<figure><img src="image_117.png" /></figure>

SAGES POSTER ABSTRACTS

121 minutes (67-182 minutes).

**CONCLUSIONS:** This technique is feasible and preserves optimal cosmetic results for the patient of a minimal invasive procedure.

## Colorectal/Intestinal Surgery - P236

**PRELIMINARY RESULTS OF LAPAROSCOPIC SURGERY FOR ACUTE DIVERTICULITIS.**, Marty Zdichavsky MD, Stephan Coerper MD, Kramer Michael MD, Alfred Königsrainer MD, Frank Granderth MD, University Hospital Tübingen, Dept. Surgery, Tübingen, Germany

**BACKGROUND:** Laparoscopic sigmoid resection for diverticulitis has become an acceptable technique of surgical treatment for diverticulitis. To date, the optimal waiting period after acute symptoms of diverticular disease has not been established. Laparoscopic sigmoid colectomy of acute diverticulitis may challenge the technical feasibility of the laparoscopic approach and reduce the overall time of hospitalization for these patients.

**METHODS:** 13 patients underwent laparoscopic sigmoid resection within 10 days after acute symptoms. Patients were treated immediately with antibiotics and fasting. Operating time point was determined when clinical symptoms and inflammation signs in blood samples were significantly reduced.

**RESULTS:** An end-to-end anastomosis was performed in all 13 patients (7 male, 6 female; mean age 50.0 and 65.3 years, respectively; ASA I: 4/13, ASA II: 8/13, ASA III: 1/13). Average operation time was 113 minutes (60-168 minutes). One patient suffered an uncomplicated wound seroma, another an incision hernia. No leakage of the anastomosis was detected. None of the patients had conversion to laparotomy or increased rate of recovery period compared to elective resections in the literature.

**CONCLUSIONS:** Our preliminary data show the feasibility of the laparoscopic sigmoid resection procedure in acute diverticulitis. Waiting period after acute symptoms of diverticulitis can be reduced to a short period of time decreasing the length of hospitalization and hospital expense.

## Complications of Surgery - P237

**PROCEDURE FOR USE THE SEPRAFILM ADHESION BARRIER IN LAPAROSCOPIC SURGERY**, Hideaki Andoh MD, Yoshio Kobayashi MD, Tatsuru Akashi MD, Manabu Onuki MD, Kouji Fukuda MD, Yuichi Tanaka MD, Takao Hanaoka MD, Division of Surgery, Nakadori General Hospital

**[Introduction]** Seplafilm adhesion barrier is indicated for use in patients undergoing abdominal laparotomy as an adjunct intended to reduce the incidence, extent and severity of postoperative adhesions between the abdominal wall and underlying viscera. Even in the laparoscopic surgery, Seplafilm is useful to prevent the adhesion between viscera and viscera. However, insertion technique under laparoscopic surgery is difficult. In this report, present the easy method to insert the Seplafilm under laparoscopic surgery.

**[Patients]** Fourteen patient undergoing the laparoscopic surgery such as cholecystectomy, colectomy were applied insertion of Seplafilm in our hospital.

**[Method]** 1. Use of the applicator which is exclusively for laparoscopic surgery; Applicator method. 2. Direct insertion of the Seplafilm held with the Tyvek holder; Tyvek holder method. 3. Direct insertion of the Seplafilm held with Vinyl Sheet; Vinyl sheet method.

**[Result]** Cost: applicator cost $80 in each cases and which is disposable device, but Tyvek holder and vinyl sheet took no cost because these were contained the package of the Seplafilm. Time during laying the Seplafilm: Applicator method took 325 seconds Direct methods held with Tyvek or Vinyl sheet took 132 seconds. Vinyl method was more easy than Tyvek method because vinyl sheet could be pulled out easy, and handling easy because clearness of the surgical field.

**[Conclusion]** The vinyl sheet method was easy and useful for the insertion of Seplafilm undergoing laparoscopic surgery.

## Complications of Surgery - P238

**LAPAROSCOPIC REPAIR OF DUCT OF LUSHKA INJURY.**, Justin Boccardo MD, Gerardo Kahane MD, Patrick Gatmaitan MD, Celine Gisbert MD, Bruce E Duke III MD, Conemaugh Memorial Medical Center

More than 500,000 laparoscopic cholecystectomies are performed annually in the USA (1 in every 500 persons). The rate of major bile leaks after this procedure is around 1%, and less than a third of those are from injuries to the accessory ducts (aka duct of Lushka). It is an uncommon complication, but in such a frequent procedure around 15000 leaks from accessory ducts occur every year, and there is very little information reported on how to diagnose, treat and follow up this type of injuries.

We present a 67yo woman who had an uneventful laparoscopic cholecystectomy and post operatively continued with upper abdominal pain. She was noted to have increased LFTs and underwent an MRCP that showed an intact biliary tree. A HIDA scan showed evidence of a bile leak coming from the right lobe of the liver. An ultrasound failed to show a biloma in the right upper quadrant. An ERCP was attempted but the common bile duct could not be selectively cannulated. The patient was taken to the operating room for an exploratory laparoscopy. The bile leak was noted to originate from the liver bed. An accessory, solitary, bile leaking duct was identified. The duct was suture ligated and the leak controlled. The patient was discharged home and on her follow up visit she was free of symptoms and fully recovered from her surgery.

Injury to a duct of Lushka is an uncommon event, but with enough number of laparoscopic cholecystectomies performed, it is bound to happen at some point in a surgeon's career. Interestingly, there is no set of guidelines or recommendations on how to approach this complication. The role of HIDA scan and cholangiography is well established in the initial evaluation of a suspected bile leak. However the differentiation between a leak originating from an accessory duct or the common or hepatic ducts is extremely challenging. The few reports in the English literature found about duct of Lushka injuries recommended exploratory laparotomy with repair or suture-ligation of the leak. We performed an exploratory laparoscopy with excellent results. We believe that the laparoscopic approach provides a good exposure of the anatomy to identify the injury and properly repair these types of injuries.

## Complications of Surgery - P239

**ENDOSCOPIC PERFORATION OF DUODENAL DIVERTICULUM:** A REPORT OF TWO CLINICAL CASES, Steven P Bowers MD, Steven M Abbate MD, Steven P Larsen MD, Wilford Hall Medical Center

**BACKGROUND:** Duodenal diverticula are common but spontaneous clinical sequelae are rare. Endoscopic perforation into the retroperitoneum can usually be managed non-operatively, thus current reports of surgical management of perforated duodenal diverticula are scarce. Historically, diverticulotomy is complicated by a 20% risk of duodenal fistula.

**METHODS:** We report two cases of endoscopic perforation of duodenal diverticulum requiring surgical intervention. Case one is a 65 year-old woman who underwent ERCP and was found to have periampullary diverticula- one small proximal diverticulum with a retained enterolith, and a larger diverticulum containing the papilla. The retained enterolith was extracted, and during cholangiography, the patient became hypoxic and manifested massive subcutaneous emphysema. She was intubated and tube thoracostomy placed on the right for pneumothorax. CT scan and surgical consultation were obtained. Case two is a 59 year-old man who underwent EGD and was found to have a large duodenal diverticulum, without enterolith or inflammation. After the procedure, the patient was noted to have severe right-sided pain and massive subcutaneous emphysema from the chest to the right scrotum. CT scan and surgical consultation were obtained. During both cases, endoscopic insufflation was set to high (20 - 35 L/min).

**RESULTS:** Both patients were found to have focal peri-
toniteal irritation and CT showing retroperitoneal air track-
ing back to the duodenal diverticulum. Both were similarly
treated with midline laparotomy and extensive Kocher
maneuver. The perforations were identified and closed pri-
marily, and closure was buttressed with pedicled omentum.
Closed suction drains were placed in the retroperitoneum.
Diverticulectomy was not performed because of involve-
ment of the ampulla or bile duct. Both patients had unevent-
ful post-operative recoveries.

**DISCUSSION:** Primary closure of diverticular perforation with omental buttress and drainage is sufficient for treatment of iatrogenic endoscopic perforation of duodenal diverticulum. During endoscopic procedures involving duodenal diverticula, the lowest tolerable insufflator setting should be used.

Complications of Surgery - P240

COMPLICATIONS OF ENDOSCOPIC IMPLANTATION OF
PERITONEAL DIALYSIS CATHETER,

Zoran Cala PhD,Ivo
Soldo PhD,Visnja Nesek-Adam MSc,Aleksandra Smiljanic
MD, University Department of Surgery GH Sveti Duh Zagreb

**Introduction:** We analyze the complications of endoscopic implantation of the catheter for peritoneal dialysis using trocar especially constructed for this purpose.

**Method:** Operation is performed under general anesthesia. After pneumoperitoneum is obtained and laparoscope introduced, the catheter trocar is passed obliquely through the abdominal wall and directed into the pelvis with the laparoscopic monitoring of the trocar tip. This trocar consists of two essential parts. The outer cannula can be separated longitudinally in two symmetric parts. The inner metal part has a pyramid shaped tip. The catheter is introduced through trocar cannula. The cannula is dismantled longitudinally and removed while the catheter tip is kept into the pelvis by the forceps. During these procedures some complications as during any other laparoscopic operation and some typically for these procedure are possible. Between December 1993 and September 2006 catheter for peritoneal dialysis was placed endoscopically in 192 patients using our trocar.

**Results:** There were only several minor complications - bleeding from abdominal wall vessels in 5 cases, wound infections in 3 cases, umbilical hernia in 2 cases, and dialysis solution leakage in 2 cases. There were not severe complications like intraabdominal bleeding, visceral injury or retroperitoneal vascular injury.

**Conclusion:** Laparoscopic placement of catheter for peritoneal dialysis using our specially constructed trocar is a safe, simple, quick, efficient and patient convenient technique.

Complications of Surgery - P241

LAPAROSCOPIC TRANSMEDIASTINAL DRAINAGE - A SIMPLE AND EFFECTIVE PROCEDURE FOR THE TREATMENT OF ACCIDENTAL PNEUMOTHORAX IN LAPAROSCOPIC ANTI-REFLUX SURGERY,

Gustavo L Carvalho PhD,Alexandre W
Dantas,Ana Beatriz T Ramos,Daniel G Araújo,Pedro P
Albuquerque,Carlos H Ramos MD,Gilvan Loureiro
MD,Frederico W Silva MD, Pernambuco State University,
School of Medicine, Recife, Brazil

**Introduction:** The pleural lesion is an uncommon accident in laparoscopic anti-reflux surgery (LARS) and its frequency range from 0.9 to 2.7%. In a major lesion, the difference between the pressure in the pleural and the abdominal cavities during the pneumoperitoneum may cause the development of a pneumothorax (PTX). This situation, when serious, raises the diaphragm dome, hindering the execution of the surgery. The current therapy for transoperative PTX is the thoracic intercostal drainage, which is not without complications, and may alter the patient's progression and the desirability of minimum invasive surgery. The aim was to evaluate the treatment of accidental transoperative PTX through a new procedure - laparoscopic transmediastinal drainage (LTD).

**Method:** From January 2000 to August 2006, 256 patients underwent LARS. Six patients presented a transoperative left pleural lesion that hindered or prevented the completion of the surgical procedure. The therapeutic option used in all cases was LTD. LTD was performed through the insertion of

a 8F silicon drain between the diaphragmatic pillars in such a way as to leave all the holes of the drain in the pleural cavity. The exit of the drain was made by the abdominal route using a 3-mm minilaparoscopic trocar in all patients, preserving the characteristic of a minimally invasive procedure. The patients were maintained on mechanical ventilation with PEEP by the anesthetist. The drains were removed on average of 15 minutes after the end of the operation, and a chest radiograph was taken to confirm the absence of PTX.

**Results:** No significant complications were observed in this therapy used for the treatment of PTX. Radiography confirmed the absence of PTX in all patients. Conclusion: The treatment of pneumothorax by laparoscopic transmediastinal drainage was shown to be a safe, simple and effective method. Laparoscopic transmediastinal drainage should be considered the procedure of choice during a LARS as it is a minimally invasive technique and produces a good esthetic quality.

Complications of Surgery - P242

SAFETY AND EFFICACY OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN PATIENTS WITH PRIOR UPPER ABDOMINAL SURGERY,

David Cox MD,Bhargav Mistry MD,Robert P
Sticca MD, University of North Dakota, MeritCare Health
System

**Background:** Percutaneous Endoscopic Gastrostomy (PEG) placement is the preferred access route for enteral nutrition in most patients who are unable to take oral feedings for any of a variety of causes. Reasons for this preference include ease of placement, avoidance of laparotomy, a low overall complication rate and cost effectiveness. Prior upper abdominal surgery has been considered a relative contraindication to PEG placement due to concerns surrounding altered anatomy, adhesions and increased risk of complications. There is a lack of objective evidence for these concerns. This study examined the outcomes of PEG placement in a large cohort of patients with comparisons between groups who had prior upper abdominal surgery, prior lower abdominal surgery and no prior abdominal surgery in order to determine if prior upper abdominal surgery is associated with increased morbidity or mortality.

**Methods:** A retrospective chart review of all consecutive patients who underwent PEG placement by multiple surgeons and a gastroenterologist between 12/1/2000 and 2/28/2005. Data was collected on patient age, sex, reason for need of enteral nutrition, history of prior abdominal surgery, type of prior surgery, and outcome including morbidity and mortality. All PEGs were placed using the Ponsky pull through technique. Data was analyzed using Fisher's exact tests.

**Results:** The total study group consisted of 266 patients. Twenty-four patients (9%) had prior upper abdominal surgery. Patients in this group had undergone a diverse array of procedures to the esophagus, diaphragm, stomach, spleen, duodenum, pancