turkey Introduction: Constipation is a common symptom in surgical clinics. Determining
the etiology is important in the success of treatment. In this study, we aimed to
Background: Chronic constipation is a common, chronic and frequent problem of the
determine the value of colonic transit time measurement in revealing the etiology of
general population. Roma III criteria can be used for the diagnosis of patients pre-
constipation.
sented with constipation. The aim of the study is etiological investigation of
Materials and methods: 130 patients who were diagnosed with constipation
constipation according to Roma III criteria.
according to Rome III criteria were included in the study. Colonic transit times were
Method: 100 patients who admitted consecutively to outpatient clinic with the
measured in all patients.
complaint of chronic constipation were included in this study after excluding other
Results: 13 of 130 patients showed prolonged colonic transit time. In 9 of 13 patients
causes of constipation by history and physical examination. Patients were assessed
capsules were accumulated in the rectosigmoid area, in 2 patients in the right colon,
by complete blood count, glucose, urea, creatine, AST, ALT, Na, K, Ca, Mg,
in 2 patients in left in the colon. Conclusions: Colonic transit time measurement is a
phosphorus and thyroid function tests. Colonic transit time measurement, cinedef-
useful diagnostic tool in the evaluation of chronic constipation, however it gives
ecography, double-contrast colon graphies were performed in all patients.
limited information about the etiology.
Results: These examinations showed the presence of a pathology in %90 of the
patients. %75 of them had anterior rectocele and %66 of them had internal
intussusception.
Conclusion: Co-occurence of rectocele and internal rectal mucosal intussusception
with chronic constipation was significantly high.

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P223 – Intestinal, Colorectal and Anal Disorders
RESULTS OF LAPAROSCOPIC SURGERY IN PATIENTS
WITH COLORECTAL CANCER
A.V. Sazhin, S.V. Mosin, A.E. Tjagunov, J.N. Lebedeva
Russian National Research Medical University named after NI
Pirogov, MOSCOW, Russia
Materials and Methods: From 2005 to 2011 was performed 64 laparoscopic procedures for colo-
rectal cancer. Mean age ***69.3 ± 6.7 years. Male – 40.6%, female – 59.4%. Distribution of
patients according to stage of disease (TNM): I – 6 (9.4%); II – 36 (56.3%), IIIA – 3 (4.7%); IIIB –
6 (9.4%); IIIC – 3 (4.7%); IV – 10(15.6%). Histological types: adenocarcinoma – 60(93.8%),
including grade 1 – 24(37.5%), grade 2 – 25(39.1%), grade 3 – 7 (10.9%), grade 4 – 4(6.2%), and
malignant carcinoid tumor – 4 (6.2%). Localization of tumors in the colon: cecum-10 (15.6%),
ascending colon-8 (12.5%), hepatic flexure-5(7.8%), transverse colon-3(4.7%), splenic flexure-
2(3.1%), descending colon-6(9.4%), sigmoid colon-22(34.4%), rectum-8(12.5%). Following lap-
aroscopic operations are performed: abdomino-perineal resection-2(3.1%), anterior resection of the
rectum-6(9.3%), resection of the sigmoid colon-19(29.7%), left hemicolectomy-11(17.2%), right
hemicolectomy-26(40.6%). Laparoscopic operations was performed with 4 or 5 ports. Mobilization
of colon were accessed from the medial to lateral approach with initial apical vessel ligation. We
used LigaSure Atlas for ligation of vascular trunks. Monopolar coagulation and ultrasonic dis-
section was used for ligaments dividing, mesocolonectomy and mesorectumectomy in tissue
planes. Two-stapled technique applied in left side procedures. Right-sided hemicolectomy was
performed with laparoscopic assistance and specimen removing through the minilaparatomy and
manual anastomosis formation.
Results: The average duration of surgery was 206.3 ± 10.04 min (range 115–340 min). Restoration
of peristalsis took place on the 2nd day in 84.37% of the patients, independent stool appeared up to
5 days. The mean time of analgesics prescription was 4 days. Average length of hospital treatment
was 14 days (from 7 to 33). Postoperative morbidity occurred in 7 (10.9%) patients. Postoperative
mortality was 3.1% (2 patients). Long-term results were followed in 32(50%) patients within 1 and
3 years. One-year overall and recurrence-free survival rate of 82.1%. Three-years overall and
recurrence-free survival of 67.8% and 60.7% respectively. The median survival was 34.3 months.
By the time of the study 10 respondent patients (31.25%) died.
Conclusions: Our experience demonstrates the appropriateness of laparoscopic approach in the
surgical treatment of patients with colorectal cancer.
P224 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC ABDOMINOPERINEAL RESECTION FOR
LOW RECTAL CANCER: RISK FACTORS FOR PERINEAL
WOUND COMPLICATIONS AND IMPACT ON LONG-TERM
OUTCOMES
D. Saavedra-Perez1, C. Adelsdorfer1, R. Almenara1, S. Delgado1,
M. Pavel1, W. Adelsdorfer1, A. Ibarzabal1, D. Momblan1,
C. Ginestà1, M. Valentini1, O. Vidal1, G. Benarroch2,
J.C. Garcia-Valdecasas1, A.M. Lacy1
1
Hospital Clı́nic of Barcelona, BARCELONA, Spain; 2Hospital
Clinic i Provincial, BARCELONA, Spain
To evaluate the risk factors for perineal wound complications (PWC) and the impact on long-term
oncological outcomes of low-rectal-cancer patients undergoing abdominoperineal resection (APR)
assisted by laparoscopy. In a prospective manner, from January 1998 to September 2010, patients
admitted to our colorectal cancer unit with adenocarcinoma of the low rectum, were enrolled. For
patients with locally advanced clinical stages (TNM classification), neoadjuvant chemoradiother-
apy (NCRT) was based on 5-fluoracyl with concomitant radiotherapy in a cycle of 45 Gy.
Laparoscopic APR was carried out around 8 weeks after treatment start. Patients were followed-up
in our surgical outpatient clinic. Significant clinical, pathological and surgical characteristics
associated with wound infection, healing delay ([30 days), reintervention, recurrence and survival
were ascertained at univariate and multivariate analysis. A total of 80 patients with a mean age of
68 ± 18 (29–90) years were evaluated. NCRT was employed in 77.5% of the patients. Intraop-
erative rectal perforation was present in 9 cases, and conversion to open surgery was needed in 10%
of the patients. Primary closure was performed after all interventions. Complete resection was
achieved in 82.5% of the patients. Overall PWC rate was 16.3% (13/80) with healing delay in 10%
and needed for reintervention in 3.8% of the patients. Associated factors with PWC were tumoral
invasion to other organs (p = 0.016), intraoperative rectal perforation (p \ 0.001), conversion to
open surgery (p = 0.006), and clinical stages III-IV (p = 0.017). At multivariate analysis intra-
operative rectal perforation (RR 12; 95% CI, 1.01–12.7; p = 0.004) and clinical stages III-IV
(RR1.3; 95% CI, 1.1–1.4; p = 0.005) remained statistically significant. Although, 14.5% (9/62) of
patients receiving NCRT had wound complications, no association was found (p = 0.16). Mean for
patient follow-up was 40.8 months with an overall recurrence rate of 16.3% (13/80), and 5-year
overall survival of 61.7%. No statistical significant differences according to PWC were found for
recurrence (p = 0.121) and 5-year overall survival (p = 0.187). PWC rate after laparoscopic APR
completed with primary closure for low rectal cancer patients was lower than previously reported
for open series. Clinical stages III-IV and intraoperative rectal perforation are predictive factors for
PWC. No effect of PWC on local recurrence and overall survival was found.
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Surg Endosc (2013) 27:S53–S166
P225 – Intestinal, Colorectal and Anal Disorders
TRANSANAL ENDOSCOPIC MICROSURGERY FOR
BENIGN DISEASE AND EARLY RECTAL CANCER: OUR
EXPERIENCE AT A HIGH LEVEL ACADEMIC
INSTITUTION
M. Paquin-Gobeil, S. Duhaime, R. Auer, J. Mamazza, R. Boushey,
H. Moloo
The Ottawa Hospital, OTTAWA, Canada
Aim: This study is to assess outcomes of all patients with benign pathologies of the rectum and
early rectal cancer that are amenable for TEM in Ottawa.
Methods: We conducted a retrospective chart review of all patients who underwent local excision
of early rectal cancer and benign pathology at The Ottawa Hospital (TOH) between October 2009
and June 2011. The retrieved data included patient demographics, preoperative work up, intra-
operative data and in hospital stay. Patients were followed to assess the need for reoperation based
on final pathology, postoperative complications and mortality. The Clavian-Dindo Classification
was used for the surgical complications up to 30 days.
Results: A total of 35 patients fit our selection criteria. 65% (n = 23) of the patients were male with
an average age of 67 ± 12 years old. 68% (n = 24) had a preoperative diagnosis of rectal adenoma.
Within the cancer population, 76% of the patients had stage 1 disease on imaging (n = 13). No
patients required adjuvant treatment, however 2 patients received brachytherapy. The operative
time was in average 109 ± 50 minutes with a set up time of 47 minutes. Three cases required
conversion to a transanal approach. Closure of the defect was at the discretion of the surgeon. A
rectal block with Marcaine 0.25% was used in 68% of the patients to control postoperative pain.
The median length of stay was 1 day. Only 1 patient needed transfusion postoperatively. 43% of the
patients were discharged home with antibiotic therapy for UTI, wound contamination or large open
defect of the wound. Two patients pre-identified because of previous pelvic surgery developed a
fistula. The Clavian-Dindo classification was 0 for 29 patients. There was no mortality. Fifteen
patients were diagnosed with adenocarcinoma, 2 had rectal carcinoid, 16 had an adenoma and 2 had
benign disease. Following pathology results, 7 patients required further surgical management.
Conclusions: In our experience, TEM is a safe option for early rectal pathologies
with few complications and short length of stay. 7 patients had to undergo another
intervention based on pathology as per actual recommendations. TEM combined
with adjuvant treatment is currently evaluated for stage II disease.
P226 – Intestinal, Colorectal and Anal Disorders
TRANSUMBILICAL HIDDEN SCAR LAPAROSCOPIC
SURGERY USING GELPORT?Ò/GELPOINTÒ THROUGH AN
UMBILICAL ZIGZAG SKIN INCISION FOR COLORECTAL
CANCER
T. Kinoshita, T. Hachisuka, N. Kurata, M. Tsutsuyama, S. Umeda,
A. Yarita, T. Shikano, Y. Mizuno, T. Mori, M. Shinohara, M. Miyauchi
Yokkaichi Municipal Hospital, YOKKAICHI, MIE, Japan
Introduction: Recently, laparoscopic surgery is widely applied to colorectal cancer in Japan.
However, in the standard technique of laparoscopic surgery for colorectal cancer, an additional
5-cm skin incision is required to extract the resected specimen and do anastomosis after laparo-
scopic procedure. To minimize the incision and reduce the number of ports for less invasive
colorectal surgery, we applied an umbilical zigzag skin incision by using Gelport. Meanwhile, for
hidden scar surgery, GelPOINT, was developed to maintain triangulation, fulcrum and pneu-
moperitoneum during the laparoscopic procedure. The product was available in Japan this year and
used to many procedures through zigzag incision in our institution. We herein describe our new
method that has some of the technical challenges in reduced port laparoscopic surgery for colo-
rectal cancers.
Methods and Procedures: After marking a zigzag skin incision in the umbilical region, the skin was
incised along this line. After the peritoneum was opened, a Gelport/GelPOINT ‘s double-ring
wound retractor was inserted through the incision, which enlarged the diameter of the fascial
opening to 6 cm. Its GelSeal cap was latched on the wound retractor ring, following inflation of
the pneumoperitoneum by CO2. One or more additional ports were inserted as necessary. All
operations were performed in the standard fashion. The specimen was easily extracted from the
abdomen through the umbilical incision, and anastomosis was performed. At the end of the
operation, the peritoneum, fascia and skin were sewn.
Results: Using the above method, we performed the following: 7 colectomy for
colon cancer, 5 high anterior resection for rectal cancer. All cases were accomplished
by this method without any complications. The wounds of the umbilical region were
almost ‘scarless’ in all cases.
Conclusion: We developed an umbilical zigzag skin incision technique to perform laparoscopic
operations for colorectal cancer using Gelport/GelPOINT through an umbilical zigzag skin
incision without any additional skin incisions. In the effort to minimize surgical trauma our
umbilical zigzag skin incision technique have been attempted. We consider that our method is one
new way to lessen the technical difficulties and keep cosmesis in reduced port laparoscopic surgery
for colorectal cancer.
Surg Endosc (2013) 27:S53–S166
P227 – Intestinal, Colorectal and Anal Disorders
TRANSUMBILICAL HIDDEN SCAR LAPAROSCOPIC
APPENDECTOMY AND CHOLECYSTECTOMY USING
GELPORTÒ/GELPOINTÒ THROUGH AN UMBILICAL
ZIGZAG SKIN INCISION
M. Tsutsuyama, T. Kinoshita, T. Hachisuka, N. Kurata, S. Umeda,
A. Yarita, T. Shikano, Y. Mizuno, T. Mori, M. Shinohara, M. Miyauchi
Yokkaichi Municipal Hospital, YOKKAICHI, MIE, Japan
Introduction: The objective of the modern surgery is not only to perform surgical procedures
aiming to improve the health condition of the patient, but whenever possible to use minimally
invasive approach and to ensure the satisfying cosmetic result. Hidden scar surgery is a new way in
which surgeons perform abdominal operations through one incision made in the patient’s folds of
umbilicus. However, with a straight incision of the umbilicus, the opening of fascia is maximally 2
cm. The 2-cm fascial opening is not enough to keep the triangulation of instruments. To overcome
this problem, we developed an umbilical zigzag skin incision with a 3–6 cm opening of fascia and
peritoneum and used Gelport to keep pneumoperitoneum, which finally resulted in scarless
wound. Meanwhile GelPOINT was developed to maintain triangulation, fulcrum and pneumo-
peritoneum. The product was available in Japan last year. We herein describe our new method that
has reduced some of the technical challenges in single port appendectomy and cholecystectomy.
Methods and Procedures: After marking a zigzag skin incision, the skin was incised along this line.
After the peritoneum was opened, a Gelport/GelPOINT ‘s double-ring wound retractor was
inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. Its
GelSeal cap was latched on the wound retractor ring, following inflation of the pneumoperito-
neum. All operations were performed in the standard fashion. At the end of the operation, the
peritoneum, fascia and skin were sewn.
Results: Using the above method, we performed the following: 5 appendectomy for appendicitis, 8
cholecystectomy for gallstones and gallbladder polyps. All cases were accomplished by this
method without any complications. The wounds of the umbilical region were almost ‘scarless’ in
all cases.
Conclusion: We developed an umbilical zigzag skin incision technique to perform laparoscopic
appendectomy and cholecystectomy using Gelport/GelPOINT through an umbilical zigzag skin
incision without any additional skin incisions. In the effort to minimize surgical trauma our
umbilical zigzag skin incision technique have been attempted. We consider that our method is one
new way to lessen the technical difficulties and keep cosmesis in single port laparoscopic
appendectomy and cholecystectomy.
P228 – Intestinal, Colorectal and Anal Disorders
EXPERIENCE OF THE THREE TROCARS METHOD
FOR COLORECTAL LAPAROSCOPIC SURGERY
S. Kitashiro, S. Okushiba, Y. Kawarada, S. Pawdel, D. Saikawa,
T. Onoda, T. Sasaki, Y. Suzuki, M. Kawada, O. Tetuyuki, H. Katoh
TONAN hospital, SAPPORO, Japan
Introduction: We introduce our technique of the three trocars method for colorectal cancer. This
method means to perform surgery without assistant. It may operative offer many unique advan-
tages, e.g., operator can control the operative view directory, it may diminish human error, enable
the operation to progress speedily, and provide significant economic benefits (human assistant in
not necessary. And it’s very useful when Single port surgery was introduced, because many points
(operative procedure, the way to obtain adequate operative field) are similar to the three trocar
method.
Method: A total of 460 cases (included 40 Single port surgery) diagnosed with colorectal cancer
between 2004 and 2011. Operative, and post operative characteristics including overall survival
and surgical complication were analyzed.
Result: The 5-years survival rate is 89% in stage II and 70% in stage III. The average surgical time
was about 120 minutes for the colon, 150 minutes for the rectum and 130 minutes for single port
surgery. In almost all operations, we successfully managed to get an adequate operative field. Only
14 patients were converted to conventional technique, but there were no additional trocar in single
port surgery cases.
Conclusion: We hereby report on the characteristics and outcomes of the three trocars method in
our institute. And feasibility of this method was indicated. We believe that this method will prevail
in terms of bringing benefits for single port colorectal cancer surgery.
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P229 – Intestinal, Colorectal and Anal Disorders
HAND-ASSISTED LAPAROSCOPIC COLECTOMY (HALS) IS
USEFUL TECHNIQUE FOR RIGHT SIDE COLON CANCER
M. Nakahara, D. Sumitani, T. Fukuda, M. Hamaoka, K. Taguchi,
G. Yakahashi, M. Yamaguchi, T. Noriyuki, M. Yamaki, F. Kuranski,
Y. Kuroda
Onomicji General Hospital, ONOMICHI, Japan
Introduction: Laparoscopic colectomy in patients with colon carcinoma has been taken widely by
its less invasiveness. However, using laparoscopic procedure for colon cancer some difficulty still
remains in dissection of lymph nodes. Therefore, we began HALS (Hand Assisted Laparoscopic
Surgery) technique for right hemicolectomy.
Operative Methods: At first, we put the small supraumbilical skin incision about 6 cm in length.
Lymphatic clearance at the base of the ileocecal vessels and high ligation of these vessels were
done through direct vision. Following these process, we applied wound retractor (OMNIPORTTM)
tightly. Then, pneumoperitoneum was started and with assistance of left hand colon was mobilized.
For advanced cases, we kept colon gently without inadvertent touch (i.e.; no touch isolation
technique). After mobilization, resection and anastomosis were carried out with hand sewing
technique under direct vision.
Results: We performed on 73 colon cancer with HALS technique. 10 patients were early cancer and
63 were advanced cancer. Fifty four cases out of 63 were resected curatively and 44 out of these
cases were performed lymph node dissection toward the base of colic artery completely (D3 lymph
node clearance). The mean operative time was 198 ± 59 minutes and the median operative blood
loss was 50 g. We experienced 4 post operative complications (5.5%). Three were ileus and one
was bleeding. All of ileus cases were improved with conservative therapy but bleeding case was
necessary with operative procedure. There was no anastomotic leakage and mortality case. Five
cases were recurrenced and two out of 5 cases were peritoneal dissemination. Cancer free 5 year
survival rate were 100% for stage 0, stage I, stage II, 75% for stage IIIa, 50% for stage IIIb,
respectively.
Conclusion: Using HALS technique, Laparoscopic right hemicolectomy was carried out safely with
complete lymphatic clearance therefore HALS is useful for colon cancer.
P230 – Intestinal, Colorectal and Anal Disorders
SINGLE INCISION LAPAROSCOPIC SURGERY FOR
ULCERATIVE COLITIS
S. Homma, T. Shimokuni, H. Sakihama, N. Takahashi, A. Kataoka,
A. Taketomi
Hokkaido University Hospital, SAPPORO, Japan
Background: Single incision laparoscopic surgery for acute appendicitis or GB stones was reported
which was better cosmetic result, less invasive than conventional laparoscopic surgery. Single
incision laparoscopic total colectomy for ulcerative colitis is well adapted because of more cos-
metic benefit for young benign disease patients.
Aim: This poster showed results of single incision laparoscopic total colectomy for ulcerative
colitis.
Patients: 3 patients surgically treated for ulcerative colitis.
Surgical procedure:
1) Port position: The Umbilicus cut in 2.5 cm. SILS port was placed on umbilicus. 12 mm
trocar was inserted in the right lower abdomen where will be made in the ileostomy.
2) Rectum mobilization: Transverse colon was upheld to head side, and the pedicle of IMA
held to abdomen side. Root of IMA was recognized, mesentery of sigmoid colon and rectum
was detached from medial side approach. Sigmoid colon and rectum were completely
mobilized to the level of the levator ani muscle.
3) Total colon mobilization: Descending colon was mobilized from sigmoid to splenic flexture.
The mesentery of decending colon was cut by ultrasonic coagulation system. Ileum end was
cut by end GIA, ascending colon was mobilized to hepatic flexture. The mesentery of
ascending colon was cut by ultrasonic coagulation system. Omentum was cut into bursa
omentalis, the mesentry of transverse colon was cut from left to right side. Total colectomy
was carried out.
4) Anastomosis: Mucosectomy was performed 3 cm from pectinate line of anal canal. Total
colon was removed from anus. Ileal pauch-anal anastomosis was carried out by hand-
sowing. Ileostomy was made on the 12 mm trocar site.
Results: The mean age was 26.6 years (17–38). Duration of symptoms in ulcerative colitis was 6.6
years (2–12 years). The mean total steroid was taken in 7.63 g (6–10 g). Surgical indication of all
cases was medical refractory. Anastomosis methods were various (IAA: 1, IACA: 1, Ileostomy: (1).
Median operation time was 374 min (322–465 min). The median blood loss was 33.3 ml (0–100
ml). Postoperative complication occurred in one patient (MRSA enteritis).
Conclusion: Single incision laparoscopic total colectomy for ulcerative colitis was safe and kept
better cosmetic benefit and QOL.
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P231 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPY-ASSISTED COLECTOMY FOR RECTAL
CANCER
D. Sumitani, M. Nakahara, F. Kuranishi, T. Noriyuki, T. Fukuda,
M. Yamaki, M. Hamaoka, K. Taguchi, G. Takahashi, M. Yamaguchi,
Y. Kuroda
Onomichi general hospital, ONOMICHI, Japan
Aims: Laparoscopy assisted colectomy (LAC) for rectal cancer is not widely
accepted because of difficulty of technical skill and anxiety of inducement of cancer
cell scattering. Some meta-analysis reported that laparoscopic surgery seems to be
more advantageous than open surgery in terms of short-term outcomes. The aim of
this study was to assess whether LAC is feasible for treatment of rectal cancer or not.
Methods: From July, 1998 to September, 2010, 231 patients affected rectal cancer
were operated curatively with laparoscopic procedure. We analyzed clinicopatho-
logical characteristics, operative procedure, morbidity, mortality, recurrence type,
and survival of our cases to assess feasibility of LAC.
Results: Mean ages were 66.0 years for LAC. Tumors location were following; 89 in
rectosigmoid (RS), 98 in rectum above the peritoneal reflection (Ra), 29 in rectum
below the peritoneal reflection (Rb), and 15 in proctor. Out of these 231 cases, 177
patients were for advanced rectal cancer and 54 were for early rectal cancer. Ade-
quate methods, including total mesorectal excision, were selected for all 231 cases
and most of patients with advanced 177 rectal cancers were conducted with satis-
fying lymph nodes dissection equally to patients with open procedure. The overall
morbidity rate was 11.7%. However, anastostomotic leak rate was only 2.9% and
overall 30-day mortality rate was 0.4%. Tumor recurrence was detected in 27 cases.
20 were distant metastasis, 7 were local recurrence. No port-site recurrence was seen
in our study. Disease free survival at 5 years were 100% in stage 0 (n = 12), 95% in
stage I (n = 73), 84% in stage II (n = 77), 67% in stage IIIa (n = 47), 78% in stage
IIIb (n = 21), according to classification of Japanese Society for Cancer of the Colon
and Rectum.
Conclusions: Our data indicate laparoscopic resection is highly recommended as a
standard operation for rectal cancer because of its safety and usefulness.
P232 – Intestinal, Colorectal and Anal Disorders
CLINICAL RESULTS OF LAPAROSCOPIC
APPENDECTOMY IN OUR INSTITUTE
C. Tono, O. Shimooki, T. Abe, H. Minakawa, T. Tosha,
M. Takahashi, M. Yusuke
Iwate prefectural Kuji Hospital, IWATE PREFECTUREE, Japan
In our institute, we started laparoscopic appendectomy in 2009. We operated 3 cases
in 2009, 40 cases in 2010 and 31 cases in 2011. We analyzed clinical results of 71
cases from January 1st, 2009 to December 31, 2011. We investigated clinical data
from medical chart. The patients ages were from 5 to 84 years old (average: 41.1
years old). The numbers of Men were 41, and women were 30. Body temperature
was from 35.4 to 39.7 (average: 37.40) before operation. And White Blood Cells
were from 4600 to 26300/ll (average: 14323/ll). All cases were underwent Com-
puted Tomography to diagnose appendicitis.3 cases were falls positive. Operation
times were from 32 minutes to 208 minutes (average: 78.7 minutes). Operational
bleeding was from 1 ml to 310 ml (average: 26.4 ml). Abdominal drainage tubes
were needed for 15 patients (21.1%). Pathological diagnoses were normal appendix
were 3 (4.2%), catarrhal appendicitis were 3(4.2%), phlegmonous appendicitis were
50 (70.4%), gangrenous appendicitis were 14 (19.7%), perforated appendicitis were
1 (1.4%). Complications occurred in 12 patients (16.9%). 10 Surgical site infections
(14%) (4 cases were wound infection, 6 cases were intra abdominal abscess), one
intestinal obstruction (1.4%) and one bladder injury (1.4%) were treated. Hospital
stays after surgery was from 1 day to 22 days (average: 5.6 days). And last hospital
visits were from 6 to 60 days after surgery (average: 15 days).
123
Surg Endosc (2013) 27:S53–S166
P233 – Intestinal, Colorectal and Anal Disorders
CASE REPORT: A SUCCESSFUL LAPAROSCOPIC LEFT
COLECTOMY FOR OBSTRUCTIVE DESCENDING COLON
CANCER AFTER RADICAL CYSTECTOMY WITH ILEAL
CONDUIT
R. Suzuki, K. Nakata, T. Kato, T. Kanemura, A. Takeno, S. Nakahira,
H. Miki, Y. Takeda, S. Tamura
Kansai Rosai Hospital, AMAGASAKI, Japan
Introduction: Laparoscopic surgery after radical cystectomy with ileal conduit is rare
because possible dense adhesion in abdominal cavity should bring technical diffi-
culty. We successfully performed a laparoscopic left colectomy for obstructive
descending colon cancer after radical cystectomy with ileal conduit for cancer of the
bladder.
Case Presentation: Patient was a 75-year-old man with history of hypertension and
pacemaker implantation for severe bradycardia. He received open radical cystectomy
for cancer of the bladder with ileal conduit as urinary diversion. After 7 months, he
developed bowel obstruction. Abdominal computed tomography showed suspected
obstructive descending colon cancer. Operation for colon cancer was performed after
bowel decompression by adequate fecal drainage.
Operation: Laparoscopic exploration of abdominal cavity from the umbilical 12 mm
trocar (trocar A) turned out to continue laparoscopic surgery. Additional three trocars
were placed apart from ileal conduit in right lower quadrant. A 5 mm trocar was
inserted adjacent to the trocar A in the same incision. One 5 mm trocar was inserted
in right upper quadrant and another 12 mm trocar in left flank (4 trocars in 3
incisions). Left branch of the middle colic artery was ligated at vascular bifurcation
of the middle colic artery. Transverse colon and descending colon was mobilized by
medial-to-lateral approach. From 5 cm-midline incision at umbilicus, colonic
specimen was resected and functional end to end anastomosis was done. No drainage
tube was inserted. Operation time was 166 min., blood loss was a 50 mL. Patient had
an uneventful postoperative course and discharged at POD 10.
Summary: Though after radical cystectomy with ileal conduit, it is at least worth to
try laparoscopic surgery for colon cancer following adequate fecal drainage.
P234 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC GASTRIC BYPASS FOR DIABETES
MELLITUS IN PATIENTS BMI24-29: EFFECT ON BODY
COMPOSITION AND METABOLIC SYNDROME
M. Garcia-Caballero1, M. Valle1, J.M. Martı́nez-Moreno1,
F. Miralles2, J.A. Toval1, J.M. Mata1, D. Osorio1, A. Minguez1
1
University Malaga, MALAGA, Spain; 2Associated UH Parque
San Antonio, MALAGA, Spain
Introduction: Diabetes mellitus is a major cause of death in the world. The medical
therapy for this disease has had enormous progress, but it still leaves many patients
exposed to its complications. It is well known the beneficial effects of bariatric
surgery in the obese diabetic, however it is important to investigate if the same
principles of bariatric surgery that improve diabetes in these obese patients, could be
applied to non obese normal weight diabetics.
Material and methods: Thirteen diabetic patients operated by One Anastomosis
Gastric Bypass (BAGUA), were evaluated in the preoperative period and 1,3 and 6
months after surgery. Body weight and composition, Fasting Plasma Glucose,
HbA1c, pancreatic C Peptide levels, blood pressure and serum lipids levels were
analyzed, as well as the monitoring of the immediate postoperative treatment
necessities for Diabetes and other metabolic syndrome comorbidities.
Results: After the surgery the 77% of the patients resolves its Diabetes Mellitus, 46%
from surgery, and rest noted an significant improvement of the disease in spite of
having a C peptide level near to zero some of the patients. Metabolic syndrome
comorbidities, mainly hypertension and lipid abnormalities experience early
improvement. All patients reduce their weight and the amount of fat mass until
values consistent with their age and height.
Conclusions: The One Anastomosis Gastric Bypass leads to resolution or
improvement of Diabetes Mellitus in non obese normal weight patients as well as the
associated metabolic syndrome. The best results are obtained in patients with few
years of diabetes, without or short term use of insulin treatment and high C-peptide
levels.
Surg Endosc (2013) 27:S53–S166
P235 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC DUODENOJEJUNOSTOMY: TECHNIQUES
AND INDICATIONS
N. Hachach-Haram1, A. Al Nawfal2, C. Fraser1, A. Isla1
1
St Marks Hospital and Academic Institute, LONDON,
United Kingdom; 2North West London Hospitals NHS Trust,
HARROW, MIDDLESEX, United Kingdom
Gastric outlet obstruction is rarely secondary to conditions related to the 3rd or 4th
segment of the duodenum and D-J flexure. Very often such presentations are treated
with a gastrojejunostomy, which is not a physiological operation. Theoretically, the
obstruction in the duodenum should be overcome whilst maintaining the normal
anatomy. Laparoscopic duodenojejunostomy has been described mainly for the
management of superior mesenteric artery syndrome but there are only isolated cases
reported. We believe this operation can also be used for treating other conditions
affecting this anatomical region.
In this video presentation we present two cases with rare and remarkable causes of
significant duodenal obstruction. The first, a young female patient with a suspected
diagnosis of superior mesenteric artery syndrome, the second, an elderly male patient
with cachexia and a proven diagnosis of a stricture at the D-J flexure secondary to
tuberculosis. In both patients we performed a laparoscopic duodenojejunostomy. In
the first case completely hand sewn and in the second assisted with an endostapler.
Both techniques achieved the same result with physiological restoration of the du-
odenojejunal passage and excellent post-operative progress. More than 3 months
later the patients are still asymptomatic and functioning well.
Laparoscopic duodenojejunostomy provides a definite physiological solution for
distal duodenal obstruction of different underlying causes. This can be performed
completely hand sewn or with the help of an endoscopic linear cutter, making it a
less demanding procedure that the skilled laparoscopic surgeons can add to their
armament.
P236 – Intestinal, Colorectal and Anal Disorders
SIGNIFICANCE OF REPAIRING MESENTERIC DEFECT
AFTER LAPAROSCOPIC COLECTOMY
S. Okamura1, Y. Ide2, K. Murata1
1
Suita Municipal Hospital, SUITA, Japan; 2Yao Municipal Hospital,
YAO, Japan
Introduction: Repair of mesenteric defect is common technique after resection of
colorectal cancer in conventional open surgery to prevent internal hernia. Recently
laparoscopic colectomy has become popular for colorectal cancer, while the tech-
nique has been often omitted in laparoscopic surgery, probably due to its laborious
and time consuming aspect.
Aims: To examine significance of repairing mesenteric defect after laparoscopic
colectomy.
Methods: To review our risk management to prevent internal hernia after laparo-
scopic surgery for colorectal cancers.
Results: In 2008, we experienced a case of internal hernia due to defect of mesen-
terium three weeks after laparoscopic right hemi-colectomy for ascending colon
cancer. Emergency laparotomy revealed necrosis of long small intestine, resulting
resection more than half of small bowel and causing short bowel syndrome. Since
experience of this case, we started closing mesenteric defect in general after
resection of colorectal cancer in laparoscopic surgery: complete repair of mesenteric
defect in right colectomy, and retro-peritoneal repair in left colectomy or recto-
sigmoidectomy by continuous absorbable monofilament suture. With enough train-
ing of the technique in dry box and subsequent experiences in laparoscopic surgery,
average time of this technique has become about twelve minutes. We have experi-
enced no internal hernia after laparoscopic colectomy since then.
Conclusion: Although this type of complications is rare and reported as 0.8%, if it
occurs, it needs surgery and may cause ischemic damage to long small intestine. As
for the risk management to prevent internal hernia after laparoscopic colectomy,
repair of mesenteric defect should be considered to perform.
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P237 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC INTERSPHINCTERIC RESECTION FOR
VERY LOW RECTAL CANCERS
E. Hidaka, F. Ishida, S.H Endo, K. Nakahara, D. Takayanagi,
T. Omoto, Y. Takehara, S. Mukai, J. Tanaka, S. Kudo
Showa University Northern Yokohama Hospital, YOKOHAMA,
Japan
Aims: Recently, laparoscopic intersphincteric resection (Lap-ISR) for very low
rectal cancers located within 4 cm from anal verge has been undergone to avoid a
permanent stoma. Laparoscopic-ISR has not been accepted widely, however,
because the oncologic and functional outcomes were not clear. The purpose of this
study was to examine the oncologic safety and function after Laparoscopic-ISR.
Methods: A total eleven patients (male/female = 7/4, age 33–73 years) with very low
rectal cancers who underwent curative Lap-ISR was enrolled. Three cases which
were diagnosed T3 tumor were underwent preoperative chemo-radiation (CRT). We
would estimate the clinic-pathological data and the surgical factor in Lap-ISR.
Results: The mean operative time was 350.3 minutes (range, 233–540), and blood
loss was 359.4 ml (range, 54–946). The mean cancer free distant average margin was
17.1 mm and circumference margin was free for cancer in all cases. A diverting
stoma was created in all cases for protecting the anastomosis. Post-operative anas-
tomotic leak was observed in one case. The leakage was cured conservatively. An
anastomotic stenosis was observed in two cases, but was cured by dilatation pro-
cedure. As two of three complicated cases were underwent preoperative CRT, these
complications would be strongly affected by CRT, not laparoscopic approach.
Diverting stomas were closed in nine cases (81.8%). The function after closed stoma
was permissible. The recurrence rate was 0% at thirty-four months (range, 8–100).
Conclusions: Lap-ISR for very low rectal cancers seems safe and feasible. This
operation can be alternative procedure to avoid the permanent stoma.
P238 – Intestinal, Colorectal and Anal Disorders
COMPARISON BETWEEN FUNCTIONAL END TO END
ANASTOMOSIS AND ISOPERISTALTIC SIDE TO SIDE
ANASTOMOSIS IN SINGLE-INCISION LAPAROSCOPIC
RIGHT COLECTOMY
M.J. Kim
Samsung medical center, SEOUL, Korea
Aims: Recently, single incision laparoscopic surgery (SIL) is actively performed
worldwide as an alternative to conventional laparoscopic surgery. The purpose of
this study was to compare the method of specimen extraction and anastomosis in SIL
right colectomy; tube type extraction with isoperistaltic side-to-side anastomosis
(ISSA) vs. loop type extraction and functional end-to-end anastomosis (FEEA).
Methods: This study enrolled patients who underwent a single port laparoscopic right
colectomy between May 2011 and October 2011 at Samsung Medical Center.
Among 58 patients, 18 patients underwent functional end to end anastomosis after
loop type specimen extraction (FEEA) and 40 patients underwent isoperistaltic side
to side anastomosis after tube type the specimen on of specimen (ISSA).
Results: There were no differences between the two groups regarding sex, age, BMI,
surgical history, diagnosis, or location of the tumor. The operative time for func-
tional end to end anastomosis was 155 ± 40 minutes, and 164 ± 23 minutes for
isoperistaltic side to side anastomosis (p = 0.416). Postoperative hospital stays were
6.8 ± 2.5 days and 7.2 ± 3.9 days for FEEA and ISSA, respectively (p = 0.416),.
Days of first flatus were 2.6 ± 0.8 days and 2.8 ± 1.0 days, respectively (p = 0.532).
The 2 groups didn’t require additional ports and the tumor sizes were not signifi-
cantly different (3.7 ± 2.7 cm and 4.6 ± 2.8 cm, respectively: p = 0.261). The
additional incisions used for anastomoses were less for ISSA (35% and 61.1%,
respectively: p = 0.063), however the final incision lengths not significantly different.
The lengths from tumor to the distal resection margin were not significantly different
(17.7 ± 5.6 cm and 19.1 ± 9.6 cm, respectively: p = 0.554). There were neither
significant major complications nor postoperative mortality.
Conclusions: Both techniques are safe methods of anastomoses after SIL right
colectomy. ISSA may reduce the incidence of extension of initial incision; there
were no discrete advantages over FEEA in this study. Prospective randomized trial is
necessary to prove the benefits of the tube type extraction and isoperistaltic side-to-
side anastomosis.
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P239 – Intestinal, Colorectal and Anal Disorders
A PREDICTIVE RISK SCORE FOR COLORECTAL CANCER
USING A WEIGHTED NUMERICAL SCORE AND MARKER
OF TUMOUR METABALONE
K. Siddique, L.V. Titu, C.J. Walsh, J.A. Anderson, D.J. Smith
Wirral University Hospitals NHS Trust, STOCKPORT,
United Kingdom
Aims: The primary aim of this study was to develop a predictive score for cancer in a
symptomatic cohort of patients referred to secondary care, using a validated scoring tool in
conjunction with a faecal marker of tumour metabalone, M2-pyruvate kinase.
Methods: A prospective cross sectional framework study was undertaken. Symptomatic
patients, primarily referred under the ‘Two Week Wait’ pathway were recruited. All
completed a symptom questionnaire from which a symptom severity score was calculated,
WNS. A full blood profile and stool samples were obtained and tested for M2-PK using a
standard Sandwich ELISA technique. Full colonic assessment was undertaken and corre-
lated to WNS and M2-PK results. Univariate and multivariate analysis were performed and
predictive model generated using the logistic regression technique described by Piantadosi,
to determine high and low risk groups.
Results: Over a period of 14 months from April 2008, 149 patients were recruited, 72 men
and 77 women with a median age of 67 (IQR 57–75) and 62 (IQR 55–76) respectively. 94
patients were referred via the ‘Two Week Rule’ (TWR), with a cancer detection rate of
10.6%. Diverticulosis was the most prevalent diagnosis accounting for 43.7% of all
referrals. WNS and M2-PK (faeces and serum) were able to separate cancer from benign
pathology, p \ 0.001. ROC analysis showed faecal M2-PK to have best performance
characteristics, AUC 0.810. Univariate and multivariate analysis selected out WNS and
faecal M2-PK with high cancer association. Both were used in the model to give an overall
sensitivity and NPV of 90.3% and 95.6% respectively for cancer detection.
Conclusion: The predictive score, maybe a novel way of overcoming problems of symptom
assessment in primary care, enabling; refinement of patient pathways, efficient cancer
diagnosis and robust decision support.
P240 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC HARVEST OF PERINEAL
OMENTOPLASTY WITH ABDOMINOPERINEAL
RESECTION FOR RECTAL CANCER
K. Yamashita, T. Nakamura, Y. Sumi, D. Kuroda
Kobe University, Graduate school of medicine, KOBE CITY, Japan
Preoperative adjuvant chemoradiotherapy was recommended as the standard treatment for
patients with rectal cancer because it not only reduces local recurrence but also improves
sphincter preservation and surgical outcomes. We performed chemoradiotherapy for lower
rectal cancer. Our regimen consisted of pelvic radiation (total 39.6–45 Gy)and oral
UFT(300 mg/m2)and UZEL(75 mg/body)given during the first 28 days of radiotherapy.
Perineal wound complication after chemoradiotherapy(CRT)and abdominoperineal resec-
tion (APR) for lower rectal cancer occur in high rate of patients. To reduce this
complication, we perform the operation to fill the pelvic dead space with the formed
omentum (perineal omentoplasty; Pop). Our clinical data showed the rate of primary wound
healing with or without Pop was 66%, and 9% respectively. The healed rate at six months
was 83%, and 63.6%. These data supported that Pop wound lead to dramatic improvements
in outcomes of perineal wound infection.
In this paper, we report the feasibility and efficacy of the laparoscopic Pop for rectal cancer.
A 64-year-old woman was preoperatively treated with CRT for the low rectal cancer. We
clinically evaluated as partial response after treatment. Therefore, we performed laparo-
scopic APR. After total mesorectal excision, one port (12 mm) on the upper abdomen in
addition to the regular 5 ports was added. Pop was laparoscopically performed. The
omentum was pediculized on the right gastroepiploic artery and ligated along the stomach
wall. After the resection of a specimen in perineal operation and the closure of perineal
wound, the dead space of pelvic wall was filled with the omentum. A mild wound infection
occurred in the patient, and improved soon.
Because the Pop operation may control the delayed healing of perineal wound after CRT
and APR, laparoscopic procedure of it need to provide a less-invasive surgery and improve
QOL of the patients.
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Surg Endosc (2013) 27:S53–S166
P241 – Intestinal, Colorectal and Anal Disorders
EMERGENCY COLONIC STENTING AS BRIDGE TO
LAPAROSCOPIC SURGERY VERSUS STAGED
LAPAROSCOPIC RESECTION IN PATIENTS WITH ACUTE
MALIGNANT COLONIC OBSTRUCTION
Y. Chen, C.H. Su, C.C. Huang, W.C. Fan, C.J. Ma, C.J. Huang,
J.S. Hsieh
Kaohsiung Medical University, KAOHSIUNG, Taiwan
Aims: An endoscopic self-expanding stent has been used as a bridge to surgery for elective
laparoscopic resection. The study was aimed to compare the clinical efficacy between
colonic stenting and stoma creation as the initial treatment of elective laparoscopic surgery
in patients with acute malignant colonic obstruction.
Methods: There were 40 patients with acute colonic obstruction caused by colorectal
cancer. Of them 22 underwent first stage of laparoscopic blowhole colostomy for fecal
diversion and 18 were treated with Stent placement for relief of bowel obstruction. Sub-
sequently all of them underwent laparoscopic resection for colorectal malignancy.
Demographics and clinical data were compared. Short-term outcomes including postop-
erative complication, mortality and hospital stay were assessed.
Results: The mean total length of hospital stay was 20 (16–33 days) and 13 (11–16 days) in
stoma and stenting groups respectively. Hospital stay was significantly shorter in the
stenting patients (p \ 0.05). There were more postoperative complications in the stoma
(27%) than in the stenting (22%) groups, however the difference was not statistically
significant (P [ 0.05).
Conclusions: Our results suggest that colonic stenting can be safely performed with lower
morbidity and mortality rate compared to stoma creation and results in significantly shorter
hospital stay. The results support stenting as the treatment of choice in patients with acute
colonic obstruction. Stoma creation can only be recommended when colonic stenting is not
available.
P242 – Intestinal, Colorectal and Anal Disorders
THE BENEFITS OF LAPAROSCOPIC SURGERY
FOR COLORECTAL CANCER IN OCTOGENARIANS
C.H. Su, C.C. Huang, Y.C. Chen, W.C. Fan, C.J. Ma, C.J. Huang,
J.S. Hsieh
Kaohsiung Medical University Hospital, KAOHSIUNG, Taiwan
Aims: The benefit of minimally invasive surgery has accelerated the application of lapa-
roscopic surgery to replace conventional surgery for colorectal cancers. Laparoscopic
surgery might be favorable for the elderly with colorectal cancers. We aimed to compare
the short-term results of laparoscopic (LC) with open (OC) colectomies for colorectal
malignancy in patients aged 80 or older.
Methods: Between 2006 and 2010, 175 patients aged 80 years and over were included in
this study, in which 90 and 85 underwent OC and LC respectively. Demographics and
clinical data were compared. Short-term outcomes including postoperative complication,
mortality and hospital stay were assessed.
Results: There were no significant differences between the two groups regarding mean age,
comorbidities, and the extent of the resection. The mean operative time was shorter in the
OC (135 vs. 165 min, P\0.05). Hospital stay was shorter in the LC (9.6 vs. 11.5 days, P\
0.05). More postoperative complications were found in the OC (35.6%) than in the LC
(31.8%), however the difference was not statistically significant (P \ 0.05). Mortality rate
between the two groups was not significant different (6.67% vs.5.88%, p [ 0.05).
Conclusions: LC is safe with more favorable short-term outcomes in terms of shorter
hospital stay and less cardiopulmonary morbidity for elderly patients. LC could be rec-
ommended in all elderly patients.
Surg Endosc (2013) 27:S53–S166
P243 – Intestinal, Colorectal and Anal Disorders
THE IMPACT OF PREVIOUS SURGERY ON CLINICAL
OUTCOMES OF LAPAROSCOPIC COLECTOMY
FOR COLORECTAL CANCER
C.C. Huang, C.H. Su, Y.C. Ghen, W.C. Fan, C.J. Ma, C.J. Huang,
J.S. Hsieh
Kaohsiung Medical University, KAOHSIUNG, Taiwan
Aims: With advancement of minimally invasive surgery laparoscopic colectomy has
been widely accepted as the first choice of surgery for colorectal cancer. The fea-
sibility and safety of this procedure in patients with previous abdominal surgery is
not well known. The aim of this study was to evaluate the impact of prior abdominal
surgery on conversions and outcomes of laparoscopic colectomy.
Methods: Between 2002 and 2009, a total of 510 consecutive patients with colorectal
cancer who underwent laparoscopic colectomy were included in this study. They were
analyzed retrospectively for perioperative surgical and long-term clinical outcomes.
Results: Patients with prior abdominal surgery (PS, n = 125) were compared with
control patients (n = 385) for age, ASA classification, operation times, complication
rates, conversion and length of stay. The operation time was significantly longer in
PS patients than that in the controls. More wound infections occurred in the PS
group. However, there was no significant difference in the peri-operative compli-
cations and the overall survival between the two groups.
Conclusions: Laparoscopic colectomy for colorectal cancer is feasible and safe in
patients with previous abdominal surgery, since it is not associated with more
complications and high conversion rate.
P244 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC COLORECTAL SURGERY: OUR INITIAL
EXPERIENCE
M.T. Oruc, H.T. Turgut, M.U. Ugurlu, M. Ozyildiz, Z. Boyacioglu
Kocaeli Derince Teaching and Research Hospital, KOCAELI, Turkey
Introduction: We herein presented our initial experience with laparoscopic colorectal
cancer surgery carried out in our clinic.
Methods: A consecutive series of all patients requiring colorectal surgery for cancer
from January 2009 to December 2011 were included. Patient records were reviewed
from a retrospective database and the relevant clinical data was obtained, with a
subgroup analysis of laparoscopic cancer procedures performed.
Results: 91 patients (52 men, 38 women) underwent resection of the colon or rectal
cancer. Open surgery was performed in 67 patients and laparoscopic colorectal
resection was performed in 24 patients. We made a subgroup analysis for the lap-
aroscopic cancer procedures: Median age was 64 ± 12.7 years (range 30 to 84), the
median Body Mass Index (BMI) was 24.8 (range 19.5 to 33.3). The most common
procedure was laparoscopic low anterior resection (35.1%). The median duration of
surgery was 106 minutes (range 70 to 150). Conversions to open surgery occurred in
12 patients (50 %). The indications for conversion were adjacent organ involvement
by cancer, which exceeded the limits of laparoscopic dissection in 4 of the patients,
technical problems in 1 patient (stapler misfire), not finding cancer localization in 2
patients and bleeding in 3 patients. Postoperative complication occurred in 1 patient
(1 %) as surgical site infection. Anastomotic leak was observed after laparoscopic
colorectal surgery in 1 patient (1%). The median length of hospital stay was 9 days
(range 5 to 40). In the 24 patients with malignant disease, tumors were mostly
located at recto-sigmoid junction (45.8 %), the median number of lymph nodes
harvested was 11 (range 6 to 30), most of the tumors were well-differentiated
adenocarcinoma (58 %) and reported as Dukes B2 (50 %). We observed no loco-
regional recurrence and port site metastasis.
Conclusion: Laparoscopic colorectal resection can be safely performed in malignant
disease. We reported our short series of colorectal resections, and our results show
that it is safe, feasible and produces favorable results.
S113
P245 – Intestinal, Colorectal and Anal Disorders
LEARNING CURVE OF LAPAROSCOPIC RECTAL CANCER
RESECTION AND POSTOPERATIVE COMPLICATIONS
S. Yamaguchi, T. Ishii, J. Tashiro, H. Suwa, H. Kondo, M. Miyazawa
Saitama Medical University International Medical Center, HIDAKA,
Japan
Purpose: Laparoscopic rectal cancer resection is still challenging procedure. Sur-
geons are trying to improve standard technique to perform this procedure. In this
study, we assessed learning curve of rectal cancer resection, also postoperative
complications according to year of operation.
Methods: Two hundred thirty-eight patients underwent curative laparoscopic rectal
cancer resection since 2007 to 2011. Mean age was 65.2 and 162 males and 76
females were included. There were 56 high anterior resection (HAR), 135 low
anterior resection (LAR), 34 intersphincteric resection (ISR), 6 Hartmann’s proce-
dure, and 7 APR. There were 2 conversions because of lateral node metastasis and
severe adhesion. Group A included 49 patients since 2007 and 2008. Group B was
101 patients since 2009 to 2010, and group C was 88 patients in 2011.
Results: From Group A to C, each mean operative time (OT) was 280, 243, 250
minutes (p \ 0.05), and mean blood loss count (BLC) was 40, 39, 28 g (n.s.),
respectively. Regarding LAR (n = 31, 51, 53), each mean OT was 290, 245, 248
minutes (p \ 0.05), and mean BLC was 47, 39, 17 g (n.s.), respectively. Ileostomy
creation with LAR was performed in 22% (7), 37% (19), 74% (39). Regarding Single
surgeon (n = 49, 74, 44), each mean OT was 280, 237, 249 minutes, and mean BLC
was 47, 38, 20 g, respectively. Median postoperative hospital stay was 9, 8, 8 days.
There were no leakage in ISR and one in HAR of all. Regarding LAR leakage rate
was 16.1% (5/31), 11.8% (6/51), 5.7% (3/53). Dysuria was observed in 3.2% (1),
5.9% (3), 0% (0). Postoperative ileus and wound infection were 2.1 in Group A, 4,1
in Group B, and 5, 0 in Group C.
Conclusions: Operative time was shortened from Group A to Group B. Group B and
C was similar OT because stoma creation rate was increased. However leakage rate
after LAR was decreased from Group A to B, and from B to C.
P246 – Intestinal, Colorectal and Anal Disorders
SINGLE PORT LAPAROSCOPIC LEFT HEMICOLECTOMY:
INITIAL SERIE TOWARDS A LESS INVASIVE SURGERY
S. Morales-Conde1, F.J. Padillo2
1
H. U. Virgen del Rocı́o, SEVILLA, Spain; 2University Hospital
Virgen del Rocio, SEVILLA, Spain
Introduction: Several reports in the literature demonstrate the advantage of a lapa-
roscopic approach for malignant and benignant colonic disease, such as less
postoperative pain, less ileus and shorter hospital stay. In order to try to minimize
abdominal wall trauma and promote recovery of the patients, and at the same time to
achieve better cosmetic results, we have started our experience on single port surgery
in left colonic resection.
Methods: We present a series of 21 patients who underwent left hemicolectomy
through a transumbilical single incision without any additional trocar. Patients had a
mean age of 64.47 years old and mean BMI of 23.8%. Our indications include those
patients with BMI less than 28%. A single port device with three orifices was used in
all cases, through an incision with a medium-sized of 2.9 cm. No additional trocars
were used in any of the cases. The anastomosis was performed intracorporeally using
a circular stapler.
Results: Median time of surgery was 121 minutes, with no introperative complica-
tions and with a medium blood loss of 126 cc. Patients had an average hospital stay
of 3.12 days. Postoperative complication include one re-admission to the hospital
due to an abcess which was drained percutaneasly, one surgical wound infection and
two seromas. One patient died in day 5 after surgery due to a vascular stroke and and
another died at 12 hours postoperatively with myocardial infarction (both cases
confirmed at the necropsy). Histological exams of the specimens showed that the
oncological criteria, related to number of lymph node (100% patients more of 12
lymph nodes) and resection margin (7 cms), were preserved.
Conclusions: Single port left hemicolectomy can be performed safely and effectively
without any additional trocar port, showing similar results than conventional open or
laparoscopic surgery, both from the clinical and oncological point of view. Further
serie and prospective randomized trial are necessary to confirm these results.
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S114
P247 – Intestinal, Colorectal and Anal Disorders
REDUCED PORT SURGERY FOR COLORECTAL CANCER
J.I. Tanaka, T. Omoto, Y. Takehara, K. Nakahara, D. Takayanagi,
M. Chiyo, Y. Wada, S. Mukai, E. Hidaka, S. Endo, F. Ishida, S. Kudo
Showa University Northern Yokohama Hospital, YOKOHAMA,
Japan
Aim: Needlescopic surgery (NSS) and single port surgery (SPS) have been applied in
various diseases from the viewpoint of cosmetic outcomes as well as minimal
invasiveness, so we have applied these procedures to colorectal cancer (CRC) as
reduced port surgery (RPS). We report our initial experience of RPS for CRC to
elucidate the technical feasibility of these procedures.
Methods: The size of skin incision on the umbilicus was ranging 2.5 to 3.5 cm, and a
single multi-channel port (SILSTM port), a single access platform (EZTM port) or
three 5 mm trocars directly inserted through the single skin incision were used in
SPS. A puncture or a port with 1.8*3.0 mm was used in NSS. Seventy patients with
CRC (up to T2 N1 M0) were proposed and underwent RPS including 30 cases of
right colectomy, 25 of left colectomy and 15 of rectal resection instead of conven-
tional laparoscope-assisted colorectal resection (LAC). Procedures were medial
approach as well as conventional LAC, by parallel method with straight instruments
or combined method with articulated instruments and energy devices such as
ultrasonic coagulation shears or tissue sealing system. Endoscopic linear stapler or
circular stapler also could be used for resection and reconstruction of bowels. Wound
protectors such as Wound RetractorTM or Lap ProtectorTM were used in order to
prevent port site recurrence during extraction of bowel specimen.
Results: PRS in all patients were carried out successfully except for one case of
conversion to conventional LAC due to serious intra-abdominal adhesion. Operating
time was longer in RPS procedure for 30 to 40 minutes compared to conventional
LAC, however postoperative hospital stay of patients with RPS was not longer than
that of patients with conventional LAC. Most patients were satisfied to better cos-
metic outcomes.
Conclusion: RPS including NSS and SPS for selected colorectal cancer was feasible
with better cosmetic results.
P248 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC SURGERY FOR COLORECTAL
NEOPLASM
A. Maghiar, P.R. Sookha, G. Dejeu, D.H. Ciurtin, M. Sfirlea,
C. Macovei
Spitalul Pelican Oradea, ORADEA, Romania
Aims: Colorectal neoplasm is a common disease. Results after laparoscopic surgery
have proven to be much better regarding patients recovering much faster. We started
laparoscopic colorectal surgery 16 month ago.
Method: From October 2008 till December 2011 we had 104 patients admitted in our
clinic with colon or rectal neoplasms proposed for surgery. Except for 4 cases that
came in emergency with intestinal occlusion, we started all the cases with an
exploratory laparoscopy. In one case the anesthesiologist stopped the surgery during
the exploratory laparoscopy due to severely unstable cardiologic state.
Results: Out of the 104 patients, 26 had a palliative surgery due to an extensive
spread. In 78 cases we were able to perform a radical surgery, out of which 52 cases
were done laparoscopicaly. Out of the 24 cases done by laparotomy, 4 was started by
laparotomy due to intestinal occlusion, 15 cases were converted due to extensive
adhesions, 3 cases were converted due to invasions in adjacent organs, 2 in urinary
bladder and 1 in ileon, and 2 case was converted due to a localized peritonitis.
Conclusions: 75 % of patients admitted in our clinic had a radical surgery. 67 % of
patients who had a radical surgery were successfully operated laparoscopicaly.
Patients who had a mini-invasive surgery recovered much quicker, mean hospital
stay postoperative was 4.4 days compared to 9.6 days in patients operated classically.
We must also take in consideration that cases operated through laparotomy in our
clinic were more advanced cases. We sustain that multi-centric comparisons should
be done comparing cases with similar gravity.
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Surg Endosc (2013) 27:S53–S166
P249 – Intestinal, Colorectal and Anal Disorders
LAPAROSCOPIC RIGHT HEMICOLECTOMY
V. Surlin, D.N. Margaritescu, M.I. Bica, E.I. Georgescu, S. Fronie,
S. Scurtu, S. Bordu
University of Medicine and Pharmacy, CRAIOVA, Romania
Colon cancer is one of the most frequent malignancies in the world. Radical
resections represent the cornerstone of the multimodal treatment. Laparoscopic
surgery offers the advantage of minimal parietal trauma, faster postoperative
recovery, less parietal morbidity and less postoperative immune suppression. Today,
laparoscopic resections of colon malignancies are safe, sure and well codified.
Comparative studies validated this approach of oncologic efficiency compared to
open approach (less tumour mobilisation, vascular approach first, length of speci-
men, number of harvested lymph nodes, oncologic security margins and long-term
survival).
The authors present their first experience with laparoscopic right colon cancer
resection in the case of a 74 years old female patient, with no surgical antecedents,
co-morbidities of multinodular normofunctional goiter, ischemic coronary heart
disease, mild cardiac insufficiency and incarcerated umbilical hernia. The patient
was diagnosed by colonoscopy with ascending colon cancer, biopsy revealing ade-
nocarcinoma moderately differentiated. Blood tests including liver enzymes were
normal; there were no findings of liver or pulmonary metastasis at preoperative
abdominal ultrasound and pulmonary X-ray.
Intraoperative exploration excluded the presence of carcinomatosis and liver
metastasis, the tumor was located just above the cecum, no infiltration of serosa. The
incarcerated umbilical hernia was reduced and the authors performed a laparoscopic
assisted right hemicolectomy starting by medial approach, vessels first. Specimen
was extracted through the hernia defect and a manual ileo-colic anastomosis was
performed and hernia closed by suture. Postoperative course was simple. Length of
hospital stay was 5 days.
Laparoscopic right hemicolectomy is feasible and safe for elderly patients with
cardiac co-morbidities and incarcerated umbilical hernia.
P250 – Intestinal, Colorectal and Anal Disorders
SURGICAL OUTCOMES FOLLOWING BOWEL SURGERY
IN THE VERY ELDERLY PATIENTS
A.M. Siddika, G. Malietzis, N. Ashraf, S. Siddiqi, T.E. Pearson,
N.G.B. Richardson, A.H.M. Ross
Briimfield Hospital, CHELMSFORD, United Kingdom
Aim: The aim of this study was to assess surgical outcome in patients above the age
of 85 who underwent curative surgery for bowel cancer.
Method: This was an observational study that described surgical outcomes, in a
consecutive series of patients diagnosed with bowel cancer above the age of 85
between January 2008 and December 2010 at Broomfield Hospital.
Results: There were 96 patients with bowel cancer over this period of time. Their
median age was 87 years (Range 85–100 years). 47 patients underwent curative
surgery and 49 were palliated. The 30 day mortality for patients undergoing curative
surgery was 12.8% (6 deaths). The median survival for those undergoing curative
surgery was 19.29 months and for those that were palliated was 6.86 months. In
contrast, patients under the age of 85 years undergoing curative surgery had a median
survival of 39.44 months.
Conclusion: Very elderly patients undergoing curative elective surgery for bowel
cancer, have a greater post-operative mortality and lower overall survival than
younger patients. Despite this, survival in this carefully selected cohort of patients is
fair, and confirms that curative bowel surgery in the very elderly can result in
acceptable outcomes.
Surg Endosc (2013) 27:S53–S166 S115

