18TH SLS ANNUAL MEETING AND ENDO EXPO 2009 SCIENTIFIC ABSTRACTS:
Supplement to JSLS, Volume 13, Number 2
9100 General Surgery
Involution or Evolution: Minilaparotomy Approach to GERD Treatment
J.
Quiroz, MD, L. Guerrero, MD, J. A. Quiroz, MD, E. EN. Nova, M. EN. Flores, I. IN.
Ramirez
Centro Hospitalario San Nicolas, San Mateo Atenco Estado
de Mexico-Mexico
Background:
Gastroesophageal reflux disease (GERD) is a very serious problem. Despite the improvements
in antireflux surgery (ARS), new challenges are still ahead. We sought to
demonstrate the endpoints achieved by the minilaparotomy approach, which
include safety, excellent mobilization of the distal esophagus, and performance
of an excellent fundoplication. We
discuss the open access approach in the progression of ARS and that mini-access
is considered the evolution of surgical alternatives.
Method:
Between 2003 and 2008, 200 patients underwent minilaparotomy, clinical
evaluation, endoscopy-biopsy, manometry, 24h pH monitoring (some cases), and barium
study. Data collected included age, sex, typical and atypical symptoms, time
from onset, comorbidities, length of operating time, cost, hospital stay,
disability, complications, and medication used. Long instruments, Harmonic scalpel,
intracorporeal cool light, and special retractors were used to perform a total
floppy Nissen fundoplication. Indications
included esophagitis because of lower esophageal sphincter incompetence, hiatal
hernia, and Barrett’s-esophagus without dysplasia. Follow-up included assessment
of an annual endoscopy, quality of life (well-being index and symptom scale
rating), 3-year postoperative manometry, and 24-h pH monitoring (some cases).
Results:
Access was accomplished through an 8-cm to 9-cm long incision. Operating time was
60 minutes to 70 minutes. Cost was lower because several disposable devices
were used. Hospital stay was short at 2 days, and recovery time was short.
Complications included seroma 9 (0.4%), dysphagia 2%, bloating 10%, need for medication
<20%. Two procedures had to be redone because of reherniation. One major
complication occurred in a diabetic patient who experienced an intraabdominal
abscess, which was managed successfully.
Conclusion:
Minilaparotomy is highly effective for GERD treatment, considering that laparoscopic-ARS
has declined up to 30% in the USA and the field for endoluminal treatment is limited.
Minilaparotomy is becoming safe, durable, and a practical alternative to
laparoscopy and requires only a small incision.
9101 General Surgery
Laparoscopic Subtotal Colectomy for Multiple
Colon Polyposes
Giancarlo Basili, MD, Luca
Lorenzetti, MD, Graziano Biondi, MD, Orlando Goletti, MD
Pontedera Hospital
Introduction: Laparoscopic subtotal colectomy is probably one of the most
difficult and complex procedures in laparoscopic colorectal surgery. The
potential benefit of minimally invasive surgery, such as improved cosmesis,
reduced postoperative pain, shorter length of hospitalization, and faster
return to normal activity, could be overcome by higher complication rates and
longer lengths of surgery.
Methods: We report the case of a
55-year-old man who underwent laparoscopic subtotal colectomy for multiple
colon polyposes. A preoperative colonoscopy highlights the presence of multiple
colon polyps, with evidence of moderate to severe dysplasia.
Results: The most difficult and also
time-consuming part of the procedure is the mobilization of the transverse
colon and division of the middle colic vessels. Each branch is treated with
care, and proximal control of vessels is maintained at all times. Because this
area may be difficult to expose, a fundamental understanding of the vessels
encountered here is extremely important. The vascular pedicle should be
confirmed before division as the superior mesenteric artery and vein lie deep
to the dissection line and the pancreas is fully exposed as dissection
progresses.
Conclusions: The laparoscopic
approach to subtotal colectomy is especially attractive as there are a variety
of benign indications for this procedure and a previously necessary long
midline incision for surgery is avoided and replaced by a short McBurney
incision with all the favorable postoperative effects of minimally invasive
surgery. Although technically demanding and requiring significant expertise,
laparoscopic subtotal colectomy may be performed in select individuals.
9102 Gynecology
Transvaginal Application of a Laparoscopic Bipolar Cutting Forceps to Assist
Vaginal Hysterectomy in Extremely Obese Endometrial Cancer Patients
James Fanning, DO, Rod Hojat, MD, Jil Johnson, DO, Bradford
Fenton, MD, PhD
Summa Health System, Northeastern Ohio
Universities College of Medicine
Introduction: The purpose of this
report is to evaluate our experience with transvaginal application of a
laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely
obese women with endometrial cancer in whom obesity precluded LAVH/BSO and
lymphadenectomy and vaginal obesity limited visualization and exposure.
Materials and Methods: We performed
a retrospective review and identified 6 consecutive cases. No cases were
excluded. A laparoscopic 33-cm Plasma Kinetic (PK) cutting forceps with a 5-mm
diameter was applied transvaginally to coagulate and cut the uterosacral and
cardinal ligaments, uterine vasculature, and ovarian ligaments. The uterus was
delivered vaginally. Staging lymphadenectomy was not performed.
Results: Median patient age was 51
years, median weight was 405lb, and median BMI was 66kg/m2. Five of
6 cases were successfully performed vaginally (83%). Median operative time was
1 hour and 10 minutes, median blood loss was 500cc, and pain was only
discomforting. All patients were discharged the day after surgery. No
complications occurred. At median follow-up of 1 year, all patients were alive
with no evidence of disease.
Conclusion: It is our opinion that
the transvaginal application of a laparoscopic bipolar cutting forceps can
successfully assist vaginal hysterectomy in extremely obese endometrial cancer
patients who cannot tolerate LAVH/BSO and lymphadenectomy and vaginal obesity
limits visualization and exposure.
9103 Gynecology
Laparoscopic
Cytoreduction for Primary Advanced Ovarian Cancer
James Fanning, DO, Rod Hojat, MD, Jil Johnson, DO, Bradford
Fenton, MD, PhD
Summa Health System, Northeastern Ohio
Universities College of Medicine
Introduction: We evaluated the
feasibility of laparoscopic cytoreduction for primary advanced ovarian cancer.
Methods: All patients with presumed
stage 3/4 primary ovarian cancers underwent attempted laparoscopic
cytoreduction. All patients had CT evidence of omental metastasis and ascites.
A 5-port (5-mm) transperitoneal approach was used. A bilateral
salpingo-oophorectomy, supracervical hysterectomy, and omentectomy were
performed with the Plasma Kinetic (PK) cutting forceps. A laparoscopic 5-mm
Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal
peritoneum, intestinal mesentery, and diaphragm.
Results: Nine of 11cases (82%) were
successfully debulked laparoscopically without conversion to laparotomy. Median
operative time was 2.5 hours, and median blood loss was 275cc. All tumors were
debulked to less than 2cm, and 45% of patients had no residual disease. Stages
were as follows: 1-3B, 7-3C, and 1-4. Median postoperative length of stay was
one day. Median VAS pain score was 4 (discomforting). Two of 11 patients (18%)
had postoperative complications.
Conclusion: We present the original
series of laparoscopic cytoreduction for primary advanced ovarian cancer.
Laparoscopic cytoreduction was successful and resulted in minimum morbidity.
Because of our small sample size, additional studies are needed.
9104
Urology
Trans-Ileal-Conduit-Resection (TICR) of a Recurrent Urothelial Carcinoma in the
Ileal Conduit
Dong Soo Park, MD, PhD, Woong
Ki Jang, MD, Jong Jin Oh, MD, Sang Hyun Jee, MD
Bundang CHA
Hospital, Pochon CHA University, Sung Nam, South Korea
Introduction
and Objective: Management of
recurrent urothelial carcinoma at the uretero-ileal anastomotic site is
challenging. We present our experience with endoscopic surgical treatment of a
delicate tumor.
Methods:
A 59-year-old male was diagnosed
with invasive bladder cancer, and he had undergone a radical cystectomy with
ileal conduit urinary diversion 8 years earlier. He presented with intermittent
right flank pain and gross hematuria for 6 months. The contrast enhanced
computed tomography of the abdomen and pelvis demonstrated the presence of
hydronephrosis and a large enhancing mass in the ileal conduit. Flexible
cystoscopy confirmed a tumor in the ileal conduit arising presumably from the
right uretero-ileal junction. After formation of a right percutaneous
nephrostomy, complete trans-ileal-conduit-resection (TICR) of the tumor using
the usual resectoscopic instrument was done. Pathology of the tumor showed
high-grade urothelial cancer extending to the small bowel smooth muscle tissue.
During follow-up, right hydronephrosis redeveloped. Repeat TICR was performed.
Results:
Pinpoint right-side uretero-ileal
junction was found with difficulty. After resection around the right-side
ureteral orifice, a ureteral stent was indwelled retrogradely. The resected
tissues were cancer free on pathologic examination.
Conclusions:
Recurrence of the urothelial cancer
in the ileal conduit is extremely rare. Recurrent urothelial cancer at the
uretero-ileal junction can be controlled with TICR, avoiding complicated
surgery.
9105 General Surgery
Outcomes of Minimally Invasive Myotomy for the Treatment of Achalasia in the
Elderly
Randall O. Craft, MD, Colleen Flahive, Mark C. Mason, MD, Marianne Merritt,
RNFA, Kristi L. Harold, MD
Mayo Clinic Arizona
Objective: The goal of our study was to review our experience with
minimally invasive myotomy (MIM) in patients aged 65 and older.
Methods: We reviewed 52 patients (22
males and 30 females) 65 years or older (mean age 73.6; range, 65 to 89)
diagnosed with achalasia who underwent MIM at our institution over a 9-year
period. Prior therapies were evaluated (pneumatic dilations, Botox injection,
prior myotomy), as well as clinical outcomes. Both nonsurgical and surgical
postoperative interventions (redo myotomy, esophagectomy, Botox injections)
were also analyzed.
Results: Of the 52 patients, 29
(56%) had had prior endoscopic therapy. Twenty-two (76%) received pneumatic
dilation, 20 (69%) received Botox, and 2 (7%) had prior myotomy. Range of ASA
classification was 2 to 4. Mean duration of symptoms was 10.9 years
(range, 0.5 to 50). No perioperative mortalities occurred; mean hospital stay
was 3 days. Forty-eight patients (92.3%) had a fundoplication: 13 (27%) Dor and
35 (73%) Toupet. Three patients (5.8%) had complications. Two had pleural
effusions. One had a hole in the gastric mucosa, which was repaired
intraoperatively. Eleven patients (21%) had additional therapy postoperatively;
10 (91%) had additional pneumatic dilations, and 7 (64%) received additional
Botox injections. One (1.9%) patient had further surgical intervention,
receiving an esophagectomy. Of the 42 patients who had notes detailing their
follow-up, all claimed overall symptom improvement.
Conclusion: Age does not appear to
adversely affect outcomes of laparoscopic Heller myotomy.
9106
General Surgery
Prophylaxis of Recurrent Pancreatitis: Mini-Invasive Approach
Vincenzo Neri, Prof Dr Med
University of Foggia, Italy
Aim: Acute biliary pancreatitis (ABP) is caused by the alteration of
papillary patency. The normal transpapillar flux and the cleaning of the common
biliary duct (CBD) may prevent potentially avoidable recurrent pancreatitis.
Patients and Methods: From September
1997 to December 2008, we treated 224 cases of ABP (34 severe, 190
mild/moderate): 162 (72.4%) with the first attack, 62 (27.6%) with recurrent
ABP (second or further attack). The patients with recurrent pancreatitis had
not undergone, in the previous hospital stay elsewhere, the evaluation and, if
necessary, the treatment of the papillary obstacle and/or CBD stones, sludge,
etc. In our hospital, all patients had undergone complete treatment of ABP,
which included clinical intensive therapy, instrumental control of the
papillary patency, then ERCP/ES(180% to 80%) within 72 hours from the onset in
all SAP, in mild/moderate cases with signs of papillary lithiasic obstacle
(US/MRCP confirmation), in all recurrent pancreatitis, and
videolaparocholecystectomy.
Results: In the follow-up of
recurrent pancreatitis, we have controlled, clinical, and instrumental data,
after 90 days and 180 days in 35 patients (56%, 27 lost): 21 SAP, 14
mild/moderate. Further recurrence occurred in only 1 patient (2.8%); in the
other controls recurrence of ABP was not reported; laboratory (amylases,
cholestasis) and instrumental tests (abdominal US) have been normal.
Conclusions: Recurrent ABP has
occurred in patients discharged from the hospital without additional treatment,
by a persistent papillary obstacle (small stones, sludge, cholesterol crystals,
etc.). Therefore, we confirm the therapeutic validity of the instrumental
control (US/MRCP) and the possible treatment of the papillary or biliary
lithiasic obstacle for the prevention of recurrent ABP.
9107 General Surgery
Core Appendectomy: A New
Technique for Delayed Appendicitis
Jayarama K. Shenoy, MD, MBBS,
MS
Kasturba Medical College, Karnataka, India
Background: Acute
appendicitis is primarily an inflammation starting in the lymphoid tissue
in the submucosa of the appendix. It spreads to involve muscle and serosal
layers later in the course of development. Delayed appendicitis is treated with
the Ochsner Sherren regimen, because appendectomy has a high-risk of bowel
injury and fistulation. Surgery is performed only to drain the abscess and
peritonitis and later for a definitive second surgery.
Methods: Thirty
patients with acute appendicitis presenting after 3 to 4 days of medical
treatment with formation of phlegmon underwent operative removal of the core of
the appendix comprising mucosa and submucosa, leaving the outer shell of the
musculo-serous layer adherent to the colonic wall (24 by open and 6 by laparoscopic
technique). This is contrary to the conventional approach of the Ochsner
Sherren regime. The base of the appendix is divided as the first step followed
by dissection to create a plane between the submucosa and outer muscular layer
through the divided end of the appendix. The core of the appendix is
pulled out of the distal shell of the muscular layer and adherent serosa.
Results: The operative complications
included minor ooze from inflamed tissue (3 cases of open and one
laparoscopic), accidental division of the friable appendix requiring
getting the tip of the appendix in 2 open cases. All patients recovered without
postoperative complications.
Conclusion: Core appendectomy provides a safe surgical
technique, open or laparoscopic, for delayed acute appendicitis with mass
formation. It avoids the need for a second elective surgery.
9108 Urology
Robotic Pyeloplasty with Pyelolithotomy
Mark T. Edney, MD, Thomas M. DeMarco, MD
Peninsula Regional Medical Center, Salisbury, Maryland
Background: The use of robotics in urology has increased
significantly in the past 5 years. Robotic-assisted laparoscopic pyeloplasty is
an established urological application. We report a robotic dismembered
pyeloplasty with concomitant pyelolithotomy.
Case Report: A
39-year-old man presented with intermittent left flank pain. Intravenous
pyelogram revealed 3 stones in the left renal pelvis and evidence of
ureteropelvic junction obstruction. Retrograde ureteropyelogram confirmed the
obstructing lesion.
The Da Vinci S surgical system was used with a 3-arm technique.
The ureteropelvic junction and renal pelvis were isolated. After dividing the
ureter at the ureteropelvic junction, the pyelotomy was extended cephalad. The
first stone was immediately visible and extracted with the curved bipolar
forceps. Next, the bedside assistant advanced a flexible
cystoscope through a 12-mm port into the renal pelvis. Normal saline was
used for irrigation and a suction cannula was positioned inferior to the renal
pelvis. The remaining 2 stone were captured during pyeloscopy and extracted
using a nitinol zero tip basket. Each stone, once removed from the pelvis, was
secured with a grasper and removed through the 12-mm port. After stone removal,
the anastomosis was performed.
Conclusion:
Renal stones can occur as a result of urinary stasis from ureteropelvic
junction obstruction. We present a report of the successful repair of
ureteropelvic junction obstruction with concomitant pyelolithotomy using the
DaVinci S system.
9109 Gynecology
Treatment of Severe Hemorrhage Using Hydrothermal Endometrial Ablation
Herbert A. Goldfarb, MD
New York Downtown Hospital, New
York, New York
Introduction: Of the 600 000 hysterectomies performed each year,
over 150 000 are in patients with severe uterine bleeding as a significant
diagnosis. Many patients have bleeding to the point of severe anemia and often
require transfusion to accomplish the end point of hysterectomy. Many of these
hysterectomies as well as unnecessary transfusions can be avoided. In the
majority of cases involving severe uterine hemorrhage, we have found large
submucosal and intrauterine fibroids. Medical therapy has frequently
failed to control hemorrhage. This case report will describe a group of 6
patients treated from 2003 thru 2005 who have undergone hydrothermal
endometrial ablation to control severe persistent uterine hemorrhage. We
describe a technique for treating persistent uterine hemorrhage unresponsive to
medical therapy.
Methods: Six patients from the Department of Gynecology at an academically
affiliated general hospital underwent hydrothermal endometrial ablation after
failed medical therapy for unremitting uterine bleeding.
Results: All procedures were successful.
Conclusion: Hydrothermal endometrial ablation is effective in controlling
severe uterine bleeding in patients with large intrauterine fibroids.
9110 General Surgery
Trends and
Correlations of MORBID Scores for Adjustable Gastric Band: Weight Loss,
Resolution of Comorbid Diseases, and Quality of Life
Brad E. Snyder, MD, Todd Wilson,
MD, Ben Leong, MD, Connie Klein, NPC, Erik B. Wilson, MD
The University of Texas Health
Sciences Center at Houston, Texas
Background: To determine a patient’s success after
weight loss surgery, we must measure outcomes. The Measured Outcome Results of
Bariatric Interval Data (MORBID) score is a sum of measured quality of
life, excessive weight loss, and resolution of comorbid conditions scores used
to define outcome.
Methods: A prospective cohort
of 305 consecutive postoperative gastric banding patients was collected, and
MORBID scores were calculated. Each component of the MORBID score was divided
into quartiles. ANOVA between age, BMI, YOS, EW, %EWL, ethnicity, and other
MORBID groups were performed. Sex was analyzed with the Student t test, and trends over time were
analyzed with a correlation matrix.
Results: The average MORBID score
was 5.5±1.7. No differences were found between men and women. Quality of life
decreased over time (r=-0.73) and with weight loss (r=-0.82) after surgery.
Weight loss and comorbid scores increased over time (r=0.90 and 0.92,
respectfully), and the resolution of comorbid conditions was related to weight
loss (r=0.77). Quality of life and excessive weight loss synergistically
increased the total score (r=0.91).
Conclusion: Quality of life
decreases over time after adjustable gastric banding despite significant weight
loss and resolution of comorbid conditions. The overall outcome was a “very
good” one, but this is because of excellent weight loss scores. There are
significant psychological components of gastric banding that must be fully
addressed by weight loss programs to improve the quality of life of patients
because weight loss and resolution of comorbid conditions are not enough to
improve their overall health.
9111 Urology
Safety and Perioperative Outcomes During the Learning Curve of Robotic-Assisted
Laparoscopic Prostatectomy (RALP): A Multi-institutional Study of
Fellowship Trained (FEL) Robotic Surgeons Versus Experienced Open Radical
Prostatectomy (RRP) Surgeons Incorporating RALP
Timothy J. LeRoy, David D. Thiel, David A. Duchene, Todd C.
Igel, Michael J. Wehle, Manilo Goetzl, J. Brantley Thrasher
Mayo Clinic Florida, Jacksonville Florida
University of Kansas Medical Center, Kansas City, Kansas
Background: No
consensus exists on the number of cases and/or training required for
credentialing for robotic-assisted
laparoscopic prostatectomy (RALP). We elected to compare the safety and
perioperative outcomes of fellowship trained (FEL) versus experienced open
radical prostatectomy (RRP) surgeons incorporating RALP into their practice.
Methods: Prospective data were compiled on the initial 30
cases each of 2 FEL robotic surgeons directly following fellowship completion.
This was compared with the first 30 RALPs of 3 experienced RRP surgeons who had
incorporated RALP into their practice. The second 30 cases of the RRP group
were also compared with the first 30 of the FEL group to document improvement
with experience (Study N=240).
Results: Open
conversion (0% vs 3%), prolonged catheterization (over 14 days) (5% vs 20%),
and reoperation (0% vs 8%) were more common in the RRP group than in the FEL
group. The FEL group had a lower margin positive rate (15% vs 34%) compared
with the RRP group, but this improved to 19% in the second 30 cases for the RRP
group (P=0.009). Early PSA recurrence was higher in the RRP group compared with
the FEL group (11% vs 2%), but this dropped to 4% in the second 30 cases for
the RRP group.
Conclusion: Experienced
RRP surgeons can safely incorporate RALP into their practice without an
increased number of hospital days compared with FEL. Open conversion, prolonged
catheterization, and reoperation are more likely initially with RRP surgeons in
their first 30 cases. Margin positivity and PSA recurrence rates are higher
with RRP surgeons initially but approach those of FEL surgeons after 30 cases.
9112 General Surgery
Impact of the Robot in Vascular Surgery
Petr Štádler, MD, PhD
Na
Homolce Hospital, Prague, Czech Republic
Objective: The safety, benefits, and usefulness of laparoscopic surgery
have been demonstrated. The robot represents the next step in using the
minimally invasive technique in surgery. We describe our clinical experience
with robot-assisted aortoiliac reconstruction for occlusive disease, aneurysm,
and 2 hybrid procedures performed using the da Vinci system.
Methods: Between November
2005 and December 2008, we performed 130 robot-assisted laparoscopic aortoiliac
procedures. We prospectively evaluated 116 patients for occlusive disease, 10
patients for abdominal aortic aneurysm, 2 for a common iliac artery aneurysm,
and 2 for hybrid procedures. Dissection of the aorta and the iliac arteries was
performed laparoscopically, and the robotic system was used to construct the
vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac
reconstruction with the patch closure and for the posterior peritoneal suture.
Results: We successfully completed
126 cases (97%) robotically, in 1 patient laparoscopy was stopped because of
heavy aortic calcification, and in 3 (2.3%) patients conversion was necessary.
Thirty-day survival was 100%, and nonlethal postoperative complications were
observed in 3 patients (2.3%).
Conclusion: Our clinical experience with robot-assisted laparoscopic
surgery shows that it is a feasible technique for aortoiliac vascular and
hybrid procedures. The da Vinci robotic system facilitated the creation of the
aortic anastomosis and shortened aortic clamping time compared with purely
laparoscopic techniques. Robotic
surgery can help us in the future in hybrid procedures.
9113
Urology
Posterior Rhabdosphincter Reconstruction May Delay Time to Continence Recovery
Following Robot-Assisted Radical Prostatectomy
Joshua T. Stern, MD, R. Caleb Kovell, Mary Nguyen, RN, BSN, Meredith
Bergey, Ph.D., David I. Lee, MD,
University of Pennsylvania
Introduction: Posterior
rhabdosphincter reconstruction (PRR) as a technical modification to radical
prostatectomy has been suggested to improve rate of return to continence. We
examined continence outcomes for patients undergoing PRR during robot-assisted
radical prostatectomy (RARP).
Methods: Continence
outcomes were compared for 265 consecutive patients who underwent RARP with PRR
to a historical control of 130 RARP patients. PRR involved a running stitch
taken to approximate Denonvillier’s fascia to the posterior rhabdosphincter.
Continence was defined as use of 0 pads. Per day (PPD). We also examined
outcomes for reaching social continence 1PPD. Nerve sparing, prostate size, and
extracapsular invasion were other variables analyzed.
Results: Average age
was 59.7 and BMI 28.0. On multivariate analysis, age, prostate volume, and PRR
were significant variables. Patients undergoing PRR were less likely to achieve
continence (HR = 0.65 [0.47, 0.91], p = 0.01) such that median time to
continence was 36 weeks for the PRR group and 13 weeks for the control (p =
0.007). PRR diminished continence at 4 weeks by 45% (13% v. 24%) and at 13
weeks by 24% (39% v. 51%). PRR only modestly affected median time to 1
ppd (4 v. 7 weeks, p = 0.053). Patient age (HR = 0.98 [0.97, 1.00], p =
0.02) and prostate volume (HR = 0.99 [0.98, 1.00], p = 0.053) modestly delayed
return to continence.
Conclusions:
In our series, our method of PRR during RARP
significantly diminished early continence rates. Prospective, randomized trials
are necessary to validate this data.
9114 Urology
Laparoscopic Donor Nephrectomy: Caution in the Use of Kidneys With Multiple
Arteries
Anil S.
Paramesh, MD, Rubin Zhang, MD, Sander S. Florman, MD, Haythem Al-Abbas, MD,
Lillan C. Yau, PhD, Mary T. Killackey, MD, Brent Alper, MD, Douglas Slakey,
MD,MPH
Tulane Abdominal Transplant Institute, Tulane University School of Medicine,
New Orleans, LA
Background: Multiple arteries during
a laparoscopic donor nephrectomy may lend to longer operative times and increased
risk of donor/recipient complications with consequent decreased graft function
and survival. This study examines our experience with single vs. multiple
artery kidneys procured laparoscopically over an 11-year period.
Methods: We identified all donor/recipient
pairs who underwent living donor kidney transplants from 8/98 through
8/2008. Single (SA) vs. multiple artery (MA) groups were compared with
respect to donor and recipient demographics, operative variables, postoperative
complications, graft function, and survival for up to 5 years
posttransplant.
Results: During this time period,
278 donor/recipient pairs (218 SA & 60 MA) underwent surgery. Mean
follow-up was 3.77 years. All donors underwent a hand-assisted laparoscopic
nephrectomy. The operative time (P=0.03) and rejection rates (P=0.006) were
significantly higher in the MA group. No significant difference existed in
donor complications. There was a trend towards more ureteral complications
among the MA recipients (P=0.06). SA kidneys had a significantly better GFR
than the MA kidneys did up to 3-years posttransplant. Graft survival rates at
1, 3, and 5 years were 94.4%, 90.6%, and 86% for the SA group vs. 89.6%, 83.2%,
and 71.8% for the MA group (P=0.05).
Conclusion: Caution must be advised
in the laparoscopic procurement of kidneys with multiple arteries. These
kidneys may have a higher risk of rejection, worse graft function and survival
compared with single artery kidneys.
9115 General Surgery
Cerebral Gas Embolism Due to Upper Gastrointestinal Endoscopy
R. den Boer, MD, E. Totte, MD, R. A. van Hulst, MD, PhD, K. van
der Linde, MD, PhD, W. van der Kamp, MD, PhD, J. P. E. N. Pierie, MD, PhD
Introduction: Cerebral gas embolism as a result of upper gastrointestinal
endoscopy is a rare complication and bares a high morbidity.
Case Report: A patient is presented
who underwent an upper endoscopy for evaluation of a gastric-mediastinal
fistula after subtotal esophagectomy and gastric tube reconstruction because of
esophageal cancer. During the procedure, cerebral gas emboli developed
resulting in an acute left-sided hemiparesis. After hyperbaric oxygen therapy,
the patient recovered almost completely.
Discussion: The literature
concerning cerebral gas embolism associated with upper endoscopy is reviewed.
Conclusion: Once cerebral gas emboli
are recognized, patient outcome can be improved by hyperbaric oxygen therapy.
9116 Gynecology
Adhesion Prevention with a Resorbable Hydrogel Following Myomectomy
L. Mettler, MD, PhD
University Clinics of
Schleswig-Holstein/ Campus Kiel, Germany
Background: This multicenter,
randomized, single-blind study assessed the safety
and efficacy of a resorbable hydrogel (‘Hydrogel’) for
the reduction of postoperative adhesion formation following myomectomy.
Methods: Women (n=71) who were undergoing
laparoscopic (67.6%) or laparotomic myomectomy
were randomized (2:1) to Hydrogel (sprayed over surgically treated
areas prior to wound closure, n=48)
or to control (standard care, n=23). Patients (38 Hydrogel, 20
control) returned 8 weeks to 10
weeks later for a second look. Adhesions were
graded using a modified American Fertility Society (mAFS) scoring
method. The primary efficacy measure was the posterior uterus
mAFS score.
Results: For Hydrogel and control
patients, respectively, mean±SD mAFS scores were 0.5±1.4 and 0.0±0.0 at baseline,
and 1.1±1.9 and 2.6±2.2 at the second look.
Similarly, mean changes from baseline were 0.8±2.0 and 2.6±2.2 (P=0.01); 95% confidence intervals for
these mean changes were 0.16 to 1.44 and 1.64 to 3.56. Adverse
events were reported by 9.6% and 17.4% of Hydrogel and control
patients, respectively. No intraabdominal infections or
postoperative site infections were reported.
Conclusion: This 71-patient study
provides the first clinical evidence of the
safety and efficacy of Hydrogel for the reduction of adhesions following
myomectomy.
9117 Gynecology
Six Cases: Reports of Ileum Colpopoiesis
by Laparoscopy
Xiaoyan Ying, MD
The second affiliated
Hospital of Nanjing Medical University, Nanjing, China
Objective: To study the
feasibility and clinical outcome of laparoscopic vaginoplasty using
transforming lineal segments with blood vessels.
Methods: Six cases
of congenital absence of the vagina were assigned to total laparoscopic (2
cases) and laparoscopically assisted ileum colpopoiesis (4 cases) from April
2006 to July 2008.
Results: We have successfully completed the operations for 6 patients and
made 3 months to 24
months of follow-up. All the artificial vaginas were well done, and their
features and physical functions were close to the natural female vagina.
Patients wore a vaginal mould for at least 6 months to 8 months, and their
intercourses were satisfactory. No complications after the surgery have been
reported.
Conclusion: The procedures of total laparoscopic and laparoscopically
assisted ileal segment transplantation for vaginal construction are ideal to
this day.
9118
General Surgery
Laparoscopic Colectomy: Does the
Learning Curve Extend Beyond Colorectal Surgery Fellowship?
Joshua A. Waters, MD, Ray Chihara,
MD, Jose Moreno, MD, Bruce Robb, MD, Virgilio George, MD
Indiana University School of
Medicine
Background: As minimally invasive
colon and rectal resection has become increasingly prevalent over the past
decade, the role that fellowship training plays has become an important
question. This analysis examines the learning curve of one fellowship trained
colorectal surgeon in the first 100 cases.
Methods:
This is a prospectively collected
retrospective analysis of the first 100 laparoscopic colon and rectal
resections performed between July 2007 and July 2008 by a CRS fellowship
trained surgeon at a VA and county hospital. Included were all
nonemergent laparoscopic cases.
Results: Mean age was 63 years
(range, 36 to 91). These 100 resections included 42 right, 6 left, 32 sigmoid,
13 rectal, and 7 total colectomies. Indications were 55% cancer, 19% unresectable
polyp, 18% diverticular disease, 4% inflammatory, and 4% other. Overall
mortality was 3%. Morbidity including wound infection was 28%. Early and late
groups showed no difference in age, ASA, or indication. Overall conversion rate
was 4%. No statistical difference was seen in mortality, morbidity, EBL, LOS,
margin, lymph nodes, or conversions between the first and second 50 cases
(P<0.05). Right and sigmoid colectomy operative time decreased by 35% and
19%, respectively.
Conclusions:
Prior investigators have
demonstrated a significant learning curve in laparoscopic colorectal surgery.
In the first 100 cases, no difference in mortality or morbidity occurred
between early and late cases. Alternatively, operative times decreased over the
first 100 cases. Laparoscopic experience during CRS fellowship surpasses the
learning curve in regard to safety and outcome, whereas operative efficiency
increases over the first year of practice.
9120 Urology
Urethral Length on MRI Is Predictive of Early Return to Continence After
Robotic-Assisted Radical Prostatectomy
Joshua M. Stern, Robert Kovell, Mary
Nguyen, Rachel Natale, Kelly Monahan, David I. Lee, William Jaffe
University of Pennsylvania
Introduction: Postoperative
incontinence is multifactorial after radical prostatectomy. Using endorectal
coil MRI, we examined features of the male urethra and its accompanying
muscular sphincter to predict postoperative continence after robotic
prostatectomy.
Methods:
Eighty patients underwent preoperative
1.5 Tesla endorectal MRI. Urethral length was measured in the coronal plane.
All patients underwent robotic prostatectomy. Patients completed questionnaires
at monthly intervals. The primary end point was time to achieving continence
requiring 0 to 1 pad per day (PPD). Statistical analysis was performed using
Cox regression models to create both univariate and multivariate survival
models.
Results:
Mean age was 59.7 (SD, 7.1).
Bilateral nerve sparing was present in 98%. Mean urethral length was 17.1mm
(SD, 4.5mm). Mean sphincter thickness was 8mm (SD, 2.1). Mean prostate size was
34.7cc (SD, 17.8). Sixty patients achieved 1 PPD (mean, 8.1 weeks; SD, 9.4) and
34 patients achieved 0 PPD (mean, 10.5 weeks; SD, 8.0). On multivariate
analysis, larger prostate size (HR, 0.97; P<0.04) and older age (0.96,
P<0.07) were associated with a longer time to achieve 0 PPD. Urethral
length, as a continuous variable was associated with an increase in the
likelihood of achieving 0 PPD postoperatively (HR, 1.10; P<0.02). When
controlling for age and MRI urethral length, patients with a prostate size ≥50
grams had a 76% lower likelihood of achieving 0 PPD at any point in time than
did patients with <50 gram prostate (HR, 0.24; P<0.05).
Conclusion:
Longer urethral length increased the
likelihood of achieving continence at any time point. Increasing age and larger
prostate size were negatively associated with achieving continence.
9121 General Surgery
Chronic Calculous Cholecystitis in Chilaiditi’s Syndrome
José M. M. Ferreira-Coelho, MD, PhD
Background: The epidemiology, etiology, clinical features, differential
diagnosis, and treatment of Chilaiditi’s syndrome were analyzed.
Methods: The patient was a
69-year-old man with chronic calculous cholecystitis, with acute periods,
associated with vomiting, irregular bowel habits, and pseudo-obstruction. The
clinical situation was complex and special tests, such as chest X-ray,
abdominal plain X-ray, ultrasonography of the abdomen, and endoscopy (total
colonoscopy) did not help identify the cause of the patient’s symptoms. The
diagnosis could only be made by CT.
Results: Surgical treatment by
“minimally invasive surgery” was chosen. The hepatic flexure and transverse
colon were established by retraction and the division of the hepatocolic
ligament to make a correct cholecystectomy possible. To avoid any iatrogenic
lesion in a highly vulnerable colon, we established pneumoperitoneum and set
the first trocar, the 12-mm camera trocar, a small 2-cm laparotomy umbilically
as the main step.
Conclusion: Very good surgical
results were achieved, and the patient was discharged 24 hours after surgery.
At 5-year follow-up, the patient remains in good condition.
9122 General Surgery
A Novel Approach to Gastric Wedge Resection Using Single Incision Laparoscopic
Surgery (SILS)
Ricardo M. Mendoza, MD, Curtis E. Bower, MD, Walter E. Pofahl,
MD
Brody School of Medicine, Greenville, NC
Introduction: Single incision laparoscopic surgery (SILS) is an advanced
laparoscopic approach, offering potential benefits of improved cosmesis,
decreased pain, shorter hospitalization, and quicker return to work. We
describe a SILS approach to perform a laparoscopic gastric wedge resection.
Case Report: A 69-year-old male with vitamin B12 deficiency and a
gastric carcinoid was offered a SILS approach for resection. Two 5-mm ports
were placed through a 1-inch umbilical incision. Concurrent upper endoscopy was
performed, and the mass identified. A 2-0 nylon on a Keith needle was passed
percutaneously through the stomach wall at the site of the mass and used as a
retraction stitch. One 5-mm port was exchanged for a 12-mm port, and a stapled
wedge resection was performed. Upper endoscopy and specimen examination
confirmed removal of the mass. On POD 1, the patient was advanced to a regular
diet and discharged home on POD 2. Final pathology revealed a type I, 0.9-cm
carcinoid with clear margins. Chronic atrophic gastritis was also noted.
Discussion: SILS is more cosmetic and potentially offers decreased pain
and quicker recovery. However, this technique is technically more challenging
due to instrument conflict and restricted movement compared with traditional
multiport laparoscopy. The availability of flexible laparoscopes and roticulating
instruments has assisted in overcoming these difficulties.
Conclusion: SILS is an advanced laparoscopic approach and can be safely
applied to small gastric mass wedge resection. The clear benefit to this
approach is cosmetic, and clearly more research and development need to be
performed to further delineate advantages and disadvantages to this approach.
9123 Gynecology
Laparoscopic Replacement of Inguinal Ovaries in Mayer-Rokitansky-Kuster-Hauser
Müllerian Agenesis Syndrome.
Muhieddine Seoud, MD, Fayek
Jamali, MD
American University of
Beirut Medical Center, Beirut
Lebanon.
A 12-year-old girl presented with cyclic, monthly, alternating inguinal pain.
She had 2 previous bilateral inguinal explorations performed in another country
for possible herniorrhaphy. Review of histology slides of biopsies taken during
the second surgery revealed normal ovarian tissue. Examination revealed a
normal-looking girl for her age (breasts and pubic hair: Tanner II-IV). She had
normal external genitalia. There were bilateral scars in the groin areas where
no masses could be palpated. An ultrasound revealed inguinal structures having
the appearance of normal ovaries. The uterus, cervix, and upper vagina could
not be visualized. Magnetic resonance imaging confirmed these findings and
showed, in addition, the right kidney to be in its normal position and the left
kidney to be at the level of the right iliac fossa (cross ectopia). No
vertebral abnormality was found. Laboratory workup revealed the following: FSH
and LH, 2.72 and 1.33 mIU/mL, respectively; E2, 72 pg/mL; and T, 0.08 nmol/mL.
The karyotype (blood, R banding) was 46,XX. The diagnosis was
Mayer-Rokitansky-Kuster-Hauser müllerian agenesis syndrome (congenital absence
of the uterus and vagina) with bilateral inguinal ovaries (only 7 such cases
have been reported).
During laparoscopy, the infundilo-pelvic ligaments were both identified and
adhesions around them released. They were both followed through the inguinal
rings leading to both ovaries. These were adherent to surrounding tissues.
After lysis of the adhesions, both ovaries were replaced into the pelvis and
fixed to prevent future torsion.
Three years later, the patient is pain free with minimal cyclic pelvic
ovulation pains.
9124 Multispecialty
Transvaginal Cholecystectomies: From Hybrids to Pure
Daniel Tsin, MD1, Nestor Gomez, MD2, Guillermo Dominguez3, Fausto
Davila4
1The Mount Sinai Hospital of Queens, Long Island City, New York, USA
2Universidad de Guayaquil School of Medicine, Guayaquil, Ecuador
3Sanatorio Mitre Buenos Aires, CF, Argentina
4Universidad Nacional Autonoma de Mexico, Poza Rica, Veracruz, Mexico
Objective: To present our evolution in transvaginal cholecystectomies
since 1999.
Methods and Procedures: Transvaginal cholecystectomies were done
with rigid instruments via a circular colpotomy during vaginal hysterectomies
at The Mount Sinai Hospital of Queens in 1999. We began the use of the
transvaginal gastroscope via posterior minilaparoscopic culdotomy at the
Universidad de Guayaquil, Ecuador in 2007. In 2008, we introduced the use of a
magnetic grasper to aid in this surgery, and a pure transvaginal
cholecystectomy was performed with an operative laparoscope via a posterior
colpotomy using a vaginal port without a Veress needle or any other type of
abdominal port at the Universidad Nacional Autonoma de Mexico, Poza Rica,
Veracruz.
Results: All patients were ambulatory a few hours after surgery and
were discharged the next day without complications.
Conclusions: The experience included the hybrid technique of
culdolaparoscopy, a minilaparoscopy assisted natural orifice surgery (MANOS),
as a prelude to a pure transvaginal approach. In our opinion, an expert team
and careful progression are needed in this evolution.
9125 General Surgery
Laparoscopic Right Hemicolectomy, Notes Extraction vs. Counter Incision: A
Prospective Study
Guillermo Portillo MD, Morris E Franklin MD
Texas Endosurgery Institute, San Antonio, Texas, USA
Background: Laparoscopic colectomy
is now accepted for both benign and malignant colon diseases as safe and
effective as the open approach. Based on our experience with laparoscopic
right hemicolectomy with intracorporeal anastomosis, we designed a
nonrandomized prospective study comparing NOTES extraction (transvaginal) vs
counter incision extraction of the specimen.
Methods: From December 2007 to February 2009, all laparoscopic right
hemicolectomies were analyzed. The operative procedures and instrumentation
were standardized for all laparoscopic right hemicolectomies with either NOTES
extraction or counter incision extraction.
Results: Thirty female patients were prospectively followed. Fifty percent
received laparoscopic hemicolectomy with intracorporeal anastomosis and NOTES
extraction (transvaginal) and 15 patients laparoscopic right hemicolectomy with
intracorporeal anastomosis and counter incision extraction (RLQ muscle
splitting). The mean operative time for the NOTES extraction was 159.6±27.1
minutes vs. 133.5±29 minutes for the counter incision, the mean blood loss was
83.3±14.4mL vs. 89.0±5.5mL for the counter incision, the mean hospital stay was
5.5±2.5 days vs. 5.9±2.8 days for the counter incision, the intraoperative and
postoperative morbidity rates were 0% and 0.66%, respectively vs. 0% and 13%
for the counter incision.
Conclusion: Laparoscopic colectomy
with intracorporeal anastomosis is safe and effective for managing a variety of
colonic diseases, including malignant disease. NOTES extraction resulted in
increased operative time but decreased postoperative complications.
9126 General Surgery
Laparoscopic Approach to Colonic Emergencies
Guillermo Portillo, MD, Morris E. Franklin, MD, Sameer Mohiuddin, DO
Texas Endosurgery Institute, San Antonio, Texas
Objective: Many colonic pathologies warrant emergency treatment. However,
little has been published regarding a laparoscopic approach to colonic
emergencies. We have approached almost all colonic emergencies laparoscopically
for the past 17 years with the benefit of making subsequent clinical decisions
based on the findings of laparoscopy.
Methods: From April 1991 to July
2008, 179 patients requiring emergency laparoscopic colon procedures for right
and left colon pathologies as well as rectal emergencies were prospectively
studied at the Texas Endosurgery Institute. Data were gathered into categories
of age, sex, indication of surgery, disease process, operative time, blood loss
during surgery, length of hospitalization, postoperative complications,
conversion rate and long-term results.
Results: The indications for surgery
included acute diverticulitis (Hinchey IIb, III, IV) in 32%, perforation in
27%, obstruction in 22%, ischemic colitis in 9%, volvulus in 4%, fistula in 2%,
intussusception in 1%, and other causes in 3%. The laparoscopic procedures
included lavage and drainage, repair of perforations, segmental colonic
resection, ostomy formation, and adhesion take down. The mean operative time
was 134.3 minutes, and the mean EBL was 149.45mL. The laparoscopic approach was
100% effective in identifying the colonic pathology and was used to effectively
treat 79% of the patients. Thirty-eight patients required conversion to open
procedures (21%),
Conclusion: In experienced hands, a
laparoscopic approach to colonic emergency situations can be effective and safe
with an acceptable conversion rate. A laparoscopic approach seems to be an
effective diagnostic tool for colonic emergencies and can be a guide in
treatment strategies.
9127 General Surgery
Is There Any Value to Totally Intracorporeal Anastomosis in Laparoscopic Colon
Surgery?
Guillermo Portillo, MD, Morris E. Franklin, MD
Texas Endosurgery Institute, San Antonio, Texas
Objective: A laparoscopic approach to colon resection has been quoted as
showing numerous advantages when compared with similar open procedures.
However, controversy exists regarding the value of totally intracorporeal
anastomosis. We present our experience with intracorporeal anastomosis for
right and left colon.
Methods: From April 1991 to July
2007, 1651 patients requiring laparoscopic colon resection for right, rectal,
and left colon were prospectively followed.
Intracorporeal anastomosis (ICA)
was completed with transanal extraction (left colon) or counter incision
extraction (left, right colon). Extracorporeal anastomosis was completed with
counter incision extraction of the specimen.
Results: Of our 1240 laparoscopic
left-colon resections, 769 could be completed with transanal specimen
extraction (62%). The average operating time was 152 minutes for transanal
extraction and 170 minutes for the counterincision group. Average EBL was 94cc
for transanal extraction, but 204cc for the counterincision group.
Of our 411
patients who underwent right colon resections, 288 (65.7%) received ICA, while
the remaining 123 patients (27.4%) had ECA. The mean operative time for ICA was
159.6±27.1 minutes, and mean blood loss was 83.3±14.4mL. For ECA, the mean
operative time was 165.5±29 minutes, and mean blood loss was 135.0±65.5mL.
Conclusion: It is possible that
totally intracorporeal anastomosis may have value and may become the procedure
of choice in the future, potentially with an increased interest in natural
orifice surgery.
9128 Urology
Short-Term Outcomes of GreenLight HPS™ Laser Photoselective Vaporization
Prostatectomy (PVP) for Benign Prostatic Hyperplasia (BPH)
Carson Wong, MD, Kurt Strom, MD,
Massimiliano Spaliviero, MD
University of Oklahoma Health
Sciences Center
Introduction and Objective: GreenLight HPS laser PVP is a treatment option
for lower urinary tract symptoms (LUTS) secondary to BPH. We review our
experience using the GreenLight HPS laser system.
Methods: We prospectively
evaluated our experience with GreenLight HPS laser PVP. All patients who failed
medical therapy/surgery underwent GreenLight HPS laser PVP (CW). All had
American Urological Association Symptom Score (AUASS), Sexual Health Inventory
for Men (SHIM) Score, American Society of Anesthesiologists (ASA) risk score,
serum prostate specific antigen (PSA), maximum flow rate (Qmax) and postvoid
residual (PVR) determinations, and volumetric measurements with transrectal
ultrasonography. Transurethral PVP was performed using the GreenLight HPS side-firing
laser system.
Results: The patient cohort included 140 consecutive
patients with a mean age of 68±9 years. The mean prostate volume was 72±42mL, and
the mean ASA score was 2.3±0.7. Mean laser time, operating time, and energy
usage were 13±11 minutes, 32±24 minutes, and 89±71kJ, respectively. All were
outpatient procedures with 75 (54%) patients catheter-free at discharge.
Fifteen patients required catheter drainage for one week. Eight patients
developed a urinary tract infection. Fourteen patients had persistent hematuria
for >1 week. No urethral strictures or urinary incontinence was noted. Mean
AUASS decreased from 23 to 8, 7, 5, 5, and 4 (P<0.05) at 1, 4, 12, 24, and 52 weeks, respectively. Qmax
values showed statistically significant improvement (P<0.05) during the follow-up period. SHIM score did not
change postoperatively.
Conclusion: Our short-term results suggest GreenLight HPS
laser PVP is safe and effective for the treatment of LUTS secondary to BPH.
9129 Urology
Decreased Efficiency of GreenLight HPS™ Laser Photoselective Vaporization
Prostatectomy (PVP) With Long-Term 5α-Reductase Inhibition Therapy: Is it True?
Carson Wong, MD, Kurt Strom, MD,
Massimiliano Spaliviero, MD
University of Oklahoma Health Sciences Center
Introduction: 5α-reductase inhibitors
(5ARI) have been postulated to affect the efficiency of GreenLight HPS laser
PVP. We evaluated GreenLight HPS laser PVP as treatment for benign prostatic
hyperplasia (BPH) in patients on long-term 5ARI.
Methods: We prospectively
evaluated our GreenLight HPS laser PVP experience in patients with and without
long-term 5α-reductase inhibition.
Results: We identified 140 consecutive patients; 46 were on
finasteride/dutasteride for more than 6 months and 94 were not. Mean prostate
volumes were 71±35mL and 73±45mL (P=0.56), and mean PSA values were
2.1±2.3ng/mL and 2.8±2.7ng/mL (P=0.15), respectively. No significant
differences occurred in the parameters of laser utilization (14±8 and 12±8
minutes, P=0.45) and energy usage (85±54 kJ and 83±56kJ, P=0.97). All were
outpatient procedures with the majority of patients catheter-free at discharge.
All patients were able to discontinue their prostate medications following
surgery. The mean rates of prostate vaporization (3.7±2.2mL/min and
3.0±1.4mL/min, P=0.11; 0.55±0.33mL/kJ and 0.59±0.71mL/kJ, P=0.77) and TRUS
volume decrease 12 weeks postsurgery (54±14% and 51±12%, P=0.32) were similar
between the 2 groups. AUASS, Qmax, and PVR values showed significant
improvement within each group through 1 year (P<0.05), but the degree of
improvement between the 2 groups did not show statistical significance.
Conclusion: Our experience suggests
that 5ARI does not have a detrimental effect on the efficiency and efficacy of
GreenLight HPS laser PVP.
9130 Urology
GreenLight HPS™ Laser Photoselective Vaporization Prostatectomy (PVP) for
Failed Prior Surgical Treatment of Benign Prostatic Hyperplasia (BPH)
Kurt Strom, MD, Massimiliano
Spaliviero, MD, Carson Wong, MD
University of Oklahoma Health
Sciences Center
Introduction: Secondary procedure
rates of surgical therapy for BPH range from 1% to 14%. We evaluated GreenLight
HPS laser PVP as a treatment for symptomatic BPH previously treated with
surgical management.
Methods: We prospectively
evaluated our GreenLight HPS laser PVP experience. Only patients who failed
prior surgical therapy (transurethral prostate resection (TURP), transurethral
microwave therapy (TUMT), holmium laser ablation of prostate (HoLAP) and
potassium-titanyl-phosphate (KTP) laser PVP) for symptomatic BPH were included.
Transurethral PVP was performed using a GreenLight HPS side-firing laser
system.
Results: Thirty of 140 consecutive patients were
identified, having a mean prostate volume of 80±49mL. Prior surgical management
included TURP (14), TUMT (7), KTP laser PVP (5), HoLAP (2), TUMT and TURP (1),
and TUMT and KTP laser PVP (1). Mean laser and operative times and energy usage
were 12±10 minutes, 29±25 minutes, and 76±60kJ, respectively. One patient
developed a urinary tract infection. Two patients had persistent nonsignificant
hematuria for one week. One patient had persistent urinary retention requiring
clean intermittent catheterization. No urethral strictures or urinary
incontinence were noted. All patients were able to discontinue their prostate
medications following surgery. Mean American Urological Association Symptom
Score decreased significantly from 23 to 9, 7, 7, 6, and 5 (P<0.05) at 1, 4, 12, 24 and 52
weeks, respectively. Mean maximum flow rate and postvoid residual measurements
also showed significant improvement (P<0.05).
Conclusions: Our initial results
demonstrate that GreenLight HPS laser PVP is safe and effective for the
treatment of patients with failed prior surgical management of BPH.
9131 Urology
Does Age Affect the Safety and Efficacy of GreenLight HPS™ Laser Photoselective
Vaporization Prostatectomy (PVP)?
Kurt Strom, MD, Massimiliano
Spaliviero, MD, Carson Wong, MD
University of Oklahoma Health
Sciences Center
Introduction: We evaluated the safety
and efficacy of GreenLight HPS laser PVP for the treatment of lower urinary
tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in
patients of varying age groups.
Methods: We prospectively evaluated our initial GreenLight
HPS laser PVP experience. Patients were stratified into 2 groups: age<70
(group I) and age≥70 (group II). Transurethral PVP was performed using a
GreenLight HPS laser system. Voiding trials were performed 2 hours postsurgery.
American Urological Association Symptom Score (AUASS), maximum flow rate
(Qmax), and postvoid residual (PVR) were measured preoperatively and at 1, 4,
12, 24, and 52 weeks postsurgery.
Results: We identified 137 consecutive patients (73 group
I, 64 group II). No significant differences existed in preoperative parameters
[AUASS (I: 23±6, II: 22±6), Qmax (I: 10±4, II: 9±4mL/sec), PVR (I: 59±89,
II: 75±106mL), prostate volume (I: 64±39, II: 83±44mL)]. Additionally, there
were no significant differences in the parameters of laser utilization (I:
13±8, II: 13±8 minutes) and energy usage (I: 83±56, II: 85±55kJ). AUASS and
Qmax values showed significant improvement within each group (P<0.05). There were no significant
differences between the 2 groups. The incidence of adverse events was low and
did not differ between the 2 groups.
Conclusion: Our experience suggests that age has little effect
on the safety and efficacy of GreenLight HPS laser PVP.
9132 Urology
Incidence, Management, and Prevention of Perioperative Adverse Events of
GreenLight HPS™ Laser Photoselective Vaporization Prostatectomy: Experience in
the Initial 70 Patients
Massimiliano Spaliviero, MD, Kurt
Strom, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center
Purpose: We report the incidence, prevention, and
management of perioperative adverse events in patients treated with GreenLight
HPS laser photoselective vaporization prostatectomy (PVP).
Materials and Methods: Transurethral PVP was performed using a
GreenLight HPS side-firing laser system. Patients had American Urological
Association Symptom Score (AUASS), Quality of Life (QoL) score, Sexual Health
Inventory for Men (SHIM) score, serum prostate specific antigen (PSA), maximum
flow rate (Qmax), and postvoid residual (PVR) determinations and volumetric
prostate measurements with transrectal ultrasonography (TRUS). Laser and
operative times and energy usage were recorded. AUASS, QoL, SHIM, Qmax, and PVR
were evaluated 1, 4, 12, 24, and 52 weeks postsurgery. Serum PSA and TRUS were
obtained at 12 weeks, and serum PSA was repeated at 52 weeks. Adverse events were
recorded perioperatively and at each follow-up interval.
Results: Seventy
consecutive patients with median age of 67 years (range, 45 to 87), median
prostate volume of 61.6mL (range, 20.9 to 263.0), and median PSA of 1.4ng/mL
(range, 0.1 to 10.1) underwent GreenLight HPS laser PVP from July 2006 to March
2008. Mean laser and operative times and energy usage were 13 minutes (range, 3
to 34), 30 minutes (range, 6 to 100), and 85kJ (range, 11 to 235),
respectively. All were outpatient procedures. Perioperative complications
included intraoperative bleeding (1.4%), postoperative clinically
nonsignificant hematuria (75.7%), hematuria requiring clot evacuation (1.4%),
urinary retention requiring recatheterization (2.8%), urinary tract infection
(4.3%), and prostatitis (1.4%). No urethral strictures, bladder neck
contracture, or urinary incontinence were noted.
Conclusions: GreenLight HPS laser PVP appears to have a
low incidence of perioperative adverse events.
9133 Urology
Tissue Effects of GreenLight HPS™ and Evolve SLV™ Lasers on Canine Prostates:
an Acute In-Vivo Model
Massimiliano
Spaliviero, MD, Roman Wolf, DVM, Stanley Kosanke, DVM, Marie Chavez-Suarez, MD, Fred Broach,
Carson Wong, MD
University
of Oklahoma Health Sciences Center, Oklahoma City, OK
Introduction: We evaluated the tissue
effects and efficacy of the GreenLight HPS and Evolve SLV lasers for prostate
vaporization in living dogs.
Methods: Prostate vaporization was performed either with
GreenLight HPS (Group I) or Evolve SLV (Group II) systems. Forty kJ of energy
were delivered with both systems on canine prostates. Dogs were euthanized 2
hours following completion of prostate vaporization and prostates were excised en bloc. The volume of vaporized tissue
was determined by taking multiple measurements of the 3-dimensional cavity.
Prostates were then sectioned (3mm to 5mm) and stained with
triphenyltetrazolium chloride (TTC) and nitroblue tetrazolium (NBT) to
establish the thickness of necrotic and healthy tissue zones.
Results: Five (I) and 5 (II) consecutive mongrel dogs
underwent prostate vaporization. Mean age (I: 9±1 years, II: 8±1 years) and
weight (I: 25±1kg; II: 28±3kg) were similar between the 2 groups. Despite
similar energy utilization (I: 40.0±0.4kJ; II: 40.0±0.1kJ), laser time was
shorter in Group II (I: 359±19 seconds, II: 269±1 seconds, P<0.001).
Measurement of the vaporization cavity revealed it to be comparable (I:
3.06±1.52mL, II: 1.73±0.41mL, P=0.18). However, the depth of thermal necrosis
was thicker in Group II (TTC: I: 2.1±0.4mm, II: 5.8±0.8mm, P=0.0002; NBT: I:
2.6±0.8mm, II: 3.9±1.0mm, P=0.07) prostate specimens.
Conclusion: Despite the formation of a comparable vaporization
cavity, the depth of thermal necrosis was thinner in Group I. This factor may
have implications in the clinical outcomes of prostate vaporization in human
subjects.
9134 General Surgery
Completion Proctectomy after Laparoscopic vs. Open Subtotal Colectomy for
Ulcerative Colitis: Is There a Difference?
A. M. Morales Gonzalez, D. Geisler, F. Remzi, V. W. Fazio, R.
P. Kiran
The Cleveland Clinic Foundation
Introduction: For patients undergoing a staged total
proctocolectomy and ileoanal pouch (IPAA), the relative merits of a
laparoscopic or open approach during the colectomy or subsequent completion
proctectomy (CP) with IPAA have not been evaluated. We compare outcomes in CP
with IPAA for ulcerative colitis by the laparoscopic and open approaches after
a previous subtotal colectomy (STC) by either laparoscopic or open methods.
Methods: Patients
who underwent CP with IPAA after laparoscopic STC for UC were matched by age,
sex, body mass index, year of operation, and ASA score to twice the number of
patients who underwent open STC followed by CP/IPAA. Three groups were
obtained: laparoscopic STC followed by laparoscopic CP (LSTC/LCP), laparoscopic
STC followed by open CP (LSTC/OCP), and open STC followed by open CP (OSTC/OCP)
and compared for operative time, estimated blood loss (EBL), length of stay,
use of a diverting stoma, and complications including pouch failure.
Results: LSTC/LCP (n=23), LSTC/OCP (n=28), and OSTC/OCP (n=101) were
comparable for the matched characteristics. The 3 groups had similar EBL
(P=0.33), use of stoma (P=0.25), anastomotic leak (P=0.4), overall
complications (P=0.11), and pouch failure (P=0.11). LSTC/LCP was associated
with significantly longer operative time (P<0.001) but with a significantly
shorter length of stay (P<0.002) (4.6 days) compared with LSTC/OCP (7.7) and
OSTC/OCP (6.7).
Conclusion: The use of an LCP after LSTC is associated with the
advantage of a significantly reduced length of stay compared with that for OSTC
or LSTC followed by OCP despite comparable risk of complications and long-term
outcomes.
9135 Multispecialty
Minimally Invasive Surgery Group: Cutting Edge Goes a Cut Above
Dean K. Matsuda, MD, Kirk
Tamadoon, MD, Seth Kivnik, MD, Robert Casillas, MD, Benjamin Kim, MD
Kaiser West Los Angeles Medical
Center
Objective: To share our
collective experience and potential benefits derived from a hospital-based
minimally invasive surgery group.
Methods: Our hospital-based minimally invasive surgery
group’s 3-year experience is presented. A unique collection of endoscopic
surgeons at one site provides many opportunities that go beyond any marketing
hype. With surgeons offering everything from advanced arthroscopic hip surgery
to laparoscopic hysterectomy, robotic prostatectomy to minimally invasive
bariatric surgery, the latest technological advances and innovative techniques
are harnessed for significant patient benefit.
Results: Data favorably comparing our MIS equivalents to
more open invasive surgeries with resultant shorter hospital stays (many
outpatient procedures), minimal blood loss, quicker recovery/rehabilitation,
reduced complications (including some specific to MIS procedures), and improved
cosmesis and patient-satisfaction is discussed in this open forum. One example
is outpatient arthroscopic surgery for athletes with femoroacetabular
impingement having a 99% outpatient rate compared with 3-days to 4 days of
hospitalization for the open surgical equivalent, minimal blood loss with 0%
transfusion rate, accelerated rehabilitation with exercise bicycling 24 hours
postoperation, and an average reduction in postoperative recovery from 6 months
to 8 months (open surgery) to 3 months (arthroscopic procedure). Moreover, the
benefits of surgeon cross-education with creative innovation,
multi-disciplinary camaraderie, improved patient education, and group
purchasing power with resultant cost savings will be highlighted.
9136 Multispecialty
Arthroscopic Hip Surgery for Femoroacetabular Impingement in the Athlete
Dean K. Matsuda, MD
Objective:
To inform the audience of the latest developments in the arthroscopic
management of athletes with femoroacetabular impingement. Present
our inter-regional prospective treatment outcomes.
Methods/procedures: Femoroacetabular impingement has become an
established clinical entity causing pain and early osteoarthritis in a
relatively young and athletic group of patients. For this open forum venue, we
first show our surgical techniques for comprehensive 2-portal arthroscopic
surgery. We demonstrate via professional video and animation arthroscopic rim
trimming using a fluoroscopic templating technique designed by the author,
femoral head-neck resection osteoplasty, as well as labral refixation and even
labral reconstructive arthroscopic surgery. We then will share the early
outcomes from our inter-regional prospective study using the validated
Non-arthritic Hip Score. We conclude with the author's personal experience
(with surgical video capture) having had both hips treated for this condition.
Results: We enrolled 105 patients (52% F, 48% M), mean age
of 38.4 years, with symptomatic femoroacetabular impingement. Ninety patients
had cam-pincer FAI, 6 cam, and 7 pincer variants. Mean labral damage by Beck
scale was 2.10, Outerbridge 2.43, and Beck cartilage damage 2.76. Patients
showed a 14.43-point improvement in mean hip score, 16.60-point improvement in
mean pain scores, and 19.66-point improvement in functionality score subset.
Conclusion: Comprehensive arthroscopic surgery for
symptomatic femoroacetabular impingement improves pain and functional level in
many athletic patients.
9137 Multispecialty
Laparoscopic Appendectomy During Pregnancy
Joong Sub Choi, MD1, Jung Hun Lee,
MD1, Hyung Ook Kim, MD1, Hungdai Kim, MD1, Seon Hye Park, MD2, Moon Il
Park, MD2
1Kangbuk Samsung Hospital, Sungkyunkwan
University School of Medicine
2College of Medicine, Hanyang
University, Seoul, Korea
Objective: To evaluate the safety, feasibility, and pregnancy outcomes of
laparoscopic appendectomy (LA) during pregnancy.
Methods: This was a retrospective clinical study (Canadian Task Force
classification II-2) performed at a university teaching hospital. The study
cohort included 8 pregnant women who underwent LA from January 2007 to December
2008.
Results: The median age of the patients and median parity were 29.5 years
(range, 25 to 34 years) and 0 (range, 0 to 1), respectively. The median
operating time of LA was 22.5 minutes (range, 15 to 40). The median length of
hospital stay was 3 days (range, 2 to 4). No maternal or fetal mortality or
morbidity, laparoconversions, or uterine injuries occurred. Four patients
delivered 4 healthy infants, and the pregnancies of 3 patients are progressing
without complications. One patient underwent an elective abortion. All resected
appendices were acute appendicitis.
Conclusion: Laparoscopic
appendectomy performed during pregnancy by expert gynecological laparoscopists
is feasible and safe and does not lead to adverse pregnancy outcomes.
9138 Gynecology
Robotic Surgery in a Medium-Sized, Integrated Community and Academic Program in
Gynecology
Sean Tedjarati, MD, Karen Ballard, DO, Greg May, MD, Jay Anderson, MD, Katie
Brading, Anne Doughty, Robert Kauffman, MD
Objectives: We reviewed the evaluable RAL cases performed from 8/07 to 7/08
in a medium-sized community, and analyzed demographic, clinical, operative, and
pathologic data/outcomes.
Methods: All demographics, clinical, operative, and pathologic data were
collected and analyzed. The institutional review board approved the study.
Results: Fifty-six cases
were reviewed with follow-up of 20 weeks (range, 10 to 42). Mean age and body
mass index (BMI) were 47 years (range, 22 to 88), and 30.3 (range, 19.2 to 44).
BMI was ≥25 in 72% and ≥30 in 54%. Hysterectomy ± bilateral
salphingo-oophorectomy ± lymph node dissection were the most common
procedures. Conversion to laparotomy was 3%. Docking time was 2.4 minutes
(range, 2 to 6). Total operative and console time were 138 minutes (range, 48
to 366) and 107 minutes (range, 29 to 300). Estimated blood loss (EBL) was 76cc
(range, 10 to 300) with 1 preoperative transfusion. Uterine weight was 141g
(range, 49 to 258). Mean lymph nodes retrieved were 19 (range, 10 to 34).
Operative and postoperative complications were 1.8% and 10% with fever being
most common. Only oral analgesics were required by 70%. Length of stay (LOS)
was 1.5 days (range, 1 to 4). There were no wound infections.
Conclusions: A successful RAL
program in a medium-sized community among surgeons with variable experience is
feasible. Transition from laparotomy to RAL was achieved with results
comparable to those of larger, more experienced centers. Over half of patients
were obese with lowered LOS, EBL, recovery period, and no wound infections.
9139 General Surgery
Reinforced Circular Staples in Bariatric Surgery: Is there Any Benefit?
Marcela Ramirez, MD, Flora Varghese, MD, Richard Symmonds, MD, Joaquin
Rodriguez, MD
Scott & White Memorial, Hospital Texas A&M
Background: With the increasing prevalence of morbid obesity,
a growing demand for bariatric surgery exists. Roux-en-Y gastric bypass (RYGBP)
is the most common procedure, but has multiple complications. This study
evaluates the use of the reinforced circular stapler and its effects on
reducing gastrojejunal anastomotic complications.
Methods: Data were obtained using retrospective chart review
between January 2007 and November 2008 from a single institution. During this
time period, 287 laparoscopic RYGBP were performed. Comparison was made between
2 groups. The nonreinforced circular stapler (NRCS) group consisted of 182
patients, and the reinforced circular stapler (RCS) group consisted of 105
patients. Perioperative complications and postoperative complications were
compared between both the RCS and NRCS groups.
Results: Complications from gastrojejunal anastomosis were
found in 44 patients (15.33%). There were 10 (9.52%) patients from the RCS
group and 34 (18.68%) patients from the NRCS group with anastomotic
complications (P=0.0381). Neither group had anastomotic leaks. The bleeding
rate was 4.90% in the RCS group vs. 6.49% in the NRCS group. The stricture rate
was 1.96% in the RCS group vs. 6.49% in the NRCS group. Ulcer formation occurred
in 2.86% of the RCS group vs. 6.04% of the NRCS group.
Conclusion: The application of RCS reduced the incidence of
gastrojejunal anastomotic complications. Therefore, it is beneficial to utilize
reinforced circular staplers for the gastrojejunal anastomosis in laparoscopic
RYGBP procedures. Patients are 2.182 times more likely to develop complications
when no RCS device is used.
9140 General Surgery
Prolonged (>3 Hours) Laparoscopic Cholecystectomy: Reasons And Results
Gokulakkrishna Subhas, MD, Aditya Gupta, MD, Lorenzo Ferguson, MD, Michael
J. Jacobs, MD, William Kestenberg, MD, Ramachandra B. Kolachalam, MD, Sumet
Silapaswan, MD, Vijay K. Mittal, MD
Providence Hospital and Medical Centers, Southfield,
Michigan
Background: For the experienced surgeon, the average operative time for a
laparoscopic cholecystectomy is <1 hour. No study has documented the causes
and results of prolonged (>3 hours) surgery.
Methods: A retrospective study was
done of patients who underwent cholecystectomy from January 2003 to December
2007. In all, 3126 cholecystectomies were done. After excluding patients who
had a planned open cholecystectomy and patients who had additional (hepatic,
pancreatic, gynecological, and colonic) surgeries, we identified 70 patients
who had a planned laparoscopic cholecystectomy with operative time exceeding 3
hours. Charts were reviewed to look at the indications, investigations, and
procedure details.
Results: Patients ranged from 21 to
92 years of age (mean, 57) with most of the patients being females (n=53).
Operative time ranged from 3 hour to 6:40 hours (mean, 3:37).
Emergency:elective admission ratio was 5:9. Acute cholecystitis (n=40) was the
most common indication, followed by symptomatic gallstones (n=24) and gallstone
pancreatitis (n=6). Laparotomy had to be done in 30 patients. Common
characteristics were obesity (n=44), dense intraabdominal adhesions (n=43),
previous abdominal surgeries (n=40), obstructive jaundice (n=14), large
gallstones (>2.5cm) (n=12), and intraoperative cholangiography (n=12).
Intraoperative complications included spillage of stones (n=6), bile duct
injury (n=3), and bleeding (n=3). Histopathological examination revealed 12
gangrenous gallbladders. Postoperative stay ranged from 1 day to 41 days (mean,
5 days), and one mortality occurred.
Conclusions: The possibility of
prolonged laparoscopic cholecystectomy should be anticipated in patients with
obesity and previous abdominal operations. Prolonged surgery increases the risk
of complications (bile duct injury, bleeding) and prolongs the postoperative
hospital stay.
9141 Gynecology
Effectiveness of Microwave Endometrial Ablation for Adenomyosis
Yasuyuki Asakawa, Yasuhiro Yamamoto,
Tsuchiya Takehiko, Mami Fukuda, Nobuyuki Sakurai, Hideki Taoka, Toshimitsu
Maemura, Mineto Morita, Kaneyuki Kubushiro
Toho University School of Medicine
Objective: In recent years, microwave endometrial ablation (MEA) has been
more closely analyzed as a therapeutic option for hypermenorrhea, due to its
reduced invasiveness compared with total hysterectomy. With approval from the
hospital ethics review board, we have performed MEA on 6 consenting patients
with adenomyosis since 2004. Postoperative clinical outcomes are described
herein.
Methods: In all patients, MEA was
performed using a microwave coagulator operating at 2.45GHz, and the
endometrium was coagulated at several locations with 70W output and 50-s
conduction time. After MEA, coagulation inside the uterus cavity was confirmed
by hysteroscopy. Postoperative MRI was used to examine the extent of
endometrial coagulation.
Results: Hypermenorrhea improved in
all patients with adenomyosis, and 2 patients became amenorrheic. Significant
improvements were seen in postoperative anemia. A visual analog scale was used
to assess satisfaction, menstrual blood loss, and menstrual pain before and
after MEA. Statistical analysis showed significant improvements in
satisfaction, menstrual blood loss, and menstrual pain. No notable
postoperative infections or complications were seen.
Conclusions: These results suggest
that MEA for adenomyosis is a noninvasive and safe technique that coagulates
the endometrium in a short period of time, significantly improving
hypermenorrhea and dysmenorrhea. In the future, MEA will offer a useful
therapeutic option to take the place of total hysterectomy.
9142 General Surgery
Herniotomy in Infants, Children, and Adolescents Without Disruption of External
Ring
Ahmed A. Kareem, MBChB, DGS, Kasim M. Juma'a, BSc, MSc
Baquba Teaching Hospital, Diayla, Iraq
Background: Inguinal hernia represents one of the most common pediatric
problems that requires surgical repair as early as possible to avoid
complications that may be life threatening. In addition, operative technique
and highly qualified surgical skills used in management of inguinal hernia may
effectively contribute to reduction in cost, mortality, and morbidity,
especially the recurrence rate which represents a challenge in this type of
surgical operation.
Methods: This prospective study
included 252 inguinal hernia patients, ranging in age from 7 years to 15 years
of both sexes. The patients were admitted to Baquba General Hospital from June
2005 to March 2007. They were managed surgically with a nonlaparoscopic minimum
access method and followed up for 1 year for detection of recurrence rate.
Results: Patients tolerated this
surgical procedure very well with no need for strong analgesia. Also the new
surgical technique produced a clean wound with no incidence of wound infection.
For this reason, use of antibiotics was unnecessary. At 1-year follow-up, the
recurrence rate was zero. This type of surgical operation will decrease
in-hospital length of stay and cost.
Conclusion: Laparoscopic inguinal
hernia repair in children is not the most superior minimally invasive
technique. Open surgery can be done in a less invasive manner with lower cost,
fewer complications, maintaining the tactile sensation of the surgeon with a
most delicate and pleasurable procedure.
9143 General Surgery
Laparoscopic Loop-Ileostomy With A Single-Port Stab Incision
Gokulakkrishna Subhas, MD, Elizabeth Kim, MD, Vijay K. Mittal, MD, Alasdair
McKendrick, MD
Providence Hospital and Medical Centers, Southfield,
Michigan
Background: Loop-ileostomy is an effective means of temporary fecal
diversion. Fecal diversion may be needed as an isolated procedure in patients
with complicated perianal fistula, perianal sepsis, or distal Crohn’s disease.
With the advent of laparoscopy, many of these loop ileostomies are being
performed with laparoscopic assistance. Studies have proved the beneficial
effects of laparoscopically created loop ileostomy over the open technique for
fecal diversion.
Methods: Techniques for performing
laparoscopic loop-ileostomy have been described using 2 or more 10-mm to 12-mm
ports with Hasson’s technique at the umbilical site for pneumoperitoneum
creation. Babcock forceps holds the loop of terminal ileum through the port
placed at the ostomy site. The presence of Babcock’s forceps with the port
cannula at the site of the ostomy interferes with the expansion of the opening
in the rectus sheath. We are describing a new technique, wherein the
pneumoperitoneum is created using a 10-mm port at the site of the future
ileostomy and a second 5-mm port placed under vision at the umbilical site. The
camera is passed through the ostomy site port, and the umbilical port is used
for Babcock’s forceps. There is no interference while expanding the skin and
rectus sheath incision at the ostomy site. A final look is taken through the
umbilical port before maturing the ostomy.
Conclusion: This technique decreases
the risk of bowel injury. The umbilical port site being 5-mm does not need
closure; thus, it reduces port-site hernia and patient discomfort. Also
minimizing the intervention reduces the operative time and decreases postoperative
ileus and adhesion formation.
9144 General Surgery
NOTES Transvaginal Cholecystectomy: A Modified Surgical Technique
Giuseppe Currò, MD, Giuseppe La
Malfa, MD, Emanuela Molino, MD, Mariangela Pataria, MD, Giuseppe Sarra, MD,
Giuseppe Navarra, MD
University Hospital of Messina, Messina, Italy
Objective: Natural orifice transluminal endoscopic surgery (NOTES) allows
cholecystectomy to be performed by means of a flexible scope introduced through
the stomach, rectus, bladder, or vagina. However, available endoscopes have
several limitations if utilized in the peritoneal cavity. We describe a new
technique that overcomes these limitations by using conventional 5-mm
laparoscopic instruments through the umbilical scar and transabdominal sutures
for retraction.
Methods: After creating the
pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the
umbilicus followed by a 5-mm 30° scope. A culdotomy is then performed under
direct and laparoscopic view. The flexible endoscope is inserted into the
pelvis through the vagina and advanced to expose the gallbladder. Three or more
transabdominal sutures are placed through the gallbladder wall for retraction.
Cholecystectomy is then conventionally performed. Finally, stay sutures are
removed and the specimen is retrieved through the vagina.
Results: Six female patients
underwent hybrid transvaginal cholecystectomy. Average age was 52 years (range,
46 to 65) with an average body mass index of 32 (range, 30 to 37). No problems
or complications occurred related to the culdotomy, trocar, or stay suture
placement. No conversions were necessary, and all the procedures were performed
as planned without complications within an average of 52 minutes (range, 40 to
65).
Conclusion: In our opinion, this
hybrid approach increases safety, overcomes the limitation of the current
instrumentation, and maintains most of the advantages of NOTES.
9145 Gynecology
Medico Legal Problems with Advanced Gynecological Operative Endoscopy
Professor Mark Erian, FRCOG, FRANZCOG, MD, Dr. Glenda McLaren, FRCOG,
FRANZCOG
Objective: The purpose of this study
was to analyze the complication factors in gynecological operative endoscopy,
and to appreciate elements leading to litigation against gynecological surgeons
and ways to minimize (or completely eradicate) medico legal risk factors and,
consequently, lawsuits that can be costly in terms of monetary and emotional
expenses to the patient, health care industry, gynecologists, their practices,
and even families.
Methods: This was an observational
study performed in the Obstetrics and Gynaecology Department, Royal Brisbane
and Women’s Hospital (RBWH). This is a major tertiary referral teaching
hospital. We studied the main complications occurring at RBWH as a result of
laparoscopic and hysteroscopic operative interventions between 1990 and 2007
(inclusive) with analysis of the causative factors and ways to prevent the
same.
Results: Nearly always, there is a
reason(s) behind the complication(s), and these failures to inform, perform
and/or communicate. Advances in modern technology have improved the outcome of
simple and complicated operative laparoscopic and hysteroscopic surgery.
Nevertheless, the authors stress the importance of training, credentialing, and
maintaining a system of quality assurance (QA) that should be adhered to.
Conclusion: Advanced operative
gynecological endoscopy offers the patient an attractive alternative to
conventional surgery with less pain and discomfort, quicker return to the
workforce, and better cosmetic results. Not only does the patient benefit from
this approach but also the hospital and the national economy in general
benefit. However, the gynecological surgeon must endeavour to excel in
knowledge, manual dexterity, and communication skills if litigations are to be
avoided or reduced to an absolute minimum.
9146 General Surgery
Surgery for Chronic Abdominal and Pelvic Pain Syndrome (CAPPS)
“Is Surgery Indicated in these Patients?”
Jay A. Redan, MD, Greg McClain, MD, Steven McCarus, MD, John Kim, MD,
Aileen Caceres, MD
Florida Hospital-Celebration Health
Background: One of the most commonly encountered problems today is
abdominal/pelvic pain associated with adhesions from prior surgery. Patients
normally have a battery of studies that often leave the doctor without answers
and patients without proper treatment. We retrospectively analyzed 31 CAPPS
patients to determine the best course of treatment for them.
Methods: A retrospective chart
review of a single institution’s practice involved the treatment of CAPPS
(n=31) following prior abdominal surgery(s) from 2006 to 2008. The data set
includes patient information obtained in the preoperative interview and
postoperative follow-up at 3-, 6-, 9-, and 12-month intervals. The data points
included patients’ age, sex, and pain scale at each interval, employment
status, use of narcotics, and number of surgeries.
Results: Mostly women (n=29,
P<0.05), the age ranged from 16 to 63 years (mean, 42). The number of
abdominal surgeries ranged from 1 to 7 with an average of 2.67. Preoperative
pain averaged 7.8 on a scale of 0 to 10; 3-month follow-up was 4.7, 6-month was
3.07, 9-month was 2.5, and 12-month was 1.5. Also a 66% decrease occurred in
the use of narcotics following surgical treatment.
Conclusion: The treatment of
patients with CAPPS secondary to adhesions poses a unique and often difficult
challenge to caregivers. We offer patients diagnostic laparoscopy, lysis of
adhesions, and indicated procedures including bowel resection for chronic large
and small bowel obstructions. Our follow-up data show that the pain reported by
the patients is improved and the use of narcotics decreased.
9147 General Surgery
Laparoscopic Appendectomy Using LIGASURE™ for Mesoappendix Hemostatic Control
Vicente Spinelli, MD, Luis F. Guada, MD, William Guada, MD
Hospital Cruz Roja, Instituto de Especialidades Quirurgicas Los Mangos
Universidad de Carabobo, Valencia, Edo Carabobo Venezuela
Background: Laparoscopic
appendectomy is frequently performed where technical resources are available.
The aim of the present study was to evaluate the LIGASURE vessel sealing system
in laparoscopic appendectomy for mesoappendix hemostatic control.
Methods: This was a prospective,
nonexperimental study of 44 patients at 3 surgical centers in Valencia
city. All patients had abdominal
pain with a diagnosis of acute appendicitis. They were operated on
laparoscopically using LIGASURE, from January 2005 to December 2006.
Results: The mean operative time was
69.32 minutes (SD, 14.25). The mean hospital stay was 1.43 days (SD, 1.021).
The operation was converted to open appendectomy in only 2 patients because of
technical difficulties of dissection. Neither surgical Endoclips nor an
endostapler were used in any patients. We observed postoperative complications
in 11 patients (25%), mainly infectious. No intraabdominal abscesses were
present. We reoperated on one patient with hemoperitoneum due to bleeding from
an epigastric vessel injury after trocar insertion, identified postoperatively.
No burn injuries occurred due to use of the LIGASURE system. Pathological
diagnosis identified 50% of the ailments as phlegmonous appendicitis.
Conclusion: Laparoscopic
appendectomy using LIGASURE is a safe and efficient procedure for hemostatic
control of mesoappendix, and it has similar operative time and hospital stay as
other laparoscopic methods for hemostatic control.
9148 General Surgery
Learning Curve in Transanal Endoscopic Microsurgery: Surgeon or Operating Room
Staff Dependent?
Paul R. Sturrock MD, Ronald Figuerido, MD, Matthew Vrees, MD,
Adam Klipfel, MD, Jorge A. Lagares, MD
Rhode Island Colorectal Clinic, Pawtucket, Rhode Island
Introduction: The learning curve for transanal endoscopic
microsurgery (TEMS) is poorly described in the literature, but some studies
indicate a lack of a significant operative learning curve when surgeons have
minimally invasive experience. The aim of our study was to evaluate surgical
times of our experience with TEMS since its inception in a colorectal practice.
Methods: Thirty-two
consecutive cases have been evaluated since March 2007. Two dedicated surgeons
(A and B) with extensive experience in laparoscopic colorectal surgery
performed all the procedures. Demographic, intraoperative, and pathologic data
were collected. Comparisons and statistical analysis were performed by a
surgeon and staff learning curve using the variables early (first 15 cases)
versus late experience (>15 cases).
Results: To date, 32 cases have been performed. Average
patient age was 60 years with equal sex distribution. Mean operating room setup
time, operation length, and total procedure time were 33, 34, and 61 minutes,
respectively. Tumor surface mean was 20.4cm2,
and specimen surface averaged 32.3cm2.
Mean setup time was significantly different between the early (37 minutes) and
the late experience (30 minutes) (P<0.05), while operation length and
overall operating room time did not differ, regardless of tumor size.
Conclusion: TEMS operating room times are related to the setup
time and operating room staff familiarity with equipment and patient setup
early on in the experience. There was no difference regarding surgeon times in
early vs. late experience.
9149 General Surgery
Laparoscopic Sigmoid Resection for Complicated Diverticular Disease is
Associated with Better Outcomes
J. A. Laryea2, J. Cannon1, E. Pennington1, M. Ferguson1, M. Schertzer1, W.
Ambroze1, G. Orangio1
1Georgia Colon and Rectal Surgery Clinic, Atlanta, Georgia
2University of Arkansas for Medical Sciences, Little Rock, Arkansas
Purpose: To compare the outcomes of open versus
laparoscopic sigmoid resections for complicated diverticular disease in a large
private colorectal practice with an ACGME-approved fellowship-training program.
Methods: A retrospective review of 169 consecutive patients
undergoing sigmoid resection for complicated diverticular disease between
January 2002 and June 2007 was done. These included patients with diverticular
abscesses, phlegmon, recurrent diverticulitis, and colovaginal and colovesical
fistulas. Five experienced colorectal surgeons performed the surgeries with or
without a fellow. Follow-up ranged from 2 months to 4 years. The primary
outcomes evaluated were EBL, LOS, and complications. Univariate and
multivariate linear regression analysis was done using the SAS 9.1 (SAS
Institute, Cary, NC) statistical software. Significance was set at P<0.05
Results: There were 169 consecutive sigmoid resections for
diverticular disease (72 open and 97 laparoscopic). The laparoscopic group had
significantly lower EBL (160.4±109.8 vs. 230.7±237.0; P=0.0359) and a shorter
length of stay (5.4±2.8 days vs. 7.1±2.9 days; P=0.0003). Overall, no
significant differences existed in complications between the 2 groups
(P=0.846). On multivariate analysis, the laparoscopic procedure (P<0.0001)
and younger age (P=0.0367) were associated with a shorter length of stay. The
presence of a fellow was associated with a lower EBL (P=0.0623).
Conclusions: Laparoscopic sigmoid resection for complicated diverticular
disease is associated with better outcomes and is as safe as open sigmoid
resection.
9150 Gynecology
Can Laparoscopic Myomectomy Replace Open Myomectomy?
M. Sami Walid, MD1, PhD, Richard
L. Heaton, MD2
1Medical Center of Central Georgia, Macon, Georgia
2Houston County Medical Center, Heart of Georgia Women’s
Center, Warner Robins, Georgia
Introduction: Laparoscopic myomectomy is a procedure that
requires laparoscopic suturing skills. We report our 10-year experience with
laparoscopic myomectomy, its advantages, and possible complications.
Materials and Methods: From October 1998 to July 2008, 41
myomectomies were performed in a suburban gynecology practice. Patients were 16
to 55 years old, gravida 0-4 and para 0-2. Eleven patients had prior cesarian
deliveries, and 6 patients had prior myomectomies.
Results: One open myomectomy, 6 hysteroscopic myomectomies,
and 34 laparoscopic myomectomies, including 2 combined with the hysteroscopic
route were performed during that period. In the laparoscopy group, 10 patients
had prior cesarian deliveries, and 4 patients had prior myomectomies. Patients
had 1 to 7 fibroids in their uteri of different types, pedunculated, subserous,
and intramural. Six patients were treated with Lupron before surgery. Pitressin
was used in 19 patients during surgery. Resected fibroids weighed up to 555
grams. One case required staged myomectomy because of bleeding (800cc) after
the large fibroid was removed. Estimated blood loss was 20cc to 1200cc. No
patient required a transfusion. Sixteen patients required morcellation. No
patient required conversion to an open technique. No infections occurred. Two
patients had successful pregnancies after myomectomy. Subsequent hysterectomy
was performed in 6 patients.
Conclusions: Laparoscopic myomectomy is a safe procedure in the
hands of an experienced surgeon. Bleeding is the most common intraoperative
complication that may require performing a staged laparoscopic myomectomy.
Maintaining homeostasis is the mainstay to successfully complete the procedure.
Decreased hospital time and decreased patient pain are the most important
advantages of this procedure.
9151 General Surgery
Laparoscopic Colectomy for Colon and Upper Rectal Cancer
Pietro Venezia, MD
Azienda Ospedaliero Universitaria
Policlinico, Bari, Italy
Objective: Laparoscopic
colectomy for the management of colon and upper rectal cancer at my institution
has required advanced laparoscopic experience. This report supports the
laparoscopic procedure without compromising the completeness of the resection.
Methods: Intraoperative
colonoscopy validated the solitary localization of the adenocarcinoma and with
tattooing with methylene blue precisely identified the limits of the resection
line. Laparoscopic “classic” colectomy was performed using 3 additional ports
with the patient in a Trendelenburg-lithotomy position, and confirmation of the
preoperative staging (T2, N0, Mx) with the absence of peritoneal carcinosis.
Reconstruction was performed using lymph node dissection, extraction through
one port site for the trocars, enlarged and intracorporal for left and
extracorporal for right-sided lesions.
Results and Conclusions: From March 1999 to
September 2006, we performed 49 laparoscopic colectomy for colon and upper
rectal cancer. The length of the specimen, with clear margins and sampling of
the nodes (T2, N0, Mx) confirmed that laparoscopic colectomy is technically and
surgically acceptable. The yearly oncologic follow-up after 6 cycles of
chemotherapy and CT scan demonstrated there were no trocar site implants or
local or distal recurrence of tumor. The less-suppressed immune system may have
implications for tumor recurrence and long-term patient survival. The lifting
of the colon during the operation can reduce the number of surgical staff and
the expense of the procedure. All patients are today alive. We believe this
procedure was a better choice for the patient, certainly for the surgeon and
probably for the community too.
9152 Urology
Robotic-Assisted Laparoscopic Excision of Bladder Wall Leiomyoma
David D. Thiel, MD, Bryant F. Williams, MD, Murli Krishna, MD,
Timothy J. Leroy, MD, Todd C. Igel, MD
Mayo Clinic Florida
Introduction/Objectives: Leiomyoma
is the most frequent nonepithelial benign tumor of the bladder, and only about
170 cases have been reported in the literature. Most bladder wall leiomyomas
are found incidentally and can be observed if imaging and biopsy are consistent
with the diagnosis. Mass resection occurs for symptomatic or enlarging masses
and is indicated if the diagnosis of benign leiomyoma is in question. Our
objective was to show a minimally invasive approach to resection, if indicated.
Methods: We show resection of a
bladder wall leiomyoma with the da Vinci surgical system. This includes
demonstrations on imaging, port placement, and operative technique.
Results: Intraoperative video and
diagrams are shown of operative resection.
Conclusions: Final surgical pathology
and operative outcomes of the first reported case of robotic-assisted
laparoscopic resection of a bladder wall leiomyoma are shown.
9153 Urology
Robotic-Assisted Laparoscopic Reconstruction of the Upper Urinary Tract: Tips
and Tricks
David D. Thiel1, Timothy J. LeRoy1, Howard N. Winfield2, Todd C Igel1
1Mayo Clinic Florida, Jacksonville, Florida
2University of Iowa Hospitals and Clinics, Iowa City, Iowa
Introduction/Objectives: Urology has embraced the use of the da Vinci
surgical system for procedures that require complex laparoscopic maneuvers,
such as pyeloplasty and radical prostatectomy. A natural extension of these
techniques is to use the system for complex urinary reconstruction. The
objective of this video is to demonstrate these techniques.
Methods: Using intraoperative
video and representative diagrams, this video presentation shows various
aspects of upper urinary tract reconstruction.
Results: Video tips and tricks are
presented for the imaging, patient positioning, port placement, and operative
technique of urinary reconstruction.
Conclusions: Robotic-assisted
laparoscopic techniques are well suited for upper tract urinary reconstruction
as would be used in congenital, traumatic, iatrogenic injuries, or disease.
9154 Urology
Laparoscopic Ureterolithotomy for Large Proximal Ureteral Calculi
David Spencer, William L.Duncan
University of Mississippi School of
Medicine, Jackson Mississippi
Laparoscopy has gained greater acceptance in the world of urologic surgery.
Endourology is the mainstay for surgical management of urinary calculi. For
large calculi, regardless of location in the urinary tract, multiple endoscopic
procedures are commonly required. We evaluated the safety and efficacy of
laparoscopy for proximal ureteral calculi. This was performed in one procedure
with complete stone clearance. In this case, multiple procedures and multiple
anesthetics were avoided. Laparoscopic ureterolithotomy, although technically
challenging, is a feasible technique for treatment of large proximal ureteral
calculi. It has the potential for high rates of success and decreasing the
number of procedures required for large urinary calculi.
9155 General Surgery
Pyloromyotomy Length Directed by Preoperative Ultrasound Measurement Minimizes
Incomplete Laparoscopic Pyloromyotomy in Infants
Denis D. Bensard, MD, Richard J.
Hendrickson, Katie J. Giesting, CNP, Joshua M. Careskey, MD, Evan R. Kokoska,
MD
Peyton Manning Children’s Hospital,Cincinnati Children’s Hospital Medical Center,
University of Cincinnati School of Medicine
Background: Laparoscopic
pyloromyotomy is associated with an increased risk of incomplete myotomy (5% to
7%) compared with open myotomy (2% to 3%). In contrast, the risk of mucosal
perforation (2% to 3%) appears less when pyloromyotomy is performed
laparoscopically. We hypothesized that utilizing ultrasound-measured length
rather than visual estimation of laparoscopic pyloromyotomy would reduce the
risk of incomplete pyloromyotomy without a concomitant increase in the risk of
mucosal perforation.
Methods: In a children’s hospital, all infants (n=43) with
hypertrophic pyloric stenosis diagnosed by ultrasound over a 2-year period
(12/2006 to 12/2008) were offered laparoscopic pyloromyotomy. Pyloromyotomy
length was guided by preoperative ultrasonographic measurements. Laparoscopic
pyloromyotomy was considered complete if the measured length correlated with
the ultrasound measurement. Infants were followed prospectively for time to
full feeding, time to discharge, and complications.
Results: Forty-three infants (38 male, 5 female; mean age
37±13 days, range 17 to 72) underwent ultrasound (length 1.9±0.2mm; thickness
4.4± 0.9mm) and laparoscopic pyloromyotomy. Infants achieved full feeding 28±16
hours postoperatively and were discharged 33±13 hours postoperatively (range, 15
to116). No infant required reoperation for incomplete myotomy. One infant
sustained mucosal perforation during laparoscopic pyloromyotomy (2.3%),
recognized intraoperatively, and completed open. No patient required
readmission or suffered other complications.
Conclusion: Utilizing preoperative ultrasound measurement of
pyloric channel length to determine the length of laparoscopic pyloromyotomy
rather than visual cues alone appears to minimize the risk of incomplete
pyloromyotomy without an increase in the risk of mucosal perforation in
infants.
9156 Multispecialty
Small Bowel Obstruction after FloSeal Use
Benjamin Clapp, MD1, Antonio Santillan, MD2, Bruce
Applebaum, MD1
1Providence
Memorial Hospital, El Paso, Texas
2Texas Tech University School of Medicine at El Paso, Texas
Objective: FloSeal is a
thrombin-gelatin hemostatic matrix that is used to obtain hemostasis. There
have been isolated case reports of FloSeal causing bowel obstructions requiring
surgical intervention. We report 2 cases of what we believe were
FloSeal-induced small bowel obstructions.
Methods: This
is a case series report and review of the literature. We report a case of a
small bowel obstruction after a laparoscopic gastric bypass where FloSeal was
used on a bleeding staple line and also of a small bowel obstruction after a
robotic-assisted hysterectomy.
Results: In
both patients, FloSeal was used for hemostasis. In each instance, a small bowel
obstruction developed within days. Both patients were reexplored
laparoscopically and found to have an intense inflammatory reaction at the site
of the FloSeal. The adhesions were lysed and both cases of obstruction
resolved.
Conclusions: FloSeal
should be used with caution, because it may cause small bowel obstructions.
Whether this is an immune/allergic response or a mechanical response of the
bowel to a thrombin-based substance is yet to be determined.
9157 General Surgery
Single-Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic
Surgery (NOTES) Cholecystectomy: Is It Just About Cosmesis?
Sujit
Vijay Sakpal, MD1, Ronald Scott Chamberlain, MD, MPA1,2
1Saint Barnabas Medical Center, Livingston, New Jersey
2University of Medicine & Dentistry of New Jersey, Newark, New
Jersey
Background and Objectives: Laparoscopic
cholecystectomy is the most commonly performed minimally invasive procedure.
Significant efforts have been applied towards developing the technique and
equipment for performing this procedure using either a single-incision
laparoscopic surgery (SILS) or natural orifice transluminal endoscopic surgery
(NOTES) method. It has been suggested that these innovative techniques will
reduce postoperative pain and limit scarring while also improving cost
effectiveness and patient safety. This review highlights the technical
challenges associated with these procedures and the potential benefits, if any,
they may offer.
Methods: A comprehensive review of the worldwide literature
pertaining to “less” minimally invasive cholecystectomies—SILS and NOTES
cholecystectomy—was performed to evaluate the potential benefits, limitations,
and risk of these novel procedures.
Results: Both SILS and NOTES cholecystectomy have the
potential to produce cosmetic benefits. Whether these procedures result in less
postoperative pain is so far a subjective conclusion, lacking objective data
supporting this claim. Intraoperative or postoperative complication rates and
the safety and efficacy associated with these procedures remains undetermined.
Conclusion: Clinical reports of both SILS and NOTES are rare
and limit the ability to draw meaningful conclusions. Reports of technical
complexity, low success rates, and avoidable complications raise doubts as to
the broad applicability of these techniques. Extensive research and development
into the technical aspects of these procedures and randomized studies to
compare them with traditional laparoscopy are essential.
9158 General Surgery
Sentinel Lymph Node Mapping in Patients with Differentiated Thyroid Carcinoma
(DTC): Our Experience
Sinisa Maksimovic
General Hospital St. Vracevi Bijeljina, R. Srpska, Bosnia and Herzegovina
Introduction:
The aim of this study was to evaluate sentinel lymph node mapping in patients
with differentiated thyroid carcinoma
(DTC).
Methods:
From 2001 to 2008, we performed sentinel lymph node mapping (SLNb) in 37
patients with DTC. Before mobilization of the thyroid gland, approximately
0.2mL of 1% solution of methylene blue dye was injected peritumorally. After
approximately 10 minutes, the dissection was continued above and beyond the
omohyoid muscle towards the internal jugular vein and common carotid artery until
the blue stained lymph nodes were found and recognized and sent for frozen
section examination. If any of the nodes were positive on frozen section, a
modified radical neck dissection was performed after total thyroidectomy and
routine dissection of the central neck compartment.
Results:
Twenty-two patients had papillary thyroid carcinoma, 11 follicular carcinoma,
and 4 benign tumors. Identification of blue-stained SLN was successful in 93.5%
of cases. Negative and positive predictive values were 94.7% and 100%, while
overall accuracy of the methods was 95.6%. In the one patient with follicular
carcinoma, SLN detection failed. Four patients had one radioactive node, 1 had
3, and 1 had 4.
Conclusion:
Our results imply that SLN biopsy in the jugulo-carotid chain using methylene
blue dye mapping is a feasible and accurate method for estimating lymph node
status in the lateral neck compartment. The method could be helpful in
detection of true positive but nonpalpable lymph nodes and may be useful in
patients with DTC.
9159 Gynecology
Use of the PlasmaJet System in the Laparoscopic Treatment of Endometriosis: Early Experience
Kimberly A. Kho, MD, MPH, Ceana Nezhat, MD
Northside Hospital, Atlanta, Georgia
Objective: To examine the feasibility of the use of neutral
argon plasma for the laparoscopic treatment of endometriosis.
Methods: In this prospective pilot
study, 20 patients undergoing laparoscopic treatment of endometriosis were
included. Characteristic endometriotic lesions throughout the pelvis were
vaporized or resected using neutral argon plasma by the PlasmaJet System (PJS).
Specimens were evaluated for the presence of endometriosis and thermal effects
on tissue. The bases of the treated lesions were biopsied to determine whether
residual endometriosis was present.
Results: PlasmaJet was used in 18 of the 20 patients for
laparoscopic treatment of pelvic endometriosis. Forty-six lesions were
vaporized or excised with the PJS. Twenty-seven lesions were vaporized, and
biopsy of the base of the lesions was performed in 7 of these sites. Nineteen
lesions were resected using the PJS with biopsy of the base in 8 of these
sites. All biopsies confirmed complete vaporization or resection with no
residual endometriosis at the base. Endometriosis was identified on pathology
examination in all lesions excised using PJS. Thermal effects did not interfere
with histologic analysis in any of the lesions. No complications occurred.
Conclusions:
Neutral argon plasma may be an effective new modality for the treatment of
endometriosis. The PJS can be utilized as a multi-functional device that has vaporization,
coagulation, and superficial cutting capacities with minimal thermal spread.
The PJS appears to be efficacious for the complete treatment of endometriotic
implants.
9160 General Surgery
Laparoscopic Inguinal Hernia Repair (IPOM) with Dual-Mesh: Feasibility and
Advantages
Giovanni Cesana, MD, Stefano Olmi,
MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milan, Italy
Objective: Inguinal hernia repair by the laparoscopic approach is commonly
performed by TEP or TAPP technique. The mesh is usually placed in a
retroperitoneal position and fixed with mechanical clips. These procedures are
quite long and complicated, and many authors have shown that the learning curve
may be a serious issue. The laparoscopic inguinal hernia repair (IPOM) technique
could be an interesting alternative, as this technique is much easier and
faster.
Methods: From January 2003 to
December 2008, we performed 96 inguinal hernia repair procedures with the
laparoscopic approach (94 males, 2 females, mean age 60 years, mean weight
76kg), with the IPOM technique and using Parietex Composite mesh (Sofradim,
France) and fibrin glue (Tissucol, Baxter, USA) for mesh fixation.
Results: Mean operative time was 10
minutes. Mean hernia diameter was 2.5cm (±0.8cm), 16 hernias were direct, 80
were indirect, and 20 of 96 were recurrent. We did not have to convert any of
the laparoscopic procedures. The mean time of discharge was 1 day, and the mean
time for resumption of physical or working activities was 5 days. With a mean follow-up
of 36 months, only 1.6% of the patients had hematoma at the trocar site; no
additional complication was reported, in particular no recurrence, no mesh
migration, no occlusion, and no fistula were observed.
Conclusion: IPOM is the easiest and
fastest hernia repair technique. This study shows that with the right material
it is feasible and without serious complications.
9161 General Surgery
Atraumatic Repair of Ventral Hernia Using Fibrin Glue
Stefano Olmi, MD, Giovanni Cesana,
MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milano, Italy
Objective: The aim of this study was to establish the efficacy and
tolerability of human fibrin glue (Tissucol) for the nontraumatic fixation of a
composite prosthesis (Parietex) and a new mesh (Hi-Tex, Textile) in the
laparoscopic repair of small and medium incisional hernias and primary defects
of the abdominal wall.
Methods: From October 2003 to
December 2007, 77 patients with abdominal wall hernia underwent laparoscopic
repair; all meshes were implanted in an intraperitoneal position. Follow-up
visits were scheduled for 7 days and 1, 6, and 12 months, and 2, 3, and 5 years. These included
assessments for pain and postoperative complications.
Results: Seventy-seven patients (44
females, 33 males) with a mean age of 50 years (range, 26 to 65) and a mean BMI
of 27 (range, 25 to 30) were included in the study. Twenty-four patients had
incisional hernias, and 53 had primary defects. The size of the defects varied
from 2cm to 7cm. Adhesiolysis was necessary in 62.5% of cases. No
intraoperative complications or conversions occurred. After a mean follow-up of
32 months (range, 2 to 50), no postoperative complications were observed. The
mean surgical intervention time was 36 minutes (range, 12 to 40) with an average
hospitalization time of 1 day.
Conclusion: The use of fibrin glue provided stable and uniform fixation of
the prosthesis and minimized intra- and postoperative complications.
Consequently, laparoscopic treatment of small- to medium-sized abdominal
defects using this approach is our therapeutic option of choice.
9162 General Surgery
Laparoscopic Repair of Incarcerated Incisional Hernia: Our Experience
Stefano Olmi, MD, Giovanni Cesana,
MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milan, Italy
Objective: The emergency treatment of incisional hernias can be
accomplished by the laparoscopic approach to avoid the common postoperative
complications of the open technique.
Methods: From January 2001 to
December 2007, we performed the laparoscopic approach in an emergency regime to
treat incarcerated hernias. We used 2 types of mesh: Parietex (Covidien) and
Hi-Tex (Textile), and for dissection we used a 5-mm ultrasound dissector
(Ultracison, Ethicon)
Results: Forty-five patients with
incisional hernia (29 females and 16 males) underwent emergency treatment, due
to incarcerated incisional hernia. Exclusion criteria for the study were the
eventual necessity of intestinal resection due to intestinal necrosis (3 cases)
or the presence of great incisional hernia with loss of domain (2 cases). A
severe respiratory insufficiency (2 patients) and cardiocirculatory problem (2
patients) were not contraindications to the laparoscopic technique. Mean
operating time was 62 minutes (range, 45 to 80). The average hospitalization
time was 4 days (range, 3 to 6). Surgical complications were 8 seromas treated
by medical therapy with seroma aspiration. No prosthesis infection occurred. No
metabolic or infective complications occurred. No surgical complications, need
for reintervention, recurrence, or deaths occurred.
Conclusion: These results prove the
feasibility of the emergency laparoscopic approach to incarcerated incisional
hernias, using new generation meshes.
9163 General Surgery
Hole-Mesh Device Allows Accessing the Bypassed Stomach in Patients Who Undergo
Roux-en-Y Gastric Bypass for Severe Obesity
Giovanni Cesana, MD, Stefano Olmi,
MD, Antonio Catona, MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milan, Italy
Objective: Roux-en-Y gastric bypass (RYGBP) is the current standard of care
in bariatric surgery. It has been reported to cure type II diabetes in obese
patients. There have been reported cases of mucosal dysplasia and cancer in the
bypassed stomach following RYGBP. No possibilities to explore the residual
stomach have yet been described.
Methods: We have developed
Hole-Mesh, a specific device to access the bypassed stomach after RYGBP. It is
made of a central part (12-mm diameter and 10-mm thickness) with a radiopaque
wire at the edge, located in the middle of a 30-mm diameter polypropylene mesh.
The device is placed in the residual stomach during the RYGBP
video-laparoscopic intervention. It allows the gastric wall to connect to the
parietal peritoneum.
Results: An experimental study in
pigs has shown the feasibility of the procedure. Up to now, we have positioned
Hole-Mesh in 5 patients without any complications with a median follow-up of 6
months. The device permits radiological examination of the bypassed stomach
through the introduction of Gastrografin by a syringe; it allows making an
endoscopic exploration of the cavity through a trocar to analyze the gastric
content through needle aspiration and to establish enteric nutrition through a
catheter in case of leakage of the gastroenteric anastomosis.
Conclusion: Hole-Mesh is well
tolerated by patients, without complications. It allows exploring the bypassed
stomach, duodenum, and ileum after RYGBP. It may be useful in understanding the
biologic mechanisms of metabolic changes especially in obese diabetic patients.
9164 General Surgery
Laparoscopic Sigmoid Colectomy for Diverticulitis: A Prospective Study of
260 Patients.
Prof. Dr. Ivo. Baca, Khaled Elzarrok, Leszek Grzybowski, Armin
Jaacks
Klinik fuer Allgemein-, Viszeral- und Unfallchirurgie, Klinikum
Bremen Ost, Bremen, Germany
Background: Surgical treatment of
complicated colonic diverticular disease is still debated. The aim of this
prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy
for diverticulitis. Indications for laparoscopic surgery were acute complicated
diverticulitis (Hinchey stages I and IIa), chronically recurrent
diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.
Method:
All patients who underwent laparoscopic colectomy within a 12-year period were
prospectively entered into a PC database registry. One-stage laparoscopic
resection and primary anastomosis constituted the planned procedure. A 4-trocar
approach with suprapubic minilaparotomy was used. Main data are age, sex,
postoperative pain, return of bowel function, operation time, duration of
hospital stay, and early and late complications.
Results: During the study period,
260 sigmoid colectomies were performed for diverticulitis. Patients included
104 males and 156 females. M:F ratio is 4:6. Postoperative pain was controlled
by NSAIDs or a weak opioid, and 15 patients (5.7%) required conversion from
laparoscopic to open colectomy. Most common reasons for conversion were
directly related to the inflammatory process, abscess, or fistulas. Mean
operative times were 130±54. Average postoperative hospital stay was 10±3 days.
A longer hospital stay was required for those in Hinchey IIa. Complications
were recorded in 32 (12.3%). The most common complication requiring reoperation
was hemorrhage in 5 (1.9%) patients. Anastomotic leak occurred in 11 patients
(3 of them required reoperation). The mortality was 2 patients (0.76%).
Conclusions: Laparoscopic surgery for
diverticular disease is safe, feasible, and effective. Therefore, laparoscopic
colectomy has replaced open resection as standard surgery for recurrent and
complicated diverticulitis at our institution.
9165 General Surgery
Management of Chyloperitoneum Following Redo-Laparoscopic Nissen Fundoplication
in a 23-Month-Old Female
E. L. Galiñanes, MD, A. A.
Wheeler, MD, T. P. Mayfield, MD, V. Ramachandran, MD
University of Missouri, Columbia, Missouri
Background: Chyloperitoneum is a rare complication that has been described
after abdominal aneurysm repair, retroperitoneal node dissection, or nephrectomy
due to disruption of the cisterna chyli or thoracic duct. Rarely has it been
described in conjunction with laparoscopic surgery. We describe a case of
chyloperitoneum occurring after redo-laparoscopic Nissen fundoplication that
was successfully treated with conservative management.
Methods: We present the case of a
girl born at 25 weeks gestation with cerebral palsy, feeding difficulty, and
reflux. She received a gastrostomy and Nissen fundoplication. One year later,
she presented with a hiatal hernia and symptoms of reflux, weight loss, and
vomiting. At diagnostic laparoscopy, the previously placed wrap was found to
have slipped into the mediastinum. Operatively, it was mobilized back into the
abdominal cavity, the wrap taken down and reapplied. Postoperatively, the
patient developed abdominal distention, nausea, and vomiting prompting
reoperation. Copious milky fluid was noted, aspirated, and later confirmed to
be chyle.
Results: A pyloroplasty was
performed for delayed gastric emptying, no drains were placed, and the patient
was further treated conservatively with total parenteral nutrition. The
chyloperitoneum resolved over the course of 5 days, and the patient was then
transitioned to medium chain fatty acid lipid tube feeds.
Conclusion: We describe a rare
complication of laparoscopic foregut surgery in pediatric patients. Although
usually described after surgery involving hindgut structures whereby the
cisterna chyli are disrupted, foregut surgery more likely disrupts the thoracic
duct near its diaphragmatic hiatus but can be successfully treated with a
diet/enteral feeding with medium fatty acids.
9166 General Surgery
Laparoscopic Ventral Hernia Repair without Suture Fixation
Kevin Gillian MD
Background: The
technique for laparoscopic repair of ventral hernias has been shown to be an
effective technique for repair. Disagreements arise over which mesh should be
utilized and how it should be fixed to the abdominal wall. Laparoscopic ventral
hernia repair with polypropylene mesh fixation using a double crown of 5-mm
tacks has been shown to be a feasible repair with excellent outcomes for the
patient.
Methods: A
retrospective review of laparoscopic repair of ventral hernias utilizing a
variety of polytetrafluoroethylene (ePTFE) meshes by a solo surgeon was
undertaken. These repairs were performed without transfascial suture fixation.
Data were obtained from patient records and phone interviews.
Results: Laparoscopic
ventral hernia repair was performed in 100 patients with one conversion to open.
Multiple hernia defects were noted in 45 patients. The mean age of the patients
was 56 (range, 21 to 89) with 44 men and 56 women. Comorbidities most common in
this population were obesity (45%) and diabetes (7 %). No deaths and one
complication occurred in this series. Follow-up ranged from 33 to 84 months
(mean, 44.37). Patient satisfaction was noted on the Carolina Comfort Scale.
There were no recurrences or mesh removals during this medium-term follow-up
study.
Conclusion: Our
results support the concept that transfascial fixation can be eliminated in the
laparoscopic repair of ventral hernias with polypropylene/ePTFE mesh while
preserving low postoperative morbidity and high patient satisfaction.
9167 General Surgery
Postlaparoscopy Pain Control with Tarns Port Local Anesthesia
S. A. Vejdan, MD
Imam Reza Hospital, Birjand Medical University of Science
Objective: Laparoscopic surgery has
a short painful period after operation, but it is not a painless procedure.
Conventional painkillers in laparoscopic surgery consist of NSAIDs and
narcotics that have their specific side effects, but their use is unavoidable.
This study evaluated the role of local trans-port anesthesia with local
anesthetic drugs to reduce postlaparoscopic pain and narcotic use.
Methods and Procedures: At the end
of laparoscopic surgeries, before port withdrawal, a local anesthetic mixture
[a short-acting (Lidocaine 2%) plus a long-acting (Bupivacaine 5%)] was
instilled through the port lumen between the abdominal wall layers. This study
was performed in 2 groups of patients. Group 1, the control group, was given
traditional painkillers like narcotics and NSAIDs. Group 2 was given the
trans-port mixture. Efficacy of the medications was compared. This is
prospective clinical trial.
Results: In group 1, 95% received
Meperidine 50mL to 200mL 1 to 4 times for pain control and group 2 was
controlled with transrectal NSAIDs. In group 2, pain in 65% of the patients was
controlled with just local anesthetic drugs (this method), 30% needed NSAIDs,
and only 5% needed narcotics.
Conclusions: Use of local anesthetic
drugs for pain control after laparoscopic surgery is a modality with a low
complication rate, is very effective in all conditions, and can reduce the side
effects of narcotics.
9168 General Surgery
Laparoscopic Splenectomy for Multiple Distal Aneurysms of the Splenic Artery
M. Lombardi, MD, E. Puce, MD, D. Apa, MD, B. C. Brassetti, MD,
G. A. Senni, MD, F. Atella, MD
Introduction: Splenic artery
aneurysm is a rare pathology that carries the risk of rupture (3% to 9.6%)
when the transverse diameter reaches 2cm or more. This is associated with a
high mortality rate of 36% that increases to 75% among pregnant women. The risk
factors include portal hypertension, vasculitis, arteriosclerosis, arterial
fibrodysplasia and female sex. These aneurysms are usually incidental findings.
Management choices include open, laparoscopic, and endovascular procedures.
Case Report: We report on a
57-year-old female with a past history of insipid diabetes and
hypercortisolemia. The aneurysm was asymptomatic and was an incidental finding
as a result of a helical contrast computed tomography to investigate adrenal
glands. CT scan revealed multiple distal aneurysms of the splenic artery that
measured >2cm in diameter. We performed a laparoscopic splenectomy using a
lateral approach with optimal visualization of splenic vessels. No
postoperative complications occurred, and the patient was discharged on the
fourth postoperative day.
Conclusion: Splenic artery aneurysm
is a rare yet very important clinical entity because of its potential for
rupture with fatal consequences. Surgical treatment is recommended for
aneurysms >2cm. Angiographic interventions and laparoscopic exclusion of
splenic artery aneurysm have been shown to provide adequate therapy without the
morbidity associated with open procedures. Although many can be treated with
percutaneous embolization, tortuosity of the artery may render this approach
impossible. For distal and hilar located multiple aneurysms, laparoscopic
splenectomy represents a reasonable option.
9169 General Surgery
Laparoscopic Resection of a Retroperitoneal Mass
M. Lombardi, MD, D. Apa, MD, E. Puce, MD, B. C. Brassetti, MD,
G. A. Senni MD, F. Atella, MD
Introduction: We describe the laparoscopic resection of a
retroperitoneal mass with radiological impression of adrenal
“incidentaloma.” Surprisingly, histopathology revealed a “well-differentiated
retroperineal liposarcoma.”
Case Report: An asymptomatic
42-year-old female referred to our hospital after a screening ultrasonography
with detection of an incidental retroperitoneal tumor.
Helical CT scan and magnetic resonance imaging showed a large
solid mass >5cm in maximum diameter in the left adrenal gland space. The
tumor appeared hypervascularized, containing a large area of necrosis. The
pancreatic vessels and pancreatic tail were displaced by the mass without
images of invasion surrounding organs. Fine needle aspiratory cytology was
inconclusive due to suboptimal cellularity. With the clinical diagnosis of a
nonfunctioning adrenal tumor, the patient received laparoscopic resection. The
operation was difficult because of hypervascularization of the mass and
tenacious adherences to the left renal capsule that was resected. The
pathological diagnosis was well-differentiated liposarcoma, sclerosing type.
The histological margins were negative. After 1 year, a radiological suspect
appeared of lymphatic relapse on the celiac axis.
Conclusion: Liposarcoma is the most
frequent histotype of rare retroperitoneal tumors. The histological subtype and
margin of resection are prognostic for survival in primary tumors. Local
recurrences are the most frequent cause of failure of the surgery. The
feasibility of complete resection is crucial for prognosis. The open approach
is the gold standard, but in this case, laparoscopy was technically safe and
successful in maintaining oncologic principles of radicality. In select cases,
this approach represents a feasible alternative to open surgery.
9170 Gynecology
Laparoscopic Isthmic Cerclage: A Simplified Technique
Antoine Watrelot, Jean Michel
Dreyfus
Centre de Recherche et d'Etude de la Stérilité (CRES), Lyon, France
We describe the technique of laparoscopic isthmic cerclage for cervical incompetency.
By using an artefact described by Tulandi, we performed the technique using a
percutaneous needle. The technique is therefore very simple and easy to learn.
Indications for isthmic cerclage are not so frequent, but due to the
mini-invasiveness of this approach it is probably suitable to propose this
operation even if the patient has only one late miscarriage (and not 2 as
classically recommended). To date, we have performed 7 cerclages with this
technique; 5 patients have been pregnant and have undergone a caesarian
delivery between 32 to 36 weeks of gestation. The 2 other patients are
still not pregnant, 6 and 10 months after surgery, respectively. We
believe that the laparoscopic isthmic cerclage (namely Benson's cerclage) is an
attractive alternative to the vaginal Shirodkar technique.
9171 Gynecology
Report of the Largest Case Series of Parasitic Myomas
Kimberly Kho, MD, MPH, Ceana Nezhat, MD
Atlanta Center for Special Minimally Invasive Surgery &
Reproductive Medicine, Atlanta, Georgia
Objective:
To report the largest case series of parasitic myomas in the medical
literature, and an examination of causes, associations, and risk factors.
Methods:
A retrospective chart review was performed on 12 patients found to have
parasitic myomas between August 2000 and September 2008. The following data
were systematically collected: surgery date; indications for surgery; number,
dates, and types of prior surgeries; prior use of morcellation; and locations
of parasitic myomas. Pathologic confirmation of all specimens was obtained.
Results:
Laparoscopic evaluation confirmed the presence of intraperitoneal and
retroperitoneal myomas distinct from the uterus in 12 patients. Ten of the 12
patients had prior abdominal surgery. Six patients had prior morcellation
procedures during laparoscopic myomectomy, and 2 patients had abdominal
myomectomies. Three patients had multiple parasitic fibroids; all of them had a
history of laparoscopic myomectomy with morcellation. The majority (14/15) of
parasitic myomas were found in the pelvis, 2 of which were retroperitoneal.
Conclusion:
Parasitic myomas may occur spontaneously as pedunculated subserosal myomas lose
their uterine blood supply and parasitize to other organs. However, this series
supports what the literature has suggested; more parasitic myomas may be
iatrogenically created after prior surgery, particularly surgery using
morcellation techniques. With increasing rates of laparoscopic procedures,
surgeons should be aware of the potential for iatrogenic parasitic myoma
formation, their likely increasing frequency, and intraoperative precautions to
minimize occurrence.
9172 Multispecialty
Laparoscopic Gastrostomy Utilizing a Multidisciplinary Approach is Safe and
Beneficial in Infants Under 10 Kilograms with Congenital Heart Disease
Richard Hendrickson, MD2, Denis
Bensard, MD2, Monte Harrison, DO1, Katie Giesting, PNP1, Simon Abraham, MD1, Josh
Careskey, MD1, Evan Kokoska, MD2
1Peyton Manning Children’s Hospital at St. Vincent, Cincinnati, Ohio
2University of Cincinnati School of Medicine, Cincinnati, Ohio
Background: Infants with
congenital heart disease often have feeding difficulties and poor weight gain.
Cardiac procedures may require staged correction. Feeding access is often
beneficial. The safety and efficacy in this cohort of cardiac patients
undergoing laparoscopic procedures is unclear. We hypothesized that a
multidisciplinary team approach and laparoscopic gastrostomy can be
performed safely.
Methods: In a women’s and
children’s hospital, all complex congenital heart disease infants with failure
to thrive and poor enteral intake (n=10) were offered a laparoscopic approach
for enteral access over a 15-month period (09/2007 to 12/2008). All patients
had at least one cardiac procedure and had demonstrated failure to thrive
without clinical or radiographic evidence of gastroesophageal reflux.
Pediatric cardiology, cardiac surgery, intensivist, neonatologist, and surgery
personnel all participated in the pre-, intra- and postoperative management.
Results: Ten infants (6 male, 4
female; average age at surgery 12 weeks (range 3 to 51) underwent
laparoscopic-assisted gastrostomy placement. Average operative weight
was 4.2 kilograms (range 2.75 to 6.8). Operating room time average was 80
minutes (range, 59 to 120). Average surgical time was 38 minutes (range,
28 to 70). All patients were started on feeds within 24 hours and reached full
feeds on average in 92 hours (range, 58 to 141). No infant required conversion
to an open procedure. No intra- or postoperative complications occurred.
Conclusion: Utilizing a
multidisciplinary approach in infants with complex congenital heart disease
safely permits minimally invasive feeding access.
9173 Multispecialty
Laparoscopic Application of a Hyaluronate/Carboxymethylcellulose Slurry Does
Not Increase Postoperative Adhesions
Bradford W. Fenton, MD, PhD
Summa Health System Department of Obstetrics and Gynecology, Pelvic Pain
Specialty Center
Background: Postoperative adhesion
formation is a significant problem with any surgery, but most approved adhesion
prevention measures are difficult to apply through the laparoscope. Cut up
sheets of hyaluronate/carboxymethylcellulose can be suspended in saline and
then applied as a slurry through a laparoscopic irrigator. It is unknown
whether the slurry formulation retains adhesion prevention properties, or if it
might induce more adhesions after application.
Method: A slurry of
hyaluronate/carboxymethylcellulose was created by cutting three 5x7-cm sheets
into squares <1cm each, and suspending them in 60cc of 2% lidocaine. The
resultant slurry was then applied following laparoscopic fulguration of
endometriosis and lysis of adhesion for chronic pelvic pain in 2 patients.
Following 1 year of medical suppression therapy, the patients requested a
repeat of the fulguration for their recurrent pain. The number of sites of
fulguration and adhesion lysis at the initial laparoscopy were evaluated at the
second laparoscopy for the presence of adhesions.
Results: No adhesions were
encountered at the level of the umbilicus or upper pelvis. At the sites of
hyaluronate/carboxymethylcellulose slurry application, previous fulguration,
and adhesion lysis, no adhesions were encountered.
Conclusion: Prevention of
postoperative adhesions depends on many factors, and application of adhesion
barriers provides a potential to decrease postoperative adhesion formation.
Using a slurry of hyaluronate/carboxymethylcellulose extends the options for
adhesion prevention in laparoscopic surgery. From these patients, there is no
evidence that the hyaluronate/carboxymethylcellulose slurry increases adhesion
formation.
9174 Gynecology
Dysautonomias Are Not Associated with Chronic Pelvic Pain
Andrea Crane, MD, Bradford W. Fenton, MD, PhD
Summa Health System, Pelvic Pain
Specialty Center
Background: Several studies have suggested that disorders of the autonomic
nervous system are associated with chronic pelvic pain (CPP) and interstitial
cystitis (IC) in particular. Because diagnostic criteria are available for
several dysautonomias, this association can be investigated with a survey.
Method: As part of an ongoing
survey, 100 women in an urban, resident-run gynecology practice and 73 women in
a CPP referral center (CPPrc) filled out identical surveys with the diagnostic
criteria for postural orthostatic (POTS), vasodepressor syncope (VDS), chronic
fatigue (CFS), irritable bowel syndrome (IBS), migraines, and IC. IC was
diagnosed by cystoscopy in the CPPrc. CPP patients also underwent orthostatic
blood pressure and pulse testing.
Results: No patient met criteria for
VDS or CFS in either group. In the general gynecology population, 21% had CPP,
16% had POTS, 24% had migraines, 5% had IC, and 4% had IBS. The presence of CPP
was associated (chi square; P<0.001) with migraines, but not POTS, IC, or
IBS. In the CPPrc, 32% had POTS, 36% had migraines, 16% had IC, and 33% had
IBS. The presence of IC was associated with IBS (P=0.04), but not POTS or
migraines. Hemodynamic parameters were not related to the presence of IC.
Conclusion: Although it has been
suggested that chronic pain syndromes are associated with dysautonomias, no
clear relationship was demonstrated by this data set. The lack of change in
orthostatic blood pressure testing supports these conclusions. A larger series
or more intensive testing may produce different results.
9175 Gynecology
Lifelong Dysmenorrhea is Associated with Other Muscle Tension Pain Syndromes
Andrea Crane, MD, Eileen Witten, MD, Bradford W. Fenton, MD,
PhD
Summa Health System, Pelvic Pain
Specialty Center
Background: Dysmenorrhea is a significant problem that is one component of
chronic pelvic pain (CPP), a standardly defined syndrome. Several other chronic
pain disorders have similarly defined criteria, which can be used to construct
diagnostic surveys. It is unknown whether a lifelong history of dysmenorrhea
(painful menses from menarche onward) has any relationship to other chronic
pain disorders. If so, it may suggest that these women have an inherent
heightened sensitivity to pain.
Methods: As part of an ongoing
survey, 100 women seen in an urban residency clinic filled out a survey
containing the definitional criterion for chronic pelvic pain, irritable bowel
syndrome (IBS), interstitial cystitis (IC), migraines, and scales for traumatic
stress, childhood trauma, abuse, anxiety, depression, and fibromyalgia (FMS).
Results: Lifelong dysmenorrhea (LD)
was present in 38% and was significantly more frequent (chi squared: P<0.05)
in patients with any or all criteria for CPP, IC, and migraines, and was
related to (t test: P<0.05) higher
FMS scores. Neither a history of abuse nor IBS was more common in LD patients.
LD patients were not significantly older (average age 34), of higher parity,
nor had higher anxiety, depression, traumatic stress, or childhood trauma
scores.
Conclusion: The association of LD
with other muscle tension pain syndromes (migraines, FMS, and IC) suggests that
these patients may have an inherent, possibly cerebral, hypersensitivity to
pain. In this population of LD patients, psychiatric symptoms were not more
pronounced, suggesting that centralized pain sensitivity may not be related to
trauma, abuse, or other experiences.
9176 Gynecology
Limbic Brain Areas are Activated in Chronic Pelvic Pain
Bradford W. Fenton, MD, PhD
Summa Health System, Pelvic Pain
Specialty Center
Introduction: Interstitial cystitis (IC) is one of several entities
commonly associated with chronic pelvic pain. Due to the association of IC with
other chronic pain disorders, it has been suggested that some of these patients
may have a heightened sensitivity to pain. If this is the case, then it is
unknown whether the medial limbic pain pathway is more active, as has been
suggested, or if the lateral nociceptive pathway is more active.
Methods: In this pilot study, 4
healthy controls and 2 patients with simple IC underwent localization of
electroencephalographic (EEG) brain frequency analysis with their bladder
empty. All patients underwent a visual evoked oscillations assessment using a
fearful faces presentation. Comparison between groups was done using a
nonparametric log f test.
Results: In IC patients, complexity
of the EEG (omega), a global measure reflecting degree of spatial
synchronization, was significantly increased in the anterior cingulate gyrus.
Delta wave activity was also significantly increased in the anterior cingulate
in IC patients. Other frequencies were variably different: IC patients had more
alpha activity in the occiput, and controls had more diffuse beta activity,
particularly middle temporal.
Conclusions: Interstitial cystitis patients,
even immediately after voiding, continue to feel pain through an activated
medial pain perception pathway, which terminates in the anterior cingulate
gyrus. This occurs through theta wave activity, and is confirmed by the
increase in omega in these areas, consistent with other studies of affective
pain. This pilot study indicates that the limbic pain perception pathways are
activated in IC.
9177 Gynecology
An Innovative Electric Converter (M/BAC*) for Laparoscopic Surgery
Youngse Park
CHA University, CHA General Hospital, Korea
Objective: To evaluate the efficacy and safety of a new electric converter
(M/BAC*: Monopolar/Bipolar Automatic Converter) for laparoscopic surgery.
Methods: This was a
retrospective, comparative study reviewing DVDs of 40 women who underwent total
laparoscopic hysterectomy from November 2006 to September 2008 due to benign
pathology. Study populations were divided into 4 groups according to
instruments used, and each group consisted of 10 women: conventional alternate
bipolar/monopolar instruments (group 1), above instruments with both hands
(group 2), combo-coagulator* using M/BAC* (group 3), and LigaSure* (group 4).
The following were examined: (1) numbers of instrument changes per case and (2)
elapsed time for controlling bleeders in each group. Exclusion criteria
were women with any previous pelvic surgery, any concurrent surgeries, moderate
to severe pelvic adhesions, ureteral, uterine artery dissection, any
complications, RUMI system failure, and a uterus that was too small (<100g)
or too large (>500g).
Results: Baseline
characteristics were similar among the 4 groups (P>0.05). Median numbers of
instrument changes per case were 40, 25, 7.5, and 29.5 (P=0.0000),
respectively. Median elapsed time (seconds) for bleeding control was 17, 4, 3
(P=0.0000), but if blurring positive, 84 (group 1) vs. 28 (group 2).
Statistical analysis was performed using one-way analysis of variance,
Kruskal-Wallis test (a level of significance: P<0.05).
Conclusions: (1) Group 3 had
the smallest number of instrument changes (1/5 of group 1), and the shortest in
elapsed time for bleeding control. (2) M/BAC* decreased operation time, blood
loss, costs, and no related problems occurred.
9178 General Surgery
Preliminary Results with Endoscopic Plication for Revision of Gastric Bypass
Dimitrios V. Avgerinos, MD, Chiranjiv Virk, MD, Omar H. Llaguna, MD, John
L. Holup, DO, I. Michael Leitman, MD
Beth Israel Medical Center and Albert Einstein College
of Medicine, New York, New York
Objective: A new technique for endoscopic plication and revision of gastric
pouch (EPRGP) for patients who underwent gastric bypass (RGB) surgery was
evaluated in patients with severe GERD, dumping syndrome, and/or failure of
weight loss.
Patients and Methods: Patients
underwent EPRGP over an 8-month period. The StomaphyX device (Endogastric
Solutions, Redmond, WA) was utilized over a standard flexible gastroscope.
Patients were kept on a clear liquid diet for 1 week after the procedure.
Results: The study included 30
patients with a mean age of 46.3 years. EPRGP was performed an average of 4.9
years following RGB. The mean preoperative BMI was 41kg/m2. The
indications were dumping syndrome (21), GERD (6), and failure of weight loss
(3). The mean follow-up period was 4.3 months (range, 1 to 8). The average
operative time was 57 minutes, with a significant reduction with increased
operator experience. There was only one (3.3%) intraoperative complication
during the early period (equipment failure), which did not result in any
morbidity. All patients were discharged home after overnight observation.
Postoperatively, all were free of symptoms from dumping syndrome or reflux,
with no further operative-related complications. The mean weight loss was 9.2
lbs.
Conclusions: This study demonstrates
the technical feasibility and safety of EPRGP. This is a valuable technique for
the treatment of some of the gastrointestinal complications of RGB with modest
early weight loss. Further studies and extended follow-up are necessary to
determine the durability of weight loss.
9179 Gynecology
Laparoscopic Approach for Presacral Tumors: Early Experience of Initial 19
Cases
Huicheng Xu, MD, Yong Chen, MD, Yuyan Li,
MD, Junnan Li, MD, PhD, Dan Wang, MD, Zhiqing Liang, MD, PhD
Southwest Hospital, Third Military Medical University,
Chongqing, PR China
Objective: The aim of this study was to evaluate the complete surgical
resection by a laparoscopic surgical technique normally undertaken for tumors
under the sacral promontory.
Methods: This was a retrospective
review of the clinical features and results of surgical treatment of 19
patients who had laparoscopic resection of presacral tumors between 2005 and
2008.
Results: All 19 patients underwent
the laparoscopic procedure, and complete tumor resection was obtained. The mean
operative time was 182 minutes (range, 115 to 328), with a mean blood loss of
180mL (range, 120 to 230), and the average hospital stay was 6.2 days (range, 6
to 9). Pathological findings included 6 teratomas, 6 dermoid cysts, 3
schwannoma, 2 tailgut cysts, 1 hamartoma, and 1 aggressive angiomyxoma. No
complications occurred interoperatively. One patient has transitory left leg
motor dysfunction. No postoperative mortality or complication was seen. In
addition, no sensory or motor dysfunction of the bladder or rectum was observed
postoperatively. The median follow-up was 16 months (range, 3 to 32). The
postoperative course was uneventful, with one teratoma recurrence at 12 months
and 1 aggressive angiomyxoma recurrence at 29 months.
Conclusion: Laparoscopic surgery for
the removal of presacral tumors is feasible. The use of this new technical
approach offers many advantages but requires extensive experience in pelvic
surgery and laparoscopic skills. It is suggested that such laparoscopic
procedures be reserved for select cases of benign tumors, and its application
must be verified by further studies.
9180 Gynecology
Laparoscopic Gonadectomy for Androgen Insensitivity Syndrome with Serous
Gonadal Cyst
Mineto Morita, MD, Takehiko Tsuchiya, MD, Ichiro Uchiide, MD,
Masahito Nakakuma, MD, Yukiko Katagiri, MD
Toho University School
of Medicine
Introduction: Androgen insensitivity syndrome is caused by a
mutation in the androgen receptor gene. The frequency varies from 1/10,000 to
1/62,400 women. We report on a patient with androgen insensitivity syndrome
with a serous gonadal cyst who underwent laparoscopic surgery.
Case Report: The
patient was a 15-year-old phenotypic woman with height 162.5cm and weight
63.0kg. Her breasts were Tanner stage III. Abdominal findings included
bilateral inguinal scars consistent with hernia repair. Pelvic examination
revealed normal external female genitalia with Tanner stage I pubic hair. The
vaginal vault ended in a blind pouch and was approximately 8-cm deep.
Ultrasound and magnetic resonance imaging revealed the presence of a 36-mm
cystic smooth mass close to the left external iliac vein and artery. Serum
hormone concentrations were FSH 12.0mIU/mL, LH 30.5mIU/mL, E2 36.25pg/mL, T
10.12ng/mL, PRL 23.9ng/mL. The chromosome test revealed a normal 46,XY. The
diagnosis of androgen insensitivity syndrome was made on these findings.
Bilateral laparoscopic gonadectomy was performed with the patient under general
anesthesia. Histopathological finding of the gonads was immature testis.
Estrogen therapy was initiated postoperatively.
Conclusion: Due
to the reduced morbidity, shorter hospital stay, and safety, laparoscopic
gonadectomy can be considered the treatment of choice for removal of gonads in
patients with androgen insensitivity syndrome.
9181 General Surgery
Resection of Gastrointestinal Stromal Tumor of the Rectum by Transanal
Endoscopic Microsurgery
Paul R. Sturrock, MD, John C. Fondran,
MD, Adam A. Klipfel, MD, Jorge A. Lagares-Garcia
Rhode Island Colorectal Clinic,
Pawtucket, Rhode Island
Objective:
Gastrointestinal stromal tumors (GIST) involving the rectum represent a rare
clinical entity. We propose that transanal endoscopic microsurgery (TEM) may
represent an acceptable option for surgical resection of rectal GIST.
Methods: Case report and review of the literature.
Results: This case represents a successful resection
of a GIST of the rectum via TEM.
Conclusion: While currently little evidence exists in
the literature regarding the application of TEM to GIST of the rectum,
extrapolation from series in other areas of the gastrointestinal tract
indicates complete resection of the lesion is the goal of surgery. TEM may
allow a minimally invasive approach to these lesions in select patients.
9183 Multispecialty
Experimental Model in a Pig as a Training Tool in Endoscopic Axillary
Dissection
María Eugenia Aponte-Rueda,
MD, PhD, Ramón A. Saade Cárdenas, MD,
Rodolfo Miquilarena, MD
Caracas University Hospital, Central University of
Venezuela, University City,
Caracas-Venezuela
Background: Endoscopic axillary lymphatic dissection is part of our
surgical options, but its use has not been accepted with great enthusiasm.
Several factors have accounted for this, including the lack of an effective
experimental model that allows obtaining skills and abilities. The aim of this
study was to develop a training tool for endoscopic axillary dissection and to
evaluate its applicability in a pig model.
Methods: Twenty endoscopic
dissections of the axilla were performed in 10 pigs of 4 to 6 months (weight,
25 to 35kg) by a single surgeon. Subcutaneous axillary space was dissected with
blunt dissection and kept with CO2. Surgical workflow was segmented
into temporal operative phases (space creation, trocar placement, dissection,
and lymphadenectomy). Time necessary to perform this action was compared
throughout the study.
Results: The mean dissection time
was 26+7 minutes (range, 19 to 33). The axillary content was separated
from the other anatomical elements under complete visualization (85% to 100% of
the cases). Intraoperative complications happened in 2 dissections of 20 (10%)
including uncontrollable bleeding and subcutaneous emphysema. Residual
fibrofatty tissue was removed in 3 of 20 dissections.
Conclusion: We defined a pig model for commencement of training in
endoscopic axillary dissection. With this model, the surgeon can learn to
handle the structures atraumatically, to remove nodes, and to use instruments
in a close workspace with complicated anatomy, which allow the development of a
valid model for obtaining advanced laparoscopic skill that may be applicable to
other endoscopic axillary procedures.
9184 Urology
Median Lobe in Robotic Prostatectomy: Bladder Neck Reconstruction and Pelvic
Drain Not Routinely Required
Humberto J. Martinez-Suarez, MD, Asha White, MD, Ronney
Abaza, MD
Ohio State University Medical Center and James Cancer Hospital
Introduction: A median lobe (ML) may affect the outcomes of
robotic prostatectomy. We do not routinely perform cystoscopy prior to
prostatectomy, use pelvic drainage, or bladder neck reconstruction. We assessed
the incidence of ML among our patients and compared their outcomes,
specifically addressing whether bladder neck reconstruction (BNR) or use of a
drain was needed.
Methods: We reviewed 250 consecutive
robotic prostatectomies to identify patients with a median lobe and their
perioperative outcomes compared with those without ML.
Results: Forty patients had ML
(16%). Mean operative time was 171.7 minutes and 165.5 minutes, respectively
(P=0.36). Mean blood loss was 145mL (range, 50 to 500) in those with ML, which
was higher than the 116mL (range, 20 to 500) in those without (P=0.02). No
patients with ML required transfusion, while 1.4% of others did. Mean gland
size of 73.5g (range, 35.9 to 148.1) was larger in those with ML compared with
51.7g (range, 25.5 to 151.7) in those without (P<0.005). There was no
difference between those with and without ML in length of hospitalization (1.0
vs 1.0 days, P=0.56), catheterization time (5.08 vs 5.77 days, P=0.13),
anastomotic leak on cystogram (2.6% vs 1.5%, P=0.15), drain use (2.5% vs 1.4%,
P=0.42), or need for BNR (7.5% vs 3.3%, P=0.22).
Conclusion: Patients with ML had a
greater gland size and blood loss but no additional need for transfusion,
bladder neck reconstruction, or drain use and no additional catheterization
time or risk of leak. With proper handling, ML can be addressed without adverse
outcomes and without routine use of pelvic drainage or BNR.
9185 Urology
Results of Robotic Limited and Extended Pelvic Lymphadenectomy for Prostate
Cancer
Hugh J. Lavery, MD, Ronney Abaza, MD
Ohio State University Medical Center and James Cancer Hospital, Columbus, Ohio
Objectives: The
optimal extent of pelvic lymphadenectomy (PLND) for prostate cancer is unknown.
Some advocate selective lymphadenectomy; others advocate extended dissections
in all. Concerns have been raised regarding the quality of PLND with
robot-assisted laparoscopic prostatectomy (RALP). We reviewed our experience
with extended and limited PLND to determine nodal yield, complications, and
rate of node positivity.
Methods: We
reviewed 250 consecutive RALPs with PLND from February 2008 to January 2009 by
a single surgeon. “Low-risk” patients underwent limited PLND including external
iliac and obturator nodes. “High-risk” patients with PSA >10ng/dL, cT3
disease, Gleason ≥8, or biopsy ≥50% cancer had ePLND adding nodes medial to the
genitofemoral nerve including hypogastric and common iliac nodes up to the
ureter.
Results: Of
250 patients, 173 underwent limited PLND and 77 ePLND. Mean yield was 11 nodes,
with 8.6 and 16.5 nodes for limited and ePLND, respectively. Seventeen (7%)
node-positive (N+) patients were identified, 2 (1.1%) in the limited and 15
(19.4%) in the ePLND group. Of 183 organ-confined (OC) tumors, only 1 was N+
(0.5%) compared with 16 of 67 (24%) non-OC tumors. Complications of PLND
included 4 symptomatic lymphoceles, 1 ureteral injury requiring a temporary
stent, and 1 obturator nerve palsy for a PLND complication rate of 2.4%.
Conclusions: Pelvic
lymphadenectomy for prostate cancer can be safely and effectively performed
robotically with nodal yields and rate of positivity comparable to that of open
series. Given the low rate of nodal positivity in lower risk patients, the role
of limited PLND needs further evaluation.
9186 Urology
Clinical Pathway for Early Discharge After Robotic Cystectomy
Asha D. White, MD, Ronney Abaza, MD
Ohio State University Medical Center and James Cancer Hospital
Objective:
Typical reported lengths of stay for open or laparoscopic cystectomy are 7 days
to 8 days, with 5.1 days as the lowest reported mean for robotic cystectomy
(RC). We developed a clinical pathway for early discharge after RC and analyzed
our initial outcomes.
Methods: Twelve patients
underwent RC by a single surgeon. All were placed on a clinical pathway
developed at our institution with extraction incision of ≤3 inches, no ICU
stay, and no NG tube. For pain, a continuous catheter-infused local anesthetic
at the extraction site, oral analgesia, and intravenous ketorolac were used.
Patients were required to ambulate on postoperative day (POD) zero or one, with
clear liquids on POD#1 then regular food on POD#2 or #3 with discharge when
tolerating food.
Results: Mean
age was 64.1 years (range, 46 to 86), and mean operative time was 420.5
minutes. All ambulated on POD#1. Seven had a regular diet on POD#2, 3 on PO#3,
and 2 on POD#4. Four required any intravenous narcotics while 8 had none. Ten
were discharged on POD#3 and 2 on POD#4 for a mean of 3.1 days. One returned to
the emergency department on POD#6 for emesis resolving with promethazine. No
others visited the emergency department or clinic or were readmitted within the
first 7days after discharge.
Conclusion:
Our clinical pathway after RC allows shorter hospital stays than typical and
is, to our knowledge, the shortest hospitalization time reported after
cystectomy by any technique. Only one unplanned visit occurred during the first
10 days. Further experience will be necessary to confirm the initial
success.
9187 Urology
Comparison of Intraoperative Outcomes with New and Old Generation da Vinci
Robots for Robotic Prostatectomy
Ketul Shah, MD, Ronney Abaza, MD
Ohio State University Medical Center, Columbus, Ohio
Introduction: Surgical technology continues to evolve. As robotic
technology improves, the impact of new platforms on surgical procedures has not
been evaluated.
Methods: We reviewed 100 robotic
prostatectomy procedures and compared intraoperative outcomes for procedures
using the da Vinci S robot versus the previous generation “standard” robot.
Procedures where the S was specifically requested were excluded. Otherwise, procedures
were randomly performed on one robot or the other.
Results: Mean operative time for
robotic prostatectomy with lymphadenectomy was 191 minutes using the standard
robot (range, 132 to 266) versus 169 minutes with the S robot (range, 98 to
230), representing a mean difference of 22 minutes (P=0.002). This was despite
no difference in mean patient BMI of 30.6 (range, 19 to 51) for standard versus
29.3 (range, 21 to 37) for S (P=0.31), no difference in mean prostate size of
54.6g (range, 26 to 101) for standard versus 57.3g (range, 32 to 151) for S
(P=0.55), no difference in frequency of nerve-sparing, and no difference in the
portions performed by residents, which ranged from none to all of the
procedure. The standard was more often used for the surgeon’s first case of the
day than for the second, third, or fourth of the day (P=0.006). There was no
difference in blood loss (P=0.08), positive margins (P=0.87), or mean lymph
nodes removed (10.7 vs 10.6).
Conclusions: Both generations of da
Vinci robotic technology are equally effective, but the S appears to allow
shorter procedure times. This may be due to ease of docking or fewer
arm-position changes needed to adjust for shorter arm length and less range of
motion.
9188 Urology
Three-Port Robotic Urologic Surgery Without a Laparoscopic Bedside Assistant
Gregory Lowe, MD, Ronney Abaza, MD
Ohio State University Medical Center and James Cancer
Hospital
Objective: The role of robotics for upper tract urologic surgery has been
questioned in part due to the perceived need for additional bedside-assistant
ports beyond those for laparoscopy and for an experienced laparoscopist at the
bedside. We review our experience with 3-port robotic renal, adrenal, and upper
tract reconstructive surgery.
Methods: Between June 2008 and January 2009, 32 procedures were
performed through 3 ports, one for the robotic scope and 2 robotic instrument
ports. No assistant was needed beyond the scrub technician. Procedures included
4 simple nephrectomies, 14 pyeloplasties, 2 ureteral reimplantations, 1
ureteral reconstruction, 2 adrenalectomies, and 9 radical nephrectomies.
Results: Mean operative times from incision to dressing were 106 minutes
for simple nephrectomy, 159 minutes for pyeloplasty, 122 minutes for ureteral
reimplantation, 180 minutes for ureteral reconstruction, 70 minutes for
adrenalectomy, and 170 minutes for radical nephrectomy including
lymphadenectomy. During the same time period, 4 radical nephrectomies but no
other procedures required a 4-port approach, including for a 19-cm renal mass,
an enlarged liver, excessive intraabdominal fat, and one planned partial
nephrectomy. Four patients were discharged the day of surgery, and all others
the day after. Mean blood loss was difficult to measure because suction was not
routinely used.
Conclusions: Three-port robotic urologic surgery is feasible. The
ability to perform robotic upper-tract surgery without an assistant experienced
in laparoscopy is encouraging, particularly as a potential transition to
single-port or natural-orifice robotic surgery. Having developed intraoperative
strategies to minimize reliance on an assistant, most but not all procedures
can be performed without an assistant.
9189 Urology
Early Results of Robotic Lymphadenectomy for Renal Cell Carcinoma
Ronney Abaza, MD
Ohio State University Medical Center and James Cancer
Hospital
Introduction: Laparoscopic nephrectomy for renal cell carcinoma
has gained acceptance in the urologic community, but lymphadenectomy is not
uniformly performed during open or laparoscopic nephrectomy. With the advent of
targeted medical therapy for metastatic renal cell carcinoma, lymphadenectomy
for identification of micrometastatic disease may merit reconsideration. We sought
to determine whether lymphadenectomy can be performed at the time of
laparoscopic radical nephrectomy with the aid of robotic instrumentation and
present the first such cases of robotic retroperitoneal lymphadenectomy for
renal cell carcinoma.
Methods: Robotic
radical nephrectomy with lymphadenectomy was performed in 13 patients. For
right-sided tumors, the lymphadenectomy included paracaval, retrocaval, and
interaortocaval nodes, and left-sided tumors included interaortocaval and
paraaortic nodes.
Results: Mean
tumor size was 6.7cm (range, 2.2 to 19), with all revealing renal cell
carcinoma on pathology. Six were locally invasive with four T3a and two T3b
tumors. Mean operative time was 198 minutes (range, 120 to 350). A mean of 9.8
lymph nodes was obtained (range, 4 to 24), and all were negative for carcinoma.
Estimated blood loss was 65cc (range, 10 to 200). A total of 3 ports were used
in 9 of 13 cases. No patient required intravenous narcotics postoperatively,
and 11 of 13 patients were discharged on the first postoperative day with the
other 2 on the second day. One patient had a cautery injury to the bowel due to
a defect in the insulation on a robotic instrument, but there were no vascular
injuries or other complications of the lymphadenectomy.
Conclusion: Robotic
radical lymphadenectomy is feasible and safe, but the benefits are yet
uncertain.
9190 Urology
Initial Report of Robotic Radical Nephrectomy with Vena Caval Tumor
Thrombectomy
Ronney Abaza, MD
Ohio State
University Medical Center & James Cancer Hospital
Objective: Robotic surgery is increasingly being applied to
complex urologic conditions. The first report of robot-assisted laparoscopic
nephrectomy for renal cell carcinoma (RCC) with caval tumor thrombus is
presented.
Methods: A 70-year-old male was
found to have a 7.5-cm mass consistent with renal cell carcinoma with renal
vein involvement but equivocal for vena caval involvement. Thoracoscopy was
consistent with low-volume, isolated metastatic renal cell carcinoma.
Cytoreductive nephrectomy was recommended. Minimally invasive nephrectomy was
offered to potentially reduce recovery time and allow institution of
antineoplastic medical therapy.
Results: The procedure was performed
through 3 ports without a bedside assistant port. The inferior vena cava (IVC)
was dissected circumferentially at the level of the insertion of the right
renal vein. It became apparent by visual palpation of the IVC with the robotic
instruments that the tumor thrombus protruded at least midway into its lumen.
The IVC was clamped with a curved laparoscopic Satinsky clamp introduced
percutaneously and closed at a point approximately one-third of the way across
the lumen. The wall of the IVC was then incised and the tumor thrombus
delivered intact. The IVC was then closed with 2 layers of polypropylene suture
maintaining more than half of its lumen. Estimated blood loss was <50cc.
Total operative time from incision to dressing was 266 minutes. The patient was
discharged on the second postoperative day and has achieved stability of
disease with medical therapy now 4 months after surgery.
Conclusion: Robotic surgery was
safely applied for RCC with IVC tumor thrombus.
9191 Gynecology
To Assess the Clinical Efficacy of Integrating Sacral
Neuromodulator InterStim Implants in Gynecological Private Practice for
Treatment of Intractable Urinary Urgency
Radha Syed, MD
Staten Island University Hospital, Staten Island, New
York
Objective: To assess the clinical feasibility of integrating sacral
neuromodulation into a general gynecological practice for treatment of
intractable and severe urge incontinence.
Methods: Five consecutive patients
with refractory urinary urge incontinence whose ages ranged between 45 and 65
years old (mean age, 55) were selected from the private practice patient pool.
Patients had already undergone clinical investigation, urodynamic testing, and
urine culture. An evaluation by a urologist had been conducted. Patients were
unresponsive to pharmacologic and behavioral therapy and pelvic floor
reeducation. Minimally invasive screening test to assess the efficacy of
InterStim therapy was performed in the office. The successful lead test led to
the second stage, the implant procedure for the InterStim neurostimulator.
InterStim II INS (Model 3058) was permanently implanted with the patient under
anesthesia in an outpatient setting. Quantitative assessment was performed by
preoperative and postoperative 3-day bladder diaries.
Results: The cure rate was
associated with age–individuals younger than 55 years having a statistically
significant greater cure (65% vs. 35%) than the older individuals. Having a
chronic medical condition was associated with a lower cure rate as an
independent factor. Minor complications were associated with permanent
implantation including pain and infection at the site of implantation,
technical problems with lead migration, and need for repositioning.
Conclusion: Sacral nerve stimulation
is an effective therapy for decreasing the symptoms of urge incontinence that
can be easily integrated into gynecological private practice. Adequate
knowledge and training are necessary prior to undertaking this new modality.
9192 Urology
Comparing Diode Laser with KTP Laser
Manuel Ferreira Coelho, MD, Pedro Bargão Santos, MD
Hospital dos Lusíadas, Clínica São João de Deus, Lisboa, Portugal
Objective: The wavelength 980nm of a
recently introduced diode laser system for treatment of benign prostatic
enlargement and the potassium-titanyl-phosphate (KTP) laser offer a high
simultaneous absorption in water and hemoglobin and are postulated to combine
high tissue ablative properties with good hemostasis.
Methods: The Ceralas HPD150 diode
laser system was evaluated in 20 patients, and the KTP laser was evaluated in
another 20 patients. The aim of the study was to evaluate tissue ablation
capacity and hemostatic properties at different generator settings. A
histological examination of the ablated tissue followed. The results were compared
with the reference standards transurethral resection of the prostate (TURP).
Results: The diode laser displays a
higher tissue ablation capacity, reaching 7.25±1.50g after 10 minutes, compared
with the KTP laser (3.90±0.46g; P<0.05). The corresponding depths of the
coagulation zones are 295.1±47.0µm for the diode laser, 650.9±65.0µm for the
KTP laser (P<0.05), and 289.1±28.5µm for TURP.
Conclusion: The 980-nm diode laser
offers a higher tissue ablation capacity and similar hemostasis compared with
the KTP laser. In comparison with TURP, both tissue ablation and bleeding are
significantly reduced.
9193 General Surgery
Necessity for Improvement in Endoscopy Training During Surgical Residency
Aditya Gupta, MD, Gokulakkrishna Subhas, MD, Vijay K. Mittal, MD
Providence Hospital and Medical Centers,
Southfield, Michigan
Background:
ACGME has increased requirements to ensure that surgical residents obtain
adequate endoscopy skills. A survey questionnaire was sent to surgical program
directors to look at residents’ endoscopic training.
Methods: A
10-question survey was sent to all program directors in surgery. Endoscopic
training patterns, facilities, their views, and performance of residents were
examined. The national averages for the last 3 years for endoscopic procedures
were collected.
Results: Seventy-one
directors (30%) responded to the questionnaire. Of these, 42% (n=30) had a
program size of 3 to 4 residents. Ten percent (n=7) of programs could not
fulfill the minimum ACGME requirements. Only 55% (n=39) of programs had a
dedicated rotation in endoscopy, which ranged from 0.5 months to 3 months. Most
program directors (82%, n=58) thought that their residents’ exposure to
endoscopy was sufficient. Only 55% (n=39) had an endoscopic skills training
laboratory in their program. The average numbers of staff surgeons in programs
performing endoscopy were 5 for colonoscopy, 6 for gastroscopy, and only 0.2
for ERCP. Few programs had their residents performing more than 100 cases of
gastroscopy (18%) and colonoscopy (21%). According to program directors, the
average number of cases needed to achieve competency for colonoscopy (n=60),
gastroscopy (n=41), and ERCP (n=56) were more than the national averages for
the last 3 years (33, 25, and 0.3, respectively).
Conclusion: Future
endoscopy training for surgical residents needs to increase opportunities so
that they are able to perform endoscopy with confidence. This would include
provision of endoscopic skills laboratory, dedicated endoscopic postings, and
hiring staff surgeons who perform endoscopic procedures.
9194 Gynecology
Laparoscopy: Gold Standard for Ovarian Tissue Banking (OTB) in Cancer Patients
Kazem Nouri
Medical University
of Vienna
Objective: To analyze and give a
summary of our experience with laparoscopic ovarian tissue banking for ovarian
cryopreservation as a means of fertility preservation in cancer patients,
comparing this method with more conservative methods like injection of Gn-RH
analogue and antagonists or IVF with subsequent oocyte or embryo
cryopreservation.
Methods: This was a retrospective
cohort study performed at the Medical School of Vienna, Department of
Gynaecology, Endocrinology and Reproductive Medicine. The study cohort
comprised 87 patients with the wish of fertility preservation through ovarian
tissue banking (OTB). Laparoscopic surgery was performed to take out one-third
of one ovary for ovarian cryopreservation and banking.
Results: The operating time, major
and minor complications, histological and microbiological results were
analyzed. Eighty-five patients underwent cryopreservation of ovarian tissue,
mostly for malignant diseases (78/85, 91.8%). The median operating time was 30
minutes (range, 10 to 75). The intraoperative course was uneventful in these
patients. Histological examination revealed intact ovarian tissue with
primordial follicles in 81/85 patients (95.3%).
Conclusion: The increasing life
expectancy after chemo and ionization therapy brings about new aspects into the
life of cancer patients. One of the new issues and challenges in this group of
patients is to maintain fertility despite the cancer therapy. One of the most
promising new therapy options is OTB. Laparoscopy is the method of choice for
ovarian tissue harvesting. After chemo or ionization therapy, the
reimplantation of the cryopreserved ovary would also be performed by
laparoscopy. To date, worldwide 5 live births have resulted from this method of
fertility preservation.
9196 Gynecology
The Role of Minimally Invasive Surgery for Diagnosis and Treatment of Uterine
Myoma Before IVF/ICSI Cycle
Kazem Nouri
Medical
University of Vienna
Objective: To give a summary of current indications for operative therapy
of myoma before starting IVF, and to give an overview of the role of minimally
invasive surgery in both diagnosis and treatment of myoma in assisted
reproductive technology.
Methods: We performed a review of
the current available literature on the relationship between fibroids and
IVF/ICSI therapy with particular emphasis on the benefits of myomectomy
performed by minimally invasive methods and present our data and experience in
the reproductive surgery unit of the Medical School of Vienna. Approximately
20% to 40% of women of reproductive age are known to have uterine myomas. It
has been estimated that only 5% to 10% of infertile women have fibroids, and
when all other causes of infertility are excluded, myomas alone may be
responsible for only 2% to 3% of infertility cases.
Results: Five to 10% of IVF patients
have uterine myomas. Only in special cases is it necessary to intervene
surgically. The proper diagnosis is to be done by hysteroscopy. The gold
standard of therapy is the laparoscopic myomectomy.
Conclusion: Only in rare cases are
myomas of the uteri the only presenting cause of infertility. Five to 10% of
the patients for whom an IVF/ICSI cycle is indicated have fibroids. Whether
these fibroids reduce the chances of pregnancy is dependent on many factors
like their location and volume. Minimally invasive surgery measures like
hysteroscopy and laparoscopy are the most important tools in both diagnosis and
treatment of myomas in IVF/ICSI patients.
9197 General Surgery
Combined Open-Laparoscopic Technique for Difficult Incisional Hernias
K. Theodoropoulou, MBBS, A. Syed,
MBBS, J. Hill, MBBS, H. Bradpiece, FRCS
Princess Alexandra Hospital,
Essex, United Kingdom
Objective: Despite the fact that
laparoscopic incisional hernia repair is very popular among general surgeons,
there is always a small percentage of patients in whom the laparoscopic
approach is not feasible and conversion to an open technique is required. The
purpose of this study was to describe the combined approach and to demonstrate
that it is effective, realistic, and safe.
Methods: Three patients with incisional hernias were
examined. All 3 patients had incarcerated or irreducible bowel in the hernia
sac that could not be reduced safely, and conversion to an open technique was
essential. Each of these cases was commenced with a combined laparoscopic
approach. We always started the hernia
repair laparoscopically and converted to open only when further dissection and
adhesiolysis were not feasible. A smaller incision than usual was performed
followed by safe dissection and reduction of hernia sac content. Composite
polypropylene and ePTFE mesh was placed intraperitoneally and fixed in 4 sites
with staples. The abdominal wall was closed, and the fixation of the mesh was
completed laparoscopically.
Results: All 3 patients underwent successful repair
without any intraoperative complications. Two had uneventful postoperative
recovery. One patient developed superficial wound abscess that required
drainage but not removal of the mesh, as the aponeurosis was intact. No
recurrence has been recorded (follow-up, 2 to 7 months)
Conclusion: The combined approach can offer all the
advantages of an open approach and preserve most of the advantages of the
laparoscopic technique. We advocate it as an alternative to the open technique
when conversion to open is essential for patient’s safety.
9198 General Surgery
Laparoscopic Treatment of Peptic Ulcer Disease
F. Obregon, MD, M.
Vasallo, MD, H. Malave, MD, S. Navarrete, A MD
Hospital Universitario de Caracas, Caracas, Venezuela
Objective: Since the
development of proton pump inhibitors as a treatment for peptic ulcer disease,
its complications and recurrence have decreased. However, for some rare cases
of recurrence or complications such as stenosis, the role of laparoscopic
surgery has been established. We present the results of our experience with
these procedures.
Methods:
From October 2004 to December 2008, we performed 6 laparoscopic procedures for
peptic ulcer disease. Patients were 2 males and 6 females with a mean age of
51.16 years (range, 38 to 68). All patients were studied with upper digestive
endoscopy and biopsy and signed an informed consent. Preoperative diagnoses
were 3 duodenal stenoses and 3 ulcer recurrences on gastrojejunal anastomosis,
one of them with atypias. We performed 2 distal gastrectomies with Billroth II
reconstructions, 1 hemigastrectomy with posterior truncal vagotomy and anterior
selective vagotomy Billroth II type with Brown’s anastomosis, and 3
regastrectomies with resection of previous gastrojejunal anastomosis and Roux
en Y reconstruction. All the procedures were performed totally laparoscopically
using lineal endostaplers and intracorporeal suture.
Results:
The mean operative time was 145.83 minutes (range, 110 to 210). Blood loss was as high as 100cc on average.
Postoperative oral intake in all patients was on the third day, and length of
postoperative stay was 5 days on average (range, 4 to 6). We had no
conversions. No morbidity or mortality related to these procedures has
occurred. Final results of all biopsies were benign, and at 3-month follow-up,
upper digestive endoscopy was perform without pathological findings.
Conclusion: Laparoscopic
surgery for peptic ulcer disease and its complications is a feasible and safe
procedure.
9199 General Surgery
A Novel Technique for Endoscopic Repair of Symptomatic Diastasis Recti With or
Without Simultaneous Ventral Hernia
Richard P. Franklin, MD, Robert S.
Baxt, MD
Northwest Hospital
Objectives: To be able to repair symptomatic diastasis recti laparoscopically.
The repair of a diastasis should address multiple issues: restoring normal
anatomy by reapproximation of the muscles to midline, improving abdominal wall
mechanics, resolution of the abdominal wall bulge, and low risk of recurrence.
Methods: We repaired 5 patients (3
men, 2 women) with symptomatic diastasis, 4 of which had concomitant ventral
hernias either adjacent to or just inferior to the diastasis.
This study was performed at a single center community hospital, and is a
2-surgeon series of repairs. Patients were repaired laparoscopically with an
intraabdominal mesh (CQUR Edge - Atrium) and transabdominal sutures that
allowed reapproximation of the rectus abdominus muscles in the midline, with
recreation of the linea alba, and transfascial fixation of the mesh to the
abdominal wall. In addition, the mesh covered of all defects in the standard
fashion for laparoscopic ventral hernia repair with an overlap of at least 5cm
using standard tacks Absorbatac (Covidian) or Protac (Autosuture) for lateral fixation
of the mesh to the abdominal wall.
Results: All 5 repairs
(follow-up 2 to 12 months) have excellent results without recurrence of
symptoms or abdominal wall bulge. No clinical recurrences of hernia or
diastasis bulge are apparent, and all patients are back to their normal
occupations.
Conclusion: Laparoscopic repair
of symptomatic diastasis recti is a feasible repair leading to loss of
abdominal bulge, resolution of pain, better abdominal wall mechanics, and good
cosmetic outcomes.
9200 General Surgery
Laparoscopic Repair of Bilateral Spigelian Hernias (TAPP)
Usman Jaffer, BSc (Hons), MB BS,
MSc, MSc (Ultrasound), MRCS(Eng), FHEA, DIC, Periyathambi Jambulingam, FRCS
The Luton and Dunstable NHS Trust,
Luton, United Kingdom.
Objectives:
To demonstrate a technique of
laparoscopic repair of bilateral Spigelian hernia.
Methods:
A 3-port technique was used. The
transabdominal preperitoneal approach (TAPP) was used. A right-sided direct
inguinal hernia was also encountered. This was also repaired using the same
peritoneal incision by deepening the preperitoneal plane appropriately. Two
pieces of Prolene mesh were placed in the preperitoneal space and secured with
metal tacks. The peritoneum was also closed similarly.
Results:
A sound repair was achieved. The
patient was discharged home the next day.
Conclusion:
The laparoscopic TAPP approach can
be performed safely and effectively for bilateral Spigelian hernias.
9201 Gynecology
A Multicenter Series of Over 1000 Laparoscopic Subtotal Hysterectomies in the
UK and Greece: The New Approach to Hysterectomy
Stefanos Chandakas, MD, MBA, PhD
Background: Minimally invasive surgery has influenced the techniques used
in gynecology, with an overall minimization of complications and increased
patient satisfaction. We sought to demonstrate the safety and feasibility of
laparoscopic subtotal hysterectomies in an outpatient setting.
Methods: This was a retrospective,
descriptive, nonrandomized study performed at Princess Royal University
Hospital, London, United Kingdom and Iaso Hospital, Athens Greece. For the
patients who underwent a laparoscopic subtotal hysterectomy in the last 60
months, data were collected from medical records on how the intervention was
performed, followed for 18 months. Two surgeons performed 1008 subtotal
hysterectomies. Indications included 21.6% for endometriosis, 68.2% for
menorrhagia, and 11.2% for endometrial pathology.
Results: Duration of surgery and
hospital stay, safety (morbidity and mortality), and patient satisfaction were
assessed. Estimated blood loss was 75mL (range, 20 to 2300). Intraoperative
complications were as follows: 0.4% had significant complications; 0% vascular
injuries and 0% nerve or ureter injuries; 2.2% had cyclic bleeding. Early
postoperative morbidity included 0.2% deep vein thrombosis, 0% pulmonary
embolism, 1.1% bladder infection and dysfunction. The overall complication rate
was 1.8%. Three patients required drainage for intraabdominal abscess.
Regarding hospital stay of these 1008 patients, 91% were discharged home the
same day with an average length of stay of 9 hours.
Conclusion: Laparoscopic subtotal
hysterectomy can be safely performed as an outpatient procedure.
9202 Gynecology
Single-Port Laparoscopy in Gynecology: What Can We Perform?
A Series of 35 Cases
Stefanos Chandakas, MD, MBA, PhD
Background: Minimally invasive surgery has influenced the techniques used
in gynecology, with an overall minimization of complications and increased
patient satisfaction. We sought to demonstrate the safety and feasibility of
single-port laparoscopic (SPL) surgery in gynecology.
Methods: This was a retrospective,
descriptive, nonrandomized study performed at Iaso Hospital and Attikon
University Hospital, Athens, Greece. It included 35 patients who underwent SPL
surgery between October 2008 and February 2009. Indications included 55%
salpingo-oophorectomy, 26% diagnostic laparoscopy and treatment of stage 1/2
endometriosis, 19% cystectomy.
Results: Duration of surgery and
hospital stay, safety (morbidity and mortality), and patient satisfaction were
assessed. Estimated blood loss was 35mL (range, 10 to 230). Intraoperative
complications were as follows: 0% vascular injuries and 0% nerve or ureter
injuries. Early postoperative morbidity included no major complications, 0.1%
bladder infection and dysfunction, and 0.3% incision infection. All patients
were discharged home the same day with an average length of stay for these
patients of 8
This site contains conference details and proceedings including educational materials and podcasts of
the
SLS Annual Meeting and Endo Expo. An Annual Event in Mid September,
this multispecialty conference helps increase knowledge of
laparoscopic, endoscopic and minimally invasive surgical techniques.
The Meeting consists of Postgraduate Master's Classes; Plenary
Sessions; Lap Updates of multiple topics; Expert review and discussion of surgical videos showing accidents, mishaps, and surprises; Deconstruction of video-taped surgeries performed by master surgeons; Exhibitions; Competition for Best Papers, Videos and Posters from
Professors to Fellows and Residents; Future Technology Sessions; and
over 200 General Surgery, Gynecology, Urology and Multispecialty Scientific Presentations.