P251 – Intestinal, Colorectal and Anal Disorders P253 – Intestinal, Colorectal and Anal Disorders

FLEXIBLE SIGMOIDOSCOPY FOR THE DIAGNOSIS
OF CANCER IN PATIENTS WITH RECTAL BLEEDING
J.C. Ruston, W. Hakim, D. Baskaran, N. Ashraf, B.E. Lovett,
H.W. Taylor, I.P. Linehan
Basildon Hospital, BASILDON, United Kingdom
Aims: Rectal bleeding, with or without a change in bowel habit, may be associated
with bowel cancer. This is usually left-sided as right-sided cancers typically present
with iron deficiency anaemia, an abdominal mass or with obstructive symptoms. The
aim of this study was to determine whether flexible sigmoidoscopy (FS) may be
sufficient to make a bowel cancer diagnosis in patients presenting with rectal
bleeding.
Methods: This is a retrospective analysis of patients who presented to a rectal bleed
clinic with symptoms of rectal bleeding who were found to have bowel cancer.
Patient characteristics, symptoms experienced, previous bowel cancer history, bowel
cancer family history, and cancer site were recorded.
Results: 306 patients presenting to the clinic were found to have a diagnosis of bowel
cancer. 266 cancers (87%) were either in the rectum or sigmoid colon. 5 cancers that
were in the descending colon were reached at FS. Excluding patients who would
have had to undergo whole colonic imaging (WCI), such as those with a previous
bowel cancer history and/or strong family history of bowel cancer (2), a right-sided
abdominal mass (6), iron deficiency anaemia (4), polyps (3), or those that had
obstructive symptoms (2), 94% of patients would have had their cancer diagnosis
made with FS alone.
Conclusion: FS has a high level of sensitivity for detecting bowel cancer in patients
presenting with rectal bleeding. Despite this 6% of cancers would have been missed
using FS alone. Further strategies must be identified to determine which patients with
a normal FS should undergo WCI.
CRITICAL APPRAISAL OF FIRST 1000 LAPAROSCOPIC
COLORECTAL RESECTIONS AT A BUSY COLORECTAL
UNIT
J.S. Khan, N.N. Siddiqui, O. Shihab, N. Cox, A. Price, K. Flashman,
A.C. Parvaiz, D. Miskovic, D. Dabare
Portsmouth Hospitals NHS Trust, PORTSMOUTH, United Kingdom
Aim: We aimed to analyse the outcomes of 1000 laparoscopic colorectal resections
at a large single institute.
Methods: We looked at all elective laparoscopic colorectal resections carried out at
our institution over five year period (September 2006 to December 2011). These
included both elective and emergency procedures. Data were gathered from a pro-
spective database for colorectal cancer and this included demographics, operative
and post-operative outcome data. Both surgeons contributing in this series were
fellowship trained and experienced in laparoscopic surgery.
Results: 52% of patients were male with a median age of 66 years. Median BMI was
26. The underlying diagnosis was cancer in over 76% of cases. 342 patients had
previous abdominal surgery. Conversion rate in this series as 4%. Median operating
time was 180 minutes. Major anastomotic leak rate was 2.2% and mortality was
0.9%. Median length of stay was five days. There was no statistical difference in
outcomes between 1st and 2nd half of the study (Table 1).
Conclusion: This large series from a single institution sets the standards for lapa-
roscopic colorectal surgery. Shorter hospital stay with low morbidity and mortality
can be extended to the vast majority of colorectal patients. Structured training can
reduce the learning curve and translate into excellent outcomes.
Table 1

Laparoscopic n(%)
P252 – Intestinal, Colorectal and Anal Disorders colorectal resections

LAPAROSCOPIC VERSUS OPEN COLORECTAL CANCER Total 1000

RESECTION: PERI-OPERATIVE AND EARLY Male 526 52.6
ONCOLOGICAL OUTCOMES Age mean (range) 66(18–93)
A.K. Saha, K. Shipton, A. Harikrishnan ASA 1 148 14.8
Doncaster Royal Infirmary, DONCASTER, United Kingdom ASA 2 569 56.9
Aims: To assess the utilisation of laparoscopic resection for colorectal cancer and ASA 3 or 4 244 24.4
compare early oncological outcomes with open resection. ASA unrecorded 37 3.7
Methods: A prospectively-maintained database of colorectal resections at our district
BMI median (range) 26(16–52)
general hospital was interrogated. Primary surgeon, operating time, oncological
outcomes and urgency of surgery were measured. Chi-squared tests were used to Elective 964 96.4
compare groups; student’s t-tests were used to compare continuous data. Emergency 36 3.6
Results: From August 2011 to November 2011, 66 patients had colorectal resection Adenocarcinoma 768 76.8
for cancer (65 adenocarcinoma, 1 carcinoid tumour). Of patients with adenocarci-
noma, 33 patients (50%) had a right-sided tumour, 19 patients had rectal tumour Diverticulitis 64 6.4
(29%) and 14 patients had a left-sided tumour (21%). Crohn’s Disease 61 6.1
The majority of patients had a laparoscopic operation (22 patients with right sided Colitis 42 4.2
tumour (66%), 10 patients with left sided tumour (71%), 14 patients with rectal
tumour (74%). Adenoma 30 3.0
For right sided tumours, there was no significant difference in node yield, operating Other cancer 12 1,2
time or distance from tumour to nearest longitudinal margin between laparoscopic Volvulus 9 0.9
and open procedures, though there was a tendency to longer operating time (204
Endometriosis 7 0.7
minutes vs. 170 minutes, P = 0.337) and greater node yield (20 nodes vs. 17 nodes, P
= 0.175) for laparoscopic procedures. Similar trends were found for left sided and Other 7 0.7
rectal tumours, although none reached statistical significance. Previous abdominal surgery 342 34.2
A registrar was the primary surgeon in 9 patients (14%) and first assistant in 45 cases
Converted to open 41 4.1
(69%). 22 patients had an emergency operation and of these, 7 had a laparoscopic
procedure (32%). Oncological 13 31,7
Conclusions: There was a high volume of colorectal resections of which the majority Difficult operation 11 26.8
were carried out laparoscopically. Even in the emergency setting, a third of patients Adhesions 6 14.6
had a laparoscopic resection. Early oncological outcomes and operating time were
not significantly different for between the laparoscopic or open approach. Registrars Obese 4 9.8
had good exposure to colorectal resections as primary surgeon or first assistant in Technical 3 7.3
over 80% of cases. Bleeding 2 4.9
Other 2 4.9
AR 453 45.3
APE 43 4.3
Hartmanns 20 2

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S116 Surg Endosc (2013) 27:S53–S166

Table 1 continued P254 – Intestinal, Colorectal and Anal Disorders

Laparoscopic n(%)
colorectal resections LAPAROSCOPY-ASSISTED PROXIMAL GASTRECTOMY
FOR GASTRIC CANCER
Sigmoid Colectomy 58 5.8 N. Musha, T. Tanabe, A. Kuwabara, T. Tsubono, Y. Sakai
Left Hemicolectomy 19 1,9 Saiseikai Niigata 2nd Hospital, NIIGATA, Japan
Right Hemicolectomy 290 29 Background: Gastric malignancies confined to the proximal third of the stomach are
Panproctocolectomy 13 1,3 generally treated by total gastrectomy. Proximal gastrectomy (PG) needs appropriate
Ext Right Hemicolectomy 45 4.5 resection margin and reconstruction method with function-preserving. There is lack
of consensus over a size of remnant stomach and the method of reconstruction.
Subtotal Colectomy 19 1,9
Tumors located upper third of the stomach which clinical T1 to T2 tumor without
Proctectomy 15 1,5 regional lymphnode metastases were indicated Proximal Gastrectomy (PG) in our
Other 25 2.5 institution. We introduce our technique for laparoscopy-assisted (LA) PG with
jejunal interposition and short-term outcomes.
Permanent stoma 82 8.2
Operative procedure:
Temporary stoma 282 28.2
Operating time median (range) 180(45–660) 1. Laparoscopic mobilization and transection of the stomach using endoscopic
linear stapler with lymphadenectomy.
Extraction measurement 5(2–14)
cm median (range) 2. Transection of the abdominal esophagus using linear stapler.
3. Sacrifice a 10–15-cm jejunum preserving the jejunal vascular arcade
Post-operative Mortality 9 0.9
intracorporeally.
Reoperation for complication 42 4.2 4. Resected specimen extraction through umbilical incision.
Anastomotic Leak major 22 2.2 5. Movilization of the jejunal segment followed by jejunojejunostomy and
Readmission within 30 days 119 11,9 jejunogastrostomy extracorporeally using umbilical incision.
of surgery 6. Esophagojejunostomy using the overlap technique intracorporeally.
LOS median (range) 5(1–139)
Conclusion: In laparoscopic gastric surgery, removal of a surgical specimen is
Adenocarcinoma 768 ordinarily performed by extended umbilical incision. Not only for specimen
Curative intent 648 84.4 extraction, using the umbilical incision is feasible for hand sewing jejunogastros-
R0 margins 628 96.9 tomy and jejunojejunostomy. Making good use of umbilical incision, totally
laparoscopic procedure is not nessesary for LAPG.
LN harvest median (range) 14(0–55)
Dukes A 171 22.3
Dukes B 318 41,4
Dukes C 275 35.8

T2 A B

Laparoscopic n % n %
Colorectal P438 – Intestinal, Colorectal and Anal Disorders
Resections

Total 416 584 LONG-TERM OUTCOMES OF STAPLED

emergency
BMI median (range)
operating time median
(range)
Converted to open
LOS median (range)
Anastomotic Leak (major)
Reoperation for complication
Post-operative Mortality
12 2.9 24 4.1
HAEMORRHOIDOPEXY
M. Pawlak1, M. Bobowicz2, M. Michalik1, M. Witzling1
26 (16–52) 27 (16–51) 1
Ceynowa Hospital, WEJHEROWO, Poland; 2Medical University
175 (60–430) 190 (45–660)
of Gdansk, GDANSK, Poland
23 5.5 18 3.1 Aim: Haemorrhoidal disease is one of the most common anorectal disorders
worldwide. Stapled Haemorrhoidopexy (SH) is one of the treatment modalities
4 (2–74) 5 (1–139)
associated with lesser postoperative pain and earlier mobilization. The aim of this
8 1,9 14 2.4 study is to assess long-term outcomes of SH.
15 3.6 27 4.6 Methods: All 326 patients who underwent SH in 1999–2003 were initially included.
Despite invitation letters sent to all, only 91 patients attended the final control visit.
4 1,0 5 0.9
Median follow-up was 8.7 years. Medical records, questionnaire survey and digital
rectal examination were performed. Statistical analysis was performed with com-
puter software StatSoft, Inc. (2009), Statistica 9.0.
Results: Recurrences were diagnosed in one third of the subjects. There was a
correlation between recurrences and the duration of the disease (p = 0.047), female
gender (p = 0.037) and delivery (p = 0.026). A total of 67 (73.6%) patients were
satisfied with the outcomes. In the group of dissatisfied patients the symptoms such
as pain (p = 0.0001), burning (p = 0.0002) and itching (p = 0.014) occurred more
frequently.
Long-term outcomes were good with around 75% and 88% reduction of pain sen-
sation and severe and moderate haemorrhoidal bleeding respectively. Pruritus,
burning and discomfort resolved in more than a half of patients. Flatus incontinence,
fecal incontinence, cloths soiling occurred in 21%, 11%, 32% of patients
respectively.
Conclusions: Long term results of stapled haemorrhoidopexy are satisfactory in most
patients. 36 % recurrence rates correlate with the degree of haemorrhoidal prolaps
before the operation, the duration of the disease, female gender, and previous
delivery. Recurrence predictive models for SH and classic haemorroidal operations
are urgently needed.

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Surg Endosc (2013) 27:S53–S166
P256 – Liver and Biliary Tract Surgery
LAPAROSCOPIC REMOVE OF HETEROTOPIC PANCREAS
A. Voynovskiy1, T. Kolyadencova2, V. Tebenihin2
1
The main military clinical hospital, MOSCOW, Russia; 2The main
military clinical hospital of the Ministry Affairs, MOSCOW, Russia
Aims: We describe a case of asymptomatic heterotopic pancreas localized in the area
of the Calot triangle of the hepatoduodenal ligament accidentally found during
laparoscopic cholecystectomy.
Methods: Male 45 years old, was operated in connection with gallstone disease.
When selecting the neck of the gallbladder in the area of the ?alot triangle hetero-
topic pancreas size 2 9 1.5 cm was found, lobed structure with a duct which opens
into the cystic duct. Perfusion of blood of the pancreas was from the cystic artery.
Cystic duct and artery were clipped proximal to the confluence of the cystic duct and
duct of heterotopic pancreas. Laparoscopic cholecystectomy was performed and of
heterotopic pancreas was removed.
Results: The postoperative period was uneventful. Histological examination con-
firmed the presence of excretory and incretory tissue of the pancreas with a duct
which opened into the cystic duct. Conclusion(s): This report demonstrates a rare
case of heterotopic pancreas of the ?alot triangle of the hepatoduodenal ligament
accidentally a functioning excretory and incretory tissue with pancreatic duct opens
into the bile ducts.
P257 – Liver and Biliary Tract Surgery
LAPAROSCOPIC MULTIPLE HEPATECTOMIES –
A PRELIMINARY EXPERIENCE
T. Igami, T. Ebata, Y. Yokoyama, G. Sugawara, Y. Takahashi,
M. Fukaya, K. Uehara, K. Itatsu, Y. Yoshioka, M. Nagino
Nagoya University Graduate School of Medicine, NAGOYA, Japan
Aims: For the patients who required multiple hepatectomies to obtain complete
resection, technique of laparoscopic hepatectomy, including pure laparoscopic
hepatectomy, hand-assisted laparoscopic hepatectomy, and laparoscopy-assisted
hepatectomy, was potentially difficult. The aim of the present study was to introduce
our technique of laparoscopic multiple hepatectomies and to evaluate our initial
experience.
Methods: Initially, mobilization of the liver was performed under laparoscopic
guidance with a 12-mmHg peumoperitoneum by carbon dioxide. Partial hepatec-
tomy for the tumor in the left lobe was performed under laparoscopic guidance.
Through the 10-cm incision at the right subcostal region, partial hepatectomy for the
tumor in the right lobe was performed under direct visual and/or laparoscopic
guidance. As mentioned above, our technique of laparoscopic multiple hepatecto-
mies was combination between pure laparoscopic hepatectomy and laparoscopy-
assisted hepatectomy.
Results: Seven patients underwent partial hepatectomies of both the left and right
lobes according to the presented procedure. Of them, 4 had undergone upper
abdominal surgery previously, and 1 underwent both right hemi-colectomy for colon
cancer and total gastrectomy for gastric cancer synchronously. All procedures were
completed successfully. Mean operative time, mean blood loss, and mean hospital
stay were 345 min, 720 ml, and 10 days after surgery, respectively.
Conclusions: The presented technique of laparoscopic multiple hepatectomies may
be safe and easy procedure. Further investigations are required in large prospective
series to evaluate the value of laparoscopic multiple hepatectomies, including our
procedure, for patients who have multiple hepatic tumors.
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P258 – Liver and Biliary Tract Surgery
LAPAROSCOPY-ASSISTED HEPATECTOMY USING THE
GLOVE METHOD AFTER UPPER ABDOMINAL SURGERY –
A PRELIMINARY EXPERIENCE
T. Igami, T. Ebata, Y. Yokoyama, G. Sugawara, Y. Takahashi,
M. Fukaya, K. Uehara, K. Itatsu, Y. Yoshioka, M. Nagino
Nagoya University Graduate School of Medicine, NAGOYA, Japan
Aims: For the patients who had undergone upper abdominal surgery previously,
technique of laparoscopic hepatectomy, including pure laparoscopic hepatectomy,
hand-assisted laparoscopic hepatectomy, and laparoscopy-assisted hepatectomy, was
potentially difficult. The aim of the present study was to introduce our technique of
laparoscopy-assisted hepatectomy using the glove method after upper abdominal
surgery and to evaluate our initial experience.
Methods: Initially, a single 10-cm long incision was made at the right subcostal
region. Through the 10-cm incision, adhesion due to previous upper abdominal
surgery was released under direct visual and/or laparoscopic guidance. After syn-
echiotomy, wound retractor was installed at the 10-cm incision and a non-powder
surgical glove (8 inches) was put on the wound retractor air-tightly. Three 12-mm
ports were inserted via the finger tip with a 12-mmHg peumoperitoneum by carbon
dioxide. For the left sided laparoscopy-assisted hepatectomy, a 5-mm port was
inserted in the left side of the umbilicus across the anterior axillary line. For the right
sided laparoscopy-assisted hepatectomy, a 5-mm port was inserted on the opposite
side. Under laparoscopic guidance, mobilization of the liver was performed. Through
the 10-cm incision, dissection of the liver parenchyma was performed under direct
visual and/or laparoscopic guidance.
Results: Seven patients underwent the presented procedure. Of them, 6 had metas-
tases of colorectal carcinoma and 1 had hepatocellular carcinoma, respectively.
Previously, open hepatectomy had been performed in 2 patients. Of the study
patients, 3 underwent 1 minor hepatectomy and 4 underwent 2 or more minor
hepatectomies. All procedures were completed successfully. Mean operative time,
mean blood loss, and mean hospital stay were 228 min, 265 ml, and 8 days after
surgery, respectively.
Conclusions: Laparoscopy-assisted hepatectomy using the glove method may be safe
and easy procedure even after open hepatectomy. Further investigations are required in
large prospective series to evaluate the value of laparoscopic hepatectomy, including
our procedure, for patients who had undergone upper abdominal surgery previously.
P259 – Liver and Biliary Tract Surgery
LAPAROSCOPIC CHOLECYSTECTOMY AND INCIDENTAL
GALLBLADDER CARCINOMA
M. Furukawa1, S. Izumi2, R. Ohashi2, K. Shiota2
1
Okayama University Hospital, OKAYAMA, Japan; 2Kagawa
Prefectural Hospital, TAKAMATSU, Japan
With the increasingly widespread acceptance of laparoscopic cholecystectomy (LC),
the number of cases of incidental gallbladder carcinoma (GBC) has increased;
however, management of incidental GBC is a difficult issue in the absence of
established guidelines.
The present study aims to evaluate the treatment of patients with incidental GBC
diagnosed with LC. We performed an 8-year review of 7 patients with GBC dis-
covered with LC. From January 2001 through December 2008, we performed LC for
734 patients at Kagawa Prefectural Central Hospital.
Of these patients, 7 (0.95%) were found to have GBC. Five patients were women and
2 were men, with a mean age of 75 years. Preoperative diagnosis was gallbladder
stone disease in 5 cases and acute cholecystitis in 2 cases. 2 patients had mucosal
tumors (pT1), 5 had subserosal tumors (pT2). Three of the 7 patients underwent
radical surgery. Two patients with pT1 tumors underwent no additional surgery. All
2 patients with pT1 tumors are alive without recurrence. Three patients with pT2
tumors underwent additional resection. Four of 5 patients with pT2 had recurrence
and 3 patients died. It is difficult to diagnose preoperatively GBC of flat infiltrating
type, accompanied by a large number of gallstones and acute cholecystitis. For stage
Tis or T1a tumors, LC is sufficient. Patients with T1b tumors should undergo liver-
bed resection and lymphadenectomy, and patients with[pT2 tumors should undergo
systematic liver resection with lymphadenectomy.
Even when incidental GBC diagnosed with LC is advanced, adequate additional
surgery may improve the prognosis. Bearing in mind the possibility of incidental
GBC, intraoperative pathology should be considered for gallbladder wall thickening
cases and elderly cases.
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S118
P260 – Liver and Biliary Tract Surgery
EFFECTIVE TECHNIQUES FOR LAPAROSCOPIC HEPATIC
RESECTION: A FIVE-YEAR EXPERIENCE IN A SINGLE
CENTER.
Y. Nakamoto, M. Ogata, M. Ritsuko, R. Mikami, K. Yoshiyuki,
I. Hirokuni, Y. MItsuo
Kobe City Medical Center West Hospital, KOBE, Japan
Background: Effective surgical techniques and equipment to dissect the liver in
laparoscopic hepatic resection (LHR) are required. The aim of the study is to review
our experiences of LHR and to present what techniques and equipment were the
most effective and safest.
Methods: We reviewed the clinical profiles of 37 patients who underwent LHR
between December 2006 and September 2011, and evaluated what techniques and
equipment were the most effective and safest for dissecting the liver.
Results: Out of the 37 patients, 25 had hepatocellular carcinomas with liver cirrhosis.
Twenty-one patients underwent partial resection of the hepatic segment, and four
patients underwent lateral segmentectomy. Hand-assisted laparoscopic surgery
(HALS) was performed in seven patients and laparoscopic assisted hepatic resection
(LAHR) was performed in six. LHR was accompanied by radiofrequency ablation in
four patients, cholecystectomy in three, and partial gastrectomy in one patient. The
mean operation time was 199 min. The mean blood loss was 147 ml. The mean
postoperative hospital stay was 5.9 days, except for one patient. On the other hand,
of the 12 patients with no cirrhosis nine of them had a partial resection of the hepatic
segment. Two patients underwent lateral segmentectomy, and one underwent right
hepatectomy. LHR was accompanied by abdominoperineal resection in one patient,
sigmoidectomy in one. The mean operation time was 176 min. The mean blood loss
was 49 ml. The mean postoperative hospital stay was 8.5 days.
In our experience, both HALS and LAHR could be effective options for liver dis-
section in the posterior segment or S8. Regarding techniques and equipment,
crushing with BiClamp forceps followed by the use of a vessel sealing system was
effective in dissecting a cirrhotic, hard liver. The BiClamp forceps were also
effective for the hemostasis of hepatic veins. In dissecting a normal liver, the CUSA
was used prior to the vessel sealing system for cutting vessels and bile ducts. An
endolinear stapler was another option for dissecting a liver parenchyma quickly.
Conclusions: The most effective surgical techniques and equipment for LHR vary
according to the location of tumors or the degree of liver cirrhosis.
P261 – Liver and Biliary Tract Surgery
LAPAROSCOPIC SURGERY FOR LIVER CYSTIC LESIONS
Y.G. Starkov, K.V. Shishin, S.V. Dzhantukhanova, I.Y. Nedoluzhko
Institute of Surgery n.a. A.V.Vishnevsky, MOSCOW, Russia
From February 1992 till December 2011, 143 patients underwent laparoscopic surgery for
liver cystic lesions. There were 129 females and 12 males with the mean age of 63 (32–78 y.)
Most of the patients (129) were with the simple liver cysts, 14 of them with polycystic liver
disease. Complicated cysts were diagnosed in 3 patients: 6 of them had cyst infection and 3
– intracystic bleeding.
Cyst fenestration with wide excision of its walls was performed for subcapsular and
superficial intraparenchymal cyst. Atypical liver resection with wide excision of cystic
walls with doubtful blood supply was performed in the case of large superficial intrapa-
renchymal cysts, occupying one or more segments. We also used SILS-technique and
minilaparoscopy in 6 cases.
The long-lasting post-op liquid leakage within 5–7 days was marked in the 11 patients. The
bile leakage have occurred in one case after atypical liver resection of large and resolved
spontaneously within 1 month. Median post-op stay was 9 days. Liquid contents in a
residual cavity were observed in 10 patients and were successfully treated by puncture
under ultrasound.
Long-term results from 1 to 15 years were observed in 87. Asymptomatic residual cysts
were observed in two cases, re-operation was not performed. 7 patients underwent lapa-
roscopic surgery for solitary liver cystadenoma. Intraoperative histological examination
revealed no signs of tumor growth. The recurrence was observed in 2 patients with the
follow-up period up to 7 years. The latter underwent repeated surgery (liver resection). 7
patients with liver hydatidosis were treated laparoscopically. The indications for surgery
were solitary superficial cysts with the size ranged from 3 to 10 cm, the thin fibrous capsule
and lack of daughter parasite bubbles or dead parasite. Liver resection was performed in
two cases, hydatidectomy with pre-puncture and treatment of cystic cavity with a solution
of glycerol was performed in 5 cases. The latter was sutured laparoscopically. All patients
were treated with albendazole postoperatively. No recurrence was observed with a mean
follow-up of 6 years.
Laparoscopic surgery for liver cyst lesions is feasible and accompanied by good results with
low rate postoperative complications and recurrences.
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Surg Endosc (2013) 27:S53–S166
P262 – Liver and Biliary Tract Surgery
OPEN CHOLECYSTECTOMY IN THE ERA OF ADVANCED
LAPAROSCOPIC SURGERY
J.A. Paraskevopoulos, O. Kostopoulos, Ch. Papazacharias, D. Allios,
M. Dimitrief, A. Pilavas
KAT General Hospital, KIFISIA, Greece
Aims: Laparoscopic cholecystectomy (LC) is nowadays the gold standard for the
treatment of symptomatic gallstone disease. This study aims to examine the current
indications for open cholecystectomy (OC).
Methods: The records of 2,462 consecutive patients (1,501 females, 961 males) with
a mean age of 49.5(range 26–98) years who underwent elective or emergency
cholecystectomy for benign gallbladder disease from January 2006 to December
2011 were analysed retrospectively
Results: 2,413 (98%) patients underwent LC, 49 (2%) primary OC and 14 (0.6%) of
the LC group were converted to OC. The reasons for conversion were: acute
inflammation of the gallbladder (n = 3), dense adhesions from previous abdominal
operations (n = 2), difficult anatomy recognition (n = 6) and haemorrhage (n = 3).
Primary OC was employed for Intensive Care Unit (ICU) patients with acute cho-
lecystitis (n = 27) and with severe concomitant medical diseases (n = 22) such as
coronary artery disease and chronic obstructive pulmonary disease, respectively.
Two patients of the ICU group (4%) died due to multiorgan failure. There were not
any significant postoperative complications.
Conclusions: Primary OC remains a safe, alternative surgical procedure for the
treatment of symptomatic gallbladder disease with certain absolute indications such
as complicated and severely ill (ICU) patients. On the other hand, conversion to OC
should not be regarded as a complication but as the optimal surgical intervention
when local difficulties or uncertainties make LC extremely dangerous.
P263 – Liver and Biliary Tract Surgery
LAPAROSCOPIC CHOLECYSTECTOMY AS A DAY CASE
OPERATION
J.A. Paraskevopoulos, O. Kostopoulos, Ch. Papazacharias, A. Pilavas,
M. Dimitrief, D. Allios
KAT General Hospital, KIFISIA, Greece
Aims: Day case laparoscopic cholecystectomy (LC) has been shown to have low
overnight readmission rates as low as 20%. We aimed to see if we could achieve
acceptable readmission rates without any adverse morbidity.
Methods: Patients requiring elective LC who were considered medically fit (ASA
I/II) for day case surgery were included. All patients were counselled preoperatively.
They were discharged with detailed instructions regarding antiemetics and opiate
analgesia. Follow-up was carried out by phone at day 1 and 7 postoperatively.
Results: A total of 32 patients (23 females, 9 males) with symptomatic gallstone
disease (mean age 42 years, range 23–69) underwent day case LC from August 2009
to July 2011. There were no intra- or postoperative complications. All patients were
discharged the same day, whereas 4 (12.5%) required readmission and overnight stay
due to persistent nausea. No problems were reported on follow-up.
Conclusions: In our study, 28 (87.5%) patients underwent successfully day case LC
without the need for overnight readmission or stay. Day case LC is a safe procedure
with a high satisfaction rate among patients.
Surg Endosc (2013) 27:S53–S166
P264 – Liver and Biliary Tract Surgery
SUCCESSFUL LAPAROSCOPIC COMMON BILE DUCT
EXPLORATION
M.E. Franklin
Texas Endosurgery Institute, SAN ANTONIO, United States
of America
The routine use of intraoperative cholangiogram (IOC) performed by some surgeons at the
time of laparoscopic cholecystectomy, also leads to identification of patients with totally
unsuspected choledocholithiasis.
Sequential Technique:
– Intraoperative cholangiogram: Road map of the biliary system, ID of biliary stones
– Anterior dissection of common bile duct: Stay sutures, traction on cystic duct
– Choledochotomy
– Flushing the duct: This maneuver will frequently suffice to clear stones
– Choledochoscopy: Direct visualization of the biliary system and stones, stone retrieval
with basket, trans-scope cholangiogram
– Placement of T-tube: T-tube tailoring, pre-tied sutures, suture technique
– T-tube cholangiogram
– Completion of cholecystectomy
– Extraction of specimen and stones
– Drain placement
Conclusions:
– Laparoscopic CBDE is a safe technique that allows the surgeon a successful
exploration of the common bile duct and clearance of stones.
– Systematic, stepwise technique is advised.
– Two-handed laparoscopic suturing techniques are essential
P265 – Liver and Biliary Tract Surgery
A CASE OF BILIALY PERITONITIS CAUSED BY THE
DISLOCATION OF CLIPS OF THE CYSTIC DUCT STUMP
JUST 5 DAYS AFTER SINGLE PORT LAPAROSCOPIC
CHOLECYSTECTOMY
M. Naito
Okayama Medical Center, OKAYAMA, Japan
We report a rare case of Bilialy peritonitis caused by the dislocation of clips of the
cystic duct stump just 5 days after Single Port Laparoscopic Cholecystectomy.
Case: 27 years old man was admitted our hospital with diagnosis of acute chole-
cystitis September 12th 2011. We performed Single Port Laparoscopic
Cholecystectomy using E-Z AccessTM port September 13th. Cystic duct and cystic
artery were clipped doubly using 5 mm ENDO CLIPTM III with Clip LogicTM
Technology (Covidien). Operation was performed laparoscopically with no trouble
and he was discharged from hospital September 17th. Early September 18th morning
he re-admitted our hospital with severe epigastralgia. CT findings showed ascites
around the liver.He was diagnosed with peritonitis and emergency operation was
performed.Under laparoscopy we could see clips dropped out from the cystic duct
stump. Cystic duct stump was clipped doubly again using Ligaclip ML(J&J). After
washing the peritoneal cavity with saline,operation was completed laparoscopically
without touble.
Delayed Clip dislocation from the cystic duct stump is a rare complication of lap-
aroscopic cholecystectomy.We can not find the case report of clip dislocation from
the cystic duct stump using 5 mm ENDO CLIPTM III.
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P266 – Liver and Biliary Tract Surgery
SINGLE-INCISION VS STANDARD LAPAROSCOPIC
CHOLECYSTECTOMY. COMPARISON OF SURGICAL
OUTCOMES FROM A SINGLE INSTITUTION
O. Vidal, M. Valentini, C. Ginesta, J.J. Espert, A. Martinez,
G. Benarroch, M.T. Anglada, J.C. Garcia-Valdecasas
Hospital Clinic Barcelona, BARCELONA, Spain
Background: Laparoscopic cholecystectomy via the three trocar technique is widely
used for symptomatic gallbladder stones. Single incision Laparoscopic surgery
(SILS) for cholecystectomy is a well-established procedure and represents the next
step in developing the concept of ‘mini-invasive surgery’. We here described our 24
month experience SILS cholecystectomy.
Methods: Between February 2009 and 2011, patients referred for cholecystectomy to
the General and Endocrine Unit of our institution who agreed to undergo SILS were
included in a prospective study. All operations were performed by the same surgical
team specially trained in this type of surgery. The umbilicus was the sole point of
entry for all patients. The same operative technique was used in all patients. Data of
patients undergoing SILS cholecystectomy were compared with those from an
uncontrolled group of patients undergoing standard laparoscopic cholecystectomy
during the same study period.
Results: The SILS and standard cholecystectomy groups included 120 patients each.
SILS was successfully performed in all patients and none of them required con-
version to an open procedure. The median operating time of 45 min in the SILS
group was not significantly different than that in the standard laparoscopic chole-
cystectomy group. We suture fascial edge with simple stitches under direct vision,
thus reducing the risk of incisional hernia in SILS group (p = 0.046).
Conclusions: SILS cholecystectomy was technically feasible, safe and represents a
reproducible alternative to standard laparoscopic cholecystectomy in selected
patients. The definitive clinical, esthetic and functional advantages of this technique
require further analysis.
P267 – Liver and Biliary Tract Surgery
SILS CHOLECYSTECTOMY THROUGH TRANSUMBILICAL
APPROACH IN THE TREATMENT OF PATIENTS WITH
GALLSTONE DISEASE AND ACUTE CHOLECYSTITIS
A.P. Ukhanov, A. Ignatjev, G.B. Khachatrjan
Central municipal clinical hospital, VELIKIY NOVGOROD, Russia
Aim: To evaluate the results of transumbilical SILS cholecystectomy in the treat-
ment of patients with gallstone disease and acute cholecystitis.
Materials and methods: SILS cholecystectomy through the umbilical access with the
use of Covidien port was carried out in the treatment of 153 patients. Standard
laparoscopic instruments and 10 mm clipator with a medium-large clips were used
for gallbladder dissection.
There were 132 women and 21 men. Age of patients ranged from 22 to 86 years. All
patients were admitted on an emergency basis with a diagnosis of acute cholecystitis.
During the operation in 67 patients (43.8%) was revealed catarral cholecystitis, in 57
(37.3%) – phlegmonous cholecystitis or empyema of the gallbladder and in 29
(19.0%) patients there was gangrenous cholecystitis.
Results: Operation by only transumbilical access were performed in 110 patients
(71,9 %). The introduction of an additional trocar required in 10 patients (6.5%), two
additional trocars in 22 patients (14.4 %). Conversion to standard laparoscopic
cholecystectomy with 4 port technique was needed in 11 patients (7.2%) and in one
case there was the transition to laparotomy.
Additional trocars were introduced in the patients with destructive cholecystitis in
the case of appropriate drainage of subhepatic space, difficulties in manipulating the
triangle Kahlo, severe inflammatory and infiltrative changes in hepatoduodenal
ligaments, as well as in obese patients when the length of the standard laparoscopic
instruments was not sufficient for the manipulation through transumbilical access.
Mean duration of surgery was 58.0 min. In patients with catarral cholecystitis the
mean time of operation was 54.1 min, with phlegmonous cholecystitis – 60.0 min
and with gangrenous cholecystitis – 69.1 min. There were no intraoperative mor-
bidity. Postoperative morbidity was 4.6 % (7 patients).
Conclusion: Thus, SILS cholecystectomy through transumbilical approach is a
promising minimally invasive method of removing the gallbladder for gallbladder
disease and acute cholecystitis. It is preferable method for the patients previously
operated on the abdominal cavity and having a ventral or umbilical hernia.
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S120
P268 – Liver and Biliary Tract Surgery
LAPAROSCOPIC COMMON BILE DUCT EXPLORATION –
A SAFE AND EFFECTIVE OPTION FOR THE
MANAGEMENT OF CHOLEDOCHOLITHIASIS
IN A DISTRICT GENERAL HOSPITAL
A.C. Wells, B. Warne, A. Harris
Hinchingbrooke Hospital, CAMBRIDGE, United Kingdom
Aims: Management of Common Bile Duct (CBD) stones has evolved rapidly in
recent years, but practices vary depending on local skills and resources. Endoscopic
Retrograde Cholangiopancreatography (ERCP) has a reported stone clearance of
80%. Laparoscopic Common Bile Duct Exploration (LCBDE) provides an alterna-
tive treatment when ERCP has failed or is unavailable, and previous published series
have centred on teaching hospitals. This study reports our experience of LCBDE for
the treatment of CBD stones in a district general hospital.
Methods: 41 consecutive LCBDE performed between April 2006 and September
2011 were reviewed retrospectively. The electronic and clinical notes were inspected
and patient demographics, symptoms, investigation, treatment and outcome
recorded.
Results: The median age at time of surgery was 64 years. 24 patients underwent an
emergency LCBDE. 25 patients had previous failed stone clearance with ERCP. The
clearance of CBD stones from LCBDE was 100%. There were no conversions to
open surgery. The median operating time was 225 minutes (range 133–407) and
hospital stay 4 days (range 1–16). 4 patients suffered a bile leak, notably all in the
first year of the study (4/13) – since then CBD closure technique was altered and no
further leaks have occurred (0/28). 3 patients required re-operation: 2 for repair of
bile leak and 1 for washout of collection. One bile leak was successfully managed
conservatively. The 30-day mortality was 0.
Conclusions: With appropriate expertise and equipment, LCBDE in a district general
hospital is a safe and effective minimally-invasive treatment for CBD stones. Indi-
cations include unexpected finding at operative cholangiography and failed or
incomplete stone clearance at ERCP. LCBDE is therefore a useful tool in the
management of CBD stones and ideally suited to a gastrointestinal unit where cases
can be discussed between surgeons and gastroenterologists.
P269 – Liver and Biliary Tract Surgery
LAPAROSCOPIC SUBTOTAL CHOLECYSTECTOMY (LSC)
USING THE ENDO GIA STAPLER FOR DIFFICULT
CHOLECYSTECTOMY
S.A. Rateb, M.A. El Sayed
Hadi Hospital, JABRYAH-KUWAIT, Kuwait
Objective: To evaluate the use of Endo GIA Stapler (Ethicon Endosurgery) in per-
forming lap subtotal cholecystectomy in difficult cases where safe dissection of the
triangle of Calot can not be accomplished.
Methods: Between 1995 and 2011, 1250 cholecystectomies were performed at Hadi
Clinic, Kuwait. From 2004 onwards, the Endo GIA Stapler (Ethicon Endosurgery)
was used to perform Laparoscopic Subtotal Cholecystectomy (LSC) in cases where
safe completion of laparoscopic cholecystectomy could not be achieved due to
difficult triangle dissection. The gall bladder (GB) was transected at the level of the
neck/Hartman’s pouch after milking any stone into distal GB.
All procedures were completed by suction drainage. Outcome as regards morbidity
and late complications for a median follow up of 30 month were recorded.
Results: Seven hundred and fifteen laparoscopic cholecystectomies were performed
from 1995 till 2004. The conversion rate was 2%. From 2004, LSC was performed in
difficult cases with a consequent conversion rate of 0%. A total of 15 patients under
went LSC using Endo GIA Stapler.12 Patients had severe acute cholecystitis with
totally obscured anatomy at triangle of Calot, 2 patients had Mirrizi’s syndrome
while one patient had a sessile gall bladder. The mean Operative time was 120 ± 20
minutes. The mean hospital stay was 2 ± 0.5 days. There were no bile duct injuries.
No patients developed gall stones in residual stump on follow up for 30 months.
Pathological examination of removed gall bladder revealed inflammatory changes,
no malignancy in any case.
Conclusion: LSC using Endo GIA Stapler to divide GB at neck region is a safe
effective procedure in difficult cholecystectomies. We have used it in severe acute
cholecystitis and Mirrizi’s syndrome. There were no bile duct injuries and conver-
sion to open cholecystectomy was avoided. It is now the procedure of choice in
difficult laparoscopic cholecystectomy cases.
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P270 – Liver and Biliary Tract Surgery
MINIMALLY INVASIVE TREATMENT OF LIVER
ABSCESSES.
A.M. Tischenko1, O.V. Maloshtan1, R.M. Smachylo2, D.I. Skoryi1,
N.M. Britskaya1, A.O. Maloshtan1, S.V. Sushkov1
1
Institute of General and Urgent Surgery, KHARKIV, Ukraine;
2
Kharkiv National Medical University, KHARKIV, Ukraine
Tactics in the treatment of liver abscesses includes several methods from abscess
puncture till liver resection.
Aim: To study the possibility and feasibility of laparoscopic liver abscess treatment.
Results: The experience of treatment of 102 patients with single liver abscesses was
studied. The etiological causes were: cholangitis (26), liver trauma (16), blood-borne
infection (7), infected hydatid cysts and simple liver cysts (31), cryptogenic (24).
The size of abscesses varied from 150 ml to 3 L. Right lobe of liver was affected 2–3
times more.
The percutaneous drainage under US-guidance and laparoscopic drainage were
applied in 45 and 30 patients respectively. In 5 cases laparoscopic fenestration of
abscess was applied, in 4 – laparoscopic pericystectomy (in cases of infected hydatid
cysts).
Open operations were applied in 30 cases: fenestration (10), pericystectomy (8) and
classic resection of liver with chronic abscess (12). In total in 102 patients underwent
116 operations with 5% mortality. In 6 cases laparoscopic drainage or fenestration
were applied after ineffective abscess drainage under US-guidance. The advantages
of laparoscopic technologies, such as visual control of pus leakage into abdominal
cavity during drainage, possible elimination of purulent cavity (fenestration) or
radical eradication of pus-producing infection by miniinvasive method (pericystec-
tomy), were observed. Patients who underwent laparoscopic pericystectomy or
abscess fenestration had more shorter postoperative stay, than the patients with
percutaneous drainage, and didn’t have any complications associated with the
‘residual cavity’ (biliary fistula, abscess relapse, biloma) in postoperative period.
Conclusion: Laparoscopic technology of the liver abscess treatment is characterized
by high efficiency and little percentage of complications.
P271 – Liver and Biliary Tract Surgery
SINGLE INCISION LAPROSCOPIC CHOLECYSTECTOMY
IN A PATIENT WITH SITUS INVERSUS TOTALIS
T. Watanabe
Yokohama Sakae Kyousai Hospital, YOKOHAMA, Japan
Aims: Situs inversus totalis (SIT) is very rare congenital abnormality with an
autosomal recessive genetic predisposition. It describes an anatomy that is perfect
mirror image of the normal physiologic position of the visceral organs. There have
been about 40 reports of conventional laparoscopic cholecystectomy in patients with
SIT. Because of this anatomical problem, these operation was performed by left-
right reversal of conventional laparoscopic port positions. However, so far especially
if the right-handed surgeon, the operation would be difficult, we decided to adopt
Single incision laparoscopic surgery (SILS) procedure. In addition, to perform these
procedures easily, we use our original technique that the operator uses only an
electric device with his both hands which leads to a decrease of shakes of this devise
and enable the operator to concentrate only dissection.
Case: A 67 years old women who was known to have SIT, presented with epigastric
and left upper quadrant pain. Ultorasonogaphy identified multiple gall stones and the
presence of the liver and gallbladder in the left hypochondrium. CT and MRCP
examinations revealed SIT without abnormal arrangement of the vascular and the
biliary system. A 20-mm incision was made in the umbilicus. A SILS Port (Covi-
dien, USA) was placed through an open approach, and the abdominal cavity was
explored with a 5-mm semi-flexible laparoscope. Two 5-mm ports were inserted
through the SILS port. A 2-mm mini retractor was inserted to retract the fundus of
the gallbladder. The cystic duct was dissected entirely and ligated in the left side of
common bile duct. Dissection was performed as a normal retrograde cholecystec-
tomy using an electric device with the both hands of the operator. A camera assistant
had the laparoscope and the grasper in his hands instead of the operator. She dis-
charged on the 3th postoperative day. Postoperative follow-up did not reveal any
umbilical wound complication. Conclusions. Compared with conventional laparo-
scopic cholecystectomy, SILS with both hands method in the case of SIT could
improve safety and reduce the difficulty of the surgery.
Surg Endosc (2013) 27:S53–S166
P272 – Liver and Biliary Tract Surgery
LAPAROSCOPIC SUBTOTAL CHOLECYSTECTOMY
FOR SEVERE CHOLECYSTITIS
Y. Shingu, H. Hasegawa, E. Sakamoto, S. Komatsu, Y. Kurumiya,
S. Norimizu, Y. Taguchi, T. Hirose, T. Yamaguchi, A. Arimoto,
T. Isaji, M. Watanabe, Y. Miura
Nagoya daini red cross hospital, NAGOYA, Japan
Aims: Laparoscopic approach for severe cholecystitis is associated with serious
complications, such as bile duct injury, and a high conversion rate. Recent studies
have shown that laparoscopic subtotal cholecystectomy (LSC) could be performed
safely in the patients with complicated conditions, suggesting this technique being a
potential alternative to conversion to open surgery. However, no consensus is found
among surgeons on how to manage such difficult cases. We assessed the safety and
feasibility of LSC for severe cholecystitis.
Methods: The techniques of LSC, without an attempt to dissect Calot’s triangle,
consist of transection at the gallbladder neck and removal of stones, followed by
closure of the remnant gallbladder stump. In a consecutive series of 1633 laparo-
scopic cholecystectomies from January 2004 to November 2011, 91 patients (5.5%)
with complicated severe cholecystitis or fibrosis underwent LSC, because dissection
of Calot’s triangle would be dangerous. Their clinical records in our prospectively
maintained database were analyzed.
Results: The median age of 91 patients (36 females and 55 males) was 68 years
(range, 31–81 years). There were 8 patients (8.8%) of extrahepatic anatomic variants
of the biliary tree. No patients required conversion to laparotomy. The median
operating time and blood loss were 119 minutes and 10 ml, respectively. The gall-
bladder neck was closed by endoscopic linear stapler in 58 patients and by
laparoscopic suturing in 33 patients. Simultaneous laparoscopic removal of common
bile duct stones was performed in 14 patients. The median postoperative hospital-
ization was 4 days. Postoperative complications were observed in 9 patients (9.9%).
We found a patient of delayed bile leakage from the gallbladder stump and another
of choledocholithiasis due to residual gall stones. In one patient, we found incidental
gallbladder cancer. There was no bile duct injury or mortality in this series.
Conclusion: LSC for severe cholecystitis appears to be safe and feasible, avoiding
serious complications in cholecystectomy. This procedure could be the treatment of
choice for the cases having difficulty in dissecting Calot’s triangle, conventionally
required conversion to open surgery.
P273 – Liver and Biliary Tract Surgery
SINGEL INCISION LAPAROSCOPIC CHOLECYSTECTOMY
USING TWO CURVED INSTRUMENTS: TO REDUCE
INTERFERENCE OF INSTRUMENTS
H. Kitamura, M. Kurokawa, Y. Ishiyama, M. Yamamoto, M. Kotake,
N. Inaki, H. Bando
Isikawa prefectural hospital, ISIKAWA, Japan
Aim: Single incision laparoscopic cholecystectomy(SILC) is gaining popularity
because of its cosmetic advantage. One of the major difficulties of this procedure
seems to be interference of instruments. We introduce our technique using two
curved instruments for lesser interference of instruments.
Method: An umbilical skin incision, 2 cm in length, is made vertically and LAP
PROTECTOR (Hakko; JAPAN) which is silicone rubber-made wound margin
protector is inserted to the peritoneal cavity. EZ ACCESS (Hakko; JAPAN) is
attached to LAP PROTECTOR. Because EZ ACCESS is made of silicone rubber, it
can be used as a multichannel port by optionally inserting several trocars into the
surface plate. Since EZ ACCESS is round disc-form, we express trocar site into EZ
ACCESS as a clock. A 5 mm 30 degree laparoscope is placed at site of 9 o’clock. A
curved instrument that is used to hold the fundus of gallbladder by assistant is placed
at site of 6 o’clock. Another curved instrument that is used by surgeon’s left hand is
placed at site of 12 o’clock. And laparosonic coagulating shears (LCS) or electrical
scalpel is placed at site of 3 o’clock. These orientation of instruments through EZ
ACCESS and using two curved instruments yield more external working space.
Calot’s triangle is dissected in the usual manner to obtain a critical view. After
identification of both the cystic artery and cystic duct, they are clipped respectively.
We dissect the gallbladder in a standard fashion. After the organ was dissected free
from the liver, it was removed directly through LAP PROTECTOR.
Result: We performed this procedure for four cases (2 cholelithiasis and 2 chole-
cystitis). There was no complication and no case needs additional working ports. Our
stress during surgery was reduced.
Conclusion: Interference of instruments is reduced by using two curved instruments.
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P274 – Liver and Biliary Tract Surgery
THE EVOLUTION OF THE SURGICAL INDICATION,
STRATEGY AND TECHNIQUE IN THE LAPAROSCOPIC
CHOLECYSTECTOMY
S.C. Olariu, I.R. Farca, C.G. Voina, S. Pop, N.I. Pop
University of Medicine and Pharmacy V. Babes, TIMISOARA,
Romania
Aim: The analysis of progress in the gallbladder laparoscopic surgery by comparing
the cases operated at the beginning of this procedure to the current period.
Material and method: Two series of 1000 laparoscopic cholecystectomies, which
have been performed in the clinic in a 10 years interval, have been comparative
studied. The first serie has been operated between 1994 and 1998, and the second
serie between 2008 and 2011. Analyzed data: surgical indications, the rate of con-
version to conventional surgery, intraoperative accidents, the rate of postoperative
complications and the average time of hospitalization.
Results: The indication for laparoscopic approach has been extended from 53% of
the total number of cholecystectomies in the first period, to 78% in the second
period. The rate of conversions has decreased from 4.9% (11.5% in acute cases) to
3% (5.8% in acute cases). The number of acute cholecystitis operated by laparo-
scopic approach has risen from 25.6% to 57%. The intraoperative accidents
decreased from 1.2% to 1%. In the first period the postoperative complications rate
has been 0.8% and it maintained itself constant in the second period. The mortality
has been 0 to both series.
Conclusions: 1. The comparative study has demonstrated the positive evolution of
laparoscopic method indication because of the surgical technique improvement and
of the technological progress. 2. The operative procedure’s standardization and
optimization has caused the decrease of conversions and intraoperative accidents. 3.
The laparoscopic cholecystectomy is and it will be ‘the golden standard’ as a cho-
lecyst’s ablation procedure. Key words. Laparoscopic approach, cholecystectomy,
conversion.
P275 – Liver and Biliary Tract Surgery
SINGLE INCISION LAPAROSCOPIC
CHOLECYSTECTOMY: INITIAL 50 PATIENTS
R.M. Clancy, R. Patel, R. Spencer, N. Penney, R. Cave, A. Osbourne,
C. Wong
Frenchay Hospital (North Bristol NHS trust), BRISTOL,
United Kingdom
Aims: Minimally invasive single-incision laparoscopic surgery (SILC) is gaining
popularity in general surgery. This report aims to describe the author’s initial
experience with SILC.
Methods: Patients who underwent SILC between October 2010 and Jan 2012 in a
single centre were enrolled prospectively in this study. Patient demographic data and
outcomes were analysed. Some cases were carried out with specialist ports (Covidien
SILSTM) but in the majority of cases only a 12 mm and two 5 mm ports were used
via the transumbilical route. All procedures were carried out using standard straight
laparoscopic instruments. All operations were performed or supervised by the senior
author.
Results: Of the 141 patients who underwent laparoscopic cholecystectomy 54 (44
female, 10 male) underwent SILC. The average age and BMI were 45.4 yrs
(18.3–77.5 yrs) and 28.8 kg/m2 (19.5–50 kg/m2). Operative times reduced as the
learning curve progressed to comparable times to standard laparoscopic cholecys-
tectomy (StdLC). Cost per case was reduced as a result of using fewer ports than
StdLC. There were no conversions to StdLC or additional ports required. Two
patients had a bile leak requiring return to theatre. Both were found to have bile leaks
from the cystic duct due to loose liga clips requiring postoperative endoscopic ret-
rograde cholangiopancreatography (ERCP). One of these two patients was found to
have a large duct stone at ERCP. Lessons learnt and tricks from our initial experi-
ence will be discussed.
Conclusion: Based on our initial experience, SILC is feasible, safe and comparable
results can be achieved with StdLC with potential cost savings.
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P276 – Liver and Biliary Tract Surgery
SINGE PORT CHOLECYSTECTOMY
G. Rustamov, E. Rustamov
Tusi Memorial Clinic, BAKU, Azerbaijan
Background: Findings have shown that single port laparoscopic cholecystectomy is
feasible and reproducible. The authors have pioneered a single port technique at the
Tusi Memorial Clinic of Azerbaijan. Their results for 18 patients are presented.
Methods: From Aprel 2011 to December 2011, 18 patients with symptomatic gall-
bladder disease underwent single port cholecystectomy through a 1.5- to 2-cm
umbilical incision using a single-port technique (Karl Storz). For nearly all the
patients, a 30 degrees angled scope was used. The gallbladder was retracted; the
single incision laparoscopic cholecystectomy procedure was performed using stan-
dard technique with 5-mm reticulating or conventional laparoscopic instruments.
The cystic duct and artery were well visualized, clipped, and divided. Cholecys-
tectomy was completed with electrocautery, and the specimen was retrieved through
the umbilical incision.
Results: In this series, with an average age of 36.8 years (range, 17–61 years)
underwent single incision laparoscopic cholecystectomy. Their mean BMI was 32.8
kg/m2 (range, 17–42.5 kg/m2), and 2 patients had undergone previous abdominal
surgery. The mean operative time was 53.8 min (range, 23–110 min). The mean
estimated blood loss was 35.3 ml (range, 5–125 ml), and the patients had’nt an
intraoperative cholangiography. There were no conversions of the single port cho-
lecystectomy technique. This technique was feasible for all of the patients. For the
remaining patients, either a three-channel port or three individual trocars were
required. A single port cholecystectomy technique was used for 5% of the patients to
manage acute cholecystitis or gallstone pancreatitis.
Conclusion: The single port cholecystectomy with a S-port technique is safe, fea-
sible, and reproducible. The operating times are reasonable and can be lessened with
experience. Excellent exposure of the critical view was obtained in all cases. The
single port cholecystectomy is becoming the standard of care for most of the authors’
elective patients with gallbladder disease.
P277 – Liver and Biliary Tract Surgery
MIRIZZI SYNDROME: IS IT RARE 9 YEARS AFTER
LAPAROSCOPIC SUB-TOTAL CHOLECYSTECTOMY?
M. Salama, I. Ahmed, A.R.H. Nasr
Our Lady of Lourdes Hospital, DROUGHEDA, Ireland
Introduction: Mirizzi syndrome first described in 1948 by Pablo Luis Mirizzi is a rare
complication of gallstone disease affecting about 1% of all patients with choleli-
thiasis. The condition is even rarer after subtotal cholecystectomy, developing in the
remnant of the gall bladder or the cystic duct. A thorough literature search revealed
only four reported cases after a previous subtotal cholecystectomy. We present a
unique case of gall bladder remnant calculus causing Mirizzi syndrome 9 years after
subtotal cholecystectomy.
Case report: A 48 years old lady had a Laparoscopic subtotal cholecystectomy for
severe acute cholecystitis. Nine years later she presented to the same hospital with
recurrent biliary colic. Her routine bloods and liver function tests were normal.
Ultrasound and MRI of the biliary system showed no recurrent gall stone and the
findings were consistent with long standing operative changes. The patient remained
symptomatic and an endoscopic ultrasound examination was performed. This
showed a 5 mm inflammatory mass with calcification/stone causing external com-
pression on the common bile duct. ERCP and stenting was performed on the same
endoscopic sitting. Operative procedure: A laparoscopy was performed and the
remnant of the gallbladder was mobilised. Opening of the remnant of the gallbladder
revealed type 4 Mirizzi Syndrome. The procedure was then converted to open sur-
gery. The remnant of the gallbladder removed and the bile duct was closed with
absorbable sutures.
Results: The patient made an uneventful recovery and was discharged home after 5
days. She was followed up after six months in the out patient department and she
remained asymptomatic.
Conclusions: Mirizzi syndrome is exceedingly rare after Laparoscopic subtotal
cholecystectomy in particular nine years after surgery. Diagnosis may be very dif-
ficult even with the help of modern diagnostic modalities. A high index of suspicion
may help to avoid unnecessary bile duct injuries.
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Surg Endosc (2013) 27:S53–S166
P278 – Liver and Biliary Tract Surgery
CANDIDATE FOR SINGLE-INCISION LAPAROSCOPIC
CHOLECYSTECTOMY
N. Waki, M. Ishizaki, H. Torigoe, H. Satoh, S. Kinoshita, H. Kawai,
H. Nishi, M. Mano, N. Shimizu
Okayama Rosai Hospital, OKAYAMA, Japan
Background: Laparoscopic cholecystectomy is widely performed for benign gall-
bladder disease, and there is a recent tendency in that the size and number of the
ports are decreasing.
While single port laparoscopic cholecystectomy (SILC) has more cosmetic advan-
tages than 4-port LC (4PLC) does, the general use of SILC has been hampered by the
technological constraints, such as collisions of instruments. In order to elucidate the
patients who work better with SILC, we carried out the comparison of SILC and
4PLC retrospectively.
Patients: In 2011, 49 patients underwent elective laparoscopic cholecystectomy for
cholelithiasis and chronic cholecystitis at our hospital: 9 patients underwent SILC
and 40 patients did 4PLC. Two types of patients were excluded from the experiment:
one underwent 4PLC converted from SILC and the other underwent open chole-
cystectomy converted from 4PLC.
Results: No significant difference was found with respect to demographic data
including age, sex and body mass index. Similarly, operative time and the length of
postoperative stay did not significantly differ between the 2 groups. However, the
frequency of using pain killers for the patients of SILC group was higher than that of
4PLC (P = 0.032). There were no intraoperative and postoperative complications.
Conclusion: There were no differences between 2 groups except frequency of using
pain killers, it is conceivable that SILC may contribute only cosmetic outcome. Since
umbilical incision of SILC is larger than that of 4PLC, it is rather painful than that of
4PLC, so we consider that the candidate for SILC is patients who have large gall-
stones which need big incision to be withdrawn from abdominal cavity.
P279 – Liver and Biliary Tract Surgery
A CASE OF LAPAROSCOPIC CHOLECYSTECTOMY WITH
SEVERE KYPHOSIS – OPTIMAL PROCEDURE OF THE
PLACEMENT OF TROCARS
H. Sato, H. Torigoe, N. Waki, H. Kawai, S. Kinoshita, M. Ishizaki,
H. Nishi, M. Mano
Okayama Rosai Hospital, OKAYAMA CITY, Japan
Aims: Laparoscopic cholecystectomy is a standard procedure with minimum inva-
sion for a patient with gallbladder stone. The surgical procedure may be standardized
in each institution. We experienced a patient with gallbladder stone, to whom we
could not apply the routine port placement because of severe kyphosis. So we
developed a new approach for patients with severe kyphosis.
Methods: The case was a 79 year-old lady with gallbladder stones and common bile
duct stones. She was referred to our division for laparoscopic cholecystectomy after
endoscopic sphincterotomy and choledocolithotomy. She had severe kyphosis with
the angle of almost 90 degrees,and it was impossible to place the trocars at usual
place. So we placed the trocar for the endoscope and the Minilap at lower intercostal
spaces. With this procedure, we had a good endoscopic sight for the surgery and
could accomplish the operation without any trouble. Conclusions: Placement of
several trocars at lower intercostal spaces makes the good working space for patients
with severe kyphosis.
Surg Endosc (2013) 27:S53–S166
P280 – Liver and Biliary Tract Surgery
THE VALUE OF EXTENDED POSTOPERATIVE
ANTIBIOTIC PROPHYLAXIS AFTER LAPAROSCOPIC
CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS
K Kortram1, B. van Ramshorst2, B.J.M. Vlaminckx2, M.J. Wiezer2,
D. Boerma2
1
VUMC, AMSTERDAM, The Netherlands; 2St. Antonius Hospital,
NIEUWEGEIN, The Netherlands
Aim: The aim of this retrospective study was to evaluate the peri-operative use of
antibiotic treatment in laparoscopic cholecystectomies for acute cholecystitis and to
review the available literature.
Methods: All laparoscopic cholecystectomies for acute cholecystitis between 2002
and 2010 were included in a retrospective database. The postoperative course was
studied and complications were analysed. Other parameters that were taken into
account were duration of hospital admission and mortality.
Results: 279 Patients were included, 137 male, 142 female with a median age of 60
years. A total of 248 patients were treated with antibiotics: 107 received a single
prophylactic dose according to local hospital protocol, 141 extended postoperative
treatment. The overall infectious complication rate was 11.5%. Patients receiving
extended antibiotic treatment developed significantly more infectious complications:
17% versus 6.5% in single-dose patients and 3.2% in patients not receiving any
antibiotics (p = 0.01). The only independent risk factor for the development of
infectious complications was the presence of gallbladder empyema. Overall mor-
tality was 1.1% (N = 3). Length of stay was significantly longer in patients receiving
extended antibiotics: 4.5 versus two days.
Conclusion: Surgeon’s compliance with hospital protocol is low, and the policy on
peri-operative antibiotics appears to vary widely among surgeons. Despite extended
antibiotic therapy in selected patients, infectious complication rates were high. The
available literature does not provide any evidence on the subject. A prospective,
multicenter randomised controlled trial has been initiated to provide the surgical
community with a much needed evidence based guideline.
P281 – Liver and Biliary Tract Surgery
HOW TO FURTHER LOWER THE COMPLICATION RATE
AFTER LAPAROSCOPIC CHOLECYSTECTOMY
K Kortram1, S.C. Donkervoort2, L. Dijksman2, B. van Ramshorst3,
D.J. Gouma4, D. Boerma3
1
VUMC, AMSTERDAM, The Netherlands; 2Onze Lieve Vrouwe
Gasthuis, AMSTERDAM, The Netherlands; 3St. Antonius Hospital,
NIEUWEGEIN, The Netherlands; 4Academic Medical Center,
AMSTERDAM, The Netherlands
Aim: The aim of this multicenter, retrospective study was to identify independent risk
factors for a complicated postoperative course after laparoscopic cholecystectomy for
symptomatic bile stone disease. Furthermore we seeked to point out which type of com-
plication was associated with which risk factor, in order to be able to anticipate on specific
postoperative complications in selected patients.
Methods: Two retrospective databases of two major teaching hospitals in the Netherlands
were combined. The main outcome parameters were occurrence of major complications,
mortality and length of hospital stay. Independent risk factors for the development of
complications were analysed using uni- and multivariate analysis and the distribution of
complications over these risk factors was assessed.
Results: A Total of 2634 patients were included in the database. The overall complication
rate was 8.8%. Independent risk factors for postoperative complications were older age,
acute cholecystitis, previous ERCP and conversion to open cholecystectomy. Length of
surgery was not an independent risk factor. Acute cholecystitis was a risk factor for any
complication except biliary injury, previous ERCP was mainly associated with cystic duct
leakage. Of these risk factors the only one that can be influenced is conversion to open
cholecystectomy. The overall conversion rate was 4.6%. The complication rate in converted
patients increased to 21.3% versus 6.9% in patients in whom the procedure was finished
laparoscopically (p \ 0.0001). Pneumonia was the most frequently encountered compli-
cation after conversion. The median duration of hospital admission was also significantly
longer in converted patients: six versus two days (p \ 0.0001). The overall mortality rate
was 0.4% and did not differ between the two groups.
Conclusion: Patients with complicated gall stone disease have an increased risk of sub-
sequent complicated surgery. Also, conversion to open cholecystectomy is associated with
increased postoperative morbidity and a significantly longer hospital stay. High risk cases
should therefore be planned to undergo surgery in the hands of a laparoscopiccally skilled
surgeon, and if a less experienced surgeon considers converting, consultance of a laparo-
scopic surgeon should be considered.
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P282 – Liver and Biliary Tract Surgery
LAPAROSCOPIC TREATMENT OF ACUTE
CHOLECYSTITIS – OUR 15 YEAR’S EXPERIENCE
B. Jovanovic1, M. Djordjevic2, V. Pejcic2, S. Jovanovic2,
A. Pavlovic2, N. Mitic2
1
Clinical Center Nis, NIS, Serbia; 2Center for minimally invasive
surgery, NIS, Serbia
Objective: The main goal was to show our experience in laparoscopic treatment of
acute cholecystitis in 393 patients operated in surgical clinic (since 1997 to 2012).
Methods: During this period 7860 patients were operated and 393 or 5% were
patients with acute cholecystitis. 140 women and 253 men (ASA I, II and in selected
cases ASA III) with acute cholecystitis operated by laparoscopic techniques were
prospectively analyzed. All patients were cured with antibiotics (Cephalosporin
I..V.) and conservative therapy for acute cholecystitis. The patient were born in
period of 1945 to 1973 (Average ages was 42 years). Analyze include: operation
duration, operative and postoperative complications, number of the days of hospi-
talization and time until patients is getting back to normal activity.
Results: The operation duration was from 35 min. to 95 min. (average 63 min.).
There were 28 postoperative complications Complication was injury of ductus
choledochus (3), port infection (10), bleeding from gold bladder (5), leaking bile to
drainage tube from Luschin vessel (9) and subhepatic abscessus (1). All complica-
tion were solved by conversions, except subhepatical abscess which was solved by
percutaneous biliary drainage. There were no death cases. Average time of hospi-
talization was 4 days (3–5). At 10 patients was continued administration of
antibiotics for 5 more days after living the hospital. Per oral consummation of food
begin in 24 hours whit in 60 patients. In period of 9 to 15 days all of the patients
continued whit normal life and activity, (average 11,5 days).
Conclusions: Reasons such as minimal invasive procedure with four small wounds
on abdomen, rapid recovery, quick return to normal life activity, almost painless
procedure, procedure with minimal complications and smaller economic expenses
made this procedure on our opinion as a procedure of choice in treatment of acute
cholecystitis.
P283 – Liver and Biliary Tract Surgery
NEEDLESCOPIC SURGERY FOR LAPAROSCOPIC
CHOLECYSTECTOMY AND SINGLE STEP MANAGEMENT
FOR INCIDENTALLY DIAGNOSED COMMON BILE DUCT
STONES
A. Umezawa, T. Yamaguchi, Y. Seki, T. Watanabe, K. Kasama,
Y. Negishi, YK. Kurokawa
Yotsuya Medical Cube, TOKYO, Japan
Objective: To determine the feasibility of needle forceps for laparoscopic chole-
cystectomy (LC) and laparoscopic common bile duct exploration (CBDE) for
incidentally diagnosed common bile duct stones (CBDs).
Materials and methods: Conventional LC is performed with 2 puncture and 2 inci-
sions. 2 punctures are applied through thin caliber trocar Mini-Port (Covedien, USA)
with needle forceps BJ needle (Niti On Company, Japan). BJ-needle is a thin caliber
grasper with a diameter of 2.1 mm. The puncture sites are below the right costal
margin on the mid-clavicular line and on the anterior axillary line of the navel level.
Other incisions are 12 mm trocar at umbilical site and 5 mm below the left costal
margin. We performed intraoperative cholangiography (IOC) routinely during LC.
Once confirming the diagnosis of CBDs with IOC, laparoscopic CBDE was carried
out according to the number and size of stones. The number less than four and the
size under 8 mm was the indication for trans-cystic duct exploration (LTCE). Others
were indicated for transcholedochal exploration (LCHE).
Results: Of 550 LC cases, 57 were single incision LC and 451 (91%) were suc-
cessfully completed LC with BJ-needle. There was no complication caused by using
BJ-needle. IOC had been performed through Mini-Port with catheter. Its success rate
was 99%. Incidentally diagnosed CBDs were detected in 8 patients. Those were
1.4% who received IOC. 6 out of 8 patients were performed LTCE. There was one
case switched to LCHE from LTCE because of tears off the cystic duct. During
LCHE, BJ needle had sufficient ability as suturing forceps which was comparable to
5 mm forceps. The length of postoperative hospitalization for LC was 2.0 days,
LTCE was 2.3, and LCHE was 2.8.
Conclusion: BJ-needle was feasible for LC and CBDE, and improved the cosmetic
satisfaction. Especially, LTCE shows uncomplicated post operative course which
was as same as LC alone. LTCE is feasible and should be the first line of treatment
for incidentally diagnosed CBDs and LCHE will be as redeeming approach.
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P284 – Liver and Biliary Tract Surgery
MINI-INVASIVE SURGERY OF PANCREATITIS THAT
COMPLICATED ENDOSCOPIC INTERVENTIONS ON
THE DISTAL PART OF COMMON BILE DUCT
A.K. Vlakhov, V.N. Starosek, S.N. Leonenko, O.G. Butyrsky
Crimen Medical University, SIMFEROPOL, Ukraine
Endoscopic papillosphincterotomy (EPST) is a commonly adopted method of treatment for
choledocholithiasis and diseases of the distal part of common bile duct (DPCBD). But it has
certain postoperative complications including reactive pancreatitis (pancreatonecrosis), its
incidence reaches 1,5%.
We treated 775 patients (m:f = 189:586, age 19–95) who were performed performed 836
endoscopic interventions on DPCBD; 67 (8%) were accompanied with pancreatic reaction.
We distinguish 3 degrees of pancreatic reaction after SPCBD surgery: (1) transitory
hyperamylasemia (amylase activity up to 90 g/(hrxl) without any clinical, ultrasonic (US)
and laparoscopic manifestations – 38 patients (4.9%); (2) reactive pancreatitis (mild epi-
gastric pain, single vomiting, US – moderate pancreas enlargement, hypoechoid
parenchyma, laparoscopy – insignificant serous exudation under liver, hepatoduodenal
ligament swelling) – 20 patients (2.6%); (3) pancreatonecrosis: strong stable pain, multiple
vomiting, other typical signs, US – pancreas dimensions enlargement, hypoechoid and
heterogeneous parenchyma, duodenostasis, parapancreatic liquid masses, reactive pleuritis,
laparoscopy – serous exudation above and under liver, in bursa omentalis, hepatoduodenal
ligament swelling, distension of transverse colon, patches of steatonecrosis on omentum – 9
patients (1,2%).
According to the degree of pancreatic reaction we use the following laparoscopic inter-
vention. For hyperamylasemia – laparoscopic cholecystectomy without bile ducts draining
against pancreatic secretion inhibitors (derivatives of Sandostatin); all patient survived. For
reactive pancreatitis – laparoscopic cholecystectomy with extrahepatic bile ducts draining,
draining epihepatic and subhepatic excavations, after surgery – comprehensive medication
therapy in ICU; all patients survived. For pancreatonecrosis – laparoscopic cholecystec-
tomy with extrahepatic bile ducts draining, draining epihepatic and subhepatic, and pelvic
excavations, draining bursa omentalis nad parapancreatic liquid foci under US control, after
surgery – comprehensive medication therapy in ICU with using extracorporeal detoxifi-
cation and selective drugs delivery to pancreas via the catheter in the celiac trunk. In 3 cases
we had to make sequesterectomy by mini-incision due to occurrence of postponed pan-
creatonecrosis complications; 1 patient died (post-surgery lethality made 0.13%).
Our algorithm provides good results of post-surgery complication management.
P285 – Liver and Biliary Tract Surgery
SIGNIFICANCE OF INTRAOPERATIVE
CHOLANGIOGRAPHY IN LAPAROSCOPIC
CHOLECYSTECTOMY
Y. Tanaka, T. Yumiba, Y. Morimoto, M. Fujii, Y. Akamaru,
K. Yasumasa, E. Kono, T. Konishi, H. Kasashima, K. Kawai,
Y. Okubo, Y. Taniguchi, R. Matsuura, Y. Yamasaki
Kosei-Nenkin Hospital, OSAKA, Japan
Aims: Intraoperative cholangiography(IOC) is one of means to avoid intraoperative and
postoperative complications in laparoscopic cholecystectomy(LC). This study was con-
ducted to determine whether IOC was useful to avoid complications in LC.
Methods: A retrospective clinical study was performed on 620 patients, 299 males and 321
females, with age ranging from 10 to 91 years during the period from January 2003 to
December 2009. There were 388 patients with gallstone, 137 patients with cholecystitis, 68
patients with polyps of the gallbladder, 12 patients with adenomyomatosis, 13 patients with
gallstone pancreatitis, 2 patients with others.
Results: IOC was performed in 571 patients (92.1%) and was not performed in 49 patients.
Out of these IOC cases, there were remarkable findings in 28 patients with common bile
duct stones, 4 patients with anomalous arrangement of the pancreaticobiliary ducts, 1
patient with stenosis of bile duct, 2 patients with duodenal diverticulum, 1 patient with
complete transaction of common bile duct, 1 patient with partial injury of common bile
duct, 1 patient with partial injury of common hepatic duct, 1 patient with complete
transaction of right hepatic duct, 1 patient with pancreatography, 1 patient with duodenal
fistula. In 28 patients with common bile duct stone, 10 patients underwent conversion to
open surgery and 18 patients underwent added postoperative endoscopic sphincterotomy.
The reasons why 49 patients were not able to accomplish IOC were difficulty in the catheter
insertion in 19 patients, doubt of gallbladder cancer in 10 patients, conversion to open
surgery in 8 patients, patient factor (allergy, pregnancy, asthma, chronic renal failure) in 11
patients, machine trouble in 1 patient. Technical failure to attempted IOC were recognized
in 19 patients (3.1%) and it was thought to be low rate.
Conclusion: IOC is thought to be useful to avoid intraoperative and postoperative com-
plications in LC.
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Surg Endosc (2013) 27:S53–S166
P286 – Liver and Biliary Tract Surgery
ROBOT-ASSISTED LAPAROSCOPIC BILE DUCT SURGERY
– A SINGLE CENTRE EXPERIENCE
C.Y. Chan, C.N. Tang, C.H. Lai, P.C. Yang
Pamela Youde Nethersole Eastern Hospital, HONG KONG, China
Background: Laparoscopic biliary surgery remains a major challenge for many surgeons
due to its complexity and technical difficulty. The introduction of surgical robotic system
helps to overcome the disadvantages of conventional laparoscopic surgery. This study aims
at evaluating the technical feasibility and safety of robot-assisted laparoscopic surgery on
biliary tree using the da Vinci system in a single centre.
Method: Between May 2009 and August 2011, 26 patients who underwent robot-assisted
laparoscopic biliary surgery were evaluated. Prospectively collected data were analyzed
retrospectively.
Results: There were 25 patients underwent robot-assisted laparoscopic bile duct exploration
for biliary stones. Among them, 12 patients had choledochoenteric reconstruction per-
formed. One patient suffered from hilar cholangiocarcinoma underwent robot-assisted
laparoscopic bile duct excision and palliative hepaticojejunostomy. Mean operative time
was 201 min (range 90–400 min) and mean blood loss was 10 mL (range 1–50 mL). There
was no open conversion. Three patients (11.5%) had post operative complications. There
was no mortality. Mean hospital stay was 6 days (range 3–11 days).
Conclusion: Our series shows that in experienced hands, robot-assisted laparoscopic biliary
surgery is technically feasible and safe. The use of surgical robotic system facilitates more
complex biliary surgery. As experience grows and technique becomes mature, more
patients will benefit from this procedure.
P287 – Liver and Biliary Tract Surgery
IMPORTANCE OF LAPAROSCOPIC CHOLECYSTECTOMY
IN THE THERAPY OF ASYMPTOMATIC BILLIARY
OBSTRUCTION
B. Dakovic1, L. Dakovic2, G. Vasic1
1
KBC ‘‘Dr Dragisa Misovic - Dedinje’’, BELGRADE, Serbia;
2
Belgrade University School of Medicine, BELGRADE, Serbia
Background: Calculosis in biliary tract is a pathological process in the body which is a
result of already existing or threatening obstructive icterus, cholangitis, hepatic biliary
cirrhosis or pancreatitis. In surgical terms, the calculi in biliary tract may be symptomatic
(mobile, inclaved and transitory) with accompanying symptomatology and asymptomatic
with no manifest symptoms and signs.
Methods: Without standing the application of the standard diagnostic protocol, which
includes patients medical history data, physical examination finding, laboratory analyses
and ultrasonic diagnostic, in certain number of cases, some atypical diseases, anatomic
variations and malformations of biliary tract may remain non-recognized.
Results: Asymptomatic biliary obstruction (diagnosed in 3.2% of the cases in a trial con-
ducted on 879 patients), is a particular problem and entity in the domain of biliary surgery.
The proposed diagnostic protocol includes a routine application of intravenous cholangio-
cholecystography, along with already mentioned standard diagnostic methods. The trend in
the contemporary biliary surgery comprises preoperative diagnostic of the calculi in biliary
ducts and their evacuation in compliance with the finding, and thanks to possibility of
endoscopic aces, ERCP and EST make a consolidated diagnostic and therapeutic procedure.
Conclusions: Laparoscopic cholecystectomy is a final stage in the removal of reservoir and
source of primary biliary complications and possible recurrent dissemination of the calculi
in biliary tract.
Surg Endosc (2013) 27:S53–S166
P288 – Liver and Biliary Tract Surgery
SINGLE INCISION LAPAROSCOPIC SURGERY
FOR SYMPTOMATIC POLYCYSTIC LIVER DISEASE
G. Celona, N. Romano, S. Sergiampietri, O. Goletti
Health Unit 5, PISA, Italy
The majority of patients afflicted with adult polycystic hepatic disease are asymp-
tomatic. Depending on their size or position, cysts may cause symptoms like pain,
abdominal swelling, jaundice, vomiting or dyspnoea. Elective surgical treatment
must be warranted in these events. With development of minimally invasive surgery,
laparoscopic fenestration or radical excision became the main treatment for symp-
tomatic but uncomplicated liver cysts. Recently, single incision laparoscopic surgery
(SILS) has developed as a new surgical modality producing increased cosmetic
benefits and, perhaps, less postoperative pain and morbidity. We report a case of
symptomatic polycystic hepatic disease treated with laparoscopic single site surgery.
A 54 year-old female with polycystic liver disease underwent laparoscopic fenes-
tration of five dominant hepatic cysts. Patient complained of abdominal pain and
swelling. A single multichannel port (SILS Port, Covidien) was introduced through a
2 cm umbilical incision. Both straight reusable instruments and roticulator dispos-
able devices were used. After aspiration of the contents from the cysts, a Harmonic
ACE scalpel (Ethicon Endosurgery) was used to cut out the wall of the cyst.
Operating time was 120 minutes. Intra-cystic fluid drained was 2000 ml in all. Total
blood loss was negligible. Postoperative course was uneventful. Patient was dis-
charged on the fifth postoperative day without any drainage tube. Patient was very
pleased with her cosmetic results and she remained free of complaints during follow-
up.
In conclusion, we think that single incision laparoscopic surgery may be successfully
applied as an available and effective alternative to conventional laparoscopy in the
treatment of liver cysts.
P289 – Liver and Biliary Tract Surgery
IS LAPAROSCOPIC CHOLECYSTECTOMY A SAFE
PROCEDURE DONE BY THE RESIDENT SURGEON?
B.A. Popescu, M. Beuran, M. Vartic, D. Udobong, G. Varsa
Emergency Hospital Bucharest, BUCHAREST, Romania
Aims: Laparoscopic cholecystectomy is, maybe, after the appendectomy the first
procedure done by a resident surgeon in his last years of practice. Is the resident
surgeon prepared for such a task and is it properly done?
Methods: This is a retrospective study between Jan 2006–Jan 2012 in the Emergency
Clinical Hospital Bucharest. We took in study all the laparoscopic cholecystectomies
(193 cases) done by resident surgeons in one of the three general surgery clinics. All
the residents were in their 4th-6th years of study. There were 148 female patients and
45 males. The mean age was 52.4, ranging from 20 to 94 years. Mean hospital stay
was 4.3 days (1–16 days). 180 were acute cholecystitis (48.88% chataral, 39.44%
phlegmonous, 11.66% gangrenous). The preoperative work-up usually consisted of
blood work and abdominal sonography. 11 ERCPs were performed, 4 of them
postoperatively. The operating team was formed in 46.6% by resident- senior, in
32.6% resident–resident and in 20.7% by resident-specialist. The operations were
performed between 5 p.m.–7 a.m. in 64.24%. Drainage was established in all of
them. 75.6% of patients had other illness. There were performed in the same time, 1
appendectomy, 2 ombilical hernias, 1 hepatic biopsy for presumed metastasis and 1
cholangiography.
Results: We registered 5 conversions to open surgery, 4 done by the same surgeon
but whom has 1/3 of all cases. 2 reinterventions accured, one for bilioma (Luschka
duct) and one for gallstones in the CBD. 4 ERCP-s were performed postoperatively
for remaining gallstones in the CBD. One of the patients, died in the 4th postop-
erative day, by sudden death (massive pulmonary thromboembolism – autopsy).
Conclusions: We found that laparoscopic cholecystectomy is indeed a safe procedure
done by the resident surgeon, even in the late hours of the day. The majority of cases
were acute ones, done in the same day of the admission. There were no lesions of the
CBD, one of the most feared complications of this procedure.
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P290 – Liver and Biliary Tract Surgery
SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY
USING KONYANG STANDARD METHOD: A SINGLE
SURGEON EXPERIENCES ABOUT 200 CASES
I.S. Choi, Y.M. Ra, J.I. Moon, S.M. Park, S.E. Lee, W.J. Choi,
D.S. Yoon, H.S. Min
Konyang University Hospital, DAEJEON, Korea
Aim: Single incision laparoscopic cholecystectomy (SILC) is the minimal invasive
surgery which is used widely and one of the surgical procedures that grows rapidly.
However, there is no standard method for the SILC. Therefore, in this study, we
evaluated an adequacy and feasibility of Single incision laparoscopic cholecystec-
tomy using Konyang Standard Method.
Methods: We retrospectively reviewed our series of 200 SILC performed between
April 2010 and December 2011. Initially we excluded the patients who were more
than 70 years old, cardiologic or pulmonologic problems, cystic duct abnormality.
After 50 cases, we did not apply the exclusion criteria. We performed SILC by
Konyang Standard Method using three-trocar single port (hand-made) and long
articulated instruments.
Results: Two hundred patients were underwent SILC during the study period. Male
were 81 and female were 119. Mean age was 49.9 ± 13.5 and Mean BMI was 25.0 ±
3.7. Previous abdominal operative history was 64 cases. Patients pathologies
included: chronic cholecystitis (149 cases), acute cholecystitis (19 cases), GB polyps
(28 cases), GB empyema (4 cases). Mean op time was 56.8 ± 27.6 minutes and mean
hospital stay was 2.7 ± 2.3 days. There were two cases of three port conversion due
to cystic artery bleeding and no conversion to open. Complications occurred 4 cases
including wound infection and no bile duct injury related problems.
Conclusion: Single incision laparoscopic cholecystectomy (SILC) using Konyang
Standard Method is safe and feasible. And there seems to be no typical limitation.
Therefore, almost all benign disease of gallbladder can be applied to the single
incision laparoscopic cholecystectomy (SILC) using Konyang Standard Method.
P291 – Liver and Biliary Tract Surgery
SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY
WITH CONVENTIONAL INSTRUMENTS AND PORTS;
A STUDY AT TERTIARY CARE HOSPITAL IN PAKISTAN
A.R. Shaikh, A.K. Sangrasi, M.R. Abbasi
Liaquat University of Medical Health & Sciences Jamshoro Pakistan,
HYDERABAD, Pakistan
Aims: to assess the safety, feasibility and short term outcome of single incision
laparoscopic cholecystectomy with conventional instruments.
Methods: a prospective study conducted at surgical department of Liaquat University
of Medical Health & sciences, Jamshoro, Pakistan from January 2010 to December
2011 of all the operable and fit cases of symptomatic cholelithiasis who consented
for laparoscopic surgery and wanted better cosmetic results. The exclusion criteria
were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and
patients with comorbid.
Results: total no of cases were 50. The age ranged from 30–59 years (mean 35.20
years). There were 43 females and 07 males.
A midline incision made supraumbilically and 10 mm port placed. Two 5 mm ports
placed on either side of umbilicus slightly superior and laterally in order to trian-
gulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder. The
rest of the procedure is like standard laparoscopic cholecystectomy.
The operating time was 80 minutes (range 50–120). Four case were converted to
standard four incision laparoscopic cholecystectomy due to bleeding and difficult
dissection in callots triangle. There was minimal blood loss during the operation.
There was no postoperative complication. The median pain scale was three. The
cosmetic results were satisfactory. The length of hospital stay was 01 day (range
1–2).
Conclusion: the laparoscopic cholecystectomy can be done safely with conventional
laparoscopic instruments and ports without additional cost of single port and artic-
ulated instruments the cosmetic results are excellent with minimal increase in the
operating time.
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S126
P292 – Liver and Biliary Tract Surgery
OUR EXPERIENCE OF LAPAROSCOPIC LIVER
RESECTION (LLR) FOR THE LIVER METASTASIS
H. Tarao
Hokuto hospital, OBIHIRO, Japan
Patients and Methods: Five cases (Four patients) with preoperative chemotherapy
underwent LLR between January 2009 and December 2011. We usually perform
LLR by clamp crushing method with the Vessel sealing system (Liga-sure) without
precoagulation. In addition, total or half Pringle’s maneuver for four cases was
performed with 15 minutes clamp and 5 minutes de-clamp for vascular inflow, and
one case underwent LLR without hemostasis of vascular inflow. There were 3
females and one male, he underwent twice LLR, with a mean age of 70 years (range,
44–80). There were two cases of metastatic rectal cancers, two cases of metastatic
colon cancers and one metastatic breast cancer. All the cases were recurrence after
radical resection for primary cancer tumor, and had solitary metastasis at each time
of the operation. In the site of tumor, 3 cases were in segment 7, one case in segment
3 and one case in segment 4. Two cases had received preoperative chemotherapy
with mFOLFOX6, one case with UFT/LV (oral uracil, tegafur and leucovorin), and
one case of metastatic breast cancer with AC-T (adriamycin, cyclophosphamide, and
paclitaxel).
Result: We performed 4 pure-LLR and one hybrid-LLR (all cases were partial
resections). In addition, one case of pure LLR underwent pylorus-preserving gas-
trectomy(PPG) at the same time. The mean tumor size was 25.6 mm (range, 15–36),
the average of operation time was 320.8 minutes (range, 265–363) and the average of
blood loss was 212.6 mL (range, 16–517). The average of postoperative hospital stay
was 9.4 days (range, 5–14), and there were no case with blood transfusion, com-
plications or mortalities. This result did not have the difference in comparison with
the case that did not receive preoperative chemotherapy. In spite of sinusoidal
dilatation was recognized pathologically in two cases that received mFOLFOX6. In
addition, one case had undergone a liver resection two times (open and LLR), but
there was not effect from multiple surgery.
Conclusions: The LLR can be performed safely in patients who received preoper-
ative chemotherapy, in local resection case. In addition, LLR is profitable in multiple
liver resection.
P293 – Liver and Biliary Tract Surgery
LAPAROSCOPIC CHOLECYSTECTOMY IN CIRRHOTIC
PATIENTS
A. Cotirlet, I. Motoc
Moinesti Hospital, MOINESTI, Romania
Aims: Cirrhosis of the liver contributes significantly to morbidity and mortality in
abdominal surgery. This study evaluates the technical difficulties, safety and efficacy
of laparoscopic cholecystectomy in cirrhotic patients.
Methods: Between january 2009–December 2011, 1278 laparoscopic cholecystec-
tomies were performed; 33(2.6%) of these were performed in cirrhotic patients. 20
patients had no evidence of cirrhosis at the time of operation. Based on the Child
classification, there were 7 (21,12%) grade B and 16 (78.88%) grade A patients.
Results: 33 laparoscopic cholecystectomies were performed, 5(15.15%) of which
converted into open procedure due to: 2 to excessive hemorrhage from gallblader
bed, 2 to an immobile and hypertrophic liver and 1 to severe inflammatory edema
and adhesions. Operating time room ranged between 40 to 160 minutes (the mean
operative time was 75 minutes), with the extent of coagulopathy correlating with the
length of time needed to achieve satisfactory hemostasis. There were no operative
deaths, bile duct injuries or reinterventions for bleeding. Mean length of postoper-
ative stay was 5.25 days.
Conclusion. Although technically challenging especially because of the coagulopa-
thy, laparoscopic cholecystectomy is safe for patients with mild to moderate cirrhosis
of the liver.
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Surg Endosc (2013) 27:S53–S166
P294 – Liver and Biliary Tract Surgery
READMISSIONS FOLLOWING LAPAROSCOPIC
CHOLECYSTECTOMY: LESSONS TO LEARN
K. Siddique1, S. El-abyed2, S. Basu2
1
Wirral University Hospitals NHS Trust, STOCKPORT,
United Kingdom; 2East Kent Hospitals NHS Trust, ASHFORD,
United Kingdom
Aims: To identify the reasons for readmission in post-operative patients who
underwent elective and emergency laparoscopic cholecystectomy, in a large district
general hospital covering a population of 700,000 (approximately).
Methods: A prospective audit of 820 consecutive patients who underwent a lapa-
roscopic cholecystectomy between 1st April 2009–31st March 2010 was carried out.
Patients were identified from the real-time hospital database using procedure coding
and readmitted patients’ case notes were reviewed.
Patients readmitted within 28 days were the primary focus of this study; admissions
within one year were also included.
Results: 767 (94%) and 53 (6%) patients underwent elective and emergency surgery
respectively. 49 (6%) patients were readmitted within 5? (1–87) days post-discharge
(Male 19; Female 30); median age was 53 (20–84) years. Within the readmission
subgroup, 4 (8%) patients had 2 readmissions within 28 days, and a further 2 (4%)
presented beyond the 28-day period. 47 (96%) and 2 (4%) of readmissions followed
elective and emergency procedures respectively.
Patients underwent blood (49; 100%), USS (34; 70%), selective CT (15; 31%) and
MRCP (7; 14%) investigations. 10 (20%) patients had a raised CRP ([10), 10(20%)
had deranged liver function tests and 2(4%) had raised amylase.
Causes identified for readmissions were right hypochondrial/epigastric pain: 42
(86%), nausea/vomiting: 22 (45%), a subhepatic collection: 18(37%), jaundice:
6(12%), wound infection: 3(6%), pancreatitis: 2 (4%), pulmonary embolism: 1(2%)
and urinary retention: 1(2%).
39(80%) patients were treated conservatively, 7(14%) underwent radiological
drainage and 5(10%) had an ERCP ± sphincterotomy. All recovered with a read-
mission stay of 3? (0–20) days.
Conclusions: In the current climate of austerity, a better understanding of post-
operative complications with more aggressive postoperative pain control and man-
agement of nausea and vomiting would help to achieve the government’s goal of cost
savings for the NHS. Median
P295 – Liver and Biliary Tract Surgery
IS LAPAROSCOPIC CHOLECYSTECTOMY SAFE IN THE
ELDERLY?
M. Schuijtvlot1, M. Maatouk1, A. Zaidi2, J. Bunni3, R. Aziz4
1
Weston General Hospital, WESTON SUPER MARE,
United Kingdom; 2Morriston Hospital, SWANSEA, United Kingdom;
3
Glocestershire Royal Hospital, GLOCESTER, United Kingdom;
4
LUMS, LAHORE, Pakistan
Aim: To compare the complication rate and number of previous admissions for
biliary disease between patients under the age of 70 and patients of 70 years and
older.
Methods: A Retrospective study of 629 consecutive (elective and emergency) lap-
aroscopic cholecystectomies (LC) performed in a small District General Hospital
between September 2007 and December 2010. Data collected in an exel data sheet
and statistical analysis with 2 tailed ANOVA and t-means tests.
Results: A total of 598 consecutive cases were included in the study. Excluded were
21 missing notes and 10 notes with missing data which is 5% of the study population.
The 598 LC were divided into \70 years of age (479) and 70 years and older (119).
The group demographics for gender, ASA and indication for surgery were studied
and the 70+ age group has a non-significantly higher percentage of males, ASA II
and III and indication for cholecystitis and pancreatitis.
The number of previous admissions is higher in the 70+ age group. The complica-
tions during surgery are equivalent however the conversion rate is 5x higher in the
70+ age group (4.5%). While there may be a tendency for higher bowel and bile duct
injury (0.4%) in the younger age group. Postop complications are non-significantly
higher in the 70+ age group with 2% (v 0% \70) MI, 5% (v 0.8% \70) retained
bileduct stones and 0.8% (v 0.2% \70) mortality. 75% of patients \70 years old go
home on day 1 postop while only 45% of elderly go home by day 1. Conclusion: LC
in elderly patient is as safe as LC in younger than 70 group; as there is no statistically
significant difference in the complications rate between both groups.
Surg Endosc (2013) 27:S53–S166 S127

P296 – Liver and Biliary Tract Surgery P298 – Liver and Biliary Tract Surgery

ENDOSCOPIC SPHINCTEROPLASTY FOR DIFFICULT ROBOTIC ASSISTED SURGERY FOR ADULT

BILE DUCT STONE REMOVAL
T. Akaraviputh, T. Sriprayoon
Faculty of Medicine Siriraj Hospital, BANGKOK, Thailand
Aim: Endoscopic sphincteroplasty (ESPT) using a large balloon dilatation is an
alternative technique in removing a difficult common bile duct (CBD) stone.
However, the comparison of using ESPT with using mechanical lithotripsy
(ML) in this condition had not been previously studied. To compare the out-
come and complications of endoscopic difficult CBD stone removal using
ESPT and ML.
Methods: From January 2003 to December 2009, in this a retrospective study,
eighty patients with CBD stones underwent endoscopic retrograde cholangio-
pancreaticography (ERCP) for stone removal with difficulty. ESPT using a
large balloon dilatation was performed in 62 patients (group A) and 31 patients
with ML (group B). The success rate of complete stone clearance and post
ERCP complications were analyzed.
Results: In the aspect of success rate of complete stone removal, in group A,
the treatment was more effective than in group B (88.7% vs 61.3%, p value =
0.006). In group A, there were eight patients (11.3%) required adjunctive ML
for complete stone clearance. Both techniques were associated with low
complication rate (3.2%). Post ERCP bleeding was found in one patient (1.6%)
with ESPT using a large balloon dilatation. Mild post-ERCP pancreatitis
occurred in only one patient of both groups.
Conclusion: ESPT using large diameter balloon dilatation after biliary
sphinctertomy is an effective technique for a difficult CBD stone removal
associated with a lower rate of complications.
CHOLEDOCHAL CYST: AN EARLY EXPERIENCE
IN 3 CASE SERIES
T. Akaraviputh, N. Suksamanapun
Faculty of Medicine, Siriraj Hospital, BANGKOK, Thailand
For choledochal cyst, complete excision of cyst with Roux-en-Y hepaticojej-
unostomy anastomosis is the treatment of choice. It has been performed
laparoscopically with the advancement of laparoscopic skill. Recently, a
telemanipulative robotic surgical system was introduced, providing laparo-
scopic instruments with wrist-arm technology and 3-dimensional visualization
of the operative field. We present three cases of robot-assisted total excision of
a choledochal cyst and biliary reconstruction. All were done roux-en-y, one
intracorporeal. Total operative time is 4 hours in average (range 3–5 hours).
Postoperativelly They could start enteral feeding within 2 days. Intra-abdom-
inal collection occurred in one patient who was successfully treated with
continuous percutaneous drainage. In one patient, the operation was converted
to opened technique because of bleeding from right hepatic artery. All the
patients are doing well without evidence of recurrent cholangitis or
malignancy.

P297 – Liver and Biliary Tract Surgery P299 – Liver and Biliary Tract Surgery

TRANSUMBILICAL MULTI-PORT LAPAROSCOPIC BILE DUCT CLEARANCE IN ACUTE CHOLECYSTITIS:

CHOLECYSTECTOMY DUODENOSCOPY OR LAPAROSCOPY?
M.T. Oruc, M.U. Ugurlu, H.T. Turgut, Z. Boyacioglu V. Kolomiytsev, Ja. Havrysh, M. Pavlovsky
Kocaeli Derince Teaching and Research Hospital, KOCAELI, Turkey Lviv Medical University, LVIV, Ukraine
Aim: Comparison of laparoscopic (LCBDE) and endoscopic retrograde
Introduction: We herein report our results of transumbilical multi-port lapa-
(ERCBDE) exploration and clearance of the common bile duct in patients with
roscopic cholecystectomy (TUMP-LC) that can minimize these problems.
acute cholecystitis.
Methods: Twenty-five consecutive patients with symptomatic cholelithiasis
Patients and Methods: Combined prospective and retrospective analysis of all
were included. For evaluation of surgical stress preoperative and postoperative
patients with acute cholecystitis, complicated with biliary obstruction over a
C-reactive protein (CRP) values at 6 h and 24 h were measured. Postoperative
period of 15 years in the surgical department. 2416 patients with acute cho-
pain was evaluated using a standard 10-point visual analogue scale (VAS). A
lecystitis and laparoscopic cholecystectomy were included in the study.
single 3 cm, elliptical umbilical skin incision was established. Subcutaneous
Results: 403 patients had bile ducts problems and were underwent to CBD: 12
flap was then established to provide a sufficient area for three trocars’ place-
of them had LCBDE, 385 – preoperative ERCBDE, and 6 avoided laparotomy
ment. The 5 mm camera trocar was placed into the abdominal cavity, just
by postoperative ERCBDE. Of 12 LCBD explorations 10 (83%) were chole-
above the umbilical cord. Then two more trocars were placed. Once the lap-
dochostomies with T-tube drainage and only 2 (17%) had exploration through
aroscope, grasper and dissector were in place, the overall procedures were
cystic duct with ligation. Laparoscopic clearance of the CBD was achieved in
similar to the standard laparoscopic cholecystectomy.
11 (92%) of patients; one patient required additional elective postoperative
Results: The study enrolled 42 consecutive patients who underwent TUMP-LC
ERCBD. Median operating time was 119 and 55 min in LCBDE and ERCBDE
by the same surgeon. The mean age of the patients was 49.77 years; mean BMI
respectively. To prevent poor results of LCBDE attempts the prognostic factors
of the patients was 28.3 kg/m2. The mean duration of the surgery was 43.9
for difficult and/or failed laparoscopic CBD exploration were calculated.
minutes. Additional trocars were needed in 2 (4.7%) cases. No cases were
Conclusions: Laparoscopic operations in patients with acute cholecystitis
converted to a standard 4-port cholecystectomy. Endo Wire Loops were used in
complicated with choledocholithiasis are feasible and safe, but success rate are
16 (38%) cases in order to facilitate gall bladder retraction. Plasma CRP values
not so high. In patients with predicted difficult laparoscopic CBD exploration
increased at 6 h and started to decrease at 24 h. The CRP values did not
the preoperative endoscopic retrograde dissolution of biliary problems is
decrease to baseline values at 24 h. The mean pain scores postoperatively at 4
favourable.
h, 12 h and 24 h were 3.8 ± 1.22, 3.4 ± 1.25 and 2.0 ± 1.05, respectively.
There were a statistically significant difference between the scores at 12 h and
24 h and 4 h and 24 h. The mean LOS at hospital was 1.04 ± 0.2 days. During
follow-up a superficial surgical site infection occurred in 3 (7.1%) patient and 4
(9.5%) patients suffered from non-specific gastrointestinal symptoms like
nausea and flatulence. None of the patients required any medical consultations
at 1 month follow up.
Conclusion: We believe that this approach overcomes the technical difficulties
of single port surgery and experienced laparoscopic surgeons can safely per-
form TUMP-LC.

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P300 – Liver and Biliary Tract Surgery
SILS CHOLECYSTECTOMY
A. Maghiar, P.R. Sookha, G. Dejeu
Spitalul Pelican Oradea, ORADEA, Romania
Aim: Performing single incision laparoscopic cholecystectomy in a safe and feasible
way in a more public approach.
Methods: Between August 2009 till January 2012 the surgical teams, taking in
consideration ultrasonography measurement of the thickness of the gallbladder wall,
previous surgery on superior abdominal wall, and the lack of signs of acute
inflammation, proposed the single incision laparoscopic cholecystectomy. We had
795 patients admitted for gallbladder stones, 197 were proposed SILS cholecys-
tectomy, 170 patients agreed.
Our technique involves a 2 cm transombilical incision, through which we introduce
our first 10 mm trocar and perform a exploratory laparoscopy. If the case seems
feasible for SILS cholecystectomy, we continue by placing a second 10 mm trocar
just anterior and lateral to the first one.
For our first 100 cases we used the puppeteer technique. After placing the trocars we
introduce 3 transcutaneous sutures, used to retract the gallbladder in different
positions. The cholecystectomy is performed the same as in classic laparoscopic
cases. From January 2011 we started using the double curved Dapri forceps from
Karl Storz for SILS cholecystectomies. From April 2011 we started using the En-
dograb to retract de gallbladder fundus.
Results: We had 4 conversions from SILS to classic laparoscopic cholecystectomy.
All of these cases were for bleeding difficult to control through the SILS technique.
In the whole 132 lot we never had conversions to cholecystectomy by laparotomy
and we had no major intra or postoperative incidents or accidents. Our mean surgery
time was 1 hour 13 minutes during our first seven cases, and the end of the 170 cases
our mean surgery time was 35 minutes. All patients were discharged 48 hours
postoperative.
Conclusions: Single incision laparoscopic surgery is still a new concept, it is fea-
sible, and will definitely be in great demand in the future. The puppeteer technique is
a economic way of performing SILS cholecystectomy and can be performed in all
surgery clinics that are performing laparoscopic procedures. The introduction of
curved instruments, although more expensive, comes in the aid of both surgeons
ergonomics and shortening the operating time without the sacrifice of patient safety.
P301 – Liver and Biliary Tract Surgery
CHOLEDOCHOLITHIASIS RESOLVED THROUGH
LAPAROSCOPY AND CHOLEDOCHOSCOPY – CASE
PRESENTATION
A. Maghiar, P.R. Sookha, G. Dejeu, D.H. Ciurtin, M. Sfirlea,
C. Macovei
Spitalul Pelican Oradea, ORADEA, Romania
We present the case of a 62 year old male, C. A., from urban area in Oradea,
Romania, that presented to our clinic with jaundice, abdominal pain, nausea, con-
stipation. After clinical and paraclinical (biological and imaging) evaluation the
patient was diagnosed with Choledocholithiasis, acute cholecystitis, intestinal
occlusion.
The biological investigations found increased bilirubin levels, increased AST and
ALT, increased WBC, modified coagulation. We performed a CT abdominal scan
that concluded: acute cholecystitis, cu important pericholecystic inflammation, intra
and extra hepatic cholestasis from a single Choledocholithiasis 9 mm in diameter.
The preoperative cardiology consult found high blood pressure, under treatment,
ischemic and hypertensive cardiopathy, and permitted the surgical intervention.
We decided to operate and the patient agreed to laparoscopic surgery and chole-
dochoscopy. We operated the second day of admission through laparoscopy,
adhesiolysis, cholecystectomy, trans cystic cholangiography – we found the 9 mm
choledocholithiasis in the distal choledochus. We performed a choledochoscopy
through a choledochotomy and visualized and extracted the stone with the Dormia
basket. We then placed a T-tube and sub-hepatic drainage.
The patient had a uneventfull recovery and left the hospital the 5th day with the
T-tube in place. The T-tube was removed after 10 days.
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Surg Endosc (2013) 27:S53–S166
P302 – Liver and Biliary Tract Surgery
ISSUES IN DIAGNOSIS AND THERAPY OF LIVER HYDATIC
CYST
D.N. Margaritescu, S. Patrascu, E. Georgescu, T. Bratiloveanu,
S. Ramboiu, D. Marinescu, M. Bica, M. Georgescu, B. Carju,
C.M. Surlin
University of Medicine and Pharmacy, CRAIOVA, Romania
Aims: evaluation of diagnostic and therapeutic strategy in liver hydatid cyst.
Methods: We analyzed retrospectively 102 cases of liver hydatid cyst (35 M/67 F,
aged between 5 and 85 years old) hospitalized in the past 12 years. Cysts were single
in 63 cases, 71.42% located on the right liver and multiple in 39 patients. 48 cases
(47.04%) were uncomplicated, 54 presenting one or more complications: biliary 46
(45%), infection 15 (14.7%), rupture into the peritoneum 12 (11.76%), biliobronchial
fistula in 1 case. All the cases were operated – 92 open surgery, 10 cases by lapa-
roscopic approach. Radical procedures were performed in 24 cases and conservative
otherwise. Albendazole was administered as prophylaxis of recurrence. No recur-
rence was observed at ultrasonographic and CT-scan follow-up.
Results: 76 cases (74.5%) had a favorable evolution. 26 patients (25.49%) presented
postoperative complication: suppurative 9 cases, external biliary fistula 12 cases, 6
cases general complication. Postoperative mortality was 1.96%.
Conclusions: 1. Surgery is the main therapeutic method for hydatid cyst. 2. Lapa-
roscopic approach has well codified indications. 4. Prophylaxis of recurrences should
be made with postoperative administration of albendazole.
P303 – Liver and Biliary Tract Surgery
SHORT INITIAL EXPERIENCE IN MINILAPAROSCOPIC
CHOLECYSTECTOMY
R. Vilallonga, A. Calero, J.M. Fort, E. Caubet, O. Gonzalez,
M. Armengol
Universitary Hospital Vall d’Hebron, BARCELONA, Spain
In 1997 minilaparoscopic cholecystectomy (total size of trocar incision\25 mm) was
first introduced, in order to reduce the morbidity of surgical wounds. Since then
many reports have shown its efficacy and utility in order to achieve better postop-
erative results in terms of pain, recovery and aesthetic result.
Patients and methods: In a three months period, four minilaparoscopic cholecys-
tectomies were performed in our surgical department. There were no exclusion
criteria. The indication was an elective symptomatic cholelithiasis in one case, and
emergency acute cholecystitis in the other three (gangrenous with abscess in one
case, with ictericia in another one and with transaminases raise in one another). The
aim of these short study was measure median stay, surgical timing, surgical com-
plications and cosmetic result.
Surgical procedure: Hasson umbilical throcar 12 mm for camera, 3’5 mm trocars for
the work ports (two or three) for the endograsper and cautery, or additional grasper.
Fascia closure was performed with reabsorbable suture and the skin closure was
performed with prolene 4-0. All operations were performed by the same surgeon.
Results: The patient age was median of 61’2 yrs (range 32–78). There were three females
and one male. The median length stay was 5’25 days (range 1–12 days), the longer stay
owing to icteric patient waiting RM. However, excluding this patient mean length stay was
1’6 days. Median surgical time was 75 min (range 30–120). There were no surgical
complications such as technique conversion, bleeding or wound infection. The median
following time was 2 months. The median cosmetic result was 9/10.
Conclusion: These preliminary data suggest that reducing the size of trocar incision
results in a preliminary good experience. Although there has been no reconversion,
the use of ML, carries a higher risk of conversion to conventional LC or open
cholecystectomy. Further randomized controlled trials, comparing this approach to
other such as SILS will be required.
Surg Endosc (2013) 27:S53–S166
P304 – Liver and Biliary Tract Surgery
HEPATIC PARENCHYMA FUNCTIONAL CONDITION
IMPROVEMENT AFTER LAPAROSCOPIC
CHOLECYSTECTOMY UNDER THE INFLUENCE
OF NITRIC OXIDE DONATOR ‘TIVORTIN’
V.Ye. Vansovich, V.I. Pshenichny
National Medical University, ODESSA, Ukraine
Aims:To determine the efficacy of the postoperative hepatic parenchyma
functional condition in patients who after laparoscopic cholecystectomy
(LChE) received nitric oxide donator ‘Tivortin’. The background of the these
series of clinical-laboratory observations was to evaluate the principal possi-
bility of the hepatic parenchyma improvement in patients after LChE.
Methods: 26 patients with bile stones inside the gallbladder and acute chole-
cystitis were underwent to LChE. All of them had direct indications for LChE.
These patients were randomized into the following groups: the 1st group
patients (n = 11) received traditional therapy during the after operational
period. ‘Tivortin’ was included into the complex after operational treatment of
the 2nd group patients (n = 15). Hepatic specific enzymes [alanine amino-
transferase (ALAT), aspartate aminotransferase (ASAT) and base phosphatase
(BP)] activities together with plasma total protein and urea content were
determined during the postoperative period.
Results: There were no episodes of the hepatic failure among the patients of the
2nd group. There were 2 cases of hepatic insufficiency in patients from the 1st
group. Starting from the 2nd after LChE the 2nd group patients showed
insignificant protein (+23%) and urea (+19%) level increasing and BP (-26%)
decreasing together with both ALAT (in 1.7 times, p \ 0.05) and ASAT (in 2
times, p \ 0.05) activities decreasing pertaining the same indexes in blood
samples from the patients of the 1st group without ‘Tivortin’ administration.
The forthcoming clinical observation showed better clinical condition and
more improved hepatic parenchyma functional activity in the 2nd group
patients.
Conclusions: These data are in favour of earliest start of hepatoprotective
treatment in patients with bile hypertension. ‘Tivortin’ treatment resulted in
earlier and more effective hepatic parenchyma functional state improvement in
the operated patients.
P305 – Liver and Biliary Tract Surgery
IS THERE A STRONG ARGUMENT FOR ACUTE/SEMI-
ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY
FOR BILIARY COLIC?
O. Ayodeji, P. Burgess
The Great Western Hospital, BRISTOL, United Kingdom
Introduction: Biliary colic is a common presentation of gallstone disease. The
optimal management is adequate analgesia and laparoscopic cholecystectomy
at the index presentation/admission. However, this option is the exception
rather than the rule; most patients are managed conservatively and discharged
with a future elective surgery date. It has been noted that a proportion of this
patient do re-present during this ‘window’ period with recurrent symptom or
complications. The aim of this study is to determine the proportion of patients
who re-present, at what cost to the health service and if there is need for service
re-configuration.
Method: 152 patients who had laparoscopic cholecystectomy at the Great
Western Hospital between January and June 2011 were retrospectively
reviewed. Data on waiting time to surgery, mode of presentation and recurrent
admissions were collated. The cost of readmissions was also calculated.
Findings: 137 patients had an index presentation of biliary colic confirmed by
ultrasonography. Mean waiting time to surgery 22 weeks. Acute presentation-
49, outpatient presentation-88. 23(16%) patients re-presented with recurrent
symptom/complication. The total inpatient stay was 154 days at a cost of about
£60,000.
Conclusion: There is a strong economic and health benefit to establishing an
acute/semi-elective laparoscopic cholecystectomy service for patients pre-
senting with biliary colic.
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P306 – Liver and Biliary Tract Surgery
THE EFFECT OF A SPECIALISED BILIARY SERVICE
ON OPEN CONVERSION OF LAPAROSCOPIC
CHOLECYSTECTOMY AND BILE DUCT EXPLORATION
M.K. Nassar, V.M. Gough, Z. Ahmed, H.M. Nassar
Monklands Hospital, AIRDRIE, United Kingdom
Aim: To evaluate the causes and incidence of open conversion in a referral
biliary unit treating all biliary emergencies admitted to a district hospital in one
session.
Methods: Analysis of a prospective series of 3328 laparoscopic cholecystec-
tomies (LC), including 650 common bile duct explorations over 19 years. No
cases were preselected for open surgery.
Results: The male to female ratio was 1:4 with a median age of 51 years (range
14–89 years). There were 1007 emergency admissions (30.2%) including
jaundice in 423 cases (12.7%), acute pancreatitis in 182 5.4% and acute cho-
lecystitis/empyema in 197 cases (5.9%).. 963 cases (29%) had had previous
abdominal surgery. LCBDE was done in 650
Open conversion was necessary in 27/3328 cases (o.8%) over 19 years. Two
thirds were female. The converted cases had a median age of 52.5 years
(26–78). 19 (70%) of those needing conversion were emergency admissions;
presenting with jaundice in 13/27 (48%) and acute cholecystitis/empyema in 3
cases (11%). 3 patients (11%) had abdominal scars resulting from previous
abdominal surgery. Risk factors for bile duct stones were present in 17 cases
(65.38%), and CBD stones requiring LCBDE were present in 15 cases (57.7%).
We found significant associations with jaundice, choledocholithiasis, ASA
score of 3 or higher, empyema and Mirizzi syndrome (p \ 0.01 for each), as
well as a thickened or contracted gall bladder on the preoperative ultrasound
scan (p = 0.02).
Conclusion: Referring emergency biliary cases to a specialised firm within a
district hospital can optimise the conversion rate in high risk patients. Tradi-
tional risk factors such as gender, previous abdominal surgery, acute
cholecystitis and empyema and old age should not significantly influence the
decision of conversion.
P307 – Liver and Biliary Tract Surgery
THE USE OF HOLMIUM LASER UNDER DIRECT VISION IN
THE TREATMENT OF COMMON BILE DUCT STONES
A. Bond, D Veeramootoo, T. Liston, K Singh
Worthing Hospital, WORTHING, United Kingdom
Aims: The treatment of common bile duct (CBD) stones can vary in com-
plexity and many methods have been devised to achieve this laparoscopically.
Although holmium laser is frequently used in urological surgery, it is infre-
quently used on CBD stones.
Methods: The holmium laser was passed along a fiber introduced via a flexible
ureteroscope through a choledochotomy at the time of laparoscopic chole-
cystectomy. This energy modality was used to fragment the stones to a size that
allowed easy removal with irrigation through the flexible ureteroscope.
Results: We have a series of 3 patients who have successfully undergone this
technique.
Conclusion: The use of Holmium Laser in this fashion is an alternative
modality in the treatment of difficult CBD stones.
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P308 – Liver and Biliary Tract Surgery
LAPAROSCOPIC CHOLECYSTECTOMY FOR
GANGRENOUS GALL BLADDER IN DIABETIC PATIENT
A. Abdelaal, I. Sulieman
HMC, DOHA, Qatar
41 year old male patient who presented at accident emergency department with
history of 4 days right upper abdominal pain associated with vomiting and fever on
examination he had fever 38.5 tachycardia tender right hypochondrial region u/s
showed acute cholecystitis lap exploration showed distended gangerous gall bladder
lap cholecystectomy was done and he passed unevetfull post operative recovery.
P309 – Liver and Biliary Tract Surgery
SINGLE INCISION TRANS-UMBILICAL LAPAROSCOPIC
CHOLECYSTECTOMY USING CONVENTIONAL
LAPAROSCOPIC INSTRUMENTS: INITIAL EXPERIENCE
OF A SINGLE INSTITUTE
M.A. Hassan, M. Nasr, M.S. Hedaya, A.I. Nafeh, M. Elsebae
Theodor Bilharz Research Institute, GIZA, Egypt
Background: Laparoscopic cholecystectomy (LC) had been considered the gold
standard treatment for symptomatic gall bladder (GB) stones. Single incision lapa-
roscopic cholecystectomy (SILC) was emerged as a less invasive alternative with
better cosmesis and less post operative pain.
Objective: This study evaluated the feasibility, safety, advantages and complications
of SILC using the conventional laparoscopic instruments in our institute.
Methodology: A total of 52 patients (47 females and 5 males) with symptomatic GB
stones underwent elective SILC using the conventional laparoscopic instruments.
Results: The mean operative time was 61.75 minutes and the mean estimated blood
loss was 17.21 ml. Gall bladder perforation occurred in 5 cases (9.6%) in which 3
cases calculi spillage occurred. Troublesome cystic artery bleeding occurred in 2
cases (3.8%) while gall bladder bed bleeding happened in 1 case (1.9%). An
intraoperative cholangiogram was performed in 3 cases and a drain was inserted in
one case. No conversions of the technique occurred. 49 patients discharged in the
first post operative day and 3 patients (5.8 %) in the 2nd day. Three month post
operative wound length was an average of 1.58 cm while patient satisfaction of the
surgery was an average of 9.32.
Conclusion: In uncomplicated gall bladder stone disease; SILC is feasible and safe. It
has an excellent aesthetic results and high grade of patient satisfaction, it could be
performed with the conventional laparoscopic instruments and its scale of applica-
tion could be widened once enough experience attained.
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Surg Endosc (2013) 27:S53–S166
P310 – Liver and Biliary Tract Surgery
A PROSPECTIVE STUDY OF COMPREHENSIVE
GERIATRIC ASSESSMENT OF PATIENTS UNDERGOING
ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY
M. Venianaki, K. Lasithiotakis, I. Petrakis, A. Andreou, O. Zoras,
G. Chalkiadakis
University Hospital of Crete, HERAKLION, Greece
Aims: Older age is associated with increased postoperative complications attributed
to decreased functional reserves. Geriatric Comprehensive Assessment (CGA) is a
multidimensional assessment of the functional reserves of the patients. It has been
extensively evaluated in gerontology but has never been used in patients undergoing
laparoscopic surgery. Herein, the association of GCA with postoperative outcomes in
older patients undergoing elective laparoscopic cholecystectomy is assessed.
Methods: The study prospectively included 57 patients over 65 years old who
underwent elective laparoscopic cholecystectomy for uncomplicated biliary disease,
during the period of October 2008 and December 2011. All consenting patients
underwent CGA assessment within a week prior to surgery. Demographic data were
collected and the functional status of patients was determined by contemporary
geriatric tools, such as Lawton-Brody independent activities of daily life (IADL)
scale, Katz Basic activities of daily life index (ADL), Charlson’s comorbidity index,
the malnutrition universal screening tool (MUST), the mini-mental state examination
(MMSE). Postoperative complications were classified into five severity grades (I-V).
Results: Approximately half of the study patients (50.9%) were women and the
median (interquartile range) of their age was 73(8.8) years. Patients fulfilling the
frailty criteria after using IADL-score, ADL-score MMSE-score, MUST-score and
CCI-score were 14.0%, 7.0%, 14.0% and 51% respectively. Postoperative compli-
cations occurred in 22.5% of all geriatric patients, the majority (18.8%) of which
were grade I or II (no need for intervention). The commonest complications were
fever (7.5%) and hemorrhage (3.7%). One patient (1.8%) underwent exploratory
laparotomy for postoperative bleeding and one patient (1.8%) died of severe pan-
creatitis. Frail patients, according to the CGA assessment experienced significantly
higher incidence of postoperative complications compared to their fit counterparts
(84.6% vs 15.4%, p = 0.023).
Conclusion: Comprehensive geriatric assessment may predict outcome of elective
laparoscopic cholecystectomy for biliary disease.
P311 – Morbid Obesity
SATISFACTORY EFFECT OF THE LAPAROSCOPIC
SLEEVE GASTRECTOMY – 6 YEARS EXPERIENCE
M. Kasalicky1, R. Pohnan1, M. Burian1, I. Ilievova2, M. Haluzik3
1
Central Military Hospital and 2nd Medical School Charles
University, PRAGUE 6, Czech Republic; 2Trnava University,
TRNAVA, Slovak Republic; 33rd Internal Department 1stMedical
School, Charles University, PRAGUE, Czech Republic
Aim: Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the
treatment of morbid obesity seems to be a feasible bariatric-metabolic method for
patients with BMI ?40, BMI = 35 respectively. On the base of presented studies it
appears that LSG significantly improves metabolic disturbances and T2DM of
morbid obese (MO) patients.
Material and method: 148 MO patients (32 males, 116 females) underwent LSG
from 2006 to 2011. Average age was 43.2 years (19–65), height was 169.1 cm
(151–191), weight was 127.4 kg (97–184) and average BMI was 44.5 (34.1–71,9).
Dyslipidemia was pre-operatively diagnosed in all cases. T2DM was pre-operatively
diagnosed in 27(100%) patients (21 of them were on oral antidiabetics drugs (OAD)
and 7 were on combined therapy by insulin and OAD.
Results: Finally 97 MO patients after LSG from 2006 to 2011 were statistically
evaluated, by reason that 21 MO patients were excluded because of incomplete data
and 30 MO patients because of short time after LSG. Average weight loss was 35.1
kg (9–72), average %EBL reached 61.8 % (11.1–121.3), average %EWL was 59.2 %
(14.7–114.2) and average decrease of BMI was 14.6 (4.9–24.1). Diabetes completely
resolved in 71 % of preoperative diabetic patients during the postoperative period of
24 months and in rest (29 %) improved after surgery. Most frequent long time
complication was in 21,7 % heartburn very good responds to treatment with PPI.
Conclusion: The LSG is a safe bariatric procedure with long time good results in
both weight loss, and improvement of metabolic co-morbidities of patients with
obesity.
Supported by IGA MZ grant No. 10024-4.
Surg Endosc (2013) 27:S53–S166
P312 – Morbid Obesity
BARIATRIC BERIBERI: A SEVERE COMPLICATION
AFTER GASTRIC SLEEVE RESECTION
J.J. Harlaar, L.U. Biter, G.H.H. Mannaerts
Sint Franciscus Gasthuis, ROTTERDAM, The Netherlands
Introduction: After bariatric surgery patients often visit the emergency department with
dysphagia and general illness. Restricted intake and vomiting are common postoperative
complaints. In several cases this can lead to severe vitamin-deficiency states, such as
Wernicke’s encephalopathy (WE). We present two patients with no history of alcoholism
who developed Beriberi after a gastric sleeve resection for morbid obesity despite oral
vitamin supplementation and follow up.
Case description:
A 49 year old man was presented at the Emergency department with walking difficulties
and confusion after a gastric sleeve resection for morbid obesity (BMI: 44.1 kg/m2). The
last 4 months he was readmitted for 3 times for observation of dysphagia and dehydration.
All investigations, including upper GI endoscopy were normal. The patient had symptoms
of tingling and weakness in both upper and lower extremities and memory loss of recent
events. After one week the patient was diagnosed with neurologic Beriberi and Wernicke
encephalopathy due to a low vitamin B1 level. During treatment with intravenous thiamine
the muscle strength increased, yet the patient developed Korsakov syndrome. Six weeks
later a 50 year old woman was readmitted to the hospital after laparoscopic gastric sleeve
resection 3 months earlier because of morbid obesity (BMI: 56.5 kg/m2). Due to persisting
dysphagia the patient underwent a laparoscopic gastric bypass as revision surgery. A few
days postoperative the patient had difficulty walking and complained of tingling in her legs.
Thiamine levels were also low. The patient received direct treatment with intravenous
thiamine, and the symptoms disappeared slowly.
Discussion: These cases show that even if a multidisciplinary team takes care of bariatric
patients, oral vitamin and mineral supplementation is not always sufficient. We recommend
that patients with early dysphagia after bariatric surgery should start early with intramus-
cular thiamine supplementation, because these cases show that bariatric Beriberi can
develop quite rapidly.
P313 – Morbid Obesity
COMPARISON OF THE HIGH PRESSURE AND LOW
PRESSURE GASTRIC BANDS FOR THE TREATMENT
OF MORBID OBESITY
V.V. Grubnik, V.P. Golliak, O.V. Grubnik
Odessa national medical university, ODESSA, Ukraine
LAGB is popular procedure for treatment of obesity in Europe. However, the impact of
these operations depends on the design of a silicone band.
The aim was compare the results of operations using MiniMizer band and LapBand
in the long term of weight loss and complication rate.
Materials and Methods: Between 2005 and 2010, 164 patients underwent LAGB. In 81
patients (I group) standard LAGB using high pressure – low volume systems MiniMizer
Extra and Endomed was performed. Low pressure – high volume bandages LapBand was
used for the treatment of obesity in 83 patients who entered (II group).
Results: Two groups of the patients were equal in preoperative data. The median BMI in I
group was 45 kg/m2 (range = 35–62 kg/m2), median BMI in the II group was 45.8 kg/m2
(range, 37–65 kg/m2). Median %EWL in the patients of I group at 1, 3, 6, 12, 24, 36 months
postoperatively was 10, 17, 34, 50, 54% respectively, median follow-up attendances was
6.5. Median % EWL in patients of II group at 1, 3, 6, 12, 24, 36 months postoperatively was
9, 18, 38, 69, 72%, median follow-up attendances in this group was 20.
Early postoperative complications was observed in two patients of I group as a pouch
dilatation, and 1 patient of II group has early band slippage, it was connect with design of
the silicon band.
Late complications were in 14 patients in the I group (migration of the band – 8, port
infection – 6) and only in 3 in the II group (late band slippage – 2, port infection – 1).
Reoperation was performed in 8 patients of the I group and in 2 patients of the II group (p
\0.05).
Conclusion: Our preliminary results show that laparoscopic gastric banding is effective
operation for weight loss. However, the number of the long-term complications in the I
group is significantly higher than it was noted for II group.
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P314 – Morbid Obesity
EFFECTS OF SLEEVE GASTRECTOMY ON METABOLIC
CHANGES AND THE EVOLUTION OF LIVER STEATOSIS:
PRELIMINARY RESULTS
F. Sabench, M. Vives, A. Cabrera, M. Hernández, S. Blanco,
A. Sánchez, J. Jara, D. Del Castillo, E. Raga
Rovira i Virgili University. University Hospital of S. Joan.
IISPV.F.of Medicine, REUS, Spain
Aim: Laparoscopic sleeve gastrectomy is a good treatment for severe morbid obesity.
Hepatic steatosis of these patients is usually high degree and its evolution in relation to the
postoperative outcome of metabolic parameters is still being studied. Also, several works
have studied the prevalence of H. pylori in obese patients. His relationship with weight loss
and metabolic improvement is not sufficiently studied. The objective of this study is to
identify the degree of liver steatosis before and after sleeve gastrectomy and metabolic
changes produced. Also evaluate the prevalence of H. pylori in relation to such changes.
Methods: 65 morbidly obese patients operated on in the last 24 months (beginning in April
2009). An Intraoperative liver biopsy is performed to determine the degree of steatosis
according to Brunt scale. A gastroscopy is performed preoperatively with antral biopsy to
determine H. pylori. At 18 months postoperatively, a percutaneous liver biopsy guided by
CT is performed again.
Results: Significant improvement in laboratory parameters one year after surgery. The
distribution of intraoperative hepatic steatosis is 46.4% for grade I, and 21.5% and 20.1%
for grades II and III. A 12.3% had normal liver biopsy. At 18 months postoperatively, with
20% of the biopsies, 61.5% improves the degree of steatosis, 30 % holds the same grade and
one patient worsens the degree of steatosis. 2 patients normalized pathology (15.3% of the
biopsies for the moment). Patients with more severe steatosis are those with an excess
weight loss increased (p \0.001). 22% of the sample is positive for H.pylori, with no
differences between sexes or in relationship with the postoperative weight loss. In H. Pylori
negative patients, there is no improvement of steatosis at no case (p \ 0.05).
Conclusions: Sleeve gastrectomy produces a significant improvement in metabolic
parameters and hepatic steatosis, more related to metabolic and weight improvement than
with liver parameters themselves. The prevalence of H. pylori is found in the lower limits of
the accepted range for such patients, although most studies find an increased prevalence
than in a healthy population. Their presence does not imply a lower weight loss in our
patients undergoing surgery.
P315 – Morbid Obesity
ANALYSIS OF GASTRIC EMPTYING IN MORBIDLY OBESE
PATIENTS CANDIDATES FOR BARIATRIC SURGERY:
PRELIMINARY RESULTS.
F. Sabench, M. Hernández, A. Cabrera, M. Vives, E. Raga, M. Parı́s,
S. Blanco, D. Del Castillo
Rovira i Virgili University. University Hospital of S. Joan.
IISPV.F.of Medicine, REUS, Spain
Aim: In morbidly obese patients we can observe an alteration of gastrointestinal motility
respect to non obese patients, but their meaning is not entirely known, showing contro-
versial results with Gastric scintigraphy. This emptying may be accelerated, normal or even
delayed, indicating that other factors may be involved in this variability. Moreover,
intestinal incretines (GLP-1 and GIP) are working together to reduce postprandial hyper-
glycemia inhibiting gastrointestinal motility and gastric emptying. GLP-1 is considered the
most effective of them.
Methods: We study in preoperative and preliminary form, a series of 30 morbidly obese
patients undergoing surgical treatment of their obesity (15 Sleeve gastrectomy and 15
Roux-en-Y gastrojejunal bypass). All patients were performed a preoperative Gastric
scintigraphy with marked food (Tc99) at a dose of 2 mCi. It filled the estimated gastric
emptying time at the initial small intestine and then calculates the curve activity/time of
emptying. Also, we will determine plasmatic levels of GLP-1 and Ghrelin.
Results: 30 morbidly obese patients (90% F – 27, and 10 M – 3). Average BMI of 48.4 ± 6
(36–62 kg/m2). Diabetes mellitus type 2 in 10 patients (33.3%), hypertension in 14 patients
(46.7%). T1 scintigraphy (first emptying the small intestine) 15.37 ± 11 minutes. Emptying
time curve according to activity/time:134.27 ± 65 minutes. There is a significant difference
in the emptying of patients with a higher comorbidity, whether hypertensive or diabetic
patients (111.11 ± 51 minutes) than those without a higher comorbidity (174.27 ± 46
minutes) p \0.05. We could not find any significant correlation with gastric emptying, age
and with BMI.
Conclusions: In this study we observed a significant accelerated emptying specifically for
patients with diabetes mellitus and/or preoperative hypertension. This reaffirms the
hypothesis of a possible lack of regulation of GLP-1 in the morbid obesity before surgery.
The expected increase of GLP-1 after surgery might also help to normalize gastric emp-
tying. Evaluating the results at 6 and 12 months of the intervention, the study will be
completed regard to the influence of surgery on gastric emptying according to the technique
performed and the hormone levels of GLP-1 in particular.
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P316 – Morbid Obesity
CARDIA ADENOCARCINOMA IN THE CONTEXT
OF A ROUX-EN-Y GASTROJEJUNAL BYPASS
FOR MORBID OBESITY
M. Vives, A. Cabrera, F. Sabench, M. Hernández, M. Socı́as,
S. Blanco, D. Del Castillo
University Hospital of sant Joan. Rovira i Virgili Univ.IISPV.,
REUS, Spain
Aim: The surgical procedures that alter the function of the digestive tract may predispose to
the emergence of cancer. Cases have been published of cancer in the neo-esophagus after
colonic interposition or a Collis gastroplasty.
The aim of this paper is to report the case of a female patient suffering from cardia
adenocarcinoma who had previously undergone a gastric bypass for morbid obesity and to
review whether there are any risk factors that may be associated.
Methods: 63-year-old female patient with a history of type 2 diabetes mellitus and an
adjustable gastric band inserted 11 years before. Three years later she had not lost a
sufficient amount of weight and her comorbidities had not improved, so she underwent a
second intervention with gastric band extraction. A Roux-en-Y gastrojejunal bypass was
performed. Seven years after, she presented symptoms of progressive dysphagia. A fibro-
gastroscopy revealed a neoformative process in the cardia compatible with
adenocarcinoma, and multiple hepatic metastases in the extension study. The fibrogas-
troscopy performed prior to the gastrojejunal bypass enabled pathology of the
gastroesophageal junction to be discounted at that time.
Results: Chemotherapy was initiated but the disease advanced and an expandable prosthesis
had to be placed at the level of the cardia. The patient did not respond well to the treatment
and died one year after the cardia adenocarcinoma had been diagnosed.
Conclusions: Several studies have observed an increase in the incidence of cardia adeno-
carcinoma in morbidly obese patients. One hypothesis is that obesity favours
gastroesophageal reflux disease because it increases intra-abdominal pressure. It has been
suggested that the changes in gastric motility after the gastric bypass increase the exposure
of the proximal stomach to acid. In 2007 Harutaka and Rubino observed that after the
gastric bypass the risk of developing a gastric adenocarcinoma was lower. They concluded
that the gastric bypass is a safe therapeutic option in morbid obesity even in areas with a
high incidence of gastric cancer. The presence of adenocarcinoma of the gastroesophageal
junction seems to be more associated with obesity and factors such as diet than to having
undergone a previous bariatric procedure.
P317 – Morbid Obesity
THE SAFE INTRODUCTION OF ROUX-EN-Y GASTRIC
BYPASS IN HOSPITAL WITHOUT PREVIOUS EXPERIENCE
IN THE TREATMENT OF MORBID OBESITY
S. Custovic1, H. Pandza1, N. Hadžiomerovic1, A. Alibegovic2,
R. Covic1, N. Mahmutovic1, A. Krupalija1, D. Matkovic1, S. Begic1
1
General Hospital Sarajevo, SARAJEVO, Bosnia-Herzegovina;
2
Vaxjo Central Hospital, VAXJO, Sweden
Introduction: LRYGB is today most widely spread operation in treatment of morbid
obesity. In B&H and region until recently there was no reports of successful introduction of
this procedure. The aim of this study was to evaluate safety of procedure introduction.
Materials and methods: Between November 2010 and November 2011 nine patients with
LRYGB were operated for morbid obesity. The patients with BMI greater than 40 kg/m2 or
patients BMI greater than 35 kg/m2 with comorbidities are included in the study. The loss of 5%
of initial weight was mandatory for all patients in order to reduce liver size preoperatively. All
patients were operated with the external bariatric surgeon with significant experience that
performs routine bariatric surgical procedures in his hospital in Sweden. The local team inter-
viewed the patients and explained procedure and preoperative protocol. The surgeon that
performed the operations with our team was familiar with all collected information about
patients by electronic correspondence several weeks before the procedure. Postoperatively, the
patients were sent to Intensive care unit where vital signs, blood count and CRP were monitored.
Results: There are nine patients that were successfully treated in this period. The BMI in the
first two patients changed from 44.60 kg/m2 and 47.55 kg/m2 to 31.38 kg/m2 and 32.80 kg/
m2 in 12 months. That means that these two patients lost 30.3% of their preoperative
weight. After 6 months the average weight loss for 6 of the 9 patients was 21.2%. There
were no significant complications with any of the patients and the average postoperative
hospitalization time was 3.7 days.
Discussion: Bariatric patients are connected with high operative risks. The problem with the
introduction of this procedure is the lack of experience of the staff. The learning curve for
this procedure is much longer than it is for the other laparoscopic procedures.
Conclusions: Introduction of bariatric procedure is feasible but serious learning
approach and multidisciplinary team work is necessary. The specific protocols
connected with procedure should be strictly followed in order to avoid complica-
tions. The surgeon with a lot of experience should be a leader of the team.
123
Surg Endosc (2013) 27:S53–S166
P318 – Morbid Obesity
RESOLUTION OF TYPE 2 DIABETES MELLITUS AFTER
LAPAROSCOPIC GASTRIC BYPASS
R. Corcelles, S. Delgado, A. Ibarzabal, D. Momblan, J. Vidal,
A. Lacy
Hospital Clı́nic Barcelona, BARCELONA, Spain
Background: The close relationship between obesity and type 2 diabetes (T2DM) is well
documented. Morbidly obese patients with T2DM who undergo bariatric surgery have
improvement or remission of their diabetes. Most non-surgical treatments can control
hyperglycemia but they cannot induce the remission of diabetes. Gastric bypass (GBP)
operation offers T2DM improvement or remission; however the mechanisms or variables
implied are not yet established.
Objective: To identify predictive factors of T2DM resolution after laparoscopic GBP sur-
gery in the morbidly obese patient.
Methods: We retrospectively evaluated pre- and postoperative data of 280 morbidly
obese patients with Metabolic Syndrome (MS) glucose component according Adult
Treatment Panel III (ATP-III) criteria, including demographics, duration of diabetes,
metabolic parameters and clinical outcomes that underwent laparoscopic GBP from
January 2007 to December 2008.
Results: Of 400 morbidly obese patients treated, 280 (66.5%) had MS glucose component
Glucose tolerance in basal situation was normal in 120 patients (30%), impaired fasting
glucose (IFG) in 64 (15.2%), oral glucose intolerance 86 patients (21.4%) and 130 T2DM
(32.4%). Mean T2DM years of evolution was 4.1 ± 5.2 years (range 0 to 26 years) with a
mean preoperative glycated Hb% of 5.4 ± 1.3 (range 3.9 to 11.9%). A logistic regression
statistics model developed for determining possible variables implied on MS glucose res-
olution after GBP surgery showed that patients with short age and diabetes evolution, better
metabolic control (glycated Hb%) and without insulin therapy are associated to higher
T2DM resolution rate. %EWL and preoperative elevated HOMA, have been also associated
to T2DM resolution after surgery.
Conclusion: The variables more strongly associated to a better T2DM resolution rate are
those in relation to a better metabolic glucose control before surgery, age and weight loss.
This should situate surgical therapeutic strategy in the early phases of the disease.
P319 – Morbid Obesity
LAPAROSCOPIC SLEEVE GASTROPLICATION VERSUS
LAPAROSCOPIC SLEEVE GASTRECTOMY:
PRELIMINARY RESULTS
O.B. Ospanov1, E.E. Sultanov2
1
1National Researsh Medical Center, ASTANA, Kazakhstan;
2
Medical University, ASTANA, Kazakhstan
The Aim this study was compared safety and efficiency two bariatric procedures: Lapa-
roscopic Sleeve Gastroplication (LSGP) and Laparoscopic sleeve gastrectomy (LSGE).
Methods: From June 2010 to December 2011, 15 patients (12 female) were operated.
All patients were randomly divided in two groups. In the first group 7 patients
underwent LSGP. Laparoscopic sleeve Gastroplication procedure not require gastric
resection and performed by plication greater curvature of gastric. In the second group
8 patients performed Laparoscopic sleeve Gastrectomy procedure performing with
resection greater curvature of gastric. Mean age was 34.4 years in LSGP-group and
36.5 years in LSGE-group. Mean BMI in LSGP-group was 43 kg/m2 and 41 kg/m2 in
LSGE-group. Follow-up visits for the evaluating of safety and weight loss were
scheduled for 1 week and 1, 3, 6, 12, 18, and 24 months in the postoperative period.
Results: All restrictive bariatric procedures were performed laparoscopically without
conversions. Mean operative time was 47 minutes in LSGP-group (ranging from 37
to 80 minutes) vs. 86 minutes (ranging from 74 to 120 minutes) in LSGE-group.
Mean hospital stay was 47 hours (ranging from 38 to 70 hours) in LSGP-group vs. 58 hours
(ranging from 43 to 90 hours) in LSGE.
All patients in both group returned to normal activities ten days (5–14 days) following
surgery. In LSGP-group mean percentage of excess weight loss (EWL) was calculated to be
21 percent at one month, 29 percent at three months, 51 percent at six months, 59 percent at
12 months, 61 percent at 18 months, and 62 percent at 24 months. In LSGE-group mean
percentage of EWL was calculated to be 19 percent at one month, 27 percent at three
months, 48 percent at six months, 56 percent at 12 months, 59 percent at 18 months, and 61
percent at 24 months (P [0.5). In both group were not significant complications, such as
gastric leaks. The advantage of LSGP was no need for suturing devices, allowing to save
money on each patient an average of 2400 $ US.
Conclusion: our preliminary study shows that LSGP and LSGE are safe and effective
bariatric procedures. However LSGP is simpler and cheaper LSGE.
Surg Endosc (2013) 27:S53–S166
P320 – Morbid Obesity
SPECTRUM OF REVISIONS IN BARIATRIC SURGERY:
EXPERIENCE OF A TERTIARY REFERRAL CENTRE
F. Chikh Torab1, M.Y. Kayal2, M. Taha2, A. Saleh2, F. Branicki1
1
UAE University, AL AIN, United Arab Emirates; 2Tawam Hospital,
AL AIN, United Arab Emirates
Introduction: Revisional bariatric surgery (RBS) compromises 16% of the operations per-
formed in our centre. Inadequate weight loss (70% of cases) or the presence of intolerable
side effects, technical and severe metabolic/nutritional complications are the most common
indications for RBS. We are reporting our experience in performing RBS in the period
between 2001–2011.
Patients and Method: A retrospective data collection from 1143 bariatric surgeries
including 186 RBS, 26 endoscopic intraluminal and 16 interventional drainage. RBS were
classified to 8 abdominal wall, 172 laparoscopic (92%), 6 open. Revisions were divided into
six groups (G): (G1 RBS after Gastric Banding): 6 operations on port site, 123 laparoscopic
revisions with band removal only(23), band replacement (1), sleeve (20) and bypass (78)
with or after removal of band, 2 open, 2 endoscopic (G2 revisions after gastric bypass): 1
drainage of abdominal wall abscess, 5 open revisions of leak (3), internal hernia (1),
bleeding (1), 14 laparoscopic revisions of leak (2) internal hernia (5) and GI bleeding (1),
conversion of one anastomosis to Roux-en-Y bypass (1), pouch resize (5), 10 endoscopic
revisions and 4 interventional placements of drainage, (G3 revisions after vertical gastro-
plasty): 6 laparoscopic placement of band (1), bypass (2) and sleeve (3), (G4 revisions after
sleeve gastrectomy): 17 laparoscopic revisions with resleeve (7), bypass (5), revision of a
leak (4) and bleeding (1), 14 endoscopic revisions and 12 interventional drainages, (G5
cholecystectomy) in 9 patients), and (G6 others): open conversion of Duodenal Switch to
bypass. Results: Mortality of 0.5% with bowel ischemia after internal hernia. Morbidity of
9.6% with postoperative bleeding (5), mild pulmonary embolisms (2), abdominal wall
hematoma (1) persisting collections and sepsis (2), leaks from anastomosis or stapler lines
(6), stomach outlet obstruction (1), leak from band erosion (1). After endoscopic stenting 2
patients with severe chest pain and 4 continuous leak. 5 patients have inadequate weight
loss after RBS.
Conclusions: RBS is relatively safe, can be done mostly laparoscopically and as effective as
primary procedure. It is necessary to have a detailed informed consent for individualized
and creative approach. Adequate experience is necessary to achieve satisfactory results.
P321 – Morbid Obesity
VERTICAL GASTRECTOMY POST NISSEN
FUNDOPLICATION
C.M. Velasquez Hawkins, J.C. Tamayo Leon,
J. Cribilleros Barrenechea, L. Huillca Nuñez
Clinica San Gabriel, LIMA, Peru
We report the case of a 28 year old woman with important acid gastroesophageal
reflux symptomatology, mostly daytime presentation with severe esophagitis
(DeMeester score 19.6). Small correction of moderate symptoms with proton pump
inhibitors, with more than 10 years of disease described and treated medically.
He undergoes esophageal hiatal closure calibration and gastric fundoplication
symmetric and calibrated with correction angle of His. Patient improves dramatically
from their symptoms, improving quality of life quickly. Evidenced postoperative
progressive weight gain associated with metabolic disorders quickly installed as
insulin resistance, sleep apnea and high cholesterol.
Laparoscopy is performed; 34Fr probe orogastric calibration shows normal fundo-
plication and provision of adequate correction angle of His. They decide to make
vertical gastrectomy with normal calibration, section and reinforcing the suture line.
The patient evolved favorably in maintaining normal gastric transit, free endoscopy
esophagitis and normal manometry and pH control.
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P322 – Morbid Obesity
INCYDENTALOMA DURING LAPAROSCOPIC SLEEVE
GASTRECTOMY
L. Lehmann, M. Michalik, P. Lech, W. Siczewski, A. Trybull
Ceynowa Hospital, WEJHEROWO, Poland
Aims: GIST (gastrointestinal stromal tumor) is 1 % of all malignancies in adults.
Annually there were approximately 300 cases in Poland diagnosed, with the con-
dition. GIST tumors are formed on the walls of organs nutrients and usually does not
spread from there to the internal organs, but grow freely into the peritoneal cavity.
Therefore, it is often diagnosed too late when already reached considerable size.
Method: A 28-year-old woman, 42 BMI, with no comorbidities. was admitted to
hospital for surgical treatment of obesity (laparoscopic sleeve gastrectomy). The
patient was after abdominal angioplasty 6 years ago, two caesarian section and
laparoscopic cholecystectomy. Preparing the patient for surgery included: pharma-
cological antithrombotic prophylaxis (Clexane 40 mg), the antithrombotic stockings
and pneumatic cuffs, and antibiotic prophylaxis (Cefazolin 2 g). The operation took
place on 10.08.2011 in the general and vascular surgery department, Ceynowa
Hospital, Wejherowo, Poland.
Results: The surgery lasted 65 minutes, performed a standard laparoscopic tech-
nique. The control of the peritoneal cavity – intraoperatively change on the front wall
of the stomach (\2 cm). Real-time intraoperative study – GIST. After the consul-
tation oncological treatment was continued. There were no intraoperative
complications. Patient was released home on the second day after surgery.
Conclusions: Radical surgical resection of the primary tumor is the most effective
treatment for GIST. Control tests after 3 months showed no tumor recurrence. The
patient is under constant control of oncology.
P323 – Morbid Obesity
A COMPARISON OF LONG TERM RESULTS AND
ASSESSMENT OF QUALITY OF LIFE OF PATIENTS AFTER
LAPAROSCOPIC: SLEEVE GASTRECTOMY AND
ROUX-EN-Y GASTRIC BYPASS
W.D. Majewski1, K.K Kaseja2, B. Kolpiewicz1
1
Pomeranian Medical University, SZCZECIN, Poland;
2
Szczecin- Zdunowo, SZCZECIN, Poland
Aims: A comparison of long-term results and quality of life of patients operated on
for morbid obesity by laparoscopic Sleeve Gastrectomy and laparoscopic Roux-en-Y
Gastric By-pass in one surgical center.
Material and methods: Between 2006–2011 in Department of General and Vascular
Surgery Szczecin- Zdunowo 74 patients (54 F, 20 M) with morbid obesity were
operated on by two methods. Mean age (42.4 and 45 years), and BMI (46.5 ± 8.9 kg/
m2 for SG and 45.1 ± 4.4 kg/m2 for RYGB) respectively, were comparable. One
surgeon in one center performed SG in 33 patients (24 F, 9 M) and RYGB in 41
patients (30 F, 11 M). An independent observer assessed these patients in a time of
up to 6 months (37 pts) and after 6 months (37 pts) postoperatively. Quality of life
was assessed by GIQLI questionnaire with accessory questions concerning sexual
and physical activity before and after intervention.
Results: There was no serious long term morbidity after both types of operation,
however one patient in each group felt permanent postoperative discomfort (2.44%
and 3.03%). Percentages of excess weight loss (% EWL) after 6 and 12 months in
both groups were similar and reached 38.5% SG, 39.9% RYGB and 64.5% SG,
66.9% RYGB respectively. Quality of life assessment revealed significantly lower
values in core symptoms in patients after RYGB compared to SG (fullness in epi-
gastrium, flatulence, release of gases, belly bulging, sudden unexpected movement of
intestine) but in patients after SG constipation was slightly more frequent. However
general GIQLI score for patients after both types of surgery was statistically insig-
nificant (110 for SG versus 108 for RYGB). In both groups sexual and physical
activity significantly improved after operation.
Conclusions: There were no significant differences of effectiveness of both methods:
laparoscopic Sleeve Gastrectomy and laparoscopic Roux-en-Y Gastric Bypass in
assessment of long term results and quality of life in our patients. However these
results require confirmation in larger groups of patients.
123
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P324 – Morbid Obesity
BARIATRIC OPERATIONS IN THE TREATMENT
OF METABOLIC SYNDROME
G.R. Askerkhanov1, R.G. Askerkhanov2, I.E. Khatkov2,
I.I. Shikhsaidov3, R.A. Bayramov1, M.A. Kazakmurzaev1
1
Medical centre named after Askerkhanov R.P., MAKHACHKALA,
Russia; 2State Medical Stomatologic University, MOSCOW, Russia;
3
Daghestan State Medical Academy, MAKHACHKALA, Russia
Aim: To determine the effectiveness of the treatment of fundamental component of met-
abolic syndrome (MS) with the use of different methods of bariatric interferences.
Material and methods: Analysis of the results of different laparoscopic bariatric interfer-
ences at 144 patients was performed. In 62 cases is executed the adjustable gastric banding
(LAGB), into 16 – sleeve gastrectomy (LSG), into 11 – duodenal switch (LDS), also, in 6
patients Roux en Y gastric bypass (LGB). The average age of patients was 34 years (from
21 to 59), women there were – 132 (91%), men – 12 (9%), the average pre-operation of the
body mass index of (BMI) composed 40 kg/ m2 (from 35 to 54), patients with the metabolic
syndrome (MS) there were 42 (67%). Maximally distant periods after operations are traced
of up to 6 years. The effectiveness of all forms of treatment used was evaluated according to
the action of bariatric interferences on fundamental component of MS.
Results: During first two months after operation average loss of the excess mass of body
composed 67%. The absence of result was not observed. The loss of the excess mass of
body (EMB) directly depended on initial. Thus, with BMI of 35–40 kg/m2 the loss of the
EMB composed 88%. With the BMI of 40–45 kg/m2 – 69%, with 45–50 kg/m2 – 47%, with
50 kg/m2 and more – 43%. After 1 year in 30% of patients arterial pressure were nor-
malized, the signs of disturbance of tolerance to the glucose and diabetes mellitus of II type
(DM-II) were leveled in 53%. The comfort of nourishment after LSG is noted in 94%. After
LGB is normalized general cholesterol and atherogenic lipids, glucose level of the blood to
the standard in 5 (83.3%), is reduced. 6 months after fulfillment LGB loses the symptom
complex, which distinguishes MS. After LDS is noted steadfast lipid-lowering effect and
regress of DM-II in 100% operated.
Conclusions: All bariatric operations through the half of year had improved the indices of
MS. The shunting operations possess the best effect on the action on fundamental com-
ponent of MS.
P325 – Morbid Obesity
GASTRIC LEAK IN SLEEVE GASTRECTOMY AND
GASTRIC PLICATION – THE ROLE OF DRAINAGE
AND CONSERVATIVE TREATMENT
P. Holeczy1, M. Bolek1, M. Buzga2
1
Vitkovice hospital, OSTRAVA-VITKOVICE, Czech Republic;
2
Medical Faculty, Ostrava University, OSTRAVA, Czech Republic
Aim: leak from resection line in sleeve gastrectomy is known complication. The conse-
quencies are some times fatal. Conservative treatment by means of drainage and successive
drain pull out could be very successful treatment modality. The authors describe their
experience with two cases od leak in sleeve gastrectomy and one case in gastric plication.
Material and methods: From the series of 184 operations (149 sleeve gastrectomies, 35
gastric plications) three cases of gastric leak were identified. In the first case leak from
staple line after sleeve gastrectomy was observed 6 days after the operation.. Reoperation
and suture did not solved the complication. Drainage was left in situ and the drain was
successively extracted. The gastrocutaneous fistula was created. This has healed sponta-
neously in very short time. In the second case leak from resection line was observed three
weeks after the operation. Conservative treatment with antibiotics was effective. In the third
case perforation of the gastric wall after gastric plication was observed. Reoperations and
suture did not solved the complications, too. The same access, as mentioned above, was
used successfully.
Results: All three complications were solved succesfully by means of drainage, or con-
servative treatment. The hospital stay in all cases did not exceeded three weeks. In follow
up no other complications were observed.
Conclusion: Conservative treatment and drainage with creation of gastrocuteanous fistula
could be very effective treatment modality in the management of gastric leaks in bariatric
surgery.
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Surg Endosc (2013) 27:S53–S166
P326 – Morbid Obesity
EFFECT OF ROUX-EN-Y GASTRIC BYPASS ON SKELETON,
5 YEARS FOLLOW UP
M. Raoof1, E. Szabo2, I. Näslund2
1
Lindesberg Hospital, ÖREBRO, Sweden; 2University Hospital
Örebro, ÖREBRO, Sweden
Aims: To evaluate the effect of weight loss after Roux-en-Y gastric bypass (RYGB) surgery
on Bone Mineral Density (BMD) and eventually development of osteopenia.
Methods: We analyzed changes in BMD on 26 female aged 42 ± 8 with BMI 44 ± 4.4
years after RYGB surgery. BMD scanning with DXA in the hip, lumbar spine L1-4 and
total body BMD. Plasma determination of Calcium, Parathyroid hormone and 25-hydrox-
yvitamin D. All the patients received Vitamin B12 Iron, Calcium and Vitamin D
substitution routinely.
Results: We found following results. Pre-operative BMI 44.2 ± 4.4, S-Corr. Ca 2.3 ± 0.1,
BMD-Hip 1.85 ± 0.2, BMD-L1-4 1.49 ± 0.2. Post-operative, BMI 32.3 ± 5.5, S-Corr. Ca
2.3 ± 0.1 BMD-Hip – 0.3 ± 0.9, BMD-L1-4 – 0.4 ± 1.2. 6 patients with Osteopenia and 2
patients with Post-operative Osteoporosis. PTH 83 ± 32 (36–105) 12 patients developed
secondary HPT of whom 9 with PTH [100.Vit. D 47 ± 24 (19–109). 2 patiens [75 nmol/l
and 1 patient \20 nmol/l
Conclusion: Although the routinely substitution of Calcium and Vitamin D after RYGB
surgery, can patients develop low levels of Calcium and Vitamin D and in some cases can
lead to osteopenia and secondary hyperparathyroidism. Low levels of BMD especially in
Hip and Lumbar regions increases the risk for osteoporoses in the future.
P327 – Morbid Obesity
THE PECULIARITIES OF LAPAROSCOPIC
CHOLECYSTECTOMY IN OLDER OBESE PATIENTS
A.V. Pepenin, I.V. Ioffe
State Medical University, LUGANSK, Ukraine
Aims: The improvement of laparoscopic cholecystectomy results in aged patients with an
obesity of 3–4 degrees.
Methods: The pathological obesity defines as an ideal body weight excess greater than 45.5
kg. Such form of obesity is not considered as contraindication for laparoscopic cholecys-
tectomy now. However in aged patients it coincides with a number of technical difficulties
and complications. Some conditions that we used allowed us to reach a successful outcome
of treatment in the majority of cases are given below.
Results: 1. Safe access and adequate visualization of anatomic structures in the liver gate
are the main conditions of successful laparoscopic cholecystectomy in aged patients suf-
fered with obesity. It’s important to choose the first incision correct and optimal place –
usually 2.5–12.5 sm above the umbilicum. We prefer the ‘open’ Hasson access with an
aboveumbilical trocar introduction for the avoiding of gase accumulation inside the be-
foreperitoneal space.
2. To prevent CO2 gradients of absorption changes we made its insufflation with small
speed throughout appr. 20 min. The balance between CO2 pressures in blood and in tissues
occurs during this time.
3. We used 8 Hg mm intraabdominal pressure during the surgical intervention for the
decreasing the influence on venous blood return.
4. Sometimes we used an additional trocar in right part of the abdominal cavity or laterally
for both the organs’ retraction simplification and operational field enlargement.
5. We are making the hydraulic tissues dissection in the presence of expressed perivesical
adhesions that makes significantly easier the gallbladder seizing out of adhesions.
6. The intervention finishes by the umbilical wound obligatory drainage that practically
excludes its suppuration.
Conclusions: Therefore, the complex of the abovementioned procedures allowed us
to avoid carboxyperitoneum-derived complications after the laparoscopic chole-
cystectomy in 150 aged patients with obesity.
Surg Endosc (2013) 27:S53–S166
P328 – Morbid Obesity
GALLSTONE DISEASE IN MORBIDLY OBESE PATIENTS
UNDERGOING LAPAROSCOPIC SLEEVE GASTRECTOMY.
RESULTS FROM A PROSPECTIVE SINGLE CENTER
STUDY
K. Albanopoulos, M. Natoudi, P.G. Ilias, E. Menenakos,
S.G. Panousopoulos, K. Stamou, G. Zografos, E. Leandros
Bariatric Surgical Unit, Hippocration Hospital of Athens,
Athens Medical School, ATHENS, Greece
Aim: To study the incidence of cholelithiasis in morbidly obese patients submitted to
Laparoscopic Sleeve Gastrectomy (LSG) and correlate the results with their clinicopatho-
logic characteristics and follow up data.
Methods: Fifty two patients submitted to an elective LSG between 2009 and 2010 in a
single center, participated in a prospective ultrasonographic imaging protocol in order to
assess the prevalence of pre- and post-LSG cholelithiasis. The protocol included routine
preoperative upper abdominal ultrasonography and repeat ultrasonography 6, 12 and 18
months postoperatively, or when symptoms developed. The study included 12 male (23.1%)
and 40 female (76.9%) patients; mean age: 40.7 ± 12.7 years and a mean BMI: 47.7 ± 9.7.
Patient characteristics and clinicopathological data were retrieved from our prospectively
compiled database.
Results: Five patients (9.6%) had previous laparoscopic cholecystectomy (LC) for symp-
tomatic cholelithiasis. Eight patients (15.4%) had cholelithiasis at the time of the bariatric
procedure (and were excluded from the postoperative cholelithiasis group of patients). Five
of these patients (9.6%) consented to simultaneous LSG and LC. Twenty seven patients
(51,9%) did not have a history or later development of gallstones. Cholelithiasis was
diagnosed in 11 patients (21.2%) during the 18 month follow up time, 5 of whom were
submitted to LC. Cholelithiasis patients presented a significantly greater BMI reduction at 3
months (but not at 6 or 12 months postoperatively) compared with cholelithiasis (-) patients
(10.73 vs. 8.96, p = 0.04). Symptomatic cholelithiasis developed in 3 patients (5.8%). One
of them presented with gallstones at the time of LSG while the other two during the follow
up period. LC combined with LSG did not add any kind of morbidity in our series.
Conclusions: Cholelithiasis is a common finding among morbidly obese patients especially
in those with greater BMI reduction during the first 3 months following LSG. Patients
should be advised to undergo concomitant LSG and LC if gallstones are present at the
initial bariatric procedure. This approach however is technically demanding due to severe
liver enlargement in obese patients. Patients with no previous LC should be closely fol-
lowed for newly diagnosed gallstones.
P329 – Morbid Obesity
LAPAROSCOPIC SLEEVE GASTRECTOMY WITH PSD-VÒ
REINFORCEMENT, 50 PATIENTS WITHOUT SIGNIFICANT
BLEEDING
F. Garcia-Moreno Nisa, J.L. Galindo, G. Rodriguez Velasco,
I. Botella, J. Paramo, J.D. Pina, P. Carda
Hospital Ramon y Cajal, MADRID, Spain
Introduction: Sleeve gastrectomy is a new restrictive bariatricprocedure increasingly indi-
cated in the treatment of morbid obesity. A feared complication is stapler line leak or
bleeding. Buttressing materials have been suggested as a means of reducing staple line leak
and bleeding rates. The authors report their experience of laparoscopic sleeve gastrectomy
using the PERI-STRIPS DRY with VERITAS (Synovis) staple line reinforcement and
evaluate the staple line leak and bleeding rates.
Methods: The data of 50 consecutive patients undergoing laparoscopic sleeve gastrectomy
(LSG) between November 2010 and July 2011 were analyzed prospectively. LSG was indi-
cated only for weight reduction with a body mass index (BMI)[35 kg/m(2) not associated
with severe comorbidity. PERI-STRIPS DRY with VERITAS (Synovis) staple line rein-
forcement (PSD-V) were used as a staple line reinforcement of Ethicon Echelon 60 blue
cartridges. Study endpoints included mean BMI, operative data, conversion to laparotomy,
intraoperative complications, bleeding and fistula rates and duration of hospital day.
Results: This series comprised 38 females and 12 males with a mean age of 44.24 years
(range, 24–65) Mean weight was 126.5 kg (range, 105–165) and mean preoperative BMI
was 44.5 kg/m(2) (range, 38–64). The mean operating time was 95 minutes (range,
50–210). No patients required conversion to laparotomy. The incidence and severity of
intraoperative staple line bleeding was not specifically calculated but was visually noted to
be minimal in all cases. The 96% of patients (n = 48) had not significant drain fluid and no
blood transfusion was necessary in any case. The postoperative course was uneventful in
98% patients, not gastric fistula was observed in any case. The median duration of hospital
stay was 3.7. There was no mortality.
Conclusions: Laparoscopic sleeve gastrectomy is a safe procedure. PSD-V is easy to
load on the stapler, and no operative complications related to the use. Not significant
intraoperative or postoperative bleeding was observed with the Peri-Strips Dry with
Veritas collagen matrix and it is safe line reinforcement in terms of prevent
bleeding and gastric leak.
S135
P330 – Morbid Obesity
CRP, WHITE BLOOD CELLS AND NEUTROPHILS
AS EARLY PREDICTORS OF POSTOPERATIVE
COMPLICATIONS IN PATIENTS UNDERGOING
LAPAROSCOPIC SLEEVE GASTRECTOMY
L. Alevizos, K. Albanopoulos, M. Natoudi, E. Menenakos,
K.M. Stamou, D. Dardamanis, S.G. Panousopoulos, G. Zografos,
E. Leandros
University of Athens, ATHENS, Greece
Aims: Complications after Laparoscopic Sleeve Gastrectomy (LSG) are usually
silent and difficult to interpret. The objective of this study was to evaluate the value
of C-reactive protein (CRP) levels, white blood cell (WBC) count and neutrophil
(NEU) count on the early diagnosis of major surgical complication after LSG.
Methods: We performed a prospective study of 151 patients who underwent LSG
during the period 2008–2010. WBC count, NEU count and CRP levels were mea-
sured on postoperative days 0, 1, 3, 5, 7, 9, 11, 13 and 30 and correlated with
postoperative complications that occurred during the first month.
Results: Both WBC and NEU counts on postoperative days 3, 5, 7, 9 and 11 were
correlated with postoperative leak or abscess while on postoperative day 1 only
neutrophil count was significantly increased in this group of patients. CRP levels
increase was correlated with leak or abscess on all postoperative measurements (p \
0.001). There was no correlation between any of our measurements and postoper-
ative bleeding, unless leak or abscess co-existed. Using receiver operating
characteristic (ROC) curve analysis, CRP detected leak or abscess with a sensitivity
and a specificity of 1.0 (cut-off level 150 mg/l on postoperative days 1 and 5 and 200
mg/l on postoperative day 3). WBC and NEU were less accurate in the detection of
these complications (sensitivity 0.66 and 0.78 and specificity 0.91 and 0.97 for WBC
on postoperative days 3 and 5, cut-off level 12.5 cells/mm3 and sensitivity 0.78
specificity 0.76, 0.97 and 0.97 for NEU on postoperative days 1, 3 and 5, cut-off
level 10.5 cells/mm3).
Conclusion: CRP detected leak or abscess formation in patients undergoing LSG
with a sensitivity and specificity of 1.0 and seems to be a more accurate market for
the early detection of these two complications than WBC or NEU count.
P331 – Morbid Obesity
THE EFFECT OF LSG ON GLUCOSE METABOLISM
IN MORBIDLY OBESE PATIENTS
N. Memos, M. Natoudi, S.G. Panoussopoulos, K. Albanopoulos,
K.M. Stamou, E. Menenakos, G. Zografos, E. Leandros
1st Propaedeutic Surgical Clinic,Athens University,Hippocration
General Hospital, ATHENS, Greece
Introduction: Morbid Obesity is a major health problem, achieving epidemic pro-
portion in the western world. Surgery has a pivotal role in the management of the
morbidly obese patient, offering a variety of interventions. Laparoscopic Sleeve
Gastrectomy (LSG) isd an operation that, in recent years, is gaining acclaim as the
best solution for these patients, being less complicated and technically demanding
than gastric bypass or Scopinaro’s operation. On the other hand it has been debated
that it is not as metabolically efficient.
Aim: This is a prospective observational study, aiming to investigate the effect of
LSG on glucose metabolism in morbidly obese patients.
Patients and Methods: 75 patients who underwent LSG in the Morbid Obesity
Department of the 1st Propaedeutic Surgical Clinic between March 2008 and March
2010 were subjected to OGTT testing prior to and -3 -6 -9 -12 months after surgery.
Follow up was at -1 -3 -6 -9 -12 -18 -24 months after surgery and it was performed in
the department for all patients.
Results: Of these patients, 21% were known diabetics (DM2), receiving treatment,
before surgery. 29% had a normal OGTT and no DM history. 50% had abnormal
OGTT results without prior DM diagnosis. In the DM2 group, 60% had a full
remission of DM2 with normal OGTT and no medication, while the rest 40% were
understaged into a \pre-diabetic[ state, with abnormal OGTT but no further
medicinal treatment. In the preoperatively \pre-diabetic[ group, 87.5% achieved
normal OGTT values post-operatively.
Conclusions: LSG is a safe operation for the management of morbidly obese
patients. This study shows that LSG offers significant short- and mid-term results in
dealing with the metabolic aspects of morbid obesity.
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S136
P332 – Morbid Obesity
AN EASY AND REPRODUCIBLE TECHNIQUE FOR ACCESS
TO THE ABDOMINAL CAVITY AND ESTABLISHING
PNEUMOPERITONEUM IN BARIATRIC PATIENTS
A. Assalia1, A. Mahajna1, N. Sakran2, Y. Kluger1
1
Rambam Health Care Campus, HAIFA, Israel; 2Hillel Yaffe Medical
Center, HADERA, Israel
Introduction: Many techniques have been reported describing access to abdominal
cavity in bariatric patients. Among other techniques, the most prevalent are the
closed technique with Veress needle inserted either through the umbilicus or the left
subcostal area, the open approach and the optical trocar technique. We describe
herein our experience with a simple and expedite technique for establishing pneu-
moperitoneum in bariatric patients.
Methods: All patients undergoing bariatric procedures from September 2007 through
December 2011 were included in this retrospective analysis. In patients with pre-
vious open upper abdominal surgery, either the open or the Veress needle techniques
were used. Following the first skin incision to the left of the upper midline, a
dissecting forceps were used to dissect the subcutaneous fat down to the fascia. The
fascia was bluntly punctured by the instrument and the opening was slightly dilated.
Then, a bladeless trocar was introduced to the abdominal cavity and pneumoperi-
toneum established through it. Complications related to the technique including
failures were recorded.
Results: The technique was utilized in 665 consecutive bariatric patients (493 sleeve
gastrectomy, 124 gastric bypass, 43 removal of bands and 5 adjustable gastric
banding). Failure was observed in 9 patients (1.35%), and in other 4 (0.6%) minor
controllable bleeding was seen from the omentum underneath the puncture site.
Failures were seen in muscular males (5 patients) and in 5 females who underwent
removal of bands after significant weight loss with considerable laxity of the
abdominal wall. No other complications were recorded.
Conclusion: The technique described is safe, simple, reproducible, requires no
special instrumentation, and quick for establishing pneumoperitoneum in obese
patients.
P333 – Morbid Obesity
LATE GASTRIC LINE RE-LEAK AFTER LAPAROSCOPIC
SLEEVE GASTRECTOMY. A CASE REPORT
E. Kleidi, K. Albanopoulos, M. Natoudi, J. Papailiou, E. Menenakos,
G. Zografos, E. Leandros
Hippocration General Hospital, ATHENS, Greece
Aim: The purpose of this study is to present a case of a late staple line re-leak after
initial successful management in a patient that had a laparoscopic sleeve gastrectomy
(LSG). To our knowledge no such case has been described in the literature before.
Case presentation: A 45-year-old female patient with body mass index (BMI) 45.2
kg/m2 underwent a LSG and concurrent removal of an adjusted gastric band placed 3
years earlier. On postoperative day 1, staple line leak was observed on CT scan.
Patient was taken to theatre for laparoscopy. A staple line leak was identified next to
the gastro-esophageal junction which was successfully repaired and 2 draining tubes
were sited. The patient was treated with intravenous antibiotics and stayed on total
parenteral nutrition for 45 days. After a series of negative methylene blue tests as
well as gastrografin studies, drains were removed and she was discharged home.
Two months later she presented with a subcutaneous abscess located at the site of a
previous drain. Percutaneous drainage of the abscess revealed food contents. Gast-
rografin study showed a re-leak on the original staple line site. She was treated
initially with two expandable endoscopic stents (from 29 cm till the antrum) and later
on with a pigtail drain placed under CT guidance on the left subdiaphragmatic space.
Soon she was discharged from hospital and the stents were removed after two
months and the drain six months later when the fistula had healed.
Conclusion: Staple line leak is the most morbid complication of LSG. Subclinical
leak might be present despite the negative imaging studies. More data need to be
assembled in order to determine the time period of safety after conservative leak
treatment with drainage.
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Surg Endosc (2013) 27:S53–S166
P334 – Morbid Obesity
LAPAROSCOPIC GASTRIC PLICATION IS THE BARIATRIC
EFFICIENT OPERATION. ANALYSIS OF OUR EXPERIENCE
Y.I. Havrysh1, M.P. Pavlovskyy2, I.V. Krsvchuk1, Y.B. Shvydky2,
R.Y. Havrysh2
1
Lviv Regional Hospital, LVIV, Ukraine; 2Lviv Medical University,
LVIV, Ukraine
Aim: to analyze the results of the experience of laparoscopic gastric plication.
Method: from November 2010 to January 2012 we performed laparoscopic gastric plication
in 18 patients with morbid obesity. Among them were men – 4, women – 14, average age –
38 years, the average BMI – 46 (40 -70.1). In 5 patients was revealed type 2 diabetes,
including 3 patients who were taking insulin. One patient with type 2 diabetes had trophic
ulcer on foot with the size to 5 cm, which was treated 5 months. In one patient with type 2
diabetes developed diabetic retinopathy.
Results: for all patients we performed laparoscopic gastric plication typical method. The
period of observation lasted from 2 to 14 months. The average duration of surgery was 120
min. (70–180 min). Intraoperative complication: splenic injury – bleeding was stopped with
the help of LigaSure. Postoperative complication: trombembolism of small pulmonary
arteries which developed in 2 days after the surgery. The patient was treated conservative
by thrombolytic therapy. No mortality. 10 patients after the surgery felt pain in chest during
2–3 weeks. During the first month all of the patients lost from 5 to 10 kg of their weight.
After 3 months 90% of the patients lost from 7 to 12 kg of weight. After 6 months 80% of
the patients lost from 15 to 20 kg of weight. After 1 year 70% of the patients lost from 25 to
30 kg of weight. All of the patients feel good and satisfied with the result of the operation,
but in 3 patients weight loss was only 10 kg in 9 months. During the first week in all
patients with type 2 diabetes blood sugar level was normalized. In 3 weeks after the surgery
the patient with foot trophic ulcer was finally treated. The patient with diabetic retinopathy
after 2 months after the operation felt the improvement of vision. In 2 weeks after the
operations patients who received insulin stopped to take it.
Conclusion: Laparoscopic gastric plication is the safe operation, available for most of the
surgeons, and effective for weight loss.
P335 – Morbid Obesity
SLEEVE GASTRECTOMY AS A SALVAGE PROCEDURE
IN PATIENTS WITH ACUTE ISCHEMIA OF THE GASTRIC
FUNDUS AFTER LAPAROSCOPIC ADJUSTABLE GASTRIC
BANDING
B.F. Schwack, G. Fielding, M. Kurian, C. Ren-Fielding
New York University Langone Medical Center, NEW YORK, NY,
United States of America
Aims: Laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy
(SG) have been proven to be safe and effective means of weight loss. Patients can
develop ischemia of the gastric fundus due to gastric prolapse through the band
causing vascular compromise, or acute distention of the fundus leading to ischemia.
In the past year, 3 LAGB patients presented with ischemia of the fundus. All 3 were
safely managed with exploratory laparotomy, band removal, and instead of a limited
gastric resection of the necrotic area, formal SG.
Methods: This is a retrospective review of a series of 3 cases. Patients presented with
acute abdominal pain and demonstrated gastric necrosis (full thickness) of the fun-
dus. In one case, this was the result of gastric prolapse through the band. In two
cases, this was the result of acute ischemia associated with a massively dilated
fundus and gross perforation coming on after a huge meal. This condition has pre-
viously been reported with massive overeating in patients with anorexia nervosa. In
all 3 cases, the patients were managed with extensive washout, debridement of
ischemic tissue, and wide drainage. Instead of merely resecting the ischemic portion,
formal SG was performed using a 36 or 40 French bougie.
Results: All 3 patients recovered very well from surgery. None developed sepsis,
leaks, problems eating, or required re-operation. Two of the patients required per-
cutaneous drainage of small abdominal abscesses. In a brief 1 to 5 month follow-up,
all patients remained subjectively ‘restricted’ in terms of their appetite and all of
their BMI’s remained within 1 point of their presenting BMI. All patients were
functioning, tolerating regular diets, and fully recovered from their procedures
within a month.
Conclusion: Although the follow up is limited, the experience with these patients
supports that if a LAGB patient exhibits ischemia of the fundus, one can safely and
successfully perform SG as a salvage procedure. In doing so, one can safely treat the
offending problem (removal of the band and ischemic tissue) while still giving the
patient a chance to maintain their weight loss. Furthermore, this can eliminate the
need for a second bariatric procedure.
Surg Endosc (2013) 27:S53–S166
P336 – Morbid Obesity
INCISIONAL INFILTRATION AND INTRAPERITONEAL
INSTILLATION OF ROPIVACAINE FOR THE
MANAGEMENT OF PAIN AFTER LAPAROSCOPIC SLEEVE
GASTRECTOMY
L. Alevizos, G. Stamos, K. Albanopoulos, E. Menenakos,
K.M. Stamou, G. Zografos, E. Leandros, C. Loizou, A. Louizos
University of Athens, ATHENS, Greece
Aims: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity among bariatric
surgeons as a stand-alone procedure to surgically treat morbid obesity. Postoperative
pain, however, remains a problem and leads to increased morbidity, prolonging
hospital stay. The aim of this study was to evaluate the administration of incisional
and intraperitoneal local anesthetic on optimizing analgesia after LSG
Materials and Methods: For this trial, 60 patients were randomly assigned to three
groups. Group A had infiltration of the incisions with 25 ml of ropivacaine at the
completion of the LSG and intraperitoneal instillation with 20 ml of ropivacaine.
Group B had infiltration of the incisions with 25 ml of ropivacaine at the completion
of the LSG plus normal saline intraperitoneal instillation (20 ml). Group C (control
group) had infiltration of the incisions and intraperitoneal instillation only with
normal saline. Differences in verbal pain scores (VAS scores) at rest and cough
between groups were the primary endpoints. Fentanyl consumption as recorded on
PCA, additional analgesia demand (lornoxicam or meperidine) and alterations of
vital signs and SaO2 were the secondary endpoints.
Results: All groups were homogenous in respect to age, BMI, gender and duration of
surgery. Group A and group B presented lower VAS scores at rest and cough on the
recovery room and on postoperative hours 2, 4 and 6 compared to the control group.
Moreover, fentanyl consumption and the percentage of the patients that requested
additional analgesics in the ward were also significantly less in these groups compared
to the control group. However, when group A and B were compared to each other there
was no statistically significant difference in any of the parameters examined. None
significant adverse effects from the use of ropivacaine were observed.
Conclusion: Infiltration of the incisions with ropivacaine after the completion of
LSG is a safe and valid method for reducing postoperative pain and conception of
fentanyl and additional analgesia. The addition of intraperitoneal instillation of
ropivacaine did not offer any additional benefit in this group of patients.
P337 – Morbid Obesity
LAPAROSCOPIC GASTRIC PLICATION – AS AN
ALTERNATIVE BARIATRIC PROCEDURE TO SLEEVE
GASTRECTOMY
C. Duta, A. Dobrescu, D. Barjica, C. Lazar, F. Lazar
Univeristy of Medicine and Pharmacy, TIMISOARA, Romania
Background: Since the first paper published by Talebpour in 2007 of this new
procedure for treating morbid obese patients, several studies show that the short-term
results were acceptable. In 2010 we started to perform this new technique as an
alternative bariatric procedure to sleeve gastrectomy. In this study we present our
first experience with vertical gastric plication, focusing on the effectiveness and
complications.
Methods: Starting 2010 we perform only 17 laparoscopic gastric plication in patients with
a mean age of 41.4 years (25 to 54) and a mean BMI of 45 kg/m2 (41 to 53). We used five-
port approach (three 10 mm, two 5 mm) in the same position as for sleeve gastrectomy.
The first part of the procedure was similar to sleeve gastrectomy. After dissecting greater
curvature of the stomach we invaginated it using non-absorbable running suture. We
perform a gastric plication in two layers starting from the fundus (2 cm from the His angle)
to 5 cm of the pylorus. We ensure a patent lumen using a 36-Fr bougie.
Results: All 17 procedures were completed laparoscopically. Mean operative time
was 60 min (40 to 90 min) and mean hospital stay was 48 h (24 to 72 h). Patients
returned to their regular activities at an average of 7 days (4 to 9) following surgery.
No intra-operative complications occurred. Excess weight loss (EWL) after 1 month
was 25% (20% to 30%), 3 months was 35 % (28 % to 47 %) and after 6 months was
48% (41%-57%). The postoperative complication rate in our series was 17 %
(nausea, vomiting, abdominal pain).
Conclusions: This new procedure has the same result of weight loss as others with
minimal risk of complication and very low cost, especially in developing countries.
The lack of gastric resection or intestinal bypass and the lack of the use of prosthetic
materials are the major advantages of the technique that influenced the patients’
decisions. Early postoperative complications of this method are minimal. Longer
follow-up and prospective comparative trials are needed.
S137
P338 – Morbid Obesity
IS IT JUSTIFIED TO PERFORM A GASTRIC BANDING
PROCEDURE AS A PRIMARY BARIATRIC OPERATION?
D.V. Dardamanis1, S. Carandina2, B. Cadiere2, M. Bazi2,
P. Mathonet2, A. Pallisera2, E. Capelluto2, J. Bruyns2, G. Dapri2,
G.B. Cadiere2
1
Saint Pierre University Hospital, BRUSSELS, Belgium;
2
CHU Saint-Pierre University Hospital, BRUSSELS, Belgium
Aims: The aim of our retrospective study was to examine the long-term effectiveness
of Laparoscopic Adjustable Gastric Banding (LAGB) and to compare the results
between a Primary Gastric Bypass (PGBP) and a Secondary Gastric bypass (SLGB)
after a LAGB gastroplasty.
Methods: Between 1994 and 1997, 151 patients underwent a LAGB procedure.
Eighty two patients (54%) were available for full long term evaluation. After more
than 12 years of follow-up, the % of excess weight loss (%EWL) was 42%. Between
January 2004 and August 2008, 576 patients benefited from LGBP and 470 (81,6%)
were available for full evaluation. 362 patients benefited from a primary GBP
(PGBP) and 108 from a GBP after a gastroplasty with gastric band, Secondary
Gastric Bypass (SGBP).
Results: The incidence of erosion after LAGB is 29%, the band is removed in more
than half of the patients, 60% of the patients were reoperated, 17% of the patients are
converted to gastric bypass and the comorbidities are not significantly reduced.
Median hospital stay was 4 days (3–95) after PGBP and 5 days (2–114) after SGBP
(p \ 0.001). Early complications were recorded in 67 patients (18.5%) after PGBP,
and 43 (39.8%) after SGBP (p \ 0.001). A reoperation was necessary in 19 patients
(5.2%) after PGBP and in 18 patients (16.7%) after SGBP (p \ 0.001). Median
follow-up was 33 months (11–70). Mean % excess weight loss was 74.2% after
PGBP and 69.9% after SGBP (NS).
Conclusions: Long term results and rate of reoperations after LAGB questions the
role of a gastric banding procedure as an initial or as a sole operation for morbid
obesity. Gastric bypass is a feasible alternative with good results after a failed gastric
banding procedure but a much higher morbidity accompanies these procedures.
Gastric bypass may be proposed as the primary bariatric operation in nearly all obese
patients. We found no reason for a gastric banding procedure as a first step bariatric
operation.
P339 – Morbid Obesity
ADOLESCENT OBESITY AND BARIATRIC SURGERY.
A NEW BARIATRIC PROGRAM IN A CENTER OF
EXCELLENCE IN BARCELONA. PRELIMINARY RESULTS
R. Vilallonga, J.M. Fort, E. Caubet, O. Gonzalez, D. Yeste,
A. Carrascosa, S. Redecillas, J. Bueno, J. Lloret, J. Gastaminza,
N. Montferrer, M. Roca, C. Vasquez, A. Lecube, M. Armengol
Universitary Hospital Vall d’Hebron, BARCELONA, Spain
Introduction: Childhood obesity has become a serious health condition. Recent data
suggest an increasing number of children aged below 18 years with overweight and
even obesity reaching even a 16% of all them. For these reason and to respond to this
increasing problem, our hospital and specially the adult bariatric department with the
collaboration of the pediatric and adult endocrinology department, the paidopsy-
chiatrist department, anesthesiology department and the clinical nutrition department
have decided to create this surgical area.
Results: A systematic review of the current literature has been done in order to
establish the criteria for including adolescent patients for surgery. Since december
2011, three pediatric obese children have undergone a totally robotic sleeve gas-
trectomy as a sole and standard technique to treat these patients. Mean BMI was 51
kg/m2. There were no conversions and no postoperative complications.
Discussion: Without intervention, extremely obese children may continue to suffer
from obesity as adults and a decreased quality of life is expected. Surgical treatment
is accepted for children with Tanner 4 or 5, and BMI [ 40 kg/m2 with or without co
morbidities in our department. Other criteria have been included in our protocol.
Conclusion: A multidisciplinary team is necessary to approach these patients.
Adult’s bariatric surgeons have an important role in order to develop such an
important program. Robotic surgery has benefits compared to laparoscopic approach.
Robotic surgery can be an interesting approach for these patients in order to avoid
complications by increasing intra operative precision. A continuous analyse of our
experience will be required.
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S138
P340 – Morbid Obesity
REVISIONAL BARIATRIC SURGERY: COMPARISON
OF THE PREOPERATIVE UPPER GASTROINTESTINAL
STUDIES WITH THE PERIOPERATIVE ANATOMIC
FINDINGS
H. Reusens, H. Vanommeslaeghe, E. Van Dessel,
S. Van Cauwenberge, B. Dillemans
General Hospital Sint-Jan Bruges, BRUGGE, Belgium
Introduction: Morbid obesity is recognized as a global epidemic and still continues to
increase in the world. Bariatric surgery has become one of the most important treatments
and has research proven effectiveness to reduce or resolve comorbidities such as hyper-
tension, ischemic heart disease and diabetes. From all the different types of surgery, the
Roux-and-Y gastric bypass (RNYGB) is the most common performed procedure.
The rise of bariatric surgery in the last 10 years has led to an increasing number of
reoperations for failed procedures. Revisional bariatric surgery is a complex field. The
indications and types of reinterventions vary depending on the type of initial procedure and
the reason for intervention. The most common indications are failure to lose weight, weight
regain and complications. The most common complications after restrictive procedures are
gastric outlet obstruction in case of a vertical banded gastroplasty and slippage or migration
in the case of an adjustable gastric banding.
It is important to understand the altered anatomy in order to perform a save and successful
reintervention. The most important tool in assessing the upper gastrointestinal anatomy and
why the initial bariatric procedure has failed, is imaging by Oesophago-Gastro-Duodeno
fluoroscopy (OGDF). The interpretation of an OGDF is difficult and even dynamic imaging
can easily be misinterpreted. Some radiology centres are still not familiar with the altered
anatomy after primary bariatric surgery.
Methods: In 2011 we performed 187 redo-bariatric procedures, most of them con-
versions to RNYGB. Other cases included pouch reconstructions, blind loop
trimmings, gastro-gastric fistulas and more complex cases with a variety of distorted
gastric anatomy resulting from the first procedure. We selected some interesting
cases where we compare the preoperative radiographic diagnostics with the peri-
operative anatomy. From each case, the OGDF will be discussed, and the surgical
strategy will be shown and explained.
Conclusion: The OGDF is one of the most important tools in assessing altered anatomy. Correct
interpretation helps understanding the mechanisms of failure of bariatric procedures, and helps
in deciding if reoperation is indicated or even possible. Most importantly, an adequate evalu-
ation of the OGDF will help the surgeon in preparing different surgical strategies.
P341 – Morbid Obesity
RESULTS OF HAND SEWN GASTROJEJUNAL
ANASTOMOSIS IN LAPAOSCOPIC GASTRIC BYPASS
E. Baldini, C. Grassi, S. Albertario, F. Cattadori, M. Negrati,
P. Capelli
Ospedale ‘‘G. da Saliceto’’, PIACENZA, Italy
Background: Anastomotic fistulas are one of main complications of laparoscopic gastric
bypass and the incidence is often inversely proportional to the centre volume, like other
complications in bariatric surgery.
The aim of this study was to report results of hand-sewn gastro-jejunal anastomosis in
laparoscopic gastric bypass in a low volume centre.
Patients and methods: Between April 2004 and June 2011 we carried out 179 operations and
45 gastric balloons for morbid obesity. Hundred-fifty operations were laparoscopic gastric
bypasses. Patients were 122 women and 38 men. Mean age was 42.2 years (min 20–max
63). Mean BMI was 45.3 kg/m2 (min 36 – max 55). Gastric pouch was performed in a
standard fashion, measuring 6 cm along the small gastric curve from the His angle and
calibrating in all cases with a 36 French oro-gastric tube. Gastro-jejunal anastomosis was
termino-lateral in all cases, performed with 3 layers resorbable monofilament running
suture (2 posterior, 1 anterior). A blue methilene test was negative in all cases and a
postoperative radiologic swallowing test at postoperative day 2 was normal in all but one
case. Nasogastric tube was left in place until radiologic test. After the discharge patients had
endoscopic or radiologic examinations only in cases of clinical suspicion of anastomotic
disfunction. One year follow up was 96.1 %.
Results: We did not observe postoperative fistulas. We observed a perforation of posterior
wall of gastric pouch due to inappropriate orogastric tube manipulation, that required a
laparoscopy at postoperative day 2 for drainage of a retroperitoneal abscess. In this case
anastomosis was checked, without evidence of failure. Patient recovered in 2 weeks. We did
not observe intraoperative or postoperative anastomotic haemorrhage. One patient had an
anastomotic stricture one month after operation, that was treated successfully with 2
endoscopic dilations.
Conclusion: Manual technique in performing gastro-jejunal anastomosis in laparoscopic
gastric bypass can achieve good results even in low volume centres. Standardization of
technique is essential to keep good quality level.
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Surg Endosc (2013) 27:S53–S166
P342 – Morbid Obesity
CONVERSION OF FAILED LAPAROSCOPIC ADJUSTABLE
GASTRIC BANDING TO REVISIONAL BYPASS: RESULTS
FROM 76 CASES
A.S. Bedrosian, T.M. Lee, H.A. Youn, C. Ren Fielding,
B.F. Schwack, M.S. Kurian, G.A. Fielding
New York University School of Medicine, NEW YORK,
United States of America
Aims: Laparoscopic adjustable gastric banding (LAGB) has gained popularity as a
safe, reversible surgical treatment for morbid obesity. However, there are few studies
and no consensus on revisional bariatric surgery for those patients in whom banding
has failed. We analyzed results of conversion from LAGB to Roux-en-Y gastric
bypass or biliopancreatic diversion in one high-volume center.
Methods: A single-institution retrospective review was conducted on patients who
had undergone conversion of LGB to a revisional bypass procedure during the time
period January 2003 through November 2011. Data on patient demographics, sur-
gical technique, pre- and post-operative complications, and weight loss (body mass
index [BMI] and percent excess weight loss [%EWL]) were collected and analyzed.
Results: We identified 76 patients at our institution who underwent conversion from
LAGB to Roux-en-Y gastric bypass (RYGB; n = 62), biliopancreatic diversion
(BPD; n = 12), or biliopancreatic diversion with duodenal switch (BPD/DS; n = 2).
69 of the 76 conversions (90.8%) were completed laparoscopically. 29/76 (38.2%)
had required additional surgery prior to conversion for band-related complications
including slippage, erosion, port migration, hiatal hernia, bowel obstruction, or
leakage; all occurred at [;30 days. After conversion, the rate of complications
requiring hospitalization was 27.6% (21/76); 14.5% (11/76) occurred at \30 days.
There was one mortality. Mean time from band placement to conversion was 1439 ±
661.4 days (range 245–3140). At time of conversion, mean BMI was 44.4 ± 6.6 kg/
m2, and mean %EWL was 12.21 ± 20.7 (range 67–75). Following conversion, mean
BMI and %EWL at 12 months, respectively, were 31.6 ± 4.2 kg/m2 and 55.2 ± 24.7,
at 24 months 33.6 ± 5.6 kg/m2 and 45.3 ± 20.1, and at 36 months 33.0 ± 7.5 kg/m2
and 46.0 ± 18.2.
Conclusions: There is an increasing need for proven corrective solutions to failed
LAGB. Our results show that conversion to gastric bypass or biliopancreatic
diversion is an effective option, with lower complication rates than the initial sur-
gery, as well as durable excess weight loss at 3 years.
P343 – Oesophageal and Oesophagogastric Junction
Disorder
LAPAROSCOPIC TREATMENT FOR PARAESOPHAGEAL
HIATAL HERNIA
N. Tagaya, Y. Kubota, A. Suzuki, N. Makino, K. Hirano,
T. Okuyama, S. Kouketsu, E. Takeshita, H. Yoshiba, Y. Sugamata,
S. Sameshima, M. Oya
Dokkyo Medical University Koshigaya Hospital, SAITAMA, Japan
Background: Paraesophageal hiatal hernia (PHH) can often be associated with a
number of complications such as intestinal obstruction, gastric volvulus or acute
pancreatitis, which can result in critical conditions requiring surgery. We report our
surgical procedures for PHH with a review of the pertinent literature.
Materials and methods: In the last 10 years, we have performed surgical treatment
for hiatal hernia (HH) in 18 patients, comprising 2 males and 16 females with a mean
age of 73 years (range: 62–83 years). Thirteen patients (72.2%) had type I HH, 2
(11.1%) had type III and 3 (16.7%) had type IV. The operative procedure consisted
of crural repair and antireflux maneuver.
Results: Laparoscopic procedures were completed in all patients. The mean opera-
tion time was 160. 2 min for type I and 230.8 min for types III and IV. The mean
postoperative hospital stay was 7.8 days, and there was no mortality. Three patients
(16.7%) relapsed during a mean follow-up period of 74.9 months (range: 1–140
months). Two of them were asymptomatic and one required laparoscopic
reoperation.
Conclusion: Laparoscopic surgery for PHH is safety and effective with minor
morbidity and early recovery. However, although PHH is a benign condition, it can
occasionally cause critical conditions, and therefore it is important to decide the
appropriate timing of surgery on the basis of severity, general status, or co-morbidity
in each patient.
Surg Endosc (2013) 27:S53–S166
P344 – Oesophageal and Oesophagogastric Junction
Disorder
DOUBLE TRACT RECONSTRUCTION FOR TOTALLY
LAPAROSCOPIC PROXIMAL GASTRECTOMY WITHOUT
ASSISTING LAPAROTOMY - INITIAL REPORT OF OUR
CASES-
A. Iida, K. Sawai, M. Morikawa, K. Koneri, H. Nagano,
M. Murakami, Y. Hirono, T. Goi, K. Katayama, A. Yamaguchi
Gastroenterological surgery, FUKUI, Japan
We performed double tract reconstruction (DTR) for proximal gastrectomy in the patient of gastric
carcinoma near by cardia. This procedure was superior in the volume of intake and preventing the
gastro-esophageal reflux than esophago-gastro stomy. However, this procedure is relatively com-
plicated because that has multiple anastomoses. We report our procedure of the double tract
reconstruction in the totally laparoscopic proximal gastrectomy (TLPG).
Operative procedure: After the proximal gastrectomy was performed with lymphadenectomy and
preserving celiac branch of the vagus nerve, we cut the jejunum at the 15 cm from the Treiz’ ligament
and making Roux-en Y anastomosis by linear staplers. Then, we brought up the 40 cm of the Roux
limb through the hole at the mesentelium of the transverse colon that was made at the avascular area.
The esophago-jejuno stomy was performed by linear staplers on the fashion of functional end-to-end
anastomosis. The gastro-jejuno stomy was performed at the 15 cm downwards from the esophago-
jejuno stomy by linear staplers. We always confirm the anastomosis by leakage test. The holes of the
mesentelium were closed by stitches.
Result: We performed this procedure for the four patients with gastric carcinoma. Oral intake and
walking was started at the next day of the surgery. There was no complication. The patient was
discharged at the 12 post operative days with sufficient feeding.
Discussion: There is some report revealing the superiority of DTR in the volume of intake;
however, it may depend on the volume of remnant stomach. The reports also revealed the rapid
gastric empting of DTR. In spite of the superiority of DTR in open surgery, the reported procedures
of reconstruction in LPG were almost esophago-gastro stomy by their technical matter. Moreover,
majority of the cases of LPG performed with assist wound because of their complex procedures.
The anastomosis with linear staplers was useful for completing the multiple anastomoses in totally
laparoscopic surgery.
Conclusion: Double tract reconstruction for totally laparoscopic proximal gastrectomy without
assisting laparotomy showed stable operative course. Linear stapler was useful for completing the
multiple anastomoses.
P346 – Oesophageal and Oesophagogastric Junction
Disorder
THE EFFECTIVENESS OF LAPAROSCOPIC AND
ENDOSCOPIC COOPERATIVE SURGERY FOR GASTRIC
SUBMUCOSAL TUMORS
T. Kakishita, M. Naito, H. Mori, I. Akiyama, H. Kunisue, T. Ohta,
T. Fujiwara
Okayama medical center, OKAYAMA, Japan
Aims: We describe our experience of two cases of laparoscopic and endoscopic cooperative sur-
gery (LECS) for gastric submcosal tumors (SMTs).
Patient and method: Case1; A 54-year-old man was referred to our hospital because of a SMT
located at upper body of stomach near the esophagogastric junction. The tumor was 1.5 cm in
diameter and heterogeneous on endoscopic ultrasound (EUS) and spread by intraluminal. We
performed LECS for resection of the tumor and closed laparoscopically by hand sewing. An upper
gastrointestinal imaging revealed no deformities or stenosis of the esophagogastric junction was
present on postoperative day (POD) 4. He left hospital on POD 10. The histopathological diagnosis
was leiomyoma.
Case2; A 59-year-old woman was pointed out a SMT located at middle body of stomach. The
tumor was 3.6 cm in diameter and heterogeneous on EUS. We performed LECS for resection of the
tumor and closed by a laparoscopic stapler. She was discharged on POD 12. Two months after the
operation, endoscopy showed little deformity of stomach or no saburra. Histological examination
revealed the tumor was gastrointestinal stromal tumor.
Conclusions: LECS is a novel technique for gastric SMTs. The adequate cut line enables to
minimize surgical margin and preserve the function of esophagogastric junction.
S139
P347 – Oesophageal and Oesophagogastric Junction
Disorder
A SIMPLE AND PRACTICAL PROCEDURE
IN ANTI-REFLUX SURGERY FOR GERD PATIENTS
T. Suwa, K. Karikomi, N. Asakage, E. Totsuka, N. Nakamura,
K. Okada, T. Matsumura
Kashiwa Kousei General Hospital, KASHIWA, Japan
Introduction: Laparoscopic techniques in anti-reflux surgery for GERD patients are considered
complicated by many surgeons. We have simplified it and established a simple and practical
procedure.
Surgical Procedure: Setting: Our 5-trocar setting with patients in the reverse Trendelenburg’s
position is as follows. A 12 mm trocar was inserted just below the navel for a laparoscope. A 5 mm
trocar was inserted in the upper right abdomen for a snake-retractor to pull up lateral segment of the
liver, and a holder was used for a snake-retractor. A 5 mm trocar was inserted in the upper abdomen
for operator’s left hand. A 12 mm trocar was inserted in the upper left abdomen. A 12 mm trocar
was inserted in the middle left abdomen. The operator is positioned between the patient’s legs.
Step 1: Under laparoscopic view, left part of the lesser omentum was cut with preserving the
hepatic branch of vagus nerve. The right crus has been dissected free. The soft tissue at the
posterior side of the abdominal esophagus was carefully dissected.
Step 2: The branches of left gastroepiploic vessels and the short gastric vessels were divided with
LCS. The left crus of the diaphragma was exposed and the window at the posterior side of the
abdominal esophagus was widely opened.
Step 3: The right and left crura are sutured with interrupted stitches to reduce the hiatus. From the
right side, the stomach is grasped from behind the esophagus. Then the fornix of the stomach is
pulled to obtain a 360 degree ‘stomach-wrap’ around the esophagus (fundoplication). Such as
taping technique is not needed. Using non-absorbable braided suture, stitches are placed between
both gastric flaps.
The characteristic features of our procedure
1. Floppy Nissen fundoplication
2. No use of bougie device or taping technique for esophagus
3. Rotation of scope site
Results: This procedure needs 2 surgeons (the operator and the assistant (scopist)). The mean
operation time was about 60 min. A favorable outcome was assessed by radiograms performed
during hospital stay. Resolution of the symptoms was noted at follow-up 1 month postoperatively
in mostly all cases.
P348 – Oesophageal and Oesophagogastric Junction
Disorder
LAPAROSCOPIC REPAIR OF LARGE HIATAL HERNIA
BY TEMPORARY ATTACHMENT TECHNIQUE AND
COMPOSITE MESH
T. Suwa, K. Karikomi, N. Asakage, E. Totsuka, N. Nakamura,
K. Okada, T. Matsumura
Kashiwa Kousei General Hospital, KASHIWA, Japan
Introduction: Primary repair of large hiatal hernia is associated with a high recurrence rate. We
report our standard method in laparoscopic repair for large hiatal hernia using composite mesh and
temporary attachment technique.
Surgical Procedure: Setting: Our 5-trocar setting with patients in the reverse Trendelenburg’s
position is as follows. A 12 mm trocar was inserted just below the navel for a laparoscope. A 5 mm
trocar was inserted in the upper right abdomen for a snake-retractor to pull up lateral segment of the
liver, and a holder was used for a snake-retractor. A 5 mm trocar was inserted in the upper abdomen
for operator’s left hand. Two 12 mm trocars were inserted in the upper left and the middle left
abdomen. The operator is positioned between the patient’s legs.
Step 1: Under laparoscopic view, repositioning of hernial contents was performed at first and the
dissection of adhesion was often needed in this step.
Step 2: We usually do not remove hernia sac from outside of the abdominal cavity especially in the
large hiatal hernia cases. We cut the peritoneum to expose the hiatus and separate hernia sac. The
bilateral crura have been dissected free, and the esophagus is being recognized.
Step 3: The crura of the diaphragm were widely open and seemed difficult to be approximated with
direct suturing. The defect was reinforced with Bard Composix E/X mesh (10 x15 cm) which
had two distinctly different sides, polypropylene mesh on one side to promote tissue ingrowth and
sub-micronic ePTFE (polytetrafluoroethylene) on the other side to minimize adhesions to the
prosthesis. The mesh shape was prepared by hands to be fit nicely to the defect. We used an
absorbable tack fixation device for temporary attachment of mesh to the diaphragma. After the
temporary fixation, the suturing could be performed very easily. Using nonabsorbable braided
suture, stitches are placed between the mesh and the hiatus.
Results: This procedure needs 2 surgeons (the operator and the assistant (scopist)). A favorable
outcome was assessed by radiograms performed during hospital stay. There was no recurrence or
abdominal symptoms during the follow-up period in all cases.
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P349 – Oesophageal and Oesophagogastric Junction
Disorder
NEW METHOD OF LAPAROSCOPIC REPAIR OF GIANT
HIATAL HERNIAS
V.V. Grubnik, A.V. Malynovskyy
Odessa national medical university, ODESSA, Ukraine
Background. As rates of recurrence of giant hiatal hernias and prosthetic strictures
are large, creation of fundamentally new method of repair is essential.
The aim was clinical application of new prosthesis for repair of giant hiatal hernias.
Short- and mid-term anatomical and functional results was studied.
Methods. From 2009 to 2011, 18 laparoscopic repairs of giant hiatal hernias were
performed. Mean diameter of hiatus – 10 cm (range, 8–15). The majority of patients
had weakness or complete atrophy of the crura. Mean age – 56 years (range, 45–76).
Posterior closure of the hiatus was performed with a new prosthesis which was fixed
to crura by 3–5 separated sutures. The HHRDTM prosthesis (Minnesota Medical
Development, Inc.) is heart-shaped lightweight polytetrafluorethylene (PTFE) mesh
with peripheral nitinol frame. The advantage of lightweight PTFE mesh is low
possibility of erosions of esophagus and stomach. The shape memory of the frame of
the device is key advantage that allows the mesh to be expanded and thus ensure real
tension-free hiatal repair. The upper (U-shaped) part of the frame enforces the space
between esophagus and mesh which is the most common site of recurrent herniation
following tension-free repair if giant hiatal hernias.
Results. All procedures were successfully completed. Mean time of fixation of
prosthesis was 20 min (range, 15–30). Pain scores were not larger than after standard
mesh repair. Short-term and mid-term (mean – 20 months, range – 16–24) results
studied by questionnaires, 3D barium study, endoscopic examinations, and 24 h pH
testing, showed no cases of recurrence and esophageal erosions or strictures.
Conclusion: New method is safe and provides good anatomical and functional mid-
term results, and requires further development and comparison with other
techniques.
P350 – Oesophageal and Oesophagogastric Junction
Disorder
LONG-TERM RESULTS OF LAPAROSCOPIC NISSEN
FUNDOPLICATION ON BARRETT’S ESOPHAGUS
Zs. Simonka, A. Paszt, Sz. Ábrahám, J. Pieler, J. Tajti, L. Tiszlavicz,
I. Németh, F. Izbéki, A. Rosztóczy, T. Wittmann, F. Rárosi, G. Lázár
University of Szeged, SZEGED, Hungary
Aims: The aim of our study was a retrospective investigation of the efficacy of
laparoscopic Nissen funoplication in patients with Barrett’s esophagus.
Methods: A total of 78 patients with Barrett’s esophagus underwent surgery. Patients
were divided into three groups on the basis of the preoperative endoscopic biopsies:
a non-intestinal group (n = 63) with fundic or cardiac metaplasia, an intestinal group
(n = 18) with intestinal metaplasia, and a dysplastic group (n = 7) with low-grade
dysplasia. Clinical follow-up was available in the case of 64 patients at a mean of 42
±16.9 months after surgery.
Results: Check-up examination revealed total regression of Barrett’s metaplasia in
10 patients. Partial regression was seen in 9 cases, no further progression in 34
patients, and progression into cardiac or intestinal metaplasia in 11 patients. No cases
of dysplastic or malignant transformation were registered. Where we observed the
regression of BE, among the postoperative functional examinations results of
manometry (pressure of lower esophageal sphincter) and pH-metry were signifi-
cantly better compared with those groups where no changes occurred in BE, or
progression of BE was found.
Discussions: Our results highlight the importance of the cases of fundic and cardiac
metaplasia, which can also transform into intestinal metaplasia.
Conclusions Antireflux surgery can appropriately control the reflux disease in a
majority of the patients who had unsuccessful medical treatment, and it may inhibit
the progression and induce the regression of Barrett’s metaplasia in a significant
proportion of these patients.
123
Surg Endosc (2013) 27:S53–S166
P351 – Oesophageal and Oesophagogastric Junction
Disorder
LAPAROSCOPIC HELLER MYOTOMY ABOUT 22 CASES
M.A. Majbar, H. Elfadili, M. Elalaoui, F. Sabbah, M. Raiss, A. Hrora,
M. Ahallat
Ibn Sina Hospital, RABAT, Morocco
The purpose of this study is to report and evaluate in a retrospective study the
outcomes of laparoscopic Heller myotomy.
Material and Methods: Twenty tow patients underwent laparoscopic Heller myotomy
between 2000 and 2009. The mean age was 39 years (range 16– 80 years), 14
females and 8 males. 91 % of patients had dysphagia and weight loss. All patients
had an upper endoscopy to eliminate an organic obstacle. Achalasia was diagnosed
on the basis of manometric evidence of aperistaltic oesophageal body or none
relaxing low oesophagus sphincter. 4 patients had a laparoscopic Heller myotomy
with adjunction of antireflux system and 18 without. Intraoperative esophagal per-
forations were seen in 2 cases, however conversion in open surgery was seen in only
one patient (4.5 %).
Results: After a median follow up period of 18 months, dysphagia relief was
excellent in 83.3%, good in 5.5% and fair in 11.1%. The incidence of pathologic
gastroesophageal reflux was 27.7% measured by 24 h pH metric studies. Postoper-
ative manometry was performed in seven patients and demonstrated decrease in low
oesophagus sphincter pression. The median percentage decrease in resting low
oesophagus sphincter pressure was – 68.75% and the median absolute decrease was
– 2.4%. Also the esophagogram showed a decrease of esophageal diameter with a
median percentage decrease of – 54.5%.
Conclusion: Laparoscopic Heller myotomy has been shown to be effective and safe
with Iow morbidity.
P352 – Oesophageal and Oesophagogastric Junction
Disorder
TECHNICAL PARTICULARITIES OF THE LAPAROSCOPIC
APPROACH IN LARGE HIATAL HERNIAS
N. Iordache, R.A. Stoica, D. Balan
Sf.Ioan, BUCHAREST, Romania
Large hiatal hernias represent a challenge for the laparoscopic approach. The most
difficult steps consist in hernia reduction, the management of hernia pouch and the
calibration of hiatal defect. Since 2007 we performed 326 of Nissen procedures for
hiatal hernia, 31 for giant hiatal hernia. We are presenting our technical solutions in
particular aspects of our procedures.
Mean operative time was 114 minutes (90–160), no conversions, routinely we use
prosthetic mash for intraperitoneal use. In all procedures we removed the main part
of the hernia sac. We have no recurrence. Laparoscopic approach with prosthetic
mash repair is feasible in large hiatal hernia.
Surg Endosc (2013) 27:S53–S166
P353 – Oesophageal and Oesophagogastric Junction
Disorder
ENDOSCOPIC-GUIDED LAPAROSCOPIC MYOTOMY
FOR OESPHAGEAL ACHALASIA
H.A. Omar1, A. Shehata2, A. Lashen2, H. Amen3
1
Beirut Arab Univerisity, BEIRUT, Lebanon; 2Al Azhar University,
CAIRO, Egypt; 3Benha University, BENHA, Egypt
Aim of this study is to evaluate endoscopic-guided laparoscopic Heller myotomy
(LHM), In comparison to traditional (LHM).
This study comprised 54 patients with oesphageal achalasia allocated in two equal
groups:
– Group A, included patients undergo endoscopic-guided laparoscopic (LHM).
And,
– Group B, underwent (LHM) without endoscopic guidance.
In group A. endoscopic illumination, dissection and piecemeal myotomy of esoph-
agus were done.
No case required shift to open procedure and no perforation had occurred whereas
small perforation occurred in 6 cases in group B.
There was significant reduction of the operative time (55 ± 9 vs 64.4 ± 9.5 min) and
postoperative hospital stay (3.2 ± 1 vs 4.8 ± 1.4 days) in both groups. And less
postoperative complications in group A. There were 9 cases with mild reflux
symptoms 6 in group B, and 3 In group A, both respond to medical treatment. And 3
case in group B, with persistent symptoms required endoscopic balloon dilatation.
It could be concluded that (LHM) is a safe and effective minimally invasive procedure
for treatment of oesphageal achalasia with favorable outcome and short operative time
and postoperative hospital stay when performed endoscopically-guided.
P354 – Oesophageal and Oesophagogastric Junction
Disorder
USEFULLNRSS OF A MORPHOROGICAL SCORING
SUSYEM FOR LAPAROSCOPIC FUNDOPLICATION
H. Idani
Fukluyama City Hospital, FUKUYAMA, Japan
AIM: We evaluated the usefulness of newly established morphological scoring
system for laparoscopic fundoplication.
Patients and Methods: We have established a new morphological scoring system
(MSS) for laparoscopic fundoplication. The form of fundoplication was evaluated
based on its straightness and position (very poor to excellent; 1–5, 0: not repaired)
and determined by laparoscopy (ML) and intraoperative endoscopy (ME).
Patients undergoing laparoscopic revisional surgery for recurrent GERD and/or
hiatal hernia, and single incision laparoscopic fundoplication for GERD were
evaluated using our MSS. Symptom of the patients were evaluated by a symptom
scores consisted of heart burn, regurgitation, dysphagia, chest pain (0–5; none to
daily). Esophagogastrofiberscopy, esophagogastrogram manometry and pH and
impedance monitoring were performed pre- and post-operatively.
Results: Out of 161 patients undergoing laparoscopic fundoplication between May
1997 and September 2011, 13 patients underwent laparoscopic revisional surgery in
our hospital. The patients consisted of eight women and five men with a mean age of
65.9 years. Surgery included dissection of the hiatus, closure of the hiatus with or
without mesh and refundoplication (7/13). The seven patients underwent redo fun-
doplication were evaluated with MSS. ME score was significantly improved (from
1.6 ± 0.2 to 4.2 ± 0.2: p \ 0.01) and symptom scores were also improved after
surgery.
Six patients underwent single incision laparoscopic fundoplication (SILF) between
February and August 2010 were also evaluated by MSS. Toupet fundoplication was
performed on five and anterior fundoplication on one patients. Operation time was
188 ± min and blood loss was 25 g. Liquid started on the first postoperative day
(POD). No complication was marked including dysphagia and the postoperative stay
was 7.3 day. M scores were quite satisfactory (ML: 4.8, ME: 4.6). LES pressure was
improved from 12.1 to 20.5 mmHg. Acid exposure time and DeMeester score were
also improved from 7.6 to 0% and from 24.3 to 1.1, respectively. Symptom scores
were significantly improved after surgery (p \ 0.05)
Conclusion: Our MSS is useful for evaluating the fundoplication during surgery and
can improved the outcome of the antireflux surgery especially for revisional or single
incision laparoscopic surgery in which the procedure might be difficult compared to
the standard procedure.
S141
P355 – Oesophageal and Oesophagogastric Junction
Disorder
LAPAROSCOPIC CARDIOMYOTOMY – A CASE SERIES
A. Humphreys, A.L. Karran, M.R. Nutt, A. Rasheed
Royal Gwent Hospital, CARDIFF, United Kingdom
Aims: To investigate pre and post-operative symptoms for the surgical management
of achalasia and if anti-reflux surgery affects outcome.
Methods: Laparoscopic cardiomyotomy performed during 2007–2011 were included
and case notes retrospectively assessed for referral source to an Upper Gastroin-
testinal Surgeon, severity of symptoms and whether anti-reflux surgery had been
performed.
Results: Ten patients were included [median age 43 (range 17–69), male:female 6:4].
One direct referral from a GP, the remainder (n = 9) had been referred via Gas-
troenterology and four had undergone previous gastroscopic dilation. Median length
of time from symptom to Surgical assessment was 48 weeks (range 3–96). Symp-
toms included dysphagia (n = 6) regurgitation (n = 2) nausea (n = 4) vomiting (n = 4)
indigestion (n = 3) weight loss (n = 4) and haematemesis (n = 2). All patients were
investigated with barium swallow, OGD and pH manometry (not tolerated by 3
patients). Six patients had Dor anterior fundoplication. Follow up ranged from 4
weeks – 104 weeks. Of the nine patients with documented follow-up, four reported
total resolution in symptoms (anti-reflux surgery n = 3), four reported mild symp-
toms, and only one patient reported severe reflux requiring a re-do operation.
Conclusions: Laparoscopic cardiomyotomy provides good resolution for patients
suffering from achalasia, and combined with anti-reflux surgery may provide even
better results.
P356 – Oesophageal and Oesophagogastric Junction
Disorder
OUR EXPERIENCE IN LAPAROSCOPIC NISSEN
FUNDOPLICATION
M.T. Oruc, M.U. Ugurlu, H.T. Turgut, Z. Boyacioglu
Kocaeli Derince Teaching and Research Hospital, KOCAELI, Turkey
Introduction: We analyzed our laparoscopic Nissen fundoplication (LNF) procedures
that we performed in our clinic in terms of peroperative features of the cases.
Methods: LNF was performed between January 2009–September 2011 in Kocaeli
Derince Teaching and Research Hospital for 35 patients having GERD symptoms,
esophagitis with/without Barrett, hiatal hernia and De Meester score above normal
(normal value: 14.72) in 24 hour pH monitorization. Patients were reanalyzed after 1
month postoperatively; endoscopy and pH monitorization were held out for ones
having reflux symptoms and dysphagia.
Results: Twenty two female (62.9%) and 13 (37.1%) male patients with diagnosis of
GERD were operated. Their mean age was 43.3 ± 9.46 (29–63) and their mean body
mass index was 25.51 ± 3.08 (19–32). Mean De Meester score of the patients was
54.71 ± 45.33 (15.52–194.8). According to duration of GERD symptoms patients
had complaints for 4.8 ± 4.00 (1–20) years in average. Preoperative endoscopic
examination revealed that 30 (85.7%) patient had esophagitis and 18 (51.4%) patient
had hiatal hernia. When the operative choices were interpreted, 10 (28.5%) patient
had Nissen fundoplication-cruroplasty-mesh repair, 10 (28.5%) had Nissen fundo-
plication-cruroplasty and 15 (42.8%) had Nissen fundoplication procedures. Mean
operation time was 131.71 ± 25.12 (75–210) minutes. Laparotomy was done for 3
(8.5 %) patients due to operative adversities. Mean hospital stay was 5.65 ± 2.12
(3–14) days and drains were kept for 2.14 ± 0.7 (1–4) days in average. In postop-
erative period 2 patients had pulmonary emboli and one had pneumonia. These
patients had Factor V Leiden mutations and their mean BMI was 25 ± 5.3. Two
other patients had active bleeding from drains, bleedings stopped spontaneously in
24 hours. Three patient described nonspecific symptoms and two patients suffered
from dysphagia postoperatively. We performed gastroscopy for these patients and
we detected loose fundoplication in one of them. This patient also had high De
Meester score. We observed no peroperative mortality.
Conclusion: Our results correspond with the recent literature and we observed that
LNF procedure is being held out safely in our clinic.
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P357 – Oesophageal and Oesophagogastric Junction
Disorder
LAPAROSCOPIC INTRAGASTRIC WEDGE RESECTION
FOR GASTRIC SUBMUCOSAL TUMORS LOCATED NEAR
THE ESOPHAGOGASTRIC JUNCTION
G.A. Jeong, G.S. Cho, H.C. Kim
Soonchunhyang Unisersity Hospital, BUCHEON-SI, Korea
Aims: Recently, laparoscopic gastric wedge resection has been widely used for
gastric submucosal tumors (SMTs) because the detections of these tumors are
increasing and the safety of gastric wedge resection for any conditions of gastric
SMTs (e.g. gastrointestinal stromal tumor, leiomyoma) has been established. How-
ever, sometimes laparoscopic approach for specific site of gastric SMTs cannot be
applied easily. We suggested the laparoscopic intragastric wedge resection and
evaluated the advantages for this method for gastric SMTs located near the esoph-
agogastric (EG) junction.
Materials and Methods: Of 25 patients of gastric SMTs located near the EG junction,
we performed the laparoscopic gastric wedge resection in 15 patients from January
2003 to December 2011. We divided these patients into two groups: Intragastric
wedge resection (IGWR) group and non-intragastric wedge resection (non-IGWR)
group. We compared the intra-operative and post-operative outcomes of these two
groups.
Results: The pathologic findings of 15 patients were 4 gastrointestinal stromal
tumors and 11 leiomyomas and there was no difference of pathologic findings
between IGWR group and non-IGWR group. And there were no differences between
two groups in clinical characteristics of patients also. However, there was statistical
difference of operation time of two groups (79 minutes in IGWR versus 158 minutes
in non-IGWR group, p value=0.016) and the day of first oral intake (POD 2 in IGWR
versus POD 4 days, p value=0.027), respectively. The mean postoperative hospital
stay was 6.5 days in IGWR group and 11.0 days but there was no statistical sig-
nificance. There was one wound infection in IGWR group and gastric stasis in non-
IGWR group. All patients are alive without the recurrence of disease until now.
Conclusions: The laparoscopic intragastric wedge resection was the safe and feasible
methods for treatment of gastric SMTs located near the EG junction and this pro-
cedure can help surgeons to operate easier during operation and help patients to
recover earlier after operation.
P358 – Oesophageal and Oesophagogastric Junction
Disorder
THE INCIDENCE OF RECURRANCE OF GASTRO
OESOPHAGEAL REFLUX FOLLOWING LAPAROSCOPIC
FUNDOPLICATION IS HIGHER IN PATIENTS WITH
BARRETTS OESOPHAGUS
A. Bond, D. Wilson, F Rowley, A Hastings, D Veeramootoo, K Singh
Worthing Hospital, WORTHING, United Kingdom
Aims: Laparoscopic fundoplication is carried out for symptomatic Gastro Oesoph-
ageal Reflux in patients with and without Barrett’s oesophagus. It has been suggested
that in patients with Barrett’s, only those patients with no physiological evidence of
reflux post surgery have any reduction in risk of transition to cancer. The aim of this
study is to assess any difference in reflux recurrence rates for those with and without
Barrett’s.
Methods: A retrospective study of all patients undergoing laparoscopic fundoplica-
tion by a single surgeon between January 2002 and December 2011 were identified
and information including prospectively collected data on pre and post operative pH
manometry was assessed for evidence of reflux.
Results: Of 191 Laparoscopic fundoplications performed (all Nissen fundoplica-
tions), 81 were in the presence of Barrett’s oesophagus. There is a significant
difference in the presence of ongoing reflux on pH manometry between those with
and those without Barrett’s oesophagus.
Conclusion: Patients with Barrett’s oesophagus are shown to have an increased
likelihood of continued reflux and therefore should continue with medical man-
agement of reflux alongside a fundoplication to reduce the risk of oesophageal
cancer even when asymptomatic post procedure.
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Surg Endosc (2013) 27:S53–S166
P359 – Oesophageal and Oesophagogastric Junction
Disorder
THE USE OF MESH IN SURGERY OF THE EG JUNCTION
I. Camperchioli, P. Angelini, V. Cimmino, L. Miranda, F. Pirozzi,
F. Corcione
Monaldi Hospital, NAPLES, Italy
Aims: Nowadays laparoscopy is considered the standard surgical approach for both
gastroesophageal reflux and large paraesophageal hiatal hernia repair. One of the
most frequent complications after laparoscopic antireflux surgery is intrathoracic
migration of the wrap (‘slipped’ Nissen fundoplication), due to inadequate closure of
the crura or disruption of the crural closure. To prevent hiatal hernia recurrence some
authors recommend the use of meshes for reinforcement of the hiatal crura. The aim
of this study is to evaluate surgical outcomes in selected patients who underwent
laparoscopic antireflux surgery with implantation of mesh.
Methods: Between March 1992 and December 2011, 384 patients underwent laparo-
scopic antireflux surgery for severe gastroesophageal reflux and/or hiatal hernia. The
procedure of choice was a Nissen-Rossetti fundoplication in 223 patients (58.1%), a
Toupet fundoplication in 155 cases (40.3%), while a Dor fundoplication was performed
only in 6 cases (1.6%). A mesh was used in 49 patients, 13 of which were reoperations:
as for the kind of mesh, we used a Proceed in 24 cases, a Composix in 23 cases, and a
Polytetrafluoroethylene (PTFE) mesh in 2 cases. We used a mesh only in selected
cases: to correct a large hiatal defect, or in case of a recurrent hernia or in case of
medialization of the right crus. In the group with mesh, a Nissen fundoplication was
performed in 78% of cases, while a Toupet fundoplication was preferred in 22% of
cases. Mean operative time was 120 minutes (70–230).
Results: In the group with mesh, we observed 2 recurrences, one of which treated
with a mesh replacement, and 3 cases of postoperative dysphagia lasting about six
months, one of which treated by surgical approach. Moreover, we had one case of
mesh ‘slippage’ inside the oesophagus. No postoperative dysphagia was present one
year after surgery.
Conclusions: Laparoscopic Nissen fundoplication with prosthetic cruroplasty is an
effective procedure to reduce the incidence of postoperative hiatal hernia recurrence
and intrathoracic wrap herniation. Postoperative dysphagia is higher in the early
period after mesh surgery, but this is only temporary. Because of the potential
important complications we think that the indications should be carefully selected.
P360 – Oesophageal Malignancies
TRIPLE INCISION LAPAROSCOPIC DISTAL
GASTRECTOMY FOR GASTRIC CANCER
S. Usui, M. Tashiro, K. Ito, A. Matsumoto, N. Takiguchi,
S. Hiranuma, K. Sanada
Tsuchiura Kyodo General Hospital, TSUCHIURA, Japan
We report the use of a triple incision laparoscopic distal gastrectomy (TIL-DG),
which combines single incision laparoscopic surgery with a conventional laparo-
scopic distal gastrectomy (LDG). The goal of this technique is to enable only two
surgeons to complete a full laparoscopic gastrectomy while maintaining the quality
and safety of the lymph node dissection and gastric reconstruction. For this purpose,
two types of new devices have been introduced. The first is a Mini Mini Trocar
Sleeve, which is a small trocar for 5-mm forceps developed using Hope electronics.
This trocar and 12 mm Trocar are used by attaching it to a wound protector (PATH
SAVER; SUMITOMO BAKELITE CO.,LTD. Japan). This wound protector is then
inserted into a small incision (3 cm) placed at the umbilical region. The assistant
surgeon stands between the patient’s legs and manipulates the laparoscope and
forceps through these two trocars. The second new device has been named the
‘Hanging forceps’. These forceps are based on the ready-made detachable forceps
that are used to close blood vessels. The detachable forceps are cut short and are
suspended from the abdominal wall by a thread. If the forceps are hung in an
appropriate position, they can be used to create an operative field. The operator
performs all the procedures from the right side of the patient using two trocars (5-
mm trocar). The process is similar to a conventional LADG. The stomach is tran-
sected laparoscopically and the stomach is removed through the mini-laparotomy of
the umbilical region. Reconstruction is performed laparoscopically using an R-Y
method. 65 cases of TIL-DG have been performed at our institution (D1+: 25 cases,
D2: 40 cases), and the average operation time was 256.2 ± 55.9 minutes. The
assistant operator’s role in a TIL-DG is easy and comfortable to perform. No
interference with the single forceps and laparoscope at the single incision is required.
Consequently, these procedures do not need any special training to perform. TIL-DG
is a hybrid surgery combining conventional LDG and single incision surgery and is
expected to become a new standard for laparoscopic distal gastrectomy.
Surg Endosc (2013) 27:S53–S166
P361 – Oesophageal Malignancies
THE OUTCOMES OF LAPAROSCOPY-ASSISTED DISTAL
GASTRECTOMY WITH BILLROTH I
GASTRODUODENOSTOMY BY COMPLETE DOUBLE
STAPLING TECHNIQUE (CDST)
C. Tanaka, M. Fujiwara, S. Yamada, N. Ohashi, T. Fujii,
G. Nakayama, H. Sugimoto, M. Koike, S. Nomoto, S. Takeda,
Y. Kodera
Nagoya University, NAGOYA-AICHI, Japan
Background: Although the Roux-en-Y reconstruction after distal gastrectomy is
gradually increasing, the Billroth-I (B-I) method is still widely applied because it is
physiological alimentary route and needs only one anastomosis. Various methods of
B-I reconstruction after laparoscopic or laparoscopy-assisted distal gastrectomy have
been reported. We prefer open method from the point of possibility of confirming
appropriate resection margin by macroscopic inspection and microscopic examination
if necessary. We developed novel gastroduodenostomy method with complete double
stapling technique (cDST) suitable for procedures through small laparotomy wound as
we already reported. The aim of this report was to describe the short and long term
outcomes of laparoscopy-assisted distal gastrectomy with B-I cDST reconstruction.
Patients and Methods: We retrospectively collected data from 249 patients who
underwent LADG with B-I cDST reconstruction performed at Nagoya University
Hospital between 2002 and 2011. The points of our method are shown as follows. After
finishing lymphadenectomy, a 4–5 cm incision was made at the upper midline. The anvil
of a circular stapler (ECS, Ethicon Endo-Surgery, Cincinnati, OH) was inserted into the
duodenum and fixed with a purse-string suture. A circular stapler was introduced through
the edge of the remnant stomach on the side of greater curvature. The duodenal stump and
the remnant stomach were anastomosed on the staple line of the remnant stomach by a
double stapling technique. The entry hole was closed by a linear stapler. Patient and
operative time, operative bleeding, postoperative complications, incidence of gastro-
esophageal reflux were retrospectively analyzed.
Results: The average operation time for LADG was 230 ± 47 min. The average
blood loss was 160 ± 150 ml. The anastomosis-related postoperative complication
was found in 12 patients (4.8%), including anastomotic leakage in 5 patients (2.0%),
anastomotic stenosis in 3 patients (1.2%) and anastomotic erosion in 1 patient
(0.4%). Wound infection was observed in 3 patients (1.2%). There was no postop-
erative mortality. 12 patients (8.5%) had symptoms of reflux esophagitis in 142 cases
observed more than 2 years after surgery. The 13 of 114 patients examined with
endoscopy (11.4%) were diagnosed as reflux esophagitis.
Conclusions: This method has good short and long outcomes.
P362 – Oesophageal Malignancies
MINIM INVASIVE ESOPHAGECTOMY (THORACOSCOPIC
AND LAPAROSCOPIC) FOR ESOPHAGEAL CANCER
C. Tomus, F.V. Zaharie, L. Mocan, R. Zaharie, D. Bartos, C. Iancu
‘‘Iuliu Hatieganu’’ University of Medicine and Pharmacy Cluj,
CLUJ NAPOCA, Romania
Surgical resection remains the mainstay treatment for patients with localized esophageal
cancer, but it often requires extensive surgery and is, therefore, considered one of the most
invasive elective gastrointestinal procedures.
Due to technical development and increasing experience with laparoscopic and thoracoscopic
techniques, surgeons have developed a great deal of interest in minimally invasive approach,
making an effort to decrease invasiveness without compromising the extend of lymphadenec-
tomy and consequent survival. While transhiatal and transthoracic esophagectomy are common
approaches for esophageal resection, the literature is limited regarding the combined thoraco-
scopic and laparoscopic approach to esophagectomy.
We present a case of a 43-year-old man, who was admitted to the hospital presenting retrosternal
pain, progressive dysphagia, food regurgitations, weight loss (20 kg/3 months). Based on clinical
and paraclinical data (EDS with biopsy, CT thoraco-abdominal) the diagnosis of lower esophageal
cancer was established and the patient underwent surgery.
We performed thoracoscopic and laparoscopic total esophagectomy with left cervical
anastomosis. The surgical procedure (minimally invasive esophagectomy) consisted of
three phases: thoracoscopic esophageal mobilization and mediastinal lymphadenectomy
followed by a laparoscopic gastric mobilization, abdominal lymphadenectomy and gastric
conduit formation, and finally retrieval of the resection specimen fallowed by an esoph-
agogastric anastomosis via a left cervical incision. Histopathological examination of the
specimen revealed moderately differentiated adenocarcinoma.
The postoperative course was uneventful. Oral intake was resumed on the 9th postoperative
day and the patient was discharged fourteen days after surgery.
Follow-up examination, performed seven weeks after surgery, did not reveal any
pathological changes.
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P363 – Oesophageal Malignancies
MINIMALY INVASIVE ESOPHAGECTOMY:
WISH OR REALITY?
A.M. Hafez
Al salam oncology center, CAIRO, Egypt
Aim: Minimally invasive esophagectomy (MIE), for carcinoma of the esophagus is a
complex & difficult undertaking. It requires a high level of both laparoscopic &
oncological skills. Until to date very few centers world wide performed this pro-
cedures whether combined thoracoscopic/laparoscopic or by transhiatal approach.
We present 34 cases that underwent MIE performed over a period of 3 years in al
Salam Oncology Center.
Patients & methods: 33 cases (12 females, 22 males), age range 32–75 years diagnosed as
cancer esophagus (33), & one post cricoid carcinoma, were included in this study to assess
the safety, reproducibility & oncological adequacy of the procedure. All patients were
staged appropriately & were cleared by the anesthetist to undergo single lung ventilation.
29 patients underwent combined thoracoscopic/laparoscopic esophagectomy with exten-
ded 2 fields lymphadenectomy with intent to cure. 5 patients underwent laparoscopic
transhiatal esophagectomy and gastric pull up. 4 as apalliative procedure for carcinoma of
the esophagus, and one patient as conduit after total laryngopharyngectomy.
Results: All 29 thoracoscopic/laparoscopic esophagectomies were completed with-
out conversion (0%). one of the 5 transhiatal cases was converted to open trans hiatal
(20%). All procedures were completed safely with no intraoperative complications &
no intra operative blood transfusion. We had 6 cases of post operative leaks (17.6%).
4 anastomotic leaks in the neck, treated conservatively by enteral feeding for 4
weeks. 2 intrathoracic leaks from the gastric tube, one required reoperation by
thoracoscopy. We had 3 mortalities (8.8%); the average hospital stay was 15 days.
Number of lymph nodes harvested averaged 35.
Conclusion: MIE is a safe, reproducible and oncologically adequate procedures. It
merits a randomized controlled trial to confirm these preliminary results.
P365 – Oesophageal Malignancies
THE USE OF LINEAR ENDOSCOPIC ULTRASONOGRAPHY
IN TISSUE DIAGNOSIS OF INDETERMINATE
MEDIASTINAL RECURRENCE FOLLOWING
OESOPHAGECTOMY
H.T. Malik, S. Mohandas, D. Graham, D. Mukherjee, W. Fickling
BHR University Hospitals – Queens Hospital, ESSEX,
United Kingdom
Aims?Background: After oesophago-gastectomy, mediastinal recurrence is often detected within the
first year, and[90% of recurrences are detected within 2 years post-neoadjuvant therapy. While cross-
sectional imaging of the chest may suggest locoregional recurrence, confirmation of this has challenged
clinicians due to both the altered anatomy and inaccessibility of the region. Endoscopic Ultrasound
(EUS) has revolutionized staging of oesophageal cancer, being the most accurate staging modality for
esophageal cancer with a T-stage and N-stage accuracy of 75%-85%, and 65%-75%, respectively.
However this modality is rarely employed following resection for investigation of tumour recurrence.
We present our experience of imaging the gastric conduit as well as obtaining histological samples,
thereby guiding further management.
Methods: We describe three cases of recurrence following oesophagectomy. In each case surgical
resection was successfully performed and the patients enjoyed a ‘remission’ period of at least 2 years.
Subsequently they became symptomatic, with dysphagia in two instances and hoarse voice (recurrent
laryngeal palsy) in another requiring further investigation. A combination of computed tomography,
gastroscopy and positron emission tomography were employed in each case, yet definite diagnosis of
recurrence was made with EUS guided fine-needle aspiration.
Results: Histological evidence of recurrent adenocarcinoma was identified in each case; subsequently
the patients underwent further oncological treatment to attain maximal locoregional control.
Conclusions: The benefits of endoscopic ultrasonography in the mediastinum are that it provides
both detailed assessment and access to an otherwise inaccessible anatomical region. Despite
technical difficulties arising from a lack of normal anatomical landmarks in post oesophagectomy
patients, in expert hands EUS provides critical information regarding recurrence as well as his-
tological diagnoses, which may guide further management. Thus we advocate the routine use of
endoscopic ultrasound in detailed assessment of post-operative patients with a clinical suspicion of
recurrence.
123
S144
P366 – Oesophageal Malignancies
PRONE POSITION IMPROVES THE QUALITY
OF LYMPHADENECTOMY IN THORACOSCOPIC
ESOPHAGECTOMY
M. Urata1, O Ikeda2, H. Noshiro2
1
Japan/Saga University Faculty of Medicine, SAGA CITY – SAGA,
Japan; 2Saga University Faculty of Medicine, SAGA CITY – SAGA,
Japan
Background: Thoracoscopic esophagectomy for esophageal cancer is minimal invasive method and
Chshieri reported the thoracoscopic esophagectomy with prone position in 1994.
We are accustomed by the left lateral decubitus position in esophagectomy with thoracotomy and
laparotomy, so thoracoscopic esophagectomy has been performed with the same position tradi-
tionally in Japan until 2006. We started thoracoscopic subtotal esophagectomy with prone position
from December 2007, and we want to show how it help us to work freely in small intrathoracic
space with some pictures and movies.
Method: Epidural tube is inserted in the left lateral decubitus position and intubation using a
double-rumen endotracheal tube is performed in the supine position on another bed provided at the
right side of operating table. We rotate the patient 180 degree to the left and lay the patient on the
operation table in prone position, then the right arm is raised up and the left arm is placed beside
patient’s body. First 12 mm long trocar is inserted on fifth intercostal space (ICS) on the posterior
axillary line, carefully confirming the absence of pleural adhesion. Another three trocar are inserted
under thoracoscopic control: a 12 mm trocar in the third ICS behind the midaxillaly line, a 5 mm
trocar in the seventh ICS behind the posterior axillaly line, a 12 mm trocar in the linth ICS on the
scapular angle line mainly for the thoracoscope. Thanks to the gravity and carbon dioxide pneu-
mothorax at a pressure of 6 mmHg, all organs in intrathoracic space as lung, heart, trachea and
esophagus move to the anterior and diaphragm moves to the caudal. In addition, blood and exu-
dation goes down out of the view. Wide and clean operation filed with prone position and
magnified view of thoracoscopy bring us delicate motion of lymphoadenectomy.
Result: We have experienced 72 cases of thoracoscopic subtotal esophagectomy with prone
position from December 2007 to December 2011 (three of them were performed by Robotic
surgery). Mean operating time is 608 minutes (309 minutes for intrathoracic part), blood loss is 189
ml and the number of dissected lymph nodes is 49.3 (27.6 in the intrathoracic procedure).
P367 – Oesophageal Malignancies
ENHANCED RECOVERY PATHWAYS AFTER SURGERY
FOR OESOPHAGEAL CANCER: PROMISING RESULTS,
LIMITED EVIDENCE AND THE ABSENCE OF MINIMALLY
INVASIVE SURGERY
E. Ypsilantis, A. Hamouda, Y. Abdulaal, A. Nisar, H. Ali
Maidstone Hospital, MAIDSTONE, United Kingdom
Background: The Enhanced Recovery After Surgery (ERAS) programme represents a multi-
modal approach that aims to restore the functional capacity of surgical patients to their pre-morbid
state more effectively and faster than conventional peri-operative regimes. Aims: To evaluate the
feasibility of enhanced recovery (ER) protocols in patients undergoing surgery for oesophageal
cancer and assess their effect on the outcomes of this complicated procedure that has historically
been associated with high rates of morbidity and mortality.
Methods: A systematic review of the relevant literature published in MEDLINE, EMBASE, CI-
NAHL and The Cochrane Collaboration Library in English language during the last 20 years.
Results: Six studies were identified, four of which were retrospective case-series and two pro-
spective comparative ones with historical controls (Level of evidence 3). The median length of
hospital stay (LOS) for patients in the ER groups in all studies varied between 7–10 days (range
5–98 days) with median mortality rate 0.65% (range 0%–4.4%) and median overall complication
rate 26% (range 18%–45%). The readmission rate, reported in two studies only, was in the order of
4%. Between the two comparative studies, the earliest one did not demonstrate any difference in
LOS, morbidity or mortality rates between the ER group and control, whereas the most recent study
showed statistically significant benefit in all above outcomes in favour of the ER group. The role of
minimally invasive approach was not evaluated because patients in all studies were operated via
open approaches.
Conclusions: The evidence underpinning the use of ER protocols in oesophageal surgery is cur-
rently limited and of low quality. The preliminary results are promising, indicating that
implementation of ER for these patients is feasible and can achieve short hospital stay with
acceptable morbidity and mortality. More robust evidence, in the form of randomised controlled
trials, is required, including, in particular, the role of minimally invasive oesophagectomy.
123
Surg Endosc (2013) 27:S53–S166
P368 – Oesophageal Malignancies
LAPAROSCOPIC INSERTION OF FREKA FEEDING
JEJUNOSTOMY AS A PART OF LAPAROSCOPIC
THORACOSCOPIC IVOR-LEWIS CARDIO-
OSOPHAGECTOMY – A REVIEW OF OUR OUTCOME
V. Daya Shetty, K. Akhtar
Salford Royal Hospitals NHS trust, SALFORD, United Kingdom
Aims: A retrospective review of outcome of laparoscopic insertion of feeding jejunostomy
as a part of laparoscopic thoracoscopic Ivor-Lewis cardio-oesophagectomy.
Methods: Ivor Lewis cardio-oesophagectomy is a 2-staged procedure for oesophageal
cancer. The abdominal phase involves gastric mobilisation and insertion of feeding jeju-
nostomy(to establish early enteral nutrition). The thoracic phase involves oesophageal
mobilisation,resection and oesopahagogastric anastamosis using stomach conduit. This
procedure is performed traditionally as open procedure but in recent years is performed
laparoscopically. In our institution, from October 2010–January 2012 (15 months) 18
patients that underwent laparoscopic thoracoscopic Ivor Lewis cardio-oesophagectomy had
laparoscopic insertion of feeding jejunostomy. All 18 patients are included in the study. The
feeding jejunostomy was flushed with water on the day of surgery and used for feeding from
first postoperative day. The standard regime was water at 20 ml/hour on day1 followed by
feed (jevity/osmolyte) at 30 ml/hour on day2. The rate of feed was increased on daily
increment of 10 ml/hour/day to achieve target rate based on patient’s nutritional require-
ments. All patients were discharged with feeding jejunostomy in situ. It was removed at first
follow-up clinic appointment 2 weeks after discharge if patient was nutritionally stable.
Results: In all 18 patients (12 male, 6 female) a Freka feeding jejunostomy tube was used.
The average procedure time was 20 minutes. Median duration of feeding jejunostomy
in situ was 3 weeks (range 8 days–6 weeks). Tube related complications are tube fallout (n
= 1 on day 22), minimal leak (n = 2) needing early tube removal (on day 8 and day 10
respectively). Only one of these 3 patients needed additional parenteral nutrition for 5 days.
There were no procedure related complications, blood loss or peritoneal contamination.
There were no feed related complications. The length of stay in hospital was not affected by
this procedure. The availability of enteral route was useful in n = 2 patients (one patient
with chest infection needing ventilatory support and other with gastric stasis) to provide
nutritional support for a longer than anticipated period.
Conclusion: Laparoscopic insertion of feeding jejunostomy is safe and aids early estab-
lishment of enteral route for nutrition in patients undergoing cardio-oesophagectomy. It is
also useful in providing prolonged nutritional support in those patients who develop
complications were oral route is not possible.
P370 – Paediatric Surgery
SINGLE-PORT TRANSUMBILICAL LAPAROSCOPIC
APPENDECTOMY IN CHILDREN: 39 CONSECUTIVE CASES
A. Hinoki, T. Tanimizu, R. Satake, D. Kitagawa, K. Koiwai,
T. Takeshita, M. Nishikawa, Y. Matsumoto, K. Hatsuse, K. Hase,
J. Yamamoto
National Defense Medical College, SAITAMA, Japan
Background: To reduce abdominal trauma and improve cosmesis, surgeons have adopted a
single-port laparoscopic appendectomy for patients, especially for children with acute
appendicitis. The purpose of this study is to review our initial experience with single-port
transumbilical laparoscopic appendectomy in children.
Methods: A retrospective analysis of the patients diagnosed with acute appendicitis in
children at National Defense Medical College Hospital from April 1, 2010 to November 30,
2011 was conducted. All patients underwent single-port transumbilical laparoscopic
appendectomy.
Results: All patients were performed successfully with no conversion. In only one child (2.6
%), an extension of the incision became necessary because of the bleeding. The median
operating time was 34 min and the median length of hospital stay 5 days. The histologic
findings were appendicitis of the catarrhal type in 2 cases, of the phlegmonous type in 21,
and of the gangrenous type in 16. The umbilical incision was invisible at 3 months.
Conclusion: Single-port transumbilical laparoscopic appendectomy is a safe and feasible
technique and shows excellent cosmetic results in children. This is an easy procedure for an
experienced laparoscopic surgeon even with conventional laparoscopic instruments.
Surg Endosc (2013) 27:S53–S166
P371 – Paediatric Surgery
TRANS-UMBILICAL SINGLE PORT ACCESS
LAPAROSCOPIC APPENDECTOMY IN CHILDREN
BY USING MICRO-INSTRUMENTS WITH SUPRA-PUBIC
SYMPHISIS PUNCTURE
Y. Kawakami, H. Fujii, R. Ganeko, H. Shirai, K. Hirose, M. Yoshida,
K. Doi, T. Aotake, F. Tanaka, Y. Hirose
Japanese Red Cross Fukui Hospital, FUKUI, Japan
Aims: Recently, single port access laparoscopic surgery has been widely adopted as
innovative features in minimally invasive surgery. We previously reported that trans-
umbilical single port access laparoscopic appendectomy (TUSPA-LA) for complicated
acute gangrenous appendicitis could be feasible with some difficult cases especially in
children. Thus we attempted to apply modified technique for TUSPA-LA in children
consisted in combining conventional 5 mm trocar in trans-umbilical single access and
newly developed 3 mm micro-instruments with supra-pubic approach.
Methods: From February to December of 2011, 8 consecutive pediatric patients were
assigned to undergo modified TUSPA-LA at our hospital. We conducted to study our
technique using reusable metallic trocar (ENDOTIPTM, 3.5, 6 mm in diameter, KARL
STORZ GmbH & Co. KG, Tuttlingen, Germany) as a working port, XCELTM (5 mm in
diameter, ETHICON ENDO-SURGERY, INC., Pittsburgh, PA, USA) as a camera port.
Straight-type grasping forceps and dissecting forceps (3.5 mm in diameter) were used both
in the parallel setup at umbilical site and in the triangular co-axial setup with supra-pubic
puncture.
Results: Clinical records of 228 cases of appendectomy for acute appendicitis (From Jun of
2009 to December of 2011) were analyzed retrospectively in background factors, operative
time and length of hospital stay. Of them, in 53 pediatric patients (23.2%), we had 8
modified TUSPA-LA (male 3, female 5, average age of 10.6, range 7–14) with 4 gan-
grenous cases (m 1, f 3, 10.5, 7–14), 10 pure single access (TUSPA-LA) (m 4, f 6, 13.8,
12–15) with 1 (f 1, 14.0) and 35 open cases (m 22, f 13, 9.9, 4–15) with 8 (m 4, f 4, 9.5,
4–15). The average operative time in the modified group was 78.6 min (64–118) with 84.8
in gangrenous cases, as was 86.3 (56–127) with 82.0 in the pure single access group. The
mean hospital stay in the modified group was 3.5 days with 3.5 in gangrenous cases, as was
3.9 with 4 in the pure single access group. None postoperative complications were reported.
Conclusions: We conclude that modified technique for TUSPA-LA could be a promising
option with safety and an attractive advantage of excellent cosmetic result in managing this
condition.
P372 – Paediatric Surgery
INNOVATIVE NOVEL TECHNIQUE FOR INGUINAL
HERNIA REPAIR IN CHILDREN – DESCHAMPS NEEDLE
TECHNIQUE
T. Tanimizu, A. Hinoki, R. Satake, K. Koiwai, T. Takeshita,
Y. Matsumoto, K. Hatsuse, K. Hase, J. Yamamoto
National Defense Medical College, TOKOROZAWA, Japan
Purpose: We have developed a new technique for inguinal hernia repair in children.
Since 1997, 720 children with groin hernia have undergone Deschamps Needle technique
(DNT). We retrospectively analyzed the outcomes of DNT for pediatric inguinal hernia
from April 1997 to December 2011.
Materials: A total of 720 patients underwent DNT in the study period and the mean
age was 3.17 years old ranging from 27 days to 14 years. The ratio of male to female
was 364 vs. 356.
Surgical Procedure: A 5-mm laparoscope was placed through an umbilical incision. And a 2
mm Mini potr was inserted to preperitoneal space just above the internal inguinal ring, and
normal saline was infused through Mini port in order to hernia sac was dissected. Des-
champs Needle was inserted after Mini port was removed, and hernia sac was trapped the
curvature of Deschamps Needle, subsequently the sac was pulled out from the incision, and
the base of sac was ligated with 4-0 PDS.
Results: We recorded only one recurrence (0.1%): due to a small laceration occurred during
the transfixing ligation. In 5 cases (0.7%) we found a direct hernia (2 right, 2 left, 1
bilateral). No intraoperative complications were occurred.
Conclusions: We consider that Deschamps Needle Technique for inguinal hernia
repair in children is a safe and effective procedure.
S145
P373 – Paediatric Surgery
EFFICIENCY ESTIMATION ENDOSCOPIC BOUGIENAGE
IN CHILDREN
D.V. Fokin1, M.M. Lochmatov2, I.V. Kirgizov3, D.V. Fokin1,
S.I. Yakimova2
1
Public health services municipal authority city clinical hospital ?20
of a name, KRASNOYARSK, Russia; 2Federal state budgetary
establishment - Centre of science of health of children-, MOSCOW,
Russia; 31st MSMU after I.M. Sechenov, MOSCOW, Russia
Aim:. The safest method of treatment of cicatricial strictures of gullet is endoscopic bou-
gienage along a guide string. Aim of the study was an efficiency estimation of the
endoscopic bougienage along a guide string in children.
Methods:. The set of hollow bougies from 15 (5 mm) to 39 (12.8 mm) French in diameter
was used. We used conic bougie with diameter is increasing at its extent. The guide string
was spent under endoscopic control, in case of its impossibility (a lumen less than 4.8 mm)
under x-ray control. Bougie diameter increased gradually, by 2 mm. In total for one session
2–3 bougies were used, the following session started from bougie of the previous diameter.
After the session termination endoscopic control of a gullet wall, hemostasis in places of
ruptures by cold solutions was spent.
8 children aged 1–8 years were treated. They were divided into 3 groups: I – 3 children with
peptic strictures, II – 3 children with postburn strictures and III – 2 children with cicatricial
strictures after operative treatment for malformations of esophagus in a place of esophago-
esophago anastomosis. In all cases we performed a course of antegrade endoscopic gullet
bougienage along a guide string under endotracheal narcosis before permanent effect of
lumen diameter not less than 8–9 mm was achieved.
Results: In all children the proof effect from the spent treatment was marked, the greatest
positive result was marked in the I-st and in the III-d groups of children. Patients from the
II-nd group after basic course needed carrying out supporting gullet bougienage in con-
nection with less proof result. Complications after gullet bougienage were not marked.
The conclusion: the endoscopic bougienage along a guide string is a unique effective
method of treatment of cicatricial gullet strictures, which allows to decrease risk of
complications.
P374 – Paediatric Surgery
LAPAROSCOPIC AUGMENTATION ILEOCYSTOPLASTY;
INITIAL EXPERIENCE
I. Ismail, R. Shalaby
Al-Azhar University Hospital, CAIRO, Egypt
Background: Bladder dysfunction may lead to urinary incontinence and progressive kidney
deterioration. When clinical treatment fails, bladder augmentation is the operation of choice
in most cases. Despite the widespread introduction of laparoscopy in pediatric urology,
many reconstructive procedures, such as augmentation ileocystoplasty, are still performed
in an open fashion because of the perceived intricacy and demanding nature. Routine use of
laparoscope in bladder augmentation has not been yet established in children. The aim of
this study was to present our initial experience with laparoscopic assisted bladder aug-
mentation using segment of the ileum.
Patients and Methods: Five cases with contracted bladder was the material of this study.
For many patients, augmentation cystoplasty can provide a safe functional reservoir that
allows for urinary continence and prevention of upper tract deterioration.
Materials and Methods: Indication for augmentation was hypo compliant bladder due
to meningeo-myelocele in 2 cases and Repaired ectopia vesica in 3 cases. The
operation is composed of three steps: (1) laparoscopic dissection of the bladder, (2)
preparation of the ileum extracorporeal through the umbilical port, and (3) reintro-
duction of the ileal pouch to do the ileo-vesical anastomosis laparoscopically.
Results: Age ranged from 4 to 8 years, Presenting by urinary incontinence, with small
contracted bladder. All procedures were completed laparoscopically without conversion.
Laparoscopic ileocystoplasty seems to be a feasible and safe technique. Operative time 80
minutes on average, catheter removed on 10th post op. day. Feeding started on the third
post-operative day. Hospitals stay 10 days on average. Follow up period was 2 years. The
learning curve for this complex reconstruction is Steep and extensive – probably this has
been the reason it has not been undertaken until recently compared to pyeloplasty and
ureteric reimplantation in the pediatric population. In fact, the first description of laparo-
scopic gastrocystoplasty was in 1995 by Docimo et al. Subsequently, an intracorporeal
laparoscopic ileocystoplasty (with stapled bowel anastomosis) was performed in 2007 by
Lorenzo et al.
Conclusion: In our preliminary experience, in experienced surgeon’s hands, RALIMA
seems to be a safe and feasible procedure with reasonable outcomes. Early recovery and
resumption of normal activities, as well as excellent cosmesis is seen in selected patients.
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P376 – Pancreas
LAPAROSCOPIC INTRA-OPERATIVE ULTRASOUND
AND NEEDLE GUIDED ENUCLEATION OF INSULINOMAS
J.L. Martin1, M. Marshall1, J. Jackson2, A. Isla-Martinez1
1 1
Northwick Park and St Mark’s Hospital, LONDON,
United Kingdom; 2Hammersmith Hospital, LONDON,
United Kingdom
Aims: To demonstrate laparoscopic needle guided enucleation as a novel
technique that facilitates the localisation and enucleation of non-visible insu-
linomas located deep within pancreatic parenchyma.
Methods: An 18 gauge needle is laparoscopically placed into the theoretical
location of the tumour and its position confirmed with laparoscopic intra-
operative ultrasound. The pancreatic parenchyma is then opened directly at the
site of the needle. This minimises pancreatic trauma and directs the surgeon to
the insulinoma to proceed to enucleation.
Results: We report this technique in two patients (age 35 and 43) who
underwent laparoscopic enucleation of non-visible insulinomas from the head
of the pancreas. Both patients had a solitary insulinoma (\1 cm in diameter)
located deep within the head of the pancreas. Needle-directed enucleation with
a single pancreatotomy was performed successfully, without complication, in
both patients. The postoperative period was unremarkable and they were dis-
charged on day 5 and 7.
Conclusion: This technique enables safe, laparoscopic enucleation of non-
visible pancreatic lesions that lie deep within the pancreatic parenchyma
avoiding multiple pancreatotomies and thus minimising the incidence of pan-
creatic fistula.
P377 – Pancreas
ROBOT-ASSISTED LAPAROSCOPIC
PANCREATICODUODENECTOMY
A. D’Annibale, G. Pernazza, V. Pende, P. Mazzocchi, G. Lucandri,
G. Alfano, I. Monsellato
San Giovanni Addolorata Hospital, ROME, Italy
Introduction: Robotic surgery is the most advanced development in minimally
invasive surgery. Minimally invasive pancreaticoduodenectomy (PD) remains
one of the most challenging abdominal procedures. Robotics may improve
performance in these procedure.
Methods: Twenty patients underwent PD from 2004 to 2011. In nine cases a
robotic Traverso-Longmire reconstruction, which includes a two-layered end-
to-side pancreaticojejunostomy, an end-to-side choledochojejunostomy, and a
side-to-side duodenojejunostomy, was performed.
Results: Median operative time was 520 min (390–615) and blood loss was 84
± 13 mL. Median hospital stay was 13.5 days (12–15). As a postoperative
complication, pancreatic juice leak occurred in one case, but it was conser-
vately trated.
Conclusions: Robot-assisted PD was safely performedthanks to the high degree
of freedom associated withrobotic instruments and the magnified view. Pan-
creatojejunostomy could certainly be conducted. Robotic assistance may help
surgeon during some steps which are difficult in laparoscopic technique. Fur-
ther studies and RCTs are needed to estabilished the real role of robotic
assistance in pancreatic surgery.
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P378 – Pancreas
FAST TRACK UPPER GASTROINTESTINAL SURGERY –
A SYSTEMATIC REVIEW
G.D.V. Dabare1, V.M. Patel2, E. Zacharakis2
Queen Alexandra Hospital, Portsmouth, SOUTHSEA,
United Kingdom; 2St Mary Hospital, LONDON, United Kingdom
Aims: Fast-track surgery has become ubiquitous in colorectal surgery and is
gaining acceptance in several other surgical specialities. The aim of this sys-
tematic review was to evaluate the feasibility, effectiveness and safety of fast-
track gastric, hepatic, oesophageal and pancreatic surgery.
Methods: A systematic review was performed by searching EMBASE, Med-
line, PsycINFO and Cochrane Library between 1950 and November 2011. The
search strategy included the keywords: fast track, enhanced recovery, multi-
modal rehabilitation, multimodal optimization and multimodal perioperative
care. We included all original studies and classified them according to the 17
evidence-based fast-track interventions proposed by the Enhanced Recovery
After Surgery Group. The primary endpoints were the number of implemented
interventions, median length of hospital stay (LOS), readmissions, morbidity
and mortality.
Results: 13 studies reporting on a total of 1621 patients were found; 2 ran-
domised control trials and a case-series in gastric surgery, 2 case-control
studies and a case-series in hepatic surgery, 2 case-series in oesophageal sur-
gery and 2 case-control studies and 3 case-series in pancreatic surgery. The
highest number of fast track interventions trialled in gastric, hepatic, oesoph-
ageal and pancreatic surgery were 13, 15.5 and 12 respectively. In all types of
upper gastrointestinal surgery studies demonstrated a reduction in median
length of stay ranging from 2–6 days. The studies did not show an increase in
readmission rate, morbidity and mortality with fast-track care.
Conclusions: Initial studies show that fast-track surgery is feasible in upper
gastrointestinal surgery, and may reduce length of stay. However, high quality
studies are required to determine the safety of fast-track programmes in upper
gastrointestinal surgery.
P379 – Pancreas
LAPAROSCOPIC SURGERY OF ACUTE PANCREATITIS
M.Ye. Nychytaylo, O.P. Kondratiyk, O.I. Lytvyn
National Institute of Surgery and Transplantology named by
A.A.Shalimov, KIEV, Ukraine
Aim: Surgical intervention is a main treatment approach in these patients with
high morbidity and lethality level. The aim was to assess the efficiency of
laparoscopic surgery for the treatment of patients with acute pancreatitis.
Methods: 208 patients with acute pancreatitis were treated by the following
protocol: antibacterial therapy, decontamination of the gut, intensive therapy of
the revealed disorders and ultrasound-guided fine-needle aspiration, Endo-
scopic retrograde cholangiopancreatography, laparoscopy and laparotomy. A
scoring system, APACHE II, was used to assess the patients’ state.
Results: adequate conservative therapy using minimally invasive technolo-
gies and laparoscopy allowed, the majority (56.2%) patients with acute
pancreatitis, to ensure the regressive course, avoid open surgery in the early
stages of the disease. Increase symptoms, increasing the number of free
fluid, foci of destruction in the abdomen and retroperitoneal space are
indications for the surgical laparoscopy (43.8%) from the transition to an
open surgery in 37.3% patients. Conclusion: application of a differentiated
approach in the management of patients with acute pancreatitis considering
its clinical and morphological forms, the topography of lesions of the
pancreas and the use of gentle and endoscopic techniques expands both
diagnostic and therapeutic possibilities to avoid the emergence of multiple
organ complications and ultimately improves the results of surgical treat-
ment of this pathology.
Surg Endosc (2013) 27:S53–S166
P380 – Pancreas
TOTAL LAPAROSCOPIC
PANCREATICODUODENECTOMY FOR CANCER
A.M. Hafez
Al salam oncology center, CAIRO, Egypt
Aim: Pancreaticoduodenectomy(pd), for cancer is still not widely accepted. It is a
very complex procedure that requires exceptional laparoscopic skill and experience.
The oncological safety is also another issue to consider. We present our experience
in Al Salam oncology center after performing 16 cases of total laparoscopic pds.
Patients and Methods: 16 patients were operated over 3 years by total laparoscopic
pd for cancer. They were 10 males, 6 females, age 44–69. 6 patients had cancer head
pancreas, 10 periampulary carcinomas. All under went routine investigations and
metastatic work up. all operable cases were subjected to total laparoscopic pd.
Results: operative time ranged 6–10 hours, estimated blood loss 250–750 ccs. Our
conversion rate was zero, 2 required reoperation. Major morbidity happened in 3,
with one mortality. Oncological outcome was satisfactory with all specimens having
negative margins, and lymph nodes 6–16.
Conclusion: Ttotal laparoscopic pd is a safe and feasible procedure with good oncological
outcome compared with the classical open approach, but its complexity and relative longer
operating times makes it less likely to be widely adopted.
P381 – Pancreas
TOTALLY LAPAROSCOPIC
PANCREATICODUODENECTOMY: PRIOR SURGICAL
EXPERIENCE.
P.S. Tyutyunnik1, I.E. Khatkov1, V.V. Tsvirkun2, R.E. Izrailev1
1
MSUMD, MOSCOW, Russia; 2Clinical Hospital 119, FMBA,
MOSCOW, Russia
Objectives: To show the experience in treatment of 34 patients with tumors of the head
of the pancreas and the periampullare area by using a totally laparoscopic approach.
Methods: From February 2006 to June 2011 40 patients were taken for laparoscopic
pancreaticoduodenectomy at the single center. Totally laparoscopic pancreaticoduo-
denectomy were perform for 34 patients. The indication were adenocarcinoma of the
head of the pancreas – 19, ampullae tumor – 9, distal common bile duct carcinoma – 3,
duodenal adenocarcinoma – 1, synchronous neuroendocrine tumor of the duodenum
and multiple gastrointestinal stromal tumors – 1, chronic pancreatitis 1. There were 21
females and 13 males. The mean age of the 40 patients was 60.6 (the oldest was 76)
years. Intraoperative and postoperative data were analyzed in the retrospective study.
Results: Conversions were needed in 6 from 40 cases because of tumor infiltration of
the mesenteric vessels and massive parapancreatic adhesive process. Median oper-
ative of totally laparoscopic pancreaticoduodenectomy time was 520 min, the 5 last
cases\360 min. Median blood loss was 605 ml and the last 5 cases 250 ml. Over all
post operative complication rate was 18(52.9%). Among them major complications 7
(20.5%); [this included pancreatic fistula – 5, bile leakage – 1, bowel obstruction – 1]
and the less severe complications were -6 (17.6%); [this included intraabdominal
fluid collection (n-3), delayed gastric empting (n-3)]. There were two patients (6%)
who died: one of them after insufficiency of pancreatojejenostomy and the other –
because of acute heart failure without any surgical complications. Local advanced
cancer was T3. First bowel moment was on the second postoperative day. Patients
were discharged from the hospital after full rehabilitation only.
Conclusion: Totally laparoscopic pancreaticoduodenectomy is safe and effective
procedure for patients with cancer of the biliopancreatoduodenal area. The results
are comparable with results after open approach procedures. The learning curve
becomes better after 30 cases.
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P382 – Pancreas
THE INCREASING OF THE EFFICACY OF THE PATIENTS
WITH ACUTE PANCTREATITIS SURGICAL TREATMENT
V.M. Demidov, S.M. Demidov
National Medical University, ODESSA, Ukraine
Aims: The fundamental physiological and pathological disciplines stated that pan-
creatic parenchyma can’t absorb the pharmacological compounds during the first 3–5
days of the inflammation. Correspondently, in our daily practice we use the fol-
lowing approach that intensive pharmacological treatment we started from the 5th
day after the disease onset while administering drugs with pacnreatoprotective
functions through the catheter inserted into bursa omentalis.
Methods: 28 patients with acute destructive pancreatitis (AP) were treated. The
treatment was aimed to pancreatic gland edema diminishing, extrahepatic bile tracts
decompression, usual desintoxicative and pancreatoprotective compounds adminis-
tration etc. Abdominal cavity laparoscopic drainage was performed to 23 patients.
Ten patients were treated traditionally with the very first days of the input to the
department. 13 patients constituted the group of the patients to whom we gave the
Sandostatin (Novartis Pharma Stein AG, Switzerland) and Deltaran (Russia).
Results: Traditional AP treatment resulted in the certain improvement of the disease
manifestation. Besides, the patients with the additional intrabursal Sandostatin and
Deltaran administration started after the 5th day of the disease onset showed more
progressive clinical condition improvement. There were no cases of the pancre-
onecrosis development in this group of patients (2 patients out of 10 with the
traditional AP treatment had pancreonecrosis). We didn’t observe any cases of
complication among the 13 patients treated with Sandostatin and Deltaran (2 com-
plications were in 10 patients with the traditional AP treatment). The average time of
patients treated traditionally days-in the hospital equal to 9–14 days. The average
time of patients who received Sandostatin and Deltaran days-in the hospital was 4–7
days shorter comparing with the same index in the traditionally treated patients.
Conclusions: Intrabursal pharmacons with the potent pancreatoprotective properties
administration in patients with destructive AP has some important advantages. There
are less cases of disease progression, less cases of complications and the quicker
improvement of the patient. The very important idea we worked with is that intra-
bursal drugs administration we stared 5 days later waiting for the termination of the
initial stage of pancreatic gland inflammation.
P383 – Pancreas
LAPAROSCOPIC DISTAL PANCREATECTOMY:
A RETROSPECTIVE ANALYSIS OF 9 CASES
J. Bezsilla, Á. Botos, L. Sikorszki, S. Bende
B-A-Z County Hospital, MISKOLC, Hungary
Laparoscopic pancreatic interventions are rare operations published only as case
reports or in small series. The feasibility and safety of laparoscopic distal pancrea-
tectomy has been reported with good results. Laparoscopic resection of malignant
neoplasms has raised concern about the radicality of resection and oncological
outcomes. In this report, the authors retrospectively review their experience with the
distal pancreas in benign, endocrine, and malignant diseases.
From Jan 2007 to Dec 2011, 9 patients underwent a laparoscopic procedure for
pathologies of the distal pancreas. The authors performed two distal pancreatecto-
mies with conservation of the spleen and section of the splenic vessels, six distal
splenopancreatectomies (DSP), one DSP plus a gastric wedge resection for a stromal
tumor. The use of laparoscopic ultrasonography is an integral part of the procedure.
One procedure was converted to open surgery because of a hemorrhagic compli-
cation. No other significant intraoperative complications occurred. The operation
time was 135 (90–260) minutes. The postoperative course was characterized by one
infected haematoma managed operatively, two pancreatic fistulas (grade A – no
requiring second operation). The mean postoperative stay was 7 days. The histologic
report showed 6 benign diseases and 3 malignant tumors. There were no deaths, nor
readmissions. Laparoscopic distal pancreatectomy with or without splenectomy is
feasible and can be performed with minimum morbidity rate and only slightly
increased operation time. Prospective studies are necessary to confirm that positive
impression.
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P384 – Pancreas
SINGLE INCISION LAPAROSCOPIC DISTAL PANCREAS
RESECTION – IS IT MEANINGFUL?
M.O. Biebl, J. Schirnhofer, C. Mittermair, K. Pimpl, C. Obrist,
A. Guenther, N. Waldstein, R. Frass, H.G. Weiss
SJOG Hospital, SALZBURG, Austria
Aims: Laparoscopic distal pancreatectomy is an established, however controversial tech-
nique, due to the high overall risk for pancreatic fistulas in left-sided pancreas resections.
We report out experience with a single incision laparoscopic (SIL) approach.
Patients and Methods: Between 09/2009 and 11/2011, 7 patients (3 females; mean age
57.49 ± 8.81 years, mean BMI 26.63 ± 0.68) underwent SIL-distal pancreatectomy at out
institution. Indications for surgery were solid tumors (86%), and a splenic artery aneurysm
not amendable to interventional treatment (14%). All SIL procedures were performed in a
regular laparoscopic setting, using one articulating instrument. With the patient tilted to the
right side, the pancreas was exposed using suspension sutures to the stomach and the
transverse mesocolon in 100% and 43%, respectively. The pancreatic stump was closed
using a linear vascular stapler, and the splenic vessels were sealed separately. Intraab-
dominal drains were not routinely used. Data are reported as total numbers (%) and mean ±
standard deviation.
Results: Operation time was 116.71 ± 40.61 min, time until parenchyma dissection 57.49 ±
8.81 min. Exposure was excellent in all cases, with no additional trocar placement required.
Type of resection was tumor enucleation (29%), and distal pancreatectomy (spleen pre-
serving (29%), with spleen (42%)). One patient underwent simultaneous SIL right-sided
colectomy for concomitant colon cancer. While 29% of patients had had previous upper
abdominal surgery, mild adhesiolysis was required in 43%. Specimen retrieval was per-
formed through the umbilical incision (3.76 ± 0.38 cm). All six solid tumors (33%
adenocarcinomas) were resected with negative margins. Two parenchyma fistulas (28%)
occurred, one requiring revision. Major complications (29%) included one intraabdominal
hematoma requiring revision (14%), and one severe pancreatitis and stump fistula requiring
relaparotomy (14%). With a mean follow-up of 14.12 ± 9.72 months, no tumor has recurred
and one patient undergoing relaparotomy for pancreatitis has developed an incisional hernia
(14%).
Conclusion: Stapled distal pancreatic stump closure remains challenging with considerable
fistula rates. In a minimally invasive setting, the SIL approach allows for the same exposure
and safety as the conventional laparoscopic technique.
P385 – Pancreas
LAPAROSCOPIC NECROSECTOMY FOR INFECTED
PANCREATIC NECROSIS. 2 CASE REPORTS
B. Majerus, X. De Koninck, C. Van Ruyssevelt, T. Dugernier
Clinique Saint Pierre, OTTIGNIES LOUVAIN-LA-NEUVE,
Belgium
Aims: We present two cases of laparoscopic pancreatic necrosectomy and discuss the new
modalities of treatment of infected pancreatic necrosis.
Methods: New modalities of treatment for infected necrosis after acute pancreatitis have
been developed recently. The goal of all the therapeutic strategies is the elimination of all
necrotic tissues. Aside to the classical ‘open’ necrosectomy, percutaneous drainage with
irrigation and surgical minimal invasive modalities can offer the patient less aggressive
approaches and definitive treatment. Experiences with retroperitoneoscopic approach as
well as transluminal transgastric endoscopic approach have been published. We treated our
patients through laparoscopic transabdominal approach using an infracolic route, as
described by Adamson and Cuschieri. In this technique, the lesser sac cavity is opened
through the root of the transverse mesocolon. Pus is aspired and necrosis is retrieved under
direct visual control. Double drainage is installed allowing for postoperative irrigation of
the cavity.
Results: The first patient (51 years old woman) developed infection of peripancreatic
necrosis secondary to an alcoholic pancreatitis and presented with fever and abdominal pain
3 weeks after initial admission. Percutaneous puncture revealed Staphylococcus aureus
infection for which intervention was decided. The second patient (79 years old woman) was
admitted for abdominal pain and vomiting leading to the diagnosis of a severe biliary
pancreatitis complicated with an infected peripancreatic collection and splenic vein
thrombosis. Percutaneous drainage confirmed infection due to Escherichia coli and
Enterococci. Antibiotherapy and small volumes irrigations of the infected cavity were not
successful and laparoscopic exploration was done 5 weeks after admission. In both cases, a
complete necrosectomy with drainage was performed and evolution was good.
Conclusions: Laparoscopic transabdominal necrosectomy is best indicated in the late course
of pancreatitis when necrosis is well demarcated. It allows for a complete removal of the
necrosis along with drainage of the residual cavity in one stage. We review the literature
and try to delineate the advantages and limits of the procedure in comparison with the other
modalities of treatment.
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Surg Endosc (2013) 27:S53–S166
P386 – Pancreas
LAPAROSCOPIC DISTAL PANCREATIC RESECTION
J. Stefka, R. Gürlich, Dr. Havluj, V. Bobek, V. Mandys
Faculty hospital of Královské Vinohrady, PRAGUE, Czech Republic
Introduction: The left-sided laparoscopic pancreatectomy is indicated in the diag-
nosis of benign pancreatic disease of the tail of pancreas. In the case of pancreatic
malignity of the tail of pancreas open resection is indicated. Relative contraindica-
tion is the size of the tumor, of the previous extensive operation with vascularized
adhesions, pseudoaneurysm of splenic artery and the passing splenic vein through
pancreatic parenchyma.
Material and methods: The 3rd Surgical Clinic Medical Faculty Hospital FNKV 209
surgeries were performed on the pancreas from the year 2009–2011.In 143 cases the
reason for the operation was the malignancy of pancreas and periampulary area. In
31 cases the problem was chronic pancreatitis or benign tumor of the pancreas and
35 operations were performed because of acute pancreatitis. In 15 patients (7 benign
lesions and 89 malignancy) left-sided (distal) pancreatectomy was performed. In 8
cases we indicated laparoscopic left-sided resection which was completed in 4
patients. In other four cases we converted. Pancreas was transacted in all cases by
stapler.
Results: In our group of patients we did not record any serious complications such as
pancreatic fistula, bleeding, or surgical site infection. A high percentage of con-
versions have so far been given by the initial experience and regarding the size of the
group of patients, it has not up-to now informative value.
Conclusion: Laparoscopic distal pancreatic resection belongs into the spectrum of
operativity of pancreas high-volume surgery centers and it shows better results than
opened distal pancreatectomy.
P387 – Pancreas
LAPAROSCOPIC MEDIAN PANCREATECTOMY: AN IDEAL
WAY TO PRESERVE PARENCHYMAL FUNCTION FOR MID
BODY TUMORS
P. Senthilnathan, C. Palanivelu, P.S. Rajan, S. Rajapandian,
P. Praveen Raj, V. Vaithiswaran, A. Manoj Kumar,
A.G. Alwar Ramanujam
GEM Hospital & Research Centre, COIMBATORE, India
Introduction: Pancreatic body lesions are difficult to treat, one for the late presen-
tation and other being removal of major portion of parenchyma. Distal
Pancreatectomy for benign tumors results in endocrine disturbances particularly
development of Diabetes Mellitus. Median or central pancreatectomy is an option for
centrally located tumors but is technically difficult to perform. We present our
experience of Minimally Invasive approach to treat these tumors.
Methods: Since 2001, we have performed 5 median pancreatectomy, 3 of them were
for females and 2 males. Those patients who were planned for median pancreatec-
tomy but could not be completed for technical reasons were excluded from this
study. The mean age is 36 years and the size of the lesion is 3 cm. Malignant tumors,
borderline resectable tumours and large lesions more than 3 cm were excluded.
Results: The mean operating time is 240 mins and blood loss is 160 ml. (range
30–320 ml). Mean ICU stay was 1 day and hospital stay was 4.5 days. Return of
bowel function is on the second day. There was no leak and all margins were
negative. Four of those were done for mucinous cystadenoma and one for serious
cystadenoma. Follow up ranges from 8 years to 2 months and till now no recurrence
is being reported.
Conclusion: Laparoscopic Median pancreatectomy is an ideal procedure for selected
small lesions situated in the body of pancreas which preserves both exo and endo-
crine function of pancreas.
Surg Endosc (2013) 27:S53–S166
P388 – Physiology, Pathophysiology, Immunology
PNEUMOPERITONEUM MODEL USAGE TO DELINEATE
PATHOPHYSIOLOGIC INTER-RELATIONSHIPS BETWEEN
CARDIAC AND RESPIRATORY PARAMETERS, DURING
LAPAOSCOPIC SURGERY.
A. Bickel1, J. Herzig2, A. Eitan1, N. Gavrieli3, N. Intrator2
1
Western Galilee Hospital, Bar Ilian University, NAHARIYA, Israel;
2
Tel Aviv University, TEL AVIV, Israel; 3Technion, Institute
of Technology, Faculty of Medicine, HAIFA, Israel
Background: We studied the creation of positive pressure pneumoperitoneum (PP) during
laparoscopic cholecystectomy, as a template model to evaluate cardiovascular pathophys-
iologic phenomena that might be influenced by increased intra-abdominal pressure.
Aim: To study the pathophysiologic relationship between the occurrence of the first heart
sound (S1), the ECG complex, respiratory cycle and the intra-peritoneal pressure, during
laparoscopic surgery.
Methods: Twenty five patients, electively scheduled for laparoscopic cholecystectomy,
were enrolled in the study. All were fully monitored, and PP was digitally set on 14 mmHg.
Each was connected to a computerized phonocardiogram analyzer, and data concerning the
ECG, heart sounds and their relations to the inspiration-expiration phases and PP were
evaluated, using heart sound and ECG signal morphology analysis and clustering. The
expiratory and inspiratory phases were detected from the heart sound and all analyses were
performed separately on each phase. Another robust measure of the delay between the QRS
complex and the onset of S1 was created. All measures were made immune to noise and
disturbances during the recording, so that small changes of few milliseconds can be reliably
measured. For comparison, we also analyzed morphological changes of the QRS complex
to determine whether it is indicative of the physiological stress (PP).
Results: The mean age of our study population was 47 years (28 to 82). We noticed 4
different sub-populations regarding the ECG morphological changes and QRS complex-S1
delay. Patients having medical background of cardiac problems had significantly increased
delay (decreased conductibility during PP), while patients without cardiac disease were
characterized with increased ECG morphological changes.
Conclusions: Increased intra-abdominal pressure might be reflected by changes in the ECG
morphology and QRS-S1 delay during respiratory cycle, by using sophisticated mathe-
matical means. In addition, our preliminary results suggest the use of similar methods to
delineate a latent sub-clinical cardiac disease that might not be exposed by conventional
means.
P389 – Physiology, Pathophysiology, Immunology
MAJOR MINIMALLY INVASIVE SURGERY AND
SURGICAL STRESS RESPOSNE
E. Yiannakopoulou
Technological Educational Institute of Athens, ATHENS, Greece
During and after surgical procedures there is a complex physiological host response termed
surgical stress response that involves activation of inflammatory, neuroendocrine, metabolic
and immunological mediators. Stress response to minimally invasive surgery has been
measured in both clinical and experimental trials. However, stress response to advanced
minimally invasive surgery has not been fully investigated. This systematic review aims to
critically synthesize data on the effect of advanced minimally invasive surgery on surgical
stress response
Methods: Electronic databases were searched with the search terms ‘major minimally
invasive surgery’, ‘advanced minimally invasive surgery’, ‘advanced robotic surgery’,
‘colon surgery’, ‘pancreatic surgery’, ‘endocrine surgery’, ‘surgical stress’ ‘surgical stress
response’, ‘stress response’, up to and including January 2012.
Results: Ten papers were identified including eight clinical trials and two experimental
trials. Clinical trials compared stress response in the context of laparoscopic assisted
hysterectomy, laparoscopic retroperitoneal radical prostatectomy and laparoscopic colec-
tomy with stress response to the corresponding open procedures. With the exception of one
trial, all the other trials included about twenty patients per treatment group. Measured
parameters of surgical stress response included neuroendocrine stress response markers i.e.
cortisol, growth hormone, glucagon, norepinephrine, immune response markers i.e. inter-
leukins, adypocytokin lectin, lymphocyte and leucocyte counts, Toll Like receptors, TNF-a
and metabolic response markers i.e glucose. Six trials showed that laparoscopic surgery was
associated with less postoperative stress response, one trial showed that non descent vaginal
hysterectomy was better tolerated than laparoscopic hysterectomy and one trial showed no
difference between laparoscopic assisted and open sigmoidectomy. The experimental trials
investigated stress response of small animal models in the case of colon surgery and showed
that laparoscopic surgery elicited milder stress response comparing with open surgery
Conclusion: Stress response on major surgery is clinically significant since it is
associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction
syndrome. Thus, future research efforts should focus on the investigation of the
effect of major minimally invasive surgery on surgical stress response.
S149
P390 – Physiology, Pathophysiology, Immunology
DIABETIC FOOT COMPLEX TREATMENT USING
THIOCTIC ACID AND MEXIPRIM
V.Ye. Vansovich1, A.V. Doroshenko2
1
National Medical University, ODESSA, Ukraine; 2Municipal
Hospital, KHERSON, Ukraine
Aims: To evaluate the clinical efficacy of patients with the initial signs of diabetic
foot (DF) treatment using neuroprotective treatment (thioctic acid and mexiprim)
additionally to pathogenetical antidiabetic compounds. The background of these
clinical-laboratory observations is fundamental position that ischemia, neuropathy
and infection are the three pathological components that lead to DF complications,
and they should be underwent to the pathogenetically proved treatment additionally
to the surgical one if needed.
Methods: Neuropathy and ischemia are the initiating factors, most often together as
neuroischemia, whereas infection is mostly a consequence. From these positions, 42
patients with diabetes mellitus and with the initial clinical signs of the DF were
included into observations. Starvation glycemic level in these patients was ranged
from 6.5 till 14.0 mmol/l. These patients were randomized into the following groups:
the 1st group patients (n = 17) received traditional antidiabetic therapy. Both Thioctic
acid and Mexiprim were included into the complex treatment of the 2nd group
patients (n = 25). Nerve Conductance Velocity Test was performed in these patients
for the original treatment efficacy evaluation.
Results: The 2nd group patients starting from the 10th days of the original therapy
showed significant decrease (p \ 0.05) in the blood plasma lipid peroxidation sub-
stances, increase (p \ 0.05) in antioxidant enzymes activity, blood toxic test indexes
decrease (p \ 0.05) as well as nerve conductance velocities indexes on sural nerve
and accessory deep peroneal nerve increase (p \ 0.05) in comparison with the same
indexes in the patients of the 1st group with DF who received only traditional
therapy. Such a tendency received more expressed statistical difference after 2 weeks
of the treatment.
Conclusions: The data obtained showed that neuroprotective and antioxidant treat-
ment in patients with diabetes mellitus and the initial signs of DF should be complex
and together with the pathogenetical antidiabetic treatment aimed to the diabetic-
induced metabolic disturbances elimination. Such complex scheme of DF treatment
shows that new strategies must be developed and implemented for DF patients with
vascular impairment.
P391 – Radiology/Imaging
SUB-HEPATIC Vs TRANS-HAPATIC PERCUTANEOUS
CHOLECYSTOSTOMY FOR ACUTE CHOLECYSTITIS:
IS THERE A DIFFERENCE?
H. Qandeel, A. Hammad, H. Abudeeb, M. Sajid, N. Mathias,
S. Mahmud
Hairmyres Hospital, GLASGOW, United Kingdom
Aims: Traditionally, the Trans-hepatic approach for the Percutaneous Cholecystos-
tomy (Th-PC) has been adopted to avoid the risk of bile leak and bile peritonitis.
This study aims to assess the safety and effectiveness of both Sub-hepatic Percu-
taneous Cholecystostomy (Sh-PC) and Th-PC in treating non-resolving acute
cholecystitis in high risk patients.
Methods: Data of 18 consecutive patients who underwent either Ultrasound or CT
scan-guided Percutaneous Cholecystostomy (PC) for management of acute chole-
cystitis in one hospital from December 2008 until October 2011 was evaluated.
Results: All patients were American Society of Anesthesiologists (ASA) class 4E at
the time of PC. Their mean age was 77.4 (57–91 years old). All patients had
radiological evidence of gallstones in a distended gallbladder. In all cases, PC was
done under local anaesthesia using 8 or 10-french locking Pigtail drain. PC was
either via a Sub-hepatic (11 patients-61%) or Trans-hepatic (7 patients-39%)
approach. 5 patients (28%) were CT scan-guided, while the rest (72%) were
Ultrasound-guided. None of the patients developed a bile leak or biliary peritonitis.
One patient (5.5%) died 3 weeks post PC due to associated metastatic liver disease,
unrelated to PC. 3 patients (1 Th-PC: 2 Sh-PC) were re-admitted as an emergency,
two of them with biliary obstruction which required ERCP and one patient with
further cholecystitis which was treated with open cholecystectomy.
Conclusions: Our limited series does not show a significant difference between Th-
PC and Sh-PC approaches in terms of bile leak or biliary peritonitis post PC. Both
are effective treatments for acute cholecystitis in surgically unfit patients who did not
respond to non-operative management.
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P392 – Radiology/Imaging
IS GROIN ULTRASOUND SCAN PRIOR TO HERNIA
REPAIR A USEFUL DIAGNOSTIC TOOL?
A.C. Wells, R. Fisher, S. Gergely, F. Di Franco, A. Harris
Hinchingbrooke Hospital, CAMBRIDGE, United Kingdom
Aims: The aim of this study was to report the incidence of ultrasound scan (USS)
prior to elective groin hernia repair and compare the USS result with clinical and
surgical findings.
Methods: The records of 300 consecutive patients who underwent surgery for
inguinal or femoral hernias were evaluated to determine which patients had under-
gone pre-operative USS. The ultrasound report was compared to pre-operative
clinical examination and to surgical findings.
Results: 48 patients (16%) underwent USS pre-operatively. 45 patients had laparo-
scopic and 3 patients open repair. The majority (32) of USS were requested by the
general practitioner prior to referral to surgical outpatient clinic.
Comparison of clinical examination, USS and surgery:
1. Clinical examination and USS agreed in 74% cases.
2. Clinical examination and surgical findings agreed in 77% cases.
3. USS & surgical findings agreed in 71% cases.
The positive predictive value for USS was 72% compared to 82% for clinical
examination. Moreover when the clinical examination findings were incorrect, USS
did not add any diagnostic benefit. USS errors were independent of grade of
ultrasonographer.
Conclusions: Our results contrast with previous published data which have suggested
a positive predictive value for USS of 94%. In this study clinical examination
remained the best tool for diagnosing groin hernias. Assessment in the surgical clinic
prior to USS should be recommended to avoid potentially confusing results and
unnecessary use of resources.
P393 – Radiology/Imaging
ARE IMAGE DOCUMENTATION AND OPERATIVE
DESCRIPTION OF THE TECHNIQUE AND FINDINGS
OF LAPAROSCOPIC INTRAOPERATIVE
CHOLANGIOGRAPHY SUBOPTIMAL?
A.L. Karran, A. Majoe, O. Jalil, A. Rasheed
Royal Gwent Hospital, CARDIFF, United Kingdom
Aims: To examine the details of the technique of IOC and to audit the quality of the
captured images and the content of operative notes in relation to documentation of
essential IOC anatomical landmarks.
Method: A retrospective analysis of 100 consecutive laparoscopic intra-operative
cholangiograms that were attempted at the Aneurin Bevan Health Board (ABHB)
between February 2009 and March 2010 was undertaken. The visualisation of 7
essential anatomical landmarks on captured IOC images and specific reference made
to each in the operation notes were assessed.
Results: A significant inter-operator variability was noted in the performance and the
interpretation of IOC. Only 34% of captured images identified all 7 recognised
essential IOC landmarks. The majority (63.8%) of operation notes failed to make
reference to all 7 landmarks, with a mean number of landmarks referred to as 1.
There was a significant difference (p \ 0.001) between landmarks identified on the
captured images and their documentation within the operation notes.
Conclusions: This study confirms that laparoscopic IOC is sub-optimally performed
and poorly reported. It highlights the need for standardisation of the IOC technique
and systematisation of its reporting.
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P394 – Robotics, Telesurgery and Virtual Reality
INITIAL EXPERIENCE OF ROBOTIC RECTAL SURGERY
WITH LATERAL PELVIC LYMPH NODE DISSECTION IN
A SINGLE JAPANESE INSTITUTION
K. Uehara, F. Koide, Y. Yoshioka, T. Ebata, Y. Yokoyama, T. Igami,
G. Sugawara, M. Nagino
Nagoya University Hospital, NAGOYA, Japan
Aims: Japanese guidelines recommend lateral pelvic lymph node dissection (LPLD) for
treating patients with stage II/III lower rectal cancer, even patients without preoperative
lateral lymph node (LN) swelling. Since the technique of laparoscopic LPLD is challenging
and not being widely practiced, laparoscopic surgery is generally not indicated for advanced
rectal cancer in Japan. Therefore, we introduced the use of a robotic system in rectal cancer
surgery.
Methods: We used hybrid robotic rectal resection and LPLD with autonomic nerve pres-
ervation. LPLD was defined as LN dissection of the obturator cavity and along the internal
iliac vessels. Results: Between September 2011 and October 2011, a single colorectal
surgeon performed hybrid robotic surgery in 4 patients with locally advanced rectal cancer
by using the da Vinci surgical system. Magnetic resonance imaging showed that all the
patients had poor-risk rectal cancer, and they received 4 cycles of neoadjuvant chemo-
therapy with capecitabine plus oxaliplatin (XELOX) plus bevacizumab. Left colonic
mobilization and upward LN dissection were performed laparoscopically, and thereafter,
robotic operation was indicated for rectal mobilization and LPLD. Two patients underwent
super-low anterior resection, and the remaining 2 patients underwent intersphincteric
resection with diverting ileostomy. LPLD with autonomic nerve preservation were per-
formed in 3 patients. The average console time was 245 min. Unilateral LPLD was
performed in 223 min, which was much longer than the time taken (average, 82 min) to
perform an open LPLD. The advantages of robotic rectal resection and LPLD were as
follows: (1) full high-definition quality and three-dimensional imaging, (2) free manipu-
lation of the tip of the forceps with an articulating endowrist, (3) lack of interference, and
(4) more consistent manipulation without tremors.
Conclusion: We reported the initial experience of robotic rectal surgery in a single Japanese
institution. Robotic surgery enables highly accurate surgery with a good visual field and
free manipulation of the forceps, especially around the anal canal or in the lateral pelvic
wall. We intend to standardize the operative procedure and use the learning curve effect to
shorten the long operative time.
P395 – Robotics, Telesurgery and Virtual Reality
MINIATURIZED ROBOTIC LAPAROSCOPE-HOLDER FOR
RECTOPEXY: FIRST RESULTS OF A PROSPECTIVE STUDY
J. Jarry1, A. Moreau Gaudry2, E. Chipon3, J.L. Bosson3, P. Cinquin3,
J.L. Faucheron4
1
Desgenettes hospital, LYON, France; 2TIMC-IMAG Laboratory,
CAMI team, UJF-CNRS, GRENOBLE, France; 3Clinical
Investigation Centre – Innovative Technology, CIT 803, Inserm,
GRENOBLE, France; 4Chirurgie Digestive et de l’Urgence,
University Hospital, GRENOBLE, France
Introduction: Thanks to the technical progress in instrumentation laparoscopic sur-
gery has made considerable advances over the last decade. Robotic systems have
been introduced to assist laparoscopic procedures. A new prototype of miniaturized
laparoscope-holder (called Light Endoscope Robot; LER) has been developed by the
laboratory TIMC-IMAG-CNRS in France and is now currently marketed by the
French company Endocontrol. The aim of this pilot study was to assess this first
marketed version of the LER in clinical practice.
Method: Prospective, single-centre study. The LER had already been successfully
validated on preclinical laboratory and cadaveric trials. The present study was
conducted at the Grenoble University Hospital during standardized laparoscopic
rectopexies on adult patients. Demographic and operative data, qualitative results
were collected prospectively and analyzed retrospectively. All patients signed an
inform consent and the study was approved by the local Ethic Committee.
Results: Between March 2008 and September 2010, 16 adult patients underwent
laparoscopic rectopexy with the LER. All were females with an average age of 63.6
year old and an average BMI of 24 kg/m2. The procedure was completed in 15
patients. No conversion to open surgery was required. The post-operative mortality
rate was 0% and complication occurred in one patient. On a scale from 0 (bad) to 10
(excellent) the surgeon graded ease of use 7 ± 2, global comfort 8 ± 2, and quality
of vision 8 ± 2.
Conclusion: This pilot study demonstrated the feasibility, safety, and comfort for the
surgeon of the laparoscopic rectopexy assisted by the miniaturized light endoscope-
holder LER.
Surg Endosc (2013) 27:S53–S166 S151

P396 – Robotics, Telesurgery and Virtual Reality P398 – Robotics, Telesurgery and Virtual Reality

FULL ROBOTIC GASTRECTOMY WITH EXTENDED (D2)
LYMPHADENECTOMY FOR GASTRIC CANCER:
SURGICAL TECHNIQUE AND PRELIMINARY RESULTS
A. D’Annibale, V. Pende, G. Pernazza, I. Monsellato, G. Alfano,
P. Mazzocchi, G. Lucandri
San Giovanni Addolorata Hospital, ROME, Italy
Introduction: Widespread diffusion of minimally-invasive surgery for gastric cancer
treatment is limited by the complexity of performing an extended D2-lymphade-
nectomy. This surgical step can be facilitated by using robot-assisted surgery. The
aim of this study is to describe our technique and short-term results of a consecutive
series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer,
using the da Vinci Surgical System.
Materials and Methods: Between May 2004 and December 2011, we performed 40
consecutive full robot-assisted total and subtotal gastrectomies with extended D2-
lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring
to 19 robot-assisted total gastrectomies and 21 subtotal gastrectomies were collected
in a database and analyzed.
Results: Median operative time was 267.50 min (255–305). Median intraoperative
blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23–34).
Resection margins were negative in all cases. No conversions occurred. Surgery-
related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on
postoperative d 5 (2–5). Median length of stay was 6 d (5–8).
Conclusions: Robot-assisted gastrectomy with D2-lymphadenectomy is a safe
technique and allows achieving an adequate lymph node harvest and optimal R0-
resection rates with low postoperative morbidity and the learning curve appears to be
shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials
are needed to define the role of robot-assistance in gastric cancer surgery.
ROBOT-ASSISTED DISTAL GASTRECTOMY: OUR INITIAL
EXPERIENCE
M. Nishizaki, S. Kagawa, F. Uno, H. Kishimoto, Y. Kondo,
T. Fujiwara
Okayama University Hospital, OKAYAMA-CITY, Japan
Objective: The cases of robot-assisted gastrectomy for gastric cancer using da Vinci
SHD surgical system are increasing in Japan though still not very common. We
report here our early experience of robotic-assisted distal gastrectomy (RADG).
Patients and Methods: Between February and November 2011, we performed 5 cases
of RADG for early gastric cancer. The main operator in the surgeon console was an
experienced laparoscopic surgeon. In all cases, double bipolar system was introduced
for procedure of operation. The 1st and 3rd robotic arms were manipulated with the
right hand, and the 2nd arm was done with the left hand. In the 1st arm the dissecting
forceps, and in the 2nd arm the grasping forceps were equipped with a bipolar
electric cautery device. The surgical procedures of RADG were similar to those of
laparoscopy-assisted distal gastrectomy.
Results: Mean operation time and blood loss were 289 min (209–365 min) and 30 g
(0–100 g), respectively. Mean retrieved number of LNs was 27.0 (21–42). Intra-
operative complications were not observed. The postoperative courses were as same
as those of laparoscopic surgery.
Conclusions: This study demonstrated that RADG using the da Vinci SHD surgical
system can be applied safely for patients with early gastric cancer in our institution.

P397 – Robotics, Telesurgery and Virtual Reality P399 – Robotics, Telesurgery and Virtual Reality

A NEW GLOVE FOR GESTURE RECOGNITION AND ROBOT-ASSISTED ENDOSCOPIC SURGERY OF THE
CLASSIFICATION FOR SURGICAL SKILL ASSESSMENT THYROID GLAND
A. Lazzaro, A. Corona, L. Sbernini, L. Santosuosso, F. Giannini, N. Constantea, D. Axente
C.A. Pinto, L. Iezzi, G. Saggio, P.P. Sileri, A.L. Gaspari, Cluj-Napoca County Hospital, CLUJ-NAPOCA, Romania
N. Di Lorenzo Aims: Many endoscopic minimally invasive procedures have been developed and are
University of Tor Vergata, ROME, Italy used now in thyroid and parathyroid surgery. However, the endoscopic approach is
more technically demanding and due its limitations, endoscopic thyroidectomy
Aims: The understanding of surgical gesture, by means of a measuring apparatus, can
remains limited in application and practiced in a relatively small number of centers.
play a key role in the evaluation of surgical performance. To this aim, a neural network
Recently robotic technology has been also applied to thyroid surgery. The aim of this
classification algorithm can be helpful, since it combines good generalization perfor-
study is to present our experience and to demonstrate the technical feasibility,
mances along with a parsimonious architecture when dealing with high dimensional
intraoperative safety and efficacy of robotic thyroidectomy.
classification problems. We present its use as a surgical training tool for open surgery, a
Methods: The technique that we are practicing use the unilateral transaxillary
field of research highly underrepresented in the surgical teaching scenario.
approach without gas insufflation. We used the da Vinci SI Surgical Robotic System
We operated a bounding box decomposition of surgeon’s hand movements analysis
for all interventions and we performed 35 total unilateral lobectomy and 7 total
and gesture recognition during training of novice surgeons. This feature was applied
thyroidectomy. Patients were diagnosed with unilateral thyroid nodules and 7 of
to analyze trajectories of surgeon’s wrist and finger postures, so to recognize dif-
them, whit bilateral thyroid nodules. For each patient we analyzed the clinical
ferent hand gestures.
characteristics, tumor size, pathologic type, operative time, amount of drainage,
Methods: Dataset of surgical gestures: 5 master surgeons, 5 resident surgeons and 5
duration of hospital stay, postoperative complications, postoperative neck and
attending surgeons made this tasks: interrupted stitch; running suture; knot tying
anterior chest pain, and cosmetic satisfaction.
exercise.
Results: All operations were performed successfully without any need for conven-
Gesture measurement: we developed a data glove on the basis of acquired
tional open conversion. The mean overall operation time was 155 min. respectively
experiences.
80 min. console time. The mean tumor size was 3.5 cm. There was one temporal
This glove is provided with sensors to measure movements of distal interphalangeal,
brachial plexus neuropraxia and 4 wound seroma. There were 2 malignant thyroid
proximal interphalangeal, metacarpo phalangeal finger joints and wrist postures.
lesions at the final histopathological results. In this situation we perform total thy-
Gesture classification: synthesis of an algorithm automatically assigns each gesture
roidectomy by open cervicotomy during the same hospitalisation.
to a predefined class.
Conclusions: Robotic technology overcame some technical limitations associated
Operator’s training: Currently Mentors transfer their expertise to trainee via practical
with conventional endoscopy. Robotic thyroidectomy by gasless transaxillary
demonstrations and oral instructions. With recorded data of measures it is possible to
method is feasible, safe, and provided good outcomes.
reproduce such movements via avatar representation on a PC screen. It gets the
important aspect that the same gesture can be represented several times always in the
same manner and that it is possible to look at the gesture from all possible points of
view, just rotating, translating, zooming the avatar.
Results: We developed a graphical interface capable to superimpose a ‘ghost’ avatar
of the learner upon the ‘guide’ avatar of the expert. In this manner the trainee is
capable to easily auto-evaluate her/his performance with instinctive ability.
Conclusions: This work, still in progress, would be an innovate, accurate and non
invasive method to measure and evaluate surgical gestures. It will be useful to
accelerate the attending surgeon’s learning curve who can compare the basic level of
his expertise with master surgeon’s level and verify step by step his improvement.

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P400 – Robotics, Telesurgery and Virtual Reality
INITIAL LEARNING CURVE FOR ROBOTIC SLEVE
GASTRECTOMY
R. Vilallonga, J.M. Fort, O. Gonzalez, E. Caubet, S. Valverde,
M. Armengol
Universitary Hospital Vall d’Hebron, BARCELONA, Spain
Objective: Robot-assisted sleeve gastrectomy has the potential to treat patients with
obesity and its comorbidities. Such patients can benefit from minimally invasive
surgery including robotic technology. We sought to evaluate the learning curve for
this procedure before undergoing Roux en-Y gastric bypass.
Materials and Methods: Robot-assisted sleeve gastrectomy was attempted in 23
consecutive patients. A Board approved and review of our robot-assisted sleeve
gastrectomy protocol. A survey was performed in order to identify performance
variables during completion of the learning curve. Total operative time (OT),
docking time (DT), complications, and length of hospital stay were compared among
patients divided into two cohorts according to the surgical experience of the surgeon
(Cohort 1 – less experience, Cohort 2 – more experience). Scattergrams and con-
tinuous curves were plotted to develop a robotic sleeve gastrectomy learning curve.
Results: Overall OT time decreased from 89.8 minutes in cohort 1 to 71.0 minutes in
cohort 2, with less than 5% change in OT after case 19. Time from incision to
docking decreased from 9.5 minutes in cohort 1 to 8.7 minutes in cohort 2. The time
required to dock the robotic system also decreased from 9.1 minutes in cohort 1 to
6.9 minutes in cohort 2. The complication rate was the same in the two cohorts.
Conclusion: Our survey indicates that technique and outcomes for robot-assisted
sleeve gastrectomy gradually improve with experience. We found that the learning
curve for performing a sleeve gastrectomy using the da Vinci system is completed
after about 19 cases.
P401 – Robotics, Telesurgery and Virtual Reality
SEGMENTAL RESECTION AND RECOSNTRUCTION
OF MAIN PERIPANCREATIC VESSELS DURING
LAPAROSCOPIC ROBOT ASSISTED PANCREATECTOMY
U. Boggi, S. Signori, N. De Lio, F. Costa, A. Gennai,
M.A. Belluomini
University of Pisa, PISA, Italy
Aims: To describe the first world experience with segmental resection (SR) and
reconstruction of main peripancreatic vessels during laparoscopic robot-assisted
pancreatectomy (LRAP).
Methods: Between October 2008 and January 2012, SR of main peripancreatic
vessels was performed in 4 patients out of 90 undergoing LRAP (%). In 3 patients
SR was required to achieve R0 resection, in the setting of borderline resectable
pancreatic cancer. Two of these patients had portal-mesenteric vein resection and
reconstruction during pancreaticoduodenectomy (PD), and one celiac trunk resection
without reconstruction during distal pancreatectomy (DP). In the fourth patient the
splenic vein, accidentally injured during dissection, was resected and reconstructed
during DP to avoid sinistral portal hypertension while preserving the spleen. Vein
reconstruction was always carried out using autologous jump grafts (internal jugular
vein in one patient and spiral greater saphenous vein graft in two patients).
Results: No patient was converted to laparoscopy or open surgery. Final pathology
disclosed ductal adenocarcinoma in 2 patients (1 PD; 1 DP); adenosquamous car-
cinoma in 1 patient (PD), and mild dysplasia on branch duct IPMN in one patient
(DP). All margins were tumor free (R0 resection). Mean operative time was 740
minutes in PD and 472 in DP. Intraoperative blood transfusions were not required.
The post-operative course was uneventful in all but one patient, requiring repeat
surgery because of bleeding from a pancreaticoduodenal artery. Thirty-day mortality
was nil, and no pancreatic fistula was observed. The overall mean hospital-stay was
19 days.
Conclusions: SR of main peripancreatic vessels can be performed during LRAP in
selected patients, operated on at high volume centers of pancreatic surgery having
also extensive experience with these procedures during open operations. Although
few tangential venous resections have already been described during laparoscopic
pancreatectomy, SR of main peripancreatic vessels is clearly more technically
demanding. The enhanced dexterity offered by the da Vinci surgical offers the
opportunity to manage these cases without accepting oncologic compromise or
technical shortcut.
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Surg Endosc (2013) 27:S53–S166
P402 – Robotics, Telesurgery and Virtual Reality
ABDOMINAL WALL DESMOID TUMOR RESECTION
BY TRANS PERITONEAL ROBOTIC APPROACH
S.C. Paun, R. Ganescu, I. Negoi, B. Stoica, B. Gaspar, M. Beuran
Emergency Hospital, BUCHAREST, Romania
Among aggressive fibrosarcomas, the desmoid tumor can be localized on limb’s
proximity, abdominal wall or mesenterium. Local invasion is defining such a tumor
but with rare frequency (0.03% of all neoplasia).
We are presenting a case of a female patient, 36 year old, admitted for a 29/22/14.5
mm tumor on the posterior sheath of the middle third of the left right abdominal
muscle.
Under general anesthesia, a transperitoneal da Vinci robotic approach was used for
abdominal wall tumor removal. Three trocars have been utilized; trocars’ placement
was 10 cm around the tumor site. Sharp dissection, with carefully local haemostasis
did offer a proper removal of the entire tumor along with a large portion of the
posterior sheath of the right muscle. Consequently, a 40/35 mm parietal defect has
been noticed after this tumor removal but with no aesthetic prejudice for the patient
and no signs for disturbance of the anterior abdominal wall resistance. Pathology
revealed spindle cells.
No postoperative complications were noticed; patient’s discharge after 48 hours.
Medical check out after 30 days showed no problems.
Facile approach of this tumor by robotic instruments as well as sharp dissection and
clear 3D view of the operating field, offered a secure and precise surgical removal
for such a special tumor – for these reasons we recommend such a surgical approach.
P403 – Robotics, Telesurgery and Virtual Reality
ROBOTIC SURGERY IN THE BEGINNING: WHY NOT
EMERGENCIES?
S.C. Paun, R. Ganescu, I. Negoi, B. Stoica, M. Beuran
Emergency Hospital, BUCHAREST, Romania
In the beginning of the General Surgery cases approached by Robotic Surgery, every
surgeon needs a learning curve regarding not only manipulation of the instruments
and dexterity for surgical gestures but also regarding the pathology of the cases. It is
well known the preference for the majority of the surgeons to start Robotic Surgery
with a simple, very well known minimally invasive procedure like cholecystectomy.
It is safe, it is easy, it is convenient because every surgical step is already established
and the results are perfect identical to laparoscopic gold standard procedure.
What about laparoscopic experienced surgeons starting Robotic Surgery? What
about laparoscopic experienced surgeons dealing with acute, emergency cases?.
If we don’t take into consideration trauma cases – because of the running time rush,
medical legal aspects and complexity of the cases (e.g. multiple traumas) – we can
talk about delayed emergencies or late emergencies to be robotic approached. A long
time experience like in Emergency Hospital – Bucharest, Romania, seems to offer a
solid ground to start a robotic surgery for abdominal digestive emergencies.
Reviewing the personal statistics, we can notice four cases facing an emergency
diagnosis among the patients operated by robotic approach. The first case was an
acute cholecystitis and the robotic procedure was performed with a degree of dif-
ficulty. The second case was of a transverse colon perforation due to a foreign body
(fishbone) with an omental inflammatory mass similar to an incarcerated umbilical
hernia – conversion to open laparotomy solved the case. The third case was for an
incarcerated inguinal hernia and robotic TAPP was safely performed. Fourth case
was an inflammatory mass due to acute appendicitis and a robotic appendectomy was
performed after 2 weeks from the debut.
It is quite difficult to conclude a list of safe robotic procedures for abdominal
emergencies especially in the beginning of this type of surgery. Open or laparoscopic
surgery can offer a better surgical solution for such cases.
Surg Endosc (2013) 27:S53–S166
P404 – Robotics, Telesurgery and Virtual Reality
ROBOT-ASSISTED RECTAL CANCER RESECTION:
AN ANALYSIS OF 201 CASES OF A SINGLE SURGEON
S.H. Kim, J.W. Shin, S.J. Baek, J.S. Cho, J. Kim
Korea University Anam Hospital, SEOUL, Korea
Purpose: To analyze the demographics of the single surgeon’s experience on robot-
assisted rectal cancer resection and to evaluate short-term outcomes.
Materials: Prospectively collected data was analyzed retrospectively from 201
consecutive robotic-assisted rectal cancer resection performed by one surgeon
between July 2007 and August 2011 at Korea University Anam Hospital.
Results: Robotic rectal cancer resection using a da Vinci surgical system was per-
formed on 201 patients. There were 141 low anterior resections, 45 intersphincteric
resections, 13 abdominoperineal resections, 1 Hartmann’s operation and 1 total
proctocolectomy. There was one conversion case to an open procedure. Mean BMI
was 23.5. Median tumor height was 6 cm from the anal verge. Preoperative che-
moradiation was performed in 27.4%. Total operation time was 280 minutes but
decreased with experiences (initial 50 cases vs intermediate 50 cases vs late 101
cases = 306 vs 285 vs 264 min, p = 0.002). Median blood loss was under 50 ml.
Mean number of lymph nodes retrieved was 19.1. TME incompleteness was seen
only in 3 cases. Protective ileostomy was made in 59.7%. Median hospital stay was 9
days. Overall morbidity rate was 35.8%. Anastomosis leakage rate was 10.1%. There
was no operative mortality.
Conclusions: This study justifies to continue the robotic surgery in our practice since
the data shows the acceptable morbidity and mortality. The criticism of a long
operating time of robotic surgery seems no longer existing in the near future since
robotic rectal surgery has a great potential to shorten the pelvic dissection time in
experienced hands.
P405 – Robotics, Telesurgery and Virtual Reality
COMPARISON OF SURGICAL PERFORMANCE AND
SHORT-TERM CLINICAL OUTCOMES BETWEEN
LAPAROSCOPIC AND ROBOTIC SURGERY IN DISTAL
GASTRIC CANCER
K.W. Ryu, B.W. Eom, H.M. Yoon, J.H. Lee, Y.W. Kim, J.Y. Park
National Cancer Center, GOYANG-SI, Korea
Aims: The authors aimed to compare the surgical performance and the short-term
clinical outcomes of robotic assisted laparoscopic distal gastrectomy (RADG) with
laparoscopy-assisted distal gastrectomy (LADG) in distal gastric cancer patients.
Method: From April 2009 to August 2010, 62 patients underwent LADG and 30
patients underwent RADG for preoperative stage I distal gastric cancer by one
surgeon at the National Cancer Center, Korea. Surgical performance was measured
using lymph node (LN) dissection time and number of retrieved LNs, which were
viewed as surrogates of technical ease and oncologic quality.
Results: In clinicopathologic characteristics, mean age, depth of invasion and stage
were significantly different between the LADG and RADG group. Mean dissection
time at each LN station was greater in the RADG group, but no significant intergroup
difference was found for numbers of retrieved LNs. Furthermore, proximal resection
margins were smaller, and hospital costs were higher in the RADG group. In terms
of the RADG learning curve, mean LN dissection time was smaller in the late RADG
group (n = 15) than in the early RADG group (n = 15) for 4 sb/4 d, 5, 7–12a stations,
but numbers of retrieved LNs per station were similar.
Conclusion: With the exception of operating time and cost, the numbers of retrieved
LNs and the short-term clinical outcomes of RADG were found to be comparable to
those of LADG, despite the surgeon’s familiarity with LADG and lack of RADG
experience. Further studies are needed to evaluate objectively ergonomic comfort
and to quantify the patient benefits conferred by robotic surgery.
S153
P406 – Spleen
LAPAROSCOPIC SPLENECTOMY FOR ITP: A 10 YEARS
REVIEW
J.B. Lazarevic
City Hospital Valjevo, VALJEVO, Serbia
Background: Laparoscopic splenectomy (LS) has been establisched as a safe and
effective alternative to open splenectomy (OS) for the treatment of Idiopatic
Thrombocytopenic Purpura (ITP). The purpose of this study was to review our
experience with splenectomy for ITP
Methods: Between 2001 and 2010 a total of 35 splenectomies were performed for
ITP by a single surgeon. These cases were reviewed for their post-operative out-
comes with particular atention to surgical approach.(LS vs OS) conversion and
complications.
Results:Thirty-three of 35 patients underwent planned LS with 94% success rate.
Mean spleen weight was 142 g and four accessory spleens were identified in 3
patients (8.6%). Two patients suffered post-operative complication (5.7%).Mean
follou up was 57.3 mo (2.5–120 mo), 84.8% of patients had a complete response
(platelets [150 9 10/9/L).Additionally 12% of patients had a partial response
(50–150 9 10/9/L), 3% of patients were non-responders, and 1 patient relapsed.
Conclusion: LS is ideally suited for patients with ITP, and has an excellent response
rate.
P407 – Spleen
TEN YEARS OF LAPAROSCOPY EXPERIENCE IN
TREATING HAEMATOLOGICAL AND PATIENTS WITH
HYPERSPLENISM CAUSED BY LIVER CIRRHOSIS
IN LATVIA
I. Vidmane-Ozola1, V. Boka2, E. Cunskis1, S. Lejniece3, I. Kalnins3
1
Riga East University Hospital, RIGA, Latvia; 2University of Latvia,
RIGA, Latvia; 3Riga Stradins University, Riga, Lithuania
Aim: To compare the use of conventional and laparoscopic splenectomy in Latvia in
10 years.
Material and methods: Since January 2002 till January 2012 162 patients with benign
and malignant haematological diseases and hypersplenism caused by liver cirrhosis
underwent operations. 138 conventional (CS) and 24 laparoscopic (LS) splenecto-
mies were performed. Patients’ demographic, laboratory data were analysed, as well
as the size of the spleen prior to the operation; approach to the abdominal cavity and
the spleen-conventional or laparoscopic; the duration of the operation; blood loss and
other manipulations during LS; post-operative complications and the day of dis-
charge following the operation.
Results: There is a statistically credible difference between the median ages of the
patients, LS vs. CS (p = 0.003). There is no statistically credible difference between
the diagnosis and the type of operation, the duration of the disease in both groups (p
[ 0.05). There is a statistically credible difference between the median size of the
spleen prior to the operation and the type of the operation – CS = 19 and LS = 12.4
cm, median duration of the operation (CS = 90 and LS = 137.5 min.); the post-
operative weight of the spleen (CS = 932.5 and LS = 269 g) (p \ 0.001).
There is a statistically credible difference between the median count of neutrophil
leucocytes prior to the operation (NAC) in both groups of the operations (p = 0.006),
but no difference between the median platelet count (TR). There is a statistically
credible difference between the day of discharge and the type of operation LS vs.
CS- 7 vs. 8 (p = 0.042). There was no statistically credible difference as to the
number of complications between two types of operation (p = 0.847).
Conclusion: LS is an accessible and safe operation for younger adults with practi-
cally unchanged size of the spleen compared to CS. For a more complete assessment
of the use of LS for haematological and patients with hypersplenism caused by
cirrhosis in Latvia the development of the splenic operations database and further
long-term studies should be continued.
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P408 – Spleen
LAPAROSCOPIC ASSISTED SPLENCTOMY FOR MASSIVE
SPLENOMEGALY
S. Tomiyasu1, K. Okabe1, O. Sano1, T. Yamanaka1, T. Beppu2,
H. Baba2
1
NTT West Kyushu Hospital, KUMAMOTO, Japan; 2Department
of Gastroenterological Surgery Graduate School of Medical Sciences
Ku, KUMAMOTO, Japan
Aim: Laparoscopic splenomegaly has become the standard surgery for the man-
agement of many hematological disorders and hypersplenisms. Although the benefits
of laparoscopic resection of the spleen has been widely accepted, laparoscopic and
hand assisted splenectomy for a very large spleen and portal hypertension are still
considered relative contraindications by many. Massive splenomegaly is defined as
the splenic volume of 500 ml or more by volumetry in computed tomography (CT).
The aim of this study is to estimate the operative short-term outcomes of laparo-
scopic assisted splenectomy in massive splenectomy.
Methods: At NTT West Kyushu Hospital, we performed a retrospective analysis of 14
patients who underwent laparoscopic assisted splenectomy from 2010 through 2011.
Surgical outcomes, including operation time, counted blood loss, postoperative com-
plications, postoperative hospital stays and platelet count of the preoperative and the one
month after surgery were compared in massive splenomegaly (MS) group, not massive
splenomegaly (NS) group. To compare groups, Unpaired t-test with or without Welch’s
correction was applied to continuous data and the chi-square tests were applied to cat-
egorical data. A P value of less than 0.05 was considered significant.
Results: Of the 14 patients, 4 (29%) were MS group (hematological disorders were 3,
hypersplenisms was 1) and 10 (71%) were NS group (hematological disorders were
6, hypersplenisms were 4). There was no difference in age, gender, Body Mass Index
and preoperative platelet count. In the MS group, splenic volume by volumetry in CT
was significantly bigger than that in the NS group (1382 ml vs. 186 ml; 0.025).
Operation time, postoperative complications, length of postoperative hospital stay
and platelet count of the one month after surgery were similar among both groups.
However there was no statistically significant difference, in MS group operation time
was longer (193 min vs. 162 min) and blood loss was greater (738 g vs. 97 g).
Conclusions: Among patients with massive splenomegaly, laparoscopic assisted
approach is feasible and safe if careful about operation time getting longer and blood
loss getting increasing.
P409 – Spleen
LAPAROSCOPIC SPLENECTOMY IN PATIENTS WITH
SPLENOMEGALY – TENDENCY OR CONTRAINDICATION?
I. Stipancic, R. Klicek, J. Bakovic, M. Knezevic, I. Runjic, T. Kolak,
M. Miocinovic
Clinical Hospital Dubrava, ZAGREB, Croatia
Aim: Laparoscopic splenectomy presents a challenge in patients with splenomegaly
despite being the preferred procedure for most elective splenectomies. Our experi-
ence with laparoscopic splenectomy in the setting of splenomegaly is presented.
Methods: The data were collected prospectively from May 2003. to October 2011. in
39 patients that underwent LS in Clinical Hospital ‘Dubrava’ Zagreb, Croatia. The
nature of disease, spleen size (measured on CT or ultrasound), gender, age, op time,
conversion, hospital stay, need for accessory incision, type of splenic artery ligation
preoperative and postoperative platelet values were recorded. The impact of diag-
nosis (benign/malignant) and the spleen size onto the outcome following LS in eight
years period were evaluated.
Results: Majority of patients submitted to LS had benign hematologic disease (30 of
39) and more than half of them had splenomegaly (23/39). Majority of patients with
splenic malignancy have splenomegaly (8 of 9). The mean spleen size in splenomegaly
patients was 23.88 cm (range 15–31 cm). Splenomegaly was associated with higher
conversion rate (3 vs 2) due to bleeding and longer mean operative time (128.54 vs
104.75 min). Furthermore, in splenomegaly more patients required accessory incision
and additional port (7 vs 1) and blood transfusion (8 vs 1). But length of stay and
postoperative morbidity was not associated with enlarged spleen in our series.
Conclusion: According to our results, the same as to some previously presented
studies LS has become a treatment of choice for majority of patients including those
with splenomegaly. In spite of longer operative time and more blood loss laparo-
scopic splenectomy in the setting of splenomegaly is safe in appropriately
experienced hands with full awareness of increased complexity of technical per-
formance and caution requirement.
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Surg Endosc (2013) 27:S53–S166
P410 – Technology
TECHNIQUES AND CLINICAL OUTCOMES OF
LAPAROSCOPIC EXTENDED RIGHT HEMICOLECTOMY
USING A MEDIAL-TO-LATERAL APPROACH
L.Y. Zhao1, J. Yu1, G.X. Li1, C. Zhang2, Y.F. Hu2, Y. Wang2
1
Nanfang Hospital, GUANG-ZHOU, China; 2Nan Fang Hospital,
GUANGDONG, China
Aims: Laparoscopic extended right hemicolectomy (LERH) for cancer management
was more difficult than other Laparoscopic colectomy for the difficulty to deal with
the middle colic vessels laparoscopically. The security and feasibility were still
controversial. This study aimed to introduce the critical techniques of the stan-
dardized LERH and evaluated its security and feasibility.
Methods: The anatomic element and surgical technique were described and dem-
onstrated with pictures. The clinical records of 105 patients coming from a
prospective database were analyzed retrospectively, Patients were allocated to
receive LERH using a medial-to-lateral approach (n = 48) or open extended right
hemicolectomy (OERH) (n = 57). Clinical characteristics, operative findings, and
postoperative outcome were compared.
Results: The main surgical plan of LERH using a medial-to-lateral approach was the
right Toldt‘s space. The superior mesenteric vein (SMV) was the most important
anatomical landmark of vascular dissection, and the middle boundary of the surgical
plan. Patients underwent LERH using a medial-to-lateral approach had less blood
loss compared with those underwent OERH (111.7 ± 127.8 ml vs 170.2 ± 49.7 ml, p
= 0.023). LERH was associated with earlier recovered of bowel function. There were
5 patients (10.4%) underwent conversion during laparoscopic surgery. The pathol-
ogy outcome and postoperative complications between LERH and OERH group
were equivalent.
Conclusions: The LERH using a medial-to-lateral approach was concise when the
SMV serve as the landmark and the right Toldt’s space severed as the surgical plan.
LERH could be used as safe and radical resection of cancer located at hepatic flexure
or within 10 cm distal to hepatic flexure.
P411 – Technology
INITIAL EXPERIENCE OF DUAL INCISION
LAPAROSCOPY-ASSISTED TOTAL GASTRECTOMY
(DI-LATG) FOR PATIENTS WITH GASTRIC CANCER
H. Fujii, K. Kawakami, T. Aotake, H. Yuki
Japanese Red Cross Fukui Hospital, FUKUI, Japan
Introduction: Since laparoscopic assisted total gastrectomy (LATG) is less invasive. On the
other hand, reduced port surgery has been considered as a next step in minimal access
surgery. We already introduced Dual Incision Laparoscopy-Assisted Distal Gastrectomy
last EAES conference, now we introduced DI-LATG using the technique of trans-umbilical
single incision laparoscopic surgery.
Surgical technique: A 2.5-cm longitudinal skin incision was made at the umbilicus and
subcutaneous tissue was dissected. A 100-mm XCEL trocar 12 mm in diameter was
inserted from the center of the area without fascia and an oblique-viewing endoscope 10
mm in diameter was used. XCELs 12 mm in diameter were inserted at both ends of a small
incision (5–6 cm) that was planned to make on Langer cleavage line in the epigastrium, and
65-mm Endo tip cannulas (ETC) 6 mm in diameter were inserted at the both sides of the
first inserted XCEL trocar under endoscopic observation via the port at the epigastrium.
Devices were controlled intraperitoneally in LATG through these five ports. A surgeon,
standing between the legs of the patient, was in charge of the port at the umbilicus. Gastric
resection and gastrointestinal reconstruction (Roux-Y) were carried out through the 5–6 cm
small incision that was made between the sites where two ports were created at the epi-
gastrium. Taken together, dual incisions, consisted of a single incision at the umbilicus
generally for single incision laparoscopic surgery and a transverse incision at the epigas-
trium, were made and the wound scar at the umbilicus was inconspicuous. No special
access port or flexible forceps was required in this method and some pairs of conventional
straight forceps were used. Therefore, the method was economical.
Results: DI-LATG was performed for 69 years old female patient. No additional port was
required and lymphadenectomy of D1 + lymph node number 7, 8a, and 9 (around the left
gastric artery, common hepatic artery, and celiac artery) was possible. Operation time was
347 min, and blood loss was 126 g.
Conclusions: From the point of view of reduced port surgery, DI-LADG was con-
sidered an option for laparoscopic surgery.
Surg Endosc (2013) 27:S53–S166
P412 – Technology
ERGONOMIC AND TACTILE PERCEPTION OF A NEW
HANDLE FOR LAPAROSCOPIC SURGERY
R. Sancibrian1, M.C. Gutierrez2, L. Rubio1, C.M. Palazuelos2,
C.G. Redondo1
1
University of Cantabria, SANTANDER, Spain; 2Valdecilla Virtual
Hospital, SANTANDER, Spain
Aim: The ergonomic design of instruments for endoscopic surgery has many defi-
ciencies that are well-known by surgeons. Furthermore, the lack of tactile sensitivity
reduces the feedback information that the surgeon obtains about the stiffness, size
and strength of the organs. All these factors contribute to comfort and efficiency of
use of the instruments by the surgeon. In this work a new handle for laparoscopic
instruments is investigated according to the ergonomic and tactile performance.
Methods: The new handle was developed as a prototype and is compared with a ring
handle in order to assess the ergonomic and tactile characteristics. In this study, 20
volunteers performed different tasks simulating the working conditions of the sur-
geons. Ten of these volunteers were people randomly selected without relation with
surgery or medicine. The rest of the volunteers were surgeons in training, selected
from the Valdecilla Virtual Hospital in Spain. The data measured included the
number of errors, the perception of the stiffness and size, the motion of hands and
arms and the time required to complete the task. The subjective opinions of the
volunteers were surveyed after each task.
Results: The results show that, regardless of the ergonomic design of the handle, the
physical strength of the surgeon is very important in tactile perception. This means
that in general women make more mistakes than men when the opinion about the
stiffness and size is required. The new handle design avoids extreme movements of
the hand and wrist, reducing hyperflexion and hyperextension effects. In general, the
surveys do not highlight significant differences between the results obtained by
surgeons in training and the rest of the volunteers.
Conclusions: The physical strength and hand size of the surgeon play an important
role in perception. In contrast with the ring handle, the new handle reduces extreme
motion of the hand and wrist so improving the ergonomic characteristics. Compared
with the ring handle the ergonomic design of the new handle avoids high-pressure
zones in the contact between hand and handle. Extreme differences in surgeon
fatigue could not be observed for either of the two handles.
P413 – Technology
INNOVATIVE METHOD FOR INTRA-ABDOMINAL
ESOPHAGOJEJUNOSTOMY IN LAPAROSCOPIC TOTAL
GASTRECTOMY
K. Kato
Tokyo Medical and Dental University, TOKYO, Japan
With there being no standardized procedure for esophagojejunostomy in laparo-
scopic total gastrectomy, a simple and safe method has been called for. With the
view of reproducing esophagojejunostomy using a circular stapler, i.e. the stan-
dardized procedure in laparotomy, in the abdominal cavity, our department has
developed an intra-abdominal detachable ENDO-PSI.
Objective: To examine the results of laparoscopic total gastrectomy using the
detachable ENDO-PSI.
Subjects: 20 patients for whom the detachable ENDO-PSI was used.
Anastomosis Method: With the umbilical wound extended, the stomach was resected.
From this point, the tip of the detachable ENDO-PSI and an anvil were inserted into the
abdominal cavity for re-pneumoperitoneum. The gripper of the detachable ENDO-PSI
was inserted form the 12 mm port and was attached to the tip of the device in the
abdominal cavity. The detachable ENDO-PSI was hung on the esophageal stump,
whereupon a nylon straight needle was let through to form a purse string suture. An
anvil was inserted and fixed in the esophagus, and the jejunum was pulled out and
dissected from the umbilical wound. A circular stapler was inserted into the jejunum,
which was returned inside the abdominal cavity for re-pneumoperitoneum. Thereupon,
esophagus jejunum end-to-side anastomosis was performed under laparoscopic
observation. The blind end of the jejunum was closed with a linear stapler.
Results: Of the 20 cases, 18 were completed. The average time taken for the anvil
insertion and fixation was 27 minutes, and the average time for the esophagojej-
unostomy was 49 minutes. One patient exhibited a minor leakage of anastomotic
site, and another patient developed a fistula at the drain contact portion. However,
these conditions improved conservatively. The median length of postoperative
hospitalization was 10 days.
Conclusion: The use of the detachable ENDO-PSI has enabled esophagojejunostomy
in the same procedure as laparotomy.
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P414 – Technology
DEVELOPMENT OF STEM CELL REGENERATION
THERAPY BY MULTI PIERCING SURGERY: POSSIBILITY
OF MODIFIED NEEDLESCOPIC SURGERY BY ELECTRO-
CONTROLLED FORCEPS
T. Ohdaira, M. Hashizume
Kyushu University, FUKUOKA-KEN, Japan
Objectives: A number of minimally invasive therapeutic procedures by single port
surgery have been proposed. However, there exist the following issues: (1) the flaw
that the triangular formation for the target site of treatment is impossible to establish;
and (2) clashing among multiple single port surgery instruments in the single port.
We established Multi Piercing Surgery, which is a Needlescopic Surgery assisted by
NOTES using a 3-mm diameter electro-controlled forceps. We successfully con-
ducted a preclinical study on local regeneration therapy for diabetes.
Methods: The electro-controlled forceps has one joint of 3 mm in diameter. The
forceps has a mono-polar electric power source at the hand tip. The needle type
devise was used to perform the study in five pigs. 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.
Results: In laparotomy via the ventral approach, two electro-controlled forceps
achieved complete triangular formation and allowed the conduct of surgery under a
good visual field. The dorsum of the 25-mm long electro-controlled hand was used to
very smoothly perform the procedure without damaging the organ. Furthermore, the
retroperitoneum could also be incised easily by electrocoagulation with the tip of the
electro-controlled hand, which shortened time to reach the pancreas. Any compli-
cations such as bleeding and leakage of pancreatic juice did not occur during
administration.
Conclusions: Multi Piercing Surgery by the needle-type electro-controlled forceps
left no visible surgical scar in the abdominal wall when used also via the trans-
abdominal approach and was successfully verified to allow the completion of safe
and efficacious surgical procedures under a good field of vision by ensuring the
triangular formation that is indispensable for endoscopic surgery.
P415 – Technology
APPLICATION OF THE TRANSORALLY INSERTED ANVIL
(ORVIL TM) FOR ROUX-EN-Y ESOPHAGOJEJUNOSTOMY
AFTER LAPAROSCOPY-ASSISTED TOTAL
GASTRECTOMY
T. Mou, G. Li, J. Yu
Nanfang Hospital, GUANGZHOU, China
Aims: With the increasing incidence of proximal gastric cancer over the past decade,
the necessity of performing total gastrectomy was noted. However, due to the
technical difficulty associated with reconstruction, laparoscopy-assisted total gas-
trectomy (LATG) is still not as commonly performed as laparoscopy-assisted distal
gastrectomy. Despite various modified reconstruction methods after LATG, a stan-
dard technique has not yet been established. In this study, we report the newly
developed reconstruction technique using transorally inserted anvil (OrVilTM) for
Roux-en-Y esophagojejunostomy after LATG.
Methods: Between December, 2009 and September, 2011, 13 patients with proximal
advanced gastric cancer underwent LATG with Roux-en-Y esophagojejunostomy
using OrVilTM. During operation, after transection of the mobilized abdominal
esophagus, the anvil was inserted transorally into the esophagus by using the Or-
VilTM system. Then double-stapling esophagojejunostomy was performed with a
circular stapler through a 4-cm mini-laparotomy. Results: Of the 13 patients, there
was no intraoperative complication. The mean operating time was 177.16 ± 37.83
min and the estimated blood loss was 158.33 ± 120.07 ml. Postoperative fluorog-
raphy showed no anastomotic leakage or stenosis. Postoperatively, time to liquid diet
and semi-liquid diet were 5.00 ± 1.26 days and 6.83 ± 1.72 days, respectively and
the mean hospital stay was 11.16 ± 4.07 days. Two patients experienced postop-
erative intra-abdominal infection and was handled with conservative treatment.
Conclusions: LATG with Roux-en-Y esophagojejunostomy using OrVilTM for the
treatment of advanced proximal gastric cancer can greatly simplify the surgical
procedure during reconstruction and is technically feasible with satisfactory early
recovery and acceptable morbidity. Further studies comparing OrVilTM with the
traditional purse-string technique would be needed.
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P416 – Technology
LIVER RETRACTION TECHNIQUES IN SINGLE INCISION
LAPAROSCOPIC FORGUT AND HPB SURGERY-
INNOVATIONS AND RESULTS FROM A TERTIARY
CENTRE
P. Senthilnathan, C. Palanivelu, P.S. Rajan, S. Rajapandian,
P. Praveen Raj, R. Parthasarathi, P. Kedar Pratap
GEM Hospital & Research Centre, COIMBATORE, India
Introduction: Single incision laparoscopic surgery is one of the newest branches of advanced
laparoscopy.Both simple and complex surgical procedures such as fundoplication, cholecystec-
tomy,sleeve gastrectomy etc are being currently performed with single incision laparoscopic
surgery. Liver retraction is one of the important steps in single incision surgery while operating on
upper GI tract especially around the hiatus. Various methods have been described to overcome the
difficulty of liver retraction in single incision surgeries, each having its own merits and demerits.
Objective: Aim is to compare various liver retraction techniques in single incision laparoscopic
surgery and to formulate a technique which is feasible, cost effective, reproducible, and in short
duration.
Material and Methods: Type of study- Retrospective non randomized observational study A ret-
rospective analysis of the various liver retraction techniques performed at our centre was performed
Total number of cases- 66 over a period of 2 years from January 2009 to November 2011
Results: Number of cases surgery wise Nissens fundoplication-22, Sleeve gastrectomy-20,
Cholecystectomy with sleeve gastrectomy-8, Hellers cardiomyotomy-5, Cystogastrostomy-
5, Gastric bypass-4, Fundoplication with rectopexy – 1, Fundoplication with Hystrectomy – 1
Methods of retraction
1. liver puncture and suspension with corrugated drain – 40
2. liver puncture and suspension with gauze – 12
3. Suture to the Right Crus – 8
4. Hanging with Umbilical tape-6 Method
Discussion: Liver retraction is a must in single incision surgery to facilitate a safe surgery espe-
cially around the hiatus. We have evaluated different techniques of liver retraction and our analysis
have shown that hanging the liver with corrugated drain and a pair of suture is safe, easy, repro-
ducible, and quick. Bleeding from the liver surface is transient in some cases and is not a problem
while taking sutures.
Conclusion: Different techniques are practiced to retract the liver in forgut and HPB surgeries.
Among the lot, retraction using corrugated drain by two sutures seems to be the method of choice in
our institute.
P417 – Thoracoscopic Surgery
DOUBE-COVERING METHOD INVOLVING AN OXIDIZED
REGENERATED CELLULOSE SHEET AND AUTOLOGOUS
BLOOD AFTER THORACOSCOPIC BULLECTOMY
S. Sugiyama1, S Miyahara1, Y Naka1, M. Sakai1, K. Sugiyama1,
Y. Doki2, K. Sakata2
1
Tomei-Atsugi Hospital, ATSUGI-SHI, Japan; 2Toyama Univercity,
TOYAMA, Japan
Aims: To prevent recurrent pneumothorax after video-assisted thoracoscopic surgery, various
methods involving the use of biodegradable polymers for covering the pleura have been devised.
The use of fibrin sealant should be avoided as far as possible because of the possibility of infection.
Autologous blood is used instead of chemical pleurodesis for pneumothorax. When mild emphy-
sematous changes extend to the entire pleura around the localized bulla, mild emphysema is always
observed in the pleura around the staples after bullectomy. Such patients as well those who have
weak pleural surfaces around the staples are at high risk of postoperative recurrence of pneumo-
thorax. Therefore, to address these issues and avoid postoperative recurrence, we devised a double-
covering method in which the stapling line is covered with an oxidized regenerated cellulose sheet
and autologous blood.
Method: From May to December 2011, we performed the double-covering method, which involved
thoracoscopy, for 12 patients. Bullectomy was performed under general anesthesia by using a
thoracoscopic auto device, after a sealing test confirmed the absence of air leakage. To reinforce the
stapling line and visceral pleura, we covered the stapling line with an oxidized regenerated cel-
lulose sheet (7.6 ± 10.2 cm; Ethicon Inc) and autologous blood.
Results: Air did not leak from the chest tubes after surgery. However, chest roentgenograms
showed that a small air space remained in the lung apex after surgery. The chest tubes were
removed in 5–7 days after surgery regardless of the presence or absence of air space in the apex.
Recurrent pneumothorax was not observed in these patients.
Conclusion: Our double-covering method involving an oxidized regenerated cellulose sheet and
autologous blood for reinforcing the visceral pleura after thoracoscopic bullectomy can be used as
an optional method for managing pneumothorax that occurs after this procedure.
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Surg Endosc (2013) 27:S53–S166
P418 – Thoracoscopic Surgery
LAPAROSCOPIC PERICARDIAL WINDOW IN SUSPECTED
PENETRATING CARDIAC INJURIES
M.Z. Koto, R. Jacks
University of Limpopo, VEREENIGING, South Africa
Introduction: Penetrating cardiac injuries in hemodynamically normal patients can present a
diagnostic challenge.It is even more challenging in patients where there is associated intra-
abdominal injury requiring exploration. Diagnostic modalities suggested have their own inherent
shortcomings ranging from low negative predictor value to difficulty of access.
Aim: We present our experience using laparoscopic pericardial window (LPW) in excluding car-
diac injuries in this cohort of patients.
Methods: Data was collected prospectively on all patients who presented with precordial stab
wounds and suspected cardiac injury from Jul 2011 and Dec 2011 at the Sebokeng hospital. All
patients who were hemodynamically unstable were excluded. The patients were placed under
general anesthesia and using a three port technique the pericardium was opened through the central
tendon of the diaphragm and closed extracorporeally if negative. Sternotomy would be done if
positive.
Results: There were a total of 8 patients over a 6 months period. 7 males and1 female with mean
age of 27 years (25–38 years). One patient had positive result and was converted to a sternotomy.
One patient had a large pericardial effusion and was treated with a pericardial window. Six patients
had negative pericardial window and one of these had a perforated gallbladder and had a lapa-
roscopic cholecystectomy. There was no mortality.
Conclusion: LPW is a viable and safe alternative in excluding cardiac injuries in patients
that may have associated intraabdominal injuries.
P419 – Thoracoscopic Surgery
TWO PORTS THORACOSCOPIC LOBECTOMY WITHOUT
ROUTINE INTENSIVE CARE UNIT STAY
L.C. Chen, J.Y. Lee, Y.T. Chang, H.H. Chiang, J.S. Hsieh, S.H. Chou
Kaohsiung Medical University Hospital, KAOHSIUNG, Taiwan
Aims: Video-assisted thoracoscopic surgery (VATS) is increasingly used for major pulmonary
resections and has fewer respiratory complications. Most surgeons use three or four ports to
perform a VATS lobectomy. The aim of the study is to present two ports thoracoscopic lobectomy
is safe and reliable.
Subject: 39 cases of lung tumor were operated by two-port VATS lobectomy from November 2008
to December 2011. Age: 14*78 years old (median: 58). Type of pulmonary resection:
RUL:5(12.8%)RML:7(17.9)RLL:11(28.2) LUL:4(10.2%) LLL:12(30.7%)
Surgical Technique:
1. An utility port about 3*4 cm is performed in 5th intercostal space over anterior axillary line.
2. The camera port is made in 7th intercostal space over mid-axillary line for 10-mm 30
thoracoscope.
3. VATS Lobectomy follows the oncological principles: individual dissection of veins, arteris and
lobar bronchus.
4. Lobectomy and mediastinal dissection are performed through utility port without visual access
through the wound and without rib retractor.
5. Plastic wound retractor is not used routinely.
Result: 1. Convert to open due to massive bleeding: 2 cases (5.1%). 2. Operation time: 70*360
minutes (median: 235 minutes). 3. Bleeding: 20*1250 ml (median: 100 ml). 4. Pathological stage:
IA:17 IB:6 IIA:1 IIB:2 IIIA:4 IIIB:0 IV:2. 5. Duration of postoperative drainage: 3*16 days
(median: 6 days). 6. Postoperative hospital stay: 4*17 days (median: 7 days). 7. ICU admission: 4
cases (10.8%) (mean: 1.5 day) one case: COPD, two cases: massive bleeding (ESRD/PV tear)one
case: old age. There is NO major complication or mortality during hospitalization.
Discussion: 1. Two-port VATS lobectomy is less invasive, safe and reliable procedure producing
good postoperative results. 2. The utility port located in 5th ICS over anterior axillary line is
suitable for all different lobes. 3. Most of our patients Do NOT need intensive unit care (including 1
patient received CABG operation 6 months ago). 4. The incision wound is shorter and postoper-
ative pain is less. 5. All the patients could walk well on post operative day 1. 6. As we obtain more
experience over time, results improve, especially when performing mediastinal lymph node
dissection.
Surg Endosc (2013) 27:S53–S166
P420 – Thoracoscopic Surgery
THORACOSCOPIC MANAGEMENT OF AN
INTRATHORACIC BIFID RIB
L.P. Depypere1, P. Lerut2, W. Coosemans1, H. Decaluwé1,
P. De Leyn1, B. Gheysens2, D. Van Raemdonck1, P. Nafteux1
1
University Hospitals Leuven, LEUVEN, Belgium; 2Groeninge
Hospital, KORTRIJK, Belgium
Objective: Bifid ribs and more specific intrathoracic arisings from ribs are rare and
most of the times asymptomatic. Treatment options in symptomatic patients are not
well described in the literature
Methods: An 18-year old young woman was referred to our hospital following two
years of intermittent non-specific thoracic pain. As further examination couldn’t
reveal any cause, a conservative management was advised. Recently she was
admitted on the emergency department with inframammary pain on the left side
since a few days.
Results: To prevent the patient from any complication as chronic pain, phrenic nerve
damage or even pericardial or lung perforation, the intrathoracic part of the rib was
removed by video assisted thoracoscopic surgery (VATS). Only two small skin
incisions were needed and the patient could leave the hospital 2 days postopera-
tively. After a follow up of …. months, the patient remains pain free.
Conclusion: Video assisted thoracoscopic surgery (VATS) is an elegant method of
treatment for a symptomatic intrathoracic arising from a rib that can lead to complete
recovery.
P421 – Training
TECHNICAL CHALLENGE FOR A BULLECTOMY BY VATS
FOR A PRIMARY SPONTANEOUS PNEUMOTHORAX IN
A SOLO-SURGEON OPERATION.
M. Naruke
Eiju General Hospital, TOKYO, Japan
Background: Today, some kinds of VATS (video-assisted thoracoscopic surgery) are
being conducted without other surgeon assistants. In this paper, we present a tech-
nical procedure of VATS stapler bullectomy for a primary spontaneous
pneumothorax using the ENDOLOOP Ligature (Ethicon Endo-Surgery inc., Cin-
cinnati, OH, USA) and the Endo CloseTM Trocar Site Closure Device (Covidien llc,
Mansfield, MA, USA) as a solo-surgeon operation.
Technical Considerations: VATS bullectomy was performed under complete ipsi-
lateral lung collapse with separate ventilation. VATS approach used a 15 mm
incision in the right mid-axillary line in the 6th intercoastal space (ICS), a 7 mm
incision in the right mid-axillary line in the 4th ICS and one puncture. In most cases,
the 15 mm incision was made using the preoperative drainage tube insertion wound.
After visualizing the bleb to be resected by the 10 mm rigid thoracoscope introduced
from the 15 mm incision, we grasp it, ligate it using the ENDOLOOPLigature, and
pull it using the Endo CloseTM Trocar Site Closure Device punctured into the chest
cavity from the most appropriate location. And then, we exchange the rigid thora-
coscope to the 5 mm scope from 10 mm because of using the 7 mm incision as
camera port. After that, we resect the bleb with a small rim of lung parenchyma
using the endoscopic stapler that was introduced into the chest through the15 mm
incision.
Discussion: This unique technique is useful for not only resection of a small bleb but
also resection of the broad based bulla and provide excellent visualization due to two
incisions and one puncture wound. We have performed 7 VATS bullectomies using
this technique since October 2010. The operation number is not yet sufficiently high
enough to firmly conclude that it is effective to resect for all sites of bleb, however it
can be done without other surgeon assistants for the present.
Conclusion: The result suggests that VATS bullectomy using the ENDOLOOP
Ligature and the Endo CloseTM Trocar Site Closure Device can be safely and use-
fully utilized to treat a primary spontaneous pneumothorax in a solo-surgeon
operation.
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P422 – Training
LAPAROSCOPY SKILLS TRAINING: EXPERIENCED
SURGEONS VS BEGINNERS. SURPRISING RESULTS
B. Khatsiev, A. Kuzminov
Stavropol State Medical Academy, STAVROPOL, Russia
Materials and Methods: 96 postgraduate surgical trainees (aged from 24 to 52) passed 3
month laparoscopy training course. We demanded trainees to achieve 5-minute result in
two-handed maneuvers in virtual trainer and 60-second for surgical suturing.
All students were asked to give their opinions ranging from strongly agree to strongly
disagree on the following statements: ‘Overall, I am very satisfied with my training pro-
gram’, ‘I worry about performing poorly in front of my assistant’, ‘I feel that my operating
skill is level appropriate for performing laparoscopic operations independently’, ‘I’ve
enjoyed operating laparoscopically’. All trainees were divided into two groups – the 1st
group – 40 trainees with learning curve of 4 hours and lesser, the 2nd group of 56 with
learning curve length more than 4 hours.
Results: Mean age was 30.7 ± 3.8 years in the first group, and 34.0 ± 5.3 in the second (p\
0.01). The eldest trainee had the longest learning curve of 11 hours.
Mean operation time was 46 ± 6 minutes in the first group and 53 ± 6 in the second one (p
\0.01). An operating trainee and an assisting experienced surgeon swapped their places in
2 (5%) operations in the first group and in 3 (5.4%) operations in the second, because of
difficulties (p [ 0.05). The first group was more satisfied with the training- 26 (65%)
positive answers than the second group – 30 (53.6%) positive answers (p [ 0.05). The
second group was more calm during the operation – 23 (41.1%) negative answers about
being nervous during the surgery versus 4 (10%) in the first group (p \ 0.01). Trainees of
the second group were more confident in their laparoscopic skills – 32 (37.5%) positive
answers versus 7 (17.5%) (p \ 0.05) in the first group. The first group had shown more
willingness to operate laparoscopically with 25 (62.5%) positive answers against 22
(39.3%).
We’ve found that self-confidence of more capable laparoscopic trainees is significantly
lower than that of less able. That means that those capable trainees are in great need of
constant support of their trainers, and despite spending lesser time to achieve good results,
they should spend more time mastering their skills to reach good level of self-confidence.
P423 – Training
A STUDY OF PSYCHMOTOR SKILLS FOR MINIMALLY
INVASIVE SURGERY: WHAT DIFFERENTIATES EXPERT
AND NON-EXPERT PERFORMANCE
E.F. Hofstad1, C. Våpenstad1, M. Chmarra2, T. Langø1, R. Mårvik3
1
SINTEF, TRONDHEIM, Norway; 2Norwegian University
of Science and Technology, TRONDHEIM, Norway; 3St. Olav’s
Hospital, Trondheim University Hospital, TRONDHEIM, Norway
Aims: A high level of psychomotor skills is required to perform minimally invasive surgery
(MIS) safely. To assure high quality of skills it is important to be able to measure and assess
these skills. For that, it is necessary to determine aspects that indicate the difference
between performances at various levels of proficiency. Measurement and assessment of
MIS skills should be done in an automatic and objective way. The goal of this study was to
investigate a set of nine motion-related metrics for their relevance to assess psychomotor
MIS skills during the performance of a ‘labyrinth’ task.
Method: Thirty-two surgeons and medical students were divided into three groups
according to their level of experience in MIS; experts ([500 MIS procedures), interme-
diates (31–500 MIS) and novices (no experience in MIS). The participants performed the
labyrinth task in the D-box Basic simulator (D-BOX Medical, Lier, Norway). The task
required bimanual maneuvering and threading a needle through a labyrinth of ten holes.
The nine motion-related metrics used to assess MIS skills of each participant were: time,
bimanual dexterity, path length, angular length, depth perception, response orientation,
motion smoothness, number of sub-movements and average velocity. The formula for
calculating the bimanual dexterity metric was defined in this study. The rest of the metrics
have previously been used in other studies.
Results: Experts (n = 7) and intermediates (n = 14) performed significantly better than the
novices (n = 11) in terms of time and parameters measuring the amount of instrument
movement (path length, angular length, depth perception and response orientation). The
experts had significantly better bimanual dexterity, which indicated that they made more
simultaneous movements of the two instruments, compared to the intermediates and nov-
ices. The experts also performed the task with a shorter instrument path length with the non-
dominant hand than the intermediates.
Conclusions: The performance of a MIS surgeon can be distinguished from a novice by
metrics like time and path length. An experienced MIS surgeon can be distinguished from a
less experienced one by the higher ability to control the instrument in the non-dominant
hand and the higher degree of simultaneous (coordinated) movements of the two
instruments.
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P424 – Training
DEVELOPMENT OF A STANDARDIZED TRAINING
CURRICULUM FOR LAPAROSCOPIC PROCEDURES
IMPLEMENTING A DELPHI METHODOLOGY TO REACH
EXPERT CONSENSUS
M.S. Bethlehem1, M.J. Van Det1, H.O. Ten Cate Hoedemaker2,
J.P.E.N. Pierie1
1
Leeuwarden Medical Center, LEEUWARDEN, The Netherlands;
2
University Medical Center Groningen, GRONINGEN,
The Netherlands
Aims: Content, evaluation and certification of laparoscopic skills- and procedure
training lack uniformity among different hospitals in the Netherlands. Within the
process of developing a regional laparoscopic training curriculum, we aim to con-
struct a curriculum that is uniform and transferrable througout the region for a series
of laparoscopic procedures. The aim of this study was to determine expert consensus
regarding the keysteps, for laparoscopic appendectomy and cholecystectomy, using a
Delphi methodology.
Methods: A list of suggested keysteps for both procedures was created according to
the available guidelines. Experts rated the suggested keysteps for laparoscopic
appendectomy and cholecystectomy on a Likert scale from 1 to 5. Consensus was
reached with Cronbach’s a = 0.80. Keysteps rated as important (=4) by at least 80%
of the expert panel, will be used in the further development of the training
curriculum.
Results: The first rating by the expert panel shows consensus on several operative
steps that can be used for laparoscopic procedure training. Final results will be due
by march 2012 and are available for presentation at the congress.
Conclusion: We expect that the Delphi methodology will result in consensus
regarding the keysteps for laparoscopic appendectomy and cholecystectomy. These
keysteps can be used for standardized procedure training in regional training
curriculum.
P425 – Training
IMPROVEMENT IN OPERATIVE PERFORMANCE IN CORE
SURGICAL TRAINEES USING MENTAL TRAINING IN
LAPAROSCOPIC APPENDIECTOMY
S.K. Sarker, N. Muhibullah
Safety Innovations Unit Worcestershire, DROITWICH,
United Kingdom
Aims: Opportunities for surgical training must be focused and structured. In this
study we assess technical skills in laparoscopic appendiectomy performed by junior
surgeons before and after mental training.
Methods: Two groups of junior surgeons (CT1 and CT2) were assessed for technical
skills in laparoscopic appendiectomy. Each trainee performed 4 operations before
and 4 after mental training. Generic and specific technical skills were assessed
blindly and independently by two senior surgeons using a previously published
technical skills assessment tool.
Results: There were fourteen CT1–CT2 trainees assessed for technical skills before
and after mental training. There was no significant reduction in generic technical
skills with focused teaching (Mann–Whitney, p[0.05) in each group. However with
mental training there was a significant improvement in specific technical skills in
both groups (Mann–Whitney, p \ 0.05).
Conclusions: Our study demonstrates that with mental training of junior surgeons
there is an improvement in specific technical skills (quality of the operation).
Focused training in laparoscopic surgery can be of potential benefit in the training of
junior surgeons.
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Surg Endosc (2013) 27:S53–S166
P426 – Training
MENTAL TRAINING IN LAPAROSCOPIC COLORECTAL
SURGERY
S.K. Sarker, N. Muhibullah
Safety Innovations Unit Worcestershire, DROITWICH,
United Kingdom
Aims: Opportunities for surgical training must be focused and structured. In this
study we assess technical skills in laparoscopic colorectal operations performed by
trainee surgeons before and after mental training.
Methods: Two groups of junior surgeons (ST3-5) were assessed for technical skills
in laparoscopic right hemicolectomy. Each trainee performed 4 operations before
and 4 after mental training. Generic and specific technical skills were assessed
blindly and independently by two senior surgeons using a previously published
technical skills assessment tool.
Results: There were ten ST3-ST5 trainees assessed for technical skills before and
after mental training. There was no significant reduction in generic technical skills
with focused teaching (Mann–Whitney, p [ 0.05) in each group. However with
mental training there was a significant improvement in specific technical skills in
both groups (Mann–Whitney, p \ 0.05).
Conclusions: Our study demonstrates that with mental training of junior surgeons
there is an improvement in specific technical skills (quality of the operation).
Focused training in laparoscopic surgery can be of potential benefit in the training of
junior surgeons.
P427 – Training
CHALLENGING LAPAROSCOPIC SKILLS WITH A NOVEL
ERGONOMIC PORTABLE LAPAROSCOPIC TRAINER
D.J. Xiao1, S.N. Buzink1, A. Albayrak1, J. Jakimowicz2,
R.H.M. Goossens1
1
Delft University of Technology, DELFT, Nederland; 2Catharina
Hospital, EINDHOVEN, Nederland
Aims: The aims of this study are (1) to evaluate the utility and didactic value of a
new webcam based ergonomic portable Challenge Laparoscopic skills trainer (CLS
trainer), and (2) to verify the construct validity for its four most innovative tasks for
basic skills training.
Methods: Forty-six participants were allotted to two groups based on their indicated
clinical laparoscopic experience: a Novice group (N = 26, \10 clinical laparoscopic
procedures), and an Expert group (N = 20,[10 clinical laparoscopic procedures). All
participants provided informed consent, and filled out a questionnaire based on
demographics and their laparoscopic experience. Before each task, they received a
standardized instruction and a video demonstration. Task performance was analyzed
on speed and accuracy. After completing the tasks, the participants filled out a
5-point Likert scale questionnaire to rate the usability and didactic value for every
task and this CLS trainer.
Results: The Expert group completed all the four tasks in less time than the Novice
group (P \ 0.001, Mann–Whitney U test). The accuracy analyses showed that the
Expert group completed task1, task2 and task4 with fewer errors (p \ 0.05).
Insignificant difference was found between two groups for task3.
The results of the questionnaire showed that the experts rated task2 as more difficult
than the novices (p \ 0.05), and the novices rated task4 as more difficult than the
experts (p \ 0.01). Task1 and task3 were rated equally difficult by both groups. The
participants rated the overall impression of all tasks as good or excellent.
The questionnaire also showed that 85% of novices are willing to purchase this
portable trainer, due to its convenience in use and challenge of their skills. In
addition, the majority of the experts would like to recommend this portable trainer
for medical trainees.
Conclusions: The present ergonomic portable CLS trainer can distinguish between
expert and novice users. It was rated as a useful and didactic training tool which is
easy to use. The tasks are challenging and they are able to improve basic skills for
different expertise levels. This novel portable CLS trainer is an inexpensive yet
reliable alternative for medical trainees.
Surg Endosc (2013) 27:S53–S166
P428 – Training
HELIOS – THE HEIDELBERG LAPAROSCOPIC
INTERVENTION AND OPERATION SIMULATOR
M. Wagner, H.G. Kenngott, J. Wuenscher, B.P. Mueller-Stich
University of Heidelberg, HEIDELBERG, Germany
Aims: Training of young inexperienced surgeons in a save environment is an
important issue of todays laparoscopic education. Additionally to the improvement
of patient safety, the purpose is a reduction of training in the operation room, which
is quite expensive. Due to economical pressure the provided training material does
not only have to be cost effective but also has to maximise training efficiency by
providing a highly realistic training environment. We developed a modular training
phantom for abdominal interventions, which is easy to reproduce and benefits from
advantages in anatomical and haptic realism.
Methods: The information about 3D anatomy was extracted from the CT-scan of a
young male using semiautomatic segmentation of all important organs and vessels.
The resulting models were produced using a 3D printer and moulded in silicone
afterwards. The resulting negative image was then filled with a coloured soft silicone
to form the positive copy of the formerly printed organ. For the bowel a pipe was
used as a mould. The body cavity was segmented, too, and produced using selective
laser sintering. To enable the usage of common laparoscopic instruments and trocars
for training an abdominal wall consisting of three different layers was fixed to the
solid body cavity. Reproduction accuracy was evaluated by comparison of CT-scans
of the produced organs and the original CT-data.
Results: All abdominal and pelvic organs were produced using the described tech-
niques. For the complex rectal organ the medium difference of the surfaces
reconstructed from CT was only 2 mm. The abdominal wall was airtight and allowed
for application of a carbon-dioxide pressure appropriate to laparoscopic surgery.
Conclusion: The approach of rapid prototyping is suitable for producing anatomi-
cally realistic organs. By selection of different silicones various haptic properties can
be achieved. This results in realistic properties of the phantom and therefore might
improve training efficiency and outcome. Further development needs to be con-
ducted to provide breathing and vascularisation for even more realism.
P429 – Training
FEASIBILITY AND ACCESSIBILITY TO THE
LAPAROSCOPIC PROCEDURES IN UNIVERSITY
HOSPITAL OF KINSHASA
B. Nsadi Fwene1, D. Veyi Tadulu1, J.M. Kazadi Mutshim1,
D. Sanduku Kisile2, P. Mukuna Miteo1, Y. Kosi Kola2, A. Kaba1,
O. Detry1
1
University of Kinshasa, KINSHASA, Zaire; 2University of Kinshasa,
Cuk, KINSHASA, Zaire
The authors present an experimental work entering a project of development of the
laparoscopics procedures in RDC adapted to the conditions of developing countries,
outlines of her development as well as first elements of feasibility and the realized
procedures.
In partnership with the Fallen of Liège, formative, and Wbi, landlord of funds, a
team completes, surgeon, anaesthesist and nursing was trained in Belgium then after
locally in RDC. Of the equipment of laparoscopy adapted in the conditions of Africa
was supplied and a mission of accompaniment made to share and resolve the
operational difficulties bound to this new contribution.
From december 2009 to december 2011, 116 surgical operations by laparoscopy
were realized since the beginning of this program, of which 32 appendectomy, 41
cholecystectomy, 11 hernia repairs, 9 laparoscopy explorers for peritoneal carcinoma
assessment and biopsy, 8 procedures for catheter of dialysis peritoneal, 5 gynecol-
ogics procedures, 2 laparoscopy for management of generalized peritonitis, 4
procedures for adhesiolyse, 1 procedure for acute occlusion’s small bowel, 1
drainage of liver abscess, 1 cure of rectal prolapse, and 1 cure of cystocele. Are
analyzed age, sex of patients, hospital stay, evolution, the average cost of procedures
compared to the traditional approach of laparotomy. The laparoscopic approach
appears to be beneficial in economic terms for some procedures in this environment
of low-income population.
The authors conclude that an joined approach, taking into account on one hand the
training of the skills locally trained to adapt itself to some difficulties, on the other
hand institutions of scientific support and a real program and local will of devel-
opment of this new procedure are the wages of development, accessibility and
durability of such news approach in developing countries.
(1) Dpt of surgery CUK; (2) Dpt of anesthesia CUK; (3) Dpt of anesthesia CHU
Liège; (4) Abdominal surgery, CHU Liège
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P430 – Training
TRAINEE INVOLVEMENT IN MAJOR GENERAL
SURGICAL OPERATIONS IN A DISTRICT GENERAL
HOSPITAL SETTING
A.K. Saha, K. Shipton, A. Harikrishnan
Doncaster Royal Infirmary, DONCASTER, United Kingdom
Aims: To assess the involvement of a higher surgical trainee as primary surgeon in major
general surgical operations.
Methods: A prospectively-maintained database of all cases at our institution was interro-
gated and all emergency laparotomies and elective colorectal resections were identified.
Oesophago-gastric resections for cancer were all performed by a consultant and were not
considered in this series. Primary surgeon, operating time, oncological outcomes (where
relevant) and urgency of surgery were measured. Chi-squared tests were used to compare
groups; student’s t-tests were used to compare continuous data.
Results: From August 2011 to November 2011, 125 major cases were performed. There were
74 men (60%); median age was 66 (range, 18–92) years old. A consultant was primary surgeon
in 98 cases (79%). A registrar was primary surgeon in all other cases. Amongst consultant-led
operations, a registrar was first assistant in 80 cases (82%). Emergency operations accounted
for 64 cases (51%). Primary pathology was most commonly colorectal cancer (66 patients,
54%), small bowel ischaemia or obstruction (20 patients, 16%) or diverticular disease (12
patients, 10%). There was a significant difference in primary operating surgeon when stratified
into urgency of surgery and primary pathology. Consultants were more likely to be primary
surgeon if primary pathology was cancer (57 patients operated by consultant vs. 9 patients
operated by registrar, P\0.001) or diverticular disease (9 patients vs. 2 patients, P\0.001).
Trauma cases and laparotomy for appendicitis were significantly more likely to be performed
by registrars. The majority of registrar cases were emergency cases (23 patients as emergency
vs. 4 patients as elective, P\0.001).
Conclusions: The volume of major general surgical operations in our district general
hospital setting was high with over 30 major cases per month. There was good training
exposure for registrars in major cases with 86% of cases involving a registrar as either
primary surgeon or first assistant. Careful rota management and appropriate allocation of
registrars to specific operations, as in our hospital, can maximise training opportunities.
P431 – Urology
COMPARISON BETWEEN THE HEMODYNAMIC
PARAMETERS DURING LAPAROSCOPIC RESECTION
OF ADRENAL AND EXTRA-ADRENAL
PHEOCHROMOCYTOMAS
T. Nozaki, H. Iida, A. Morii, A. Watanabe, Y. Fujiuchi, A. Komiya,
H. Fuse
Graduate School of Medicine and Pharmaceutical Sciences,
TOYAMA, Japan
Objectives: Laparoscopic resection of extra-adrenal pheochromocytomas (EAP) is a
meticulous surgical procedure due to changes in anatomical disposition and prox-
imity to major blood vessels. Complete resection can be relatively traumatic and may
cause increased incretion of catecholamines. We present our experiences during
laparoscopic resection of EAP (LEAP) and compare intraoperative hemodynamics
with those during laparoscopic resection of adrenal pheochromocytoma (LAP).
Methods: Between October 2001 and October 2011, 5 patients underwent LEAP
(retrocaval EAP, n = 2; intra-aortocaval EAP, n = 1; periadrenal EAP, n = 2), and 5
patients underwent LAP. We also examined the range of blood pressure (BP) fluc-
tuation during surgery.
Results: Tumors in the LEAP group were significantly larger than those in the LAP
group (mean 4.8 cm, range 3.9–7.0 cm vs. mean 2.9 cm, range 2.5–3.7 cm). In both
groups, the tumors were successfully removed laparoscopically without any need for
conversion or blood transfusion. During surgery, arterial BP reached higher levels in
the LEAP group (221.6 ± 52.5 mm Hg; range 160–299 mm Hg) than in the LAP
group (200.4 ± 43.1 mm Hg; range 140–262 mm Hg). Intraoperative hypertension
(BP [200 mm Hg) occurred in 3 LEAP and 4 LAP group patients. Intraoperative
hypotension (BP \80 mm Hg) occurred in 5 LEAP and 3 LAP group patients.
However, these differences were not significant.
Conclusions: We are confident in stating that LEAP is a feasible and reproducible
technique with less traumatic laparoscopic dissection and appropriate preoperative
planning, as with LAP. To ensure ideal preparation of patients undergoing LEAP,
very close communication between the endocrine, surgical, and anesthesia teams is
essential.
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P432 – Urology
LAPAROSCOPIC TRANSPERITONEAL
URETEROLITHOTOMY USING ELECTRIC INCISION:
10 CASES EXPERIENCE.
C.S. Gutue1, J. Aurelian1, B. Braticevici1, F. Turcu2, V. Ambert1,
V. Jinga1, I. Chira1
1 1
‘‘Prof. Dr. Theodor Burghele’’ Urology Clinic, BUCHAREST,
Romania; 2Saint John Emergency Hospital, General Surgery Clinic,
BUCHAREST, Romania
Aims: Indications for laparoscopic treatment of urinary lithiasis are the only choice
before open surgery when extracorporeal or endoscopic treatment fails, or when
stones are located in kidneys with congenital abnormal position which makes again
the endoscopic treatment impossible.
There are conflicting opinions regarding the use of electric current in the upper
urinary tract due to risk of stenosis (especially ureteric stenosis). Further we will
present our experience in 10 cases of using the electric cutting in laparoscopic
treatment of the upper urinary tract stones.
Method: In the last 15 months 10 patients (6 women, 4 men, ages between 22 and 61
years old) were treated laparoscopically for urinary stones (diameter between 1.3–2.2
cm). In six cases (60%) we delt with upper ureteric stones, two cases (20%) in witch
the stone was placed in the pelvic ureter, and two cases (20%) of stone placed in the
renal pelvis of an ectopic iliac kidney (the right kidney in both cases).
Results: In all 10 cases we performed laparoscopic transperitoneal ureterolitothomy
and pyelolithotomy. This approach provides a large working space, and perfect
anatomical orientation. In all cases, the ureter or renal pelvis incision was made
electrically (ONLY with cutting mode, at 30W) and no intracorporeal suture was
performed. The urinary tract was drained either by double J stent (9 cases) or
percutaneous nephrostomy. None of patients developed urinary fistula and peritoneal
drainage was maintained for 3–5 days. Length of hospital stay after surgery was four
days, no post operative complication has been encountered. Follow-up at 6 months
and 1 year (intra-venous urography and ultrasound) showed no stenosis of the ureter.
Conclusions: Transperitoneal laparoscopic treatment of urinary lithiasis is relatively
safe alternative to open surgery. Electrical section of the upper urinary tract was free
of complications, but doing it ONLY in cutting mode of the monopolar cautery.
P433 – Urology
POLYMER LOCKING CLIPS: RELIABLE AND COST-
FRIENDLY DEVICE FOR VASCULAR CONTROL DURING
LAPAROSCOPIC NEPHRECTOMY
C.S. Gutue1, I. Chira1, A. Rusu1, B. Braticevici1, F. Turcu2,
V. Ambert1, V. Jinga1
1
‘‘Prof. Dr. Theodor Burghele’’ Urology Clinic, BUCHAREST,
Romania; 2Saint John Emergency Hospital, General Surgery Clinic,
BUCHAREST, Romania
Aims: To evaluate the safety and also the cost-efficiency of the polymer locking clips for the
control of the renal pedicle during laparoscopic nephrectomy.
There are many ways to control the renal vessels during laparoscopic nephrectomy: intra-
corporeal and extracorporeal knots, mechanical suturing devices, bipolar sealing and cutting
devices, metal clips, and the polymer locking clips. However, not all of them are used in everyday
practice for different reasons. We will present further our experience in practice and also in finance
with the polymer locking clips.
Methods: We compiled a retrospective review of all laparoscopic nephrectomies (simple
nephrectomy and nephroureterectomy) performed by surgeons in our clinic.
Results: During the last 18 months, we performed in our clinic 58 laparoscopic transperitoneal
nephrectomies (55 simple nephrectomies, 3 nephroureterctomies). We used Hem-o-lok polymere
locking clips for control of both renal vessels during surgery. For each major vessel we used three
clips (two clips towards aorta or vena cava, and one clip towards kidney). The ureter was sealed
with two clips.
The number of clips used during a nephrectomy varied from 29 (a difficult renal pedicle with
multiple arterial braches) to 5 (a sclerous-atrophic kidney pedicle). The medium number of clips
used per nephrectomy was 11. In all cases we used the large clip on the artery and extra-large clip
on the vein. There were no misfirings (0%). We have encountered two complications (0.3%)
consisted in two clips placed on the renal vein who caught the artery adventitia because there was
no proper visual control while placing the clips. There was no need to remove a placed clip in any
intervention. The estimative cost per nephrectomy is about 16.5 euro when using the polymere
locking clips. The alternative is a mechanical suturing device at the average price for about 200
euro per intervention.
Conclusions: Properly applied polymer locking clips for vascular control during renal procedures
provide a safe and cost-effective option compared to other ways of managing the renal vessels.
Complications could have been avoided if the vessels dissection were completed (360 degrees) and
the clip were sealed under visual control.
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Surg Endosc (2013) 27:S53–S166
P434 – Urology
USE OF FLEXIBLE NEPHROSCOPE IN COMPLICATED
TRANSPERITONEAL LAPAROSCOPIC
URETEROLITHOTOMY FOR UPPER TRACT CALCULI
C.S. Gutue1, I. Chira1, M. Dumitrache1, B. Braticevici1, F. Turcu2,
S. Vasile1, V. Ambert1, V. Jinga1
‘‘Prof. Dr. Theodor Burghele’’ Urology Clinic, BUCHAREST,
Romania; 2Saint John Emergency Hospital, General Surgery Clinic,
BUCHAREST, Romania
Aims: The goal of endourology and minimally invasive surgery is to advance the
field of urology by applying techniques that yield results equal to open operative
procedures with less associated morbidity, shorter hospital stays, and prompt return
to normal activity.
We will present in this abstract the use of flexible nephroscopy during transperito-
neal laparoscopic ureterolithotomy for upper tract calculi in complicated cases.
Methods: During the last 16 months, we performed surgery using the 3 port trans-
peritoneal technique on five patients with impacted upper ureteric stones. In three
cases, after the incision of the ureter has been performed, the stone migrated back
into the renal pelvis becoming this way impossible to extract without conversion. A
flexible telescopic nephroscope (14–18 Ch) was passed through a 11 mm port and
guided laparascopically through the incision in the upper ureter. The stones were
extracted using a NGageTM Nitinol Stone Extractor.
Results: Median age was 40 years (37–51). Mean operative time of flexible neph-
roscopy was 12 minutes (range 10–14). Stones diameter was between 1,1–1,3 cm.
Intra-operative blood loss was inestimable. There were no complications or con-
version. The amount of serum used to dilate the renal pelvis during endoscopy was
about 200 ml. Peritoneal cavity drainage was used every time, for 3–4 days.
Conclusion: Flexible nephroscope introduced in the renal pelvis through the ureteric
incision in combination with laparoscopy is a feasible and effective technique for the
treatment of migrated urinary stones in selected cases to avoid conversion to open
surgery.
P438 – Amazing Technologies
THE EXPERIENCE OF VIDEOCAPSULAR ENDOSCOPY
IN CHILDREN WITH SUSPECTED CROHN’S DISEASE
M.M. Lohmatov1, I.V. Kirgizov2, T.V. Goryunova1
1
SCCH of RAMS, Moscow, Russia; 21st MSMU after I.M. Sechenov,
MOSCOW, Russia
Aim: Develop a methodology for conducting videocapsular endoscopy (TBE) for
children from 1–5 years.
Materials and methods: In 2011–2012, TBEV was held on 12 children aged 1–5
years. Indications for TBE-abdominal pain, abnormal stools with an unstable
alloy(mucus,blood,pus), sudden weight loss, anemia of unknown etiology. Just
TBEV was administered to children in disputed cases, the differential diagnosis of
CD and UC. Contraindications were suspected stenosis, diverticula, severe the
patient’s condition, age less than 1 year. As a result of TBEV in 5 children confirmed
CD:3 children were found ulcers of the small intestine, covered with a touch of
fibrin, with a child diagnosed pseudo-polyps in the terminal ileum, were observed at
the base of pseudo-polyps ulcers. In one girl-active bleeding from the ulcer of the
ileum.
Conclusion: videocapsular endoscopy-a comfortable and highly informative proce-
dure to examine are inaccessible to standard endoscopy departments of the
gastrointestinal tract-a lean and ileum.
Surg Endosc (2013) 27:S53–S166
P439 – Amazing Technologies
TOOL-SEWING MACHINES ATTACHMENT-COMPLEX
FOR GASTROSCOPES ESOFIX:THE EXPERIENCE
OF INTRALUMINAL OPERATIVE TREATMENT
M.M. Lohmatov1, D.V. Fokin2, I.V. Kirgizov3, T.A. Prudnikova1
1
SCCH of RAMS, Moscow, Russia; 2Public health services municipal
authority city clinical hospital ?20 of a name, KRASNOYARSK,
Russia; 31st MSMU after I.M. Sechenov, MOSCOW, Russia
Aim: Estimate efficacy of carrying out transoral intraluminal fundoplica-
tion in pediatrics.
Materials and methods: TIF was carried in patient aged 4 years with
gastroesophageal reflux disease, a reflux-esophagitis, insufficiency of
cardia, hyperacidity, continuously progressing flow, resistance to conser-
vative therapy. On EGDS erosive esophagitis, insufficiency of cardia,
gastro-esophageal prolapse, duodeno-gastral reflux came to light. On 24
hour pH-metry before operation-pH \ 4 = 23 (norm 4.5); acid refluxes-pH
\ 4.0 = 168 (norm 46.9); number of refluxes [5 mines-7 (norm 3.5).
Index De Meester 47.91 (norm \14.72).
Results: In 3 months after operation, at control inspection on EGDS cardia
closes completely, at inverse inspection dense fit of mucosa of the gen-
erated LES to endoscope is marked. Results of the 24 hour pH-metry after
operation-general pH \4 = 3-normal; acid refluxes-pH \ 4.0 = 7(N),
number of refluxes [5 mines = 1(N). Index DeMeester 9.85(N), refluxes
were observed. Signs of the gastroesophageal reflux disease were revealed.
Conclusion: The newest procedure-transoral intraluminal fundoplication
(TIF) by means of attachment-complex EsofiX has proved to be highly
effective method of treatment of GERD
P440 – Amazing Technologies
ANALYSIS OF THE EFFECTIVENESS OF ENDOSCOPIC
BOUGIENAGE IN CHILDREN
M.M. Lohmatov1, D.V. Fokin2, S.I. Yakimova3, I.A. Shishkin1
1
SCCH of RAMS, Moscow, Russia; 2Public health services municipal
authority city clinical hospital ?20 of a name, KRASNOYARSK,
Russia; 3Federal state budgetary establishment - Centre of science
of health of children-, MOSCOW, Russia
Aim: Efficiency estimation of the endoscopic bougienage along a guide
string in children.
Methods: 8 children aged 1–8 years were divided into 3 groups: I-3
children with peptic strictures, II-3 children with postburn strictures and
III-2 children with cicatricial strictures in a place of esophago-esophago
anastomosis. In all cases we performed a course of antegrade endoscopic
gullet bougienage along a guide string before permanent effect of lumen
diameter more than 8–9 mm was achieved.
Results: The greatest positive result was marked in the first and in the third
groups of children. Patients from the second group after basic course
needed carrying out supporting gullet bougienage in connection with less
proof result. Complications after gullet bougienage were not marked.
Conclusion: the endoscopic bougienage along a guide string is a unique
effective method of treatment of cicatricial gullet strictures, which allows
to decrease risk of complications.
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P441 – Amazing Technologies
ENDOVIDEOSURGICAL TECHNOLOGIES IN TREATMENT
OF ACUTE CHOLECYSTITIS WHICH MECHANICAL
JAUNDICE: UP TO DATE APPROACH
D.V. Fokin1, I.V. Kirgizov2, V.A. Dudarev3
1
Public health services municipal authority city clinical hospital ?20
of a name, KRASNOYARSK, Russia; 21st MSMU after I.M.
Sechenov, MOSCOW, Russia; 3Krasnoyarsk state medical university
of a name of professor V.F.Vojno-Jasenetsky, KRASNOYARSK,
Russia
Aim: Estimate possibilities of endovideosurgical technologies in the
treatment of acute cholecystitis which mechanical jaundice.
Materials and Methods: we have treated 425 patients with acute cholecystics. 11.7%
had symptoms of bile hypertension. For all patients was held endoscopic retrograde
cholangiopancreatography (ERCP).
Results: The reasons of bile hypertension were managed to disposed by
endoscopic papillotomy(EPT) among 39th (66.1) patients. After success-
ful EPT the positive dynamic of the acute cholecystitis was reached among
30th (50.8%) patients. For all patients in the planning regimen were made
laparoscopic cholecystectomy (LCT). The operation was made in 12th
(20.3%) patients. In 5 patients was managed to make LCT. The reasons of
bile hypertension were not disposed among 7th (14%) patients.
Conclusion: ERCP and EPT for acute cholecystics which is complicated
by mechanical jaundice allow to get full regression of disease in the major
cases and to make LCT in the planning order. If the positive dynamic is
absent this tactic allows making minimal invasive surgical intervention
P442 – Amazing Technologies
FLEXIBLE SINGLE-INCISION SURGERY
J.F. Noguera, A. Cuadrado, A. Sanchez, J. Munoz
Hospital Son Llàtzer, PALMA, Spain
Background: The development of NOTES surgery has led to other tech-
niques, such as single-port surgery. The use of the flexible endoscope for
single-incision surgery paves the way for further refinement of both sur-
gical methods.
Aim: To describe a new, single-incision surgical technique, namely flex-
ible single-incision surgery (FSIS). Methods. Assessment of the
effectiveness of endoscopic cholecystectomy with the new technique. This
technique consists of a single umbilical incision measuring 25 mm through
which a flexible endoscope is introduced, and of two parallel entry ports
measuring 3 to 5 mm for non-articulated laparoscopic instruments.
Results: The technique was applied successfully, with no need to convert
to conventional laparoscopy. No general or surgical wound complications
were noted. Surgical time was no longer than usual for single-port surgery.
The intervention cost far less than single-port surgery. FSIS is a new
single-site surgical technique allowing for further refinement of NOTES
and of single-incision surgery.
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P443 – Amazing Technologies
TOTALLY ENDOSCOPIC COLORECTAL RESECTION
LAPAROSCOPY-ASSISTED
M. Casaccia
University of Genoa, GENOA, Italy
Background: Laparoscopic colorectal resection for malignancy has
proved its efficacity and safety when compared to ‘open’ techniques,
even from an oncological point of view.
Aim: To perform a colorectal resection for malignancy in a totally
endoscopic way under laparoscopic guidance.
Project description: A circular stapler is conceived adding a ‘resec-
tion’ function to anastomosis. Technical features of this instrument
are the presence of two annular inflatable elements (on the anvil and
the body of the stapler) and the capability ‘to store’ the diseased
intestinal wall inside the instrument body by means of a vacuum
force.
Preliminary results: The potential advantages of this approach are
enormous. Since the operation is performed in a totally endoscopic
way, the opening of the intestinal lumen is avoided. As a conse-
quence, two major advantages are present: no tumor cells ‘spillage’,
and no risk of abdominal or wound infection by bacterial
contamination.
P444 – Amazing Technologies
STANDARDIZED LAPAROSCOPIC GASTRIC BAND
INSERTION TECHNIQUE IS REDUCING THE EARLY
MORBIDITY OF BAND SURGERY
A. Hussain, S. EL-Hasani
Princess Royal University Hospital, ORPINGTON, United Kingdom
Background: Gastric band surgery complications are sometimes
serious and could lead to death.
Aim is to prevent major band complications and to achieve a lower
morbidity rate.
Project description: Pars flaccida technique was used for all patients.
Patients were hospitalized for one night only. Postoperative follow up
was provided for one month, two months and for every three months
for the first year and then yearly for another two years.
Preliminary results: During January 2007–August 2011,1149 patients
were underwent Laparoscopic Adjustable Gastric Band (LAGB)
insertion including two hundreds and forty-five (21.32%) men and
904 (78.67%) women. The age range was 18–64 years (mean 44
years). Their BMI was 33–62 (mean 42). There were 2 band erosions,
6 band prolapse, 4 port problems, 1 band leak, 3 tight bands, 2 port
infections, and no mortality.
Conclusion: A standardised technique is reducing the complications
of gastric band surgery.
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Surg Endosc (2013) 27:S53–S166
P445 – Amazing Technologies
TWIN FORCEPS FOR SINGLE ACCESS LAPAROSCOPY
A. Rizutto1, G. Danieli2, R. Sacco2
1
University magna Graecia, CATANZARO, Italy; 2University
Calabria, COSENZA, Italy
Background: Recent years have been characterized by the emergence
of Single Access Laparoscopy (SAL)Limit of the method: the tech-
nical difficulties due to possibility to perform dissection with just one
grasping forcep.
Aims: An instrument to overcome the limits of the present
instrumentation.
Project Description: This instrument, can be introduced as single
instrument, and then divides into two branches, each of which is
equipped with a gripper for grasp the tissue, and able to remove the
handholds once the tissue gripped in two points, just to stretch the
tissue. The internal mechanism allows opening the two arms while the
forceps bend toward the inside, keeping their configuration, being all
this controlled by a single command. Two further commands allow
opening and closing the two forceps individually.
Preliminary Results: In our experimental experience this instrument
can be a good solution for the development of single port sur-
gery.Clinical experiences are necessary
P446 – Amazing Technologies
A NEW CONCEPT OF SIMULTANEOUSLY COMBINING
THE THORACIC AND ABDOMINAL PHASE IN
ESOPHAGEAL SURGERY
B. Dillemans, J. Lesaffar, S. Van Cauwenberge, J.P. Mulier
AZ Sint-Jan Brugge-Oostende AV, BRUGGE, Belgium
Background: Esophageal cancer surgery remains challenging with a
high morbidity rate, partly caused by the extensive operative time due
to the split of the procedure in separate and consecutive phases.
Aim: In our new concept, two surgical teams perform the abdominal
and thoracic phase simultaneously instead of consecutively.
Project Description: Since January 2012, 5 patients (midesophageal
invasive carcinoma (2), gastroesophageal junction carcinoma (2),
Barret’s esophagus with high grade dyspasia (1)) were operated
according this new simultaneous approach. Both the abdominal and
thoracic phase in all cases were performed by two surgical teams
operating simultaneously.Preliminary results: There were 2 female
and 3 male patients with mean age of 68.8 years (60–83). Mean
operative time was 253 min (160–330). There were 2 conversions to
thoracotomy but the abdominal team still proceeded simultaneously
and laparoscopically. Mean hospital stay was 12 days. Mortality rate
was zero. No leaks occurred. Two patients developed a pneumonia.
Surg Endosc (2013) 27:S53–S166
P447 – Amazing Technologies
SEALED INCISION MULTIPORT (SIMPORT): A UNIFYING
ACCESS DEVICE FOR TRANSABDOMINAL AND
TRANSANAL LAPAROENDOSCOPY
R.A. Cahill
Beaumont Hospital, DUBLIN, Ireland
Background: Despite current device specificity, the technique and
technology of Single Access Laparoscopy is a synergistic minimal
invasive surgical advance.
Aim: The SIMPORTTM is a novel unifying access construct that
converges capability to foster the provision of single/multiport lapa-
roscopic operations as well as transanal resections in a manner that is
reliable, reproducible and extremely ergonomical.
Project Description: A single piece of flexible, elastic material spe-
cifically configured for robust application onto either surgical incision
sites (2–9 cm in diameter) or natural orifices and that accommodates
standard laparoscopic trocars and instruments in a non-prescriptive
fashion (regardless of branding) with a durable hermetic seal of both a
surgical incision or the anorectum to ensure stable pneumoperito-
neum/rectum. The simplified tool-kit delivers maximum return from
the standard surgeon’s skill-set.
Preliminary Results: SIMPORTTM utility, applicability and effec-
tiveness have been shown in bench, biomedical and clinical settings
with conclusive demonstration of ideal device performance for next-
step laparoendoscopic surgery.
P448 – Amazing Technologies
ENDOVIDEOSURGICAL TECHNOLOGIES IN TREATMENT
OF ACUTE CHOLECYSTITIS WHICH MECHANICAL
JAUNDICE: UP TO DATE APPROACH.
D.V. Fokin1, I.V. Kirgizov2, V.A. Dudarev3
1
Public health services municipal authority city clinical hospital
?20 of a name, KRASNOYARSK, Russia; 21st MSMU after I.M.
Sechenov, MOSCOW, Russia; 3Krasnoyarsk state medical university
of a name of professor V.F.Vojno-Jasenetsky, KRASNOYARSK,
Russia
Aim: Estimate possibilities of endovideosurgical technologies in the
treatment of acute cholecystitis which mechanical jaundice.
Description: we have treated 425 patients with acute cholecystics. 11,7%had
symptoms of bile hypertension. After which was held the endoscopic retrograde
cholangiopancreatography(ERCP) for all patients.
Results: The reasons of bile hypertension were managed to disposed
by endoscopic papillotomy(EPT) among 39th (66.1) patients. After
successful EPT the positive dynamic of the acute cholecystitis was
reached among 30th (50.8%) patients. For all patients in the planning
regimen were made laparoscopic cholecystectomy (LCT). The oper-
ation was made in 20.3%. In 5 patients was managed to make LCT. In
3 patients were difficulties during the LCT connected to evident
infiltrate in gallbladder neck. The reasons of bile hypertension were
not disposed by using EPT among 7th (14%)patients.
Conclusion: ERCPandEPT for acute cholecystics which is compli-
cated by mechanical jaundice allow to get full regression of disease in
the major cases and to make LCT in the planning order
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P449 – Amazing Technologies
SURGICAL TREATMENT OF CYSTIC TRANSFORMATION
OF THE BILE DUCTS
D.V. Fokin1, I.V. Kirgizov2, V.A. Dudarev3
1
Public health services municipal authority city clinical hospital
?20 of a name, KRASNOYARSK, Russia; 21st MSMU after I.M.
Sechenov, MOSCOW, Russia; 3Krasnoyarsk state medical university
of a name of professor V.F.Vojno-Jasenetsky, KRASNOYARSK,
Russia
Aim: formation of the condition for unimpeded flux of bile into the
bowels, decrease biliary and pancreatic hypertension, liquidation of
inflammation process and prevention of malignant transformation of
modified ducts.
Descriptions: indication for operation of external drainage was
defined among 17th children with the mechanical jaundice and
hepatic deficiency also with the spontaneous perforation of choledoch
cyst with gall peritonitis among 8th patients. Long lasting mechanical
jaundice which is non-capable to conservative therapy and significant
disorder of coagulant system was observed among 4th 3–4 months old
babies and 4th 1.5–5 years old children. External drainage of the bile-
excreting ducts was made on the first stage of the treatment.
Conclusion: We have found out that the operation of external drain-
age it the compulsory measure for the handle of critical situation.
After external drainage on the background of giant bile loss especially
among newborns the symptoms of major abnormality of acidic-basic
and electrolytic balances were appeared.
P450 – Amazing Technologies
LAPAROSCOPIC INGUINAL HERNIA REPAIR:
PROSPECTIVE COMPARISON BETWEEN STANDARD
AND SELF-GRIPPING MESH.
F. Puccetti1, U. Fumagalli1, U. Elmore1, R. Rosati2
1
IRCCS Humanitas, ROZZANO (MI), Italy; 2Instituto Clinico
Humanitas, ROZZANO (MI), Italy
Background: Self-gripping mesh, recently introduced in clinical
practice, might reduce the incidence of chronic pain during laparo-
scopic hernioplasty in comparison to fixation with staples.
Aim and Project description: We compared length of surgery, inci-
dence of chronic pain (short-form McGill Pain Questionnaire) and
recurrence rate in 2 groups of patients who underwent a TAPP repair
with either self-gripping polyester and polylactic-acid mesh (SGM –
50 patients) or with a fixed polypropylene-poliglecaprone mesh (ST –
46 patients).
Preliminary results: Follow-up was 10 months for SGM (6–42) and 21
for ST (6–27). Length of surgery was similar. Recurrence rate was 0%
in SGM and 2.2% in ST (1 patient). The incidence of chronic pain
was 6.3% in SGM (2 mild and 1 moderate\severe pain) and 15.9% in
ST (4 mild and 3 moderate\severe pain) respectively.SGM seems to
reduce the incidence of chronic pain after TAPP.
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P451 – Amazing Technologies
SILVER NANOCLUSTER/SILICA COMPOSITE COATINGS
OBTAINED BY SPUTTERING FOR ANTIBACTERIAL
APPLICATIONS,RESULTS OF NABLA AND NASLA FP7
RESEARCH PROJECT
C. Buemi1, M. Ferraris2, C. Balagne2, S. Perero2, M. Miola2,
S. Ferraris2, F. Baino2, F. Verne2, A. Chiaravalloti1
1 1
Dipro Medical Devices srl, SAN MAURO TORINESE, Italy;
2
Politecnico di Torino, TORINO, Italy
Background: Silver in its ionic or metallic state has long been known
to have powerful antibacterial activity. Although there is still some
debate on the exact mechanism, its antimicrobial properties are well
documented and mostly linked to release of ionic silver.
Aim: in this work we describe the preparation and characterization of
a new, chemical/thermal stable and low cost antibacterial silver
nanocluster silica composite coatings, obtained by RF co-sputtering
deposition.
Project description: The antibacterial effect of coated samples has
been evaluated in different experimental conditions in accordance to
National Committee for Clinical Laboratory Standards (NCCLS),
using both a bacterial strain (Staphylococcus aureus) and a fungus
(Candida albicans). The antimicrobial properties are maintained also
after gamma ray and Eto sterilization processes.
Preliminary results: this is a promising result about the possible use of
these coatings for applications requiring sterilization procedures in
biomedical field.
P453 – Amazing Technologies
A NEW SIMPLE AND ECONOMIC SURGICAL SIMULATOR
MADE OF NEODERMA IMPROVES SURGICAL SKILLS
FOR TRANSANAL ENDOSCOPIC MICROSURGERY (TEO)
G.L. Carvalho1, M.A. Lyra1, A.G. Melani2, S.E. Araujo3,
E.A. Bonin4, F.W. Silva1, C.A.R. Veo2, A.C. Sales1, D.L. Lima1
1 1.4% having significant morbid, legal and financial implications.
Universidade de Pernambuco, RECIFE, Brazil; 2Hospital de Cancer
de Barretos, BARRETOS, Brazil; 3USP, SAO PAULO, Brazil;
4 limitations of LC. Risk for accidental cuts increases with distorted,
Universidade Positivo, CURITIBA, Brazil
Background: TEO is a safe, feasible and efficacious procedure for
rectal tumors that enables proper ‘en bloc’, resulting in reduced
hospital stay and morbidity. Although advantageous in many ways,
TEO has not yet been performed in a widespread fashion, since it is
still considered difficult to master technique.
Aim: Present the NEW TEO trainer – a simple, practical and
economic.
Project Description: Neoderma is a material that offers color, touch,
consistency and texture similar to the Human tissues. A TEO Neo-
derma trainer is a cylinder 30 cm-long, 4 cm-wide, engineered to
simulate a pathologic rectum with 3 polypoid 2 cm-sized tumors.
Rectum wall layers made in different colors helps the identification of
surgical dissection plans.
Preliminary Results: Experienced surgeons demonstrated good
acceptance by successfully completing the proposed tasks. Apart from
usual TEO instruments, harmonic scalpel was successfully used.
Surgeons agreed that the TEO simulator offers a good model for
mastering transanal resection/suturing.
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Surg Endosc (2013) 27:S53–S166
P454 – Amazing Technologies
NEW LOW FRICTION ADPTER FOR USING
MINILAPAROSOCPIC INSTRUMENTS WITH TRANSANAL
ENDOSCOPIC MICROSURGERY (TEO) IMPROVES
VISUALIZATION AND DEXTERITY
G.L. Carvalho1, A.G. Melani2, C.A.R. Veo2, M.A. Lyra1,
S.E. Araujo3, E.A. Bonin4, F.W. Silva1, A.C. Sales1, D.L. Lima1
Universidade de Pernambuco, RECIFE, Brazil; 2Hospital de Cancer
de Barretos, BARRETOS, Brazil; 3USP, SAO PAULO, Brazil;
4
Universidade Positivo, CURITIBA, Brazil
Background: TEO is a safe, feasible and efficacious device enabling
proper rectal tumors ‘en bloc’ resection, resulting in reduced hospital
stay and morbidity. Considered technically demanding, TEO has not
yet been widespread. Curved instruments have not significantly
improved visualization and high friction forces between forceps and
rubber sealing also needs improvement.
Aim: By combining established TEO advantages with better visual-
ization and higher precision offered by the new low friction MINI-
TEO Adapter, a platform to potentially become the gold standard for
TEO is proposed.
Project Description: A new device, precisely engineered with minimal
gap between the adapter and the minilaparoscopic instruments to
prevent gas loss, was successfully tested in dry lab with TEO Trainers
and in one patient with rectal adenocarcinoma. Combination of
minilaparoscopic (3 mm) and TEO instruments (5 mm) including
harmonic scalpel was possible.
Preliminary Results: Significant Improvement in surgical precision
specially for suturing resulted in less stress and higher effectivity.
P455 – Amazing Technologies
SINGLE HOLE CHOLECYSTECTOMY – A NEW APPROACH
M.M. Varma
Private Institute, KANPUR, India
Background: SAGES 2005 stated that incidence of BDI in LC is upto
Medscape 2010 reported ‘Death of Rep. John Murtha highlights
depthless vision of laparoscope.’ Aim: To design a minimally inva-
sive cholecystectomy safer and less invasive than LC.
Method: ‘Single Hole’ or Microlap cholecystectomy (MC) using
intraoperative ultrasound (IOUS) with NOTES and SILS instruments.
Preliminary Results: We performed 2960 surgeries through MC using
IOUS and LC instruments. 13 (0.4%) were converted to laparotomy
and 2947 (99.6%) were discharged within 24 hours postoperatively. 1
(0.03%) had BDI. Conclusions: ‘Hand-assisted laparoscopic surger-
ies’ exist. Popularizing microlap-assisted laparoscopic techniques will
make minimally invasive cholecystectomy more safe due to use of
IOUS; with 3D view as well as endoscopic view; gas-less and will
reduce technical challenges of NOTES/SILS; ushering new era of
minimally invasive cholecystectomy.
Surg Endosc (2013) 27:S53–S166
P456 – Amazing Technologies
DEVELOPMENT OF LAPAROSCOPIC ULTRASOUND
TRAINING SYSTEM
M.K. Chmarra1, R. Hansen2, E.F. Hofstad2, C. Våpenstad2,
R. Marvik1, T. Langø2
1
Norwegian University of Science and Technology, TRONDHEIM,
Norway; 2SINTEF Technology and Society, TRONDHEIM, Norway
Background: Laparoscopic ultrasound (LUS) increases patient safety
by allowing the surgeon to see beyond surfaces of organs. LUS,
however, is not widely used due to e.g. long learning curve and lack
of specialized training systems.
Aim: We aim to develop a simulator training model for learning and
skills assessment needed for advanced intraoperative image-guided
therapeutic procedures with the main focus on LUS.
Preliminary results: We have developed a LUS training system con-
sisting of a box trainer, endoscopic and LUS equipment, a tracking
system, and an in-house developed surgical navigation system. A new
multi-modality liver phantom suitable for LUS, CT and MR imaging
has been developed. To our knowledge, this is the first time such a
LUS training system has been proposed. We believe that including
multi-modality images is beneficial to those acquiring LUS skills,
since handling the LUS-probe is not straightforward and interpreta-
tion of LUS images can be difficult.
P457 – Amazing Technologies
INITIAL EXPERIENCE WITH PERORAL ENDOSCOPIC
ESOPHAGEAL MYOTOMY
W. Breithaupt, T. Schulz, G. Varga, V. Babic, D. von Renteln,
K-H. Fuchs
AGAPLESION Markus Krankenhaus, FRANKFURT AM MAIN,
Germany
Introduction: Recently Natural orifice transluminal endoscopic sur-
gery has been introduced in esophageal disease by peroral endoscopic
esophageal myotomy (POEM). After extensive experimental training,
our team has established this technique in clinical practice.
Aim: The purpose of this study is the assessment and documentation
of the learning curve of introducing a NOTES Technique into clinical
treatment.
Methods: The authors have trained this technique in an experimental
setting. The team has extensive experience in both advanced lapa-
roscopic and flexible endoscopic work as well as vast experience with
the management of benign esophageal disorders. IRB-approval was
applicated for and granted. The technique was learned in an experi-
enced center (T Rösch and D von Renteln, Hamburg), as published by
H Inoue. An ESD technique was used to perform an submucosal
tunnel with a triangle knife. Above the myotomy a mucosal overlap of
the tunnel was left over 5 cm and later clipped for closure. The
duration of the procedure, the length of the myotomy, all intra- and
postoperative problems were documented. Pre-and postoperative
Eckhard score, Quality of Life measurements and ph-Monitoring was
assessed.
Results: n = 12; There were no major complications, The quality of
Life was increased in 9 out of 10 patients evaluated.
Conclusion: The initial experience with POEM seems promising.
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P458 – Amazing Technologies
TRANSANAL ENDOSCOPIC DA VINCIÒ SURGERY (TEDS):
RESULTS FROM CADAVERIC EXPERIMENTS
R. Hompes1, S.M. Rauh2, M.E. Hagen3, N.J. Mortensen1
1
Churchill Hospital, OXFORD, United Kingdom; 2Rochester General
Hospital, ROCHESTER, NEW YORK, United States of America;
3
University Hospital Geneva, GENEVA, Switzerland
Background: single port platforms are increasingly used for transanal
surgery. In an effort to tackle some of the limitations associated with
these single port platforms and increase intraluminal flexibility,
robotic integration could be the logical next step.
Aim: to report our initial experience with transanal endoscopic da
Vinci Surgery (TEdS).Project description: After drylab experi-
ments, the feasibility of TEdS and ideal set-up was further evaluated
in 3 human cadavers. A da Vinci SI HD system was used in
combination with a glove port for transanal endoscopic resections.
Preliminary results: We were able to perform all necessary tasks to
complete a full thickness excision and closure of the rectal wall, with
cadavers in various positions. The stable magnified view, combined
with the endowrist technology of the robotic instruments made every
task straightforward. Intraluminal manoeuvrability could further be
improved by intersecting the robotic instruments. The glove port
proved to be very reliable and the inherent flexibility of the glove
made docking of the robotic arms, in a narrow confined space easy.
P459 – Amazing Technologies
THE IMPACT OF FENESTRATIONS IN THE JAWS OF
LAPAROSCOPIC GRASPERS
A.W. Brown, S.I. Brown, D. McLean, Z. Wang, Sir A. Cuschieri
Institute for Medical Science and Technology, DUNDEE,
United Kingdom
Fenestration features have been designed into laparoscopic grasper
jaws to resist slippage although their value has been contested in the
literature. This investigation aimed to determine if fenestrations
increased the force necessary to pull tissue from the jaws and which
fenestration design was most effective. Three fenestration designs
were investigated and compared to similar non-fenestrated jaws.
Experiments were carried out in which both the surface contact area
of the jaws and the ratio of fenestration to contact area were kept
constant. Each jaw design was tested by clamping pig colon between
jaws and applying a range of compression forces then pulling the
tissue from the jaws and recording the maximum traction force.
Results were analysed using ANOVA. The results have shown that
fenestrations in the jaws of instruments significantly increase the
force needed to pull tissue from the jaws.
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S166 Surg Endosc (2013) 27:S53–S166

P460 – Amazing Technologies

INTRAGASTRIC SILS FOR RESECTION

OF GASTROINTESTINAL STROMAL TUMOR
OF THE STOMACH
K. De Vogelaere
University Hospital Brussels, BRUSSELS, Belgium
Background: Laparoscopic resection of gastric gastrointestinal stromal tumors
(GISTs) is a feasible and safe technique which provides advantages of faster
recovery, less postoperative pain, better cosmesis and shorter hospital stay. With the
further evolution to minimal invasive laparoscopy, single-incision laparoscopic
surgery (SILS) was developed and safety together with feasibility are proven for
several procedures such as appendectomy, cholecystectomy, colonic surgery, gastric
banding and sleeve gastrectomy. Only few case reports were published in literature
on wedge resection of the stomach performed by SILS for the treatment of GIST.
Methods: For the treatment of GISTs located at the posterior wall of the stomach,
transgastric SILS can be performed. We report two cases of single-incision trans-
gastric resection of GIST of the stomach with the SILS port placed into the anterior
wall of the stomach.
Results: Total operative time was respectively 82 minutes and 67 minutes for the two
cases. Estimated blood loss was less than 30 mL in both patients. No intra- and
postoperative complications occurred.
Conclusions: This intragastric SILS procedure for GIST is feasible and safe and
these are to our knowledge the first published cases in humans.

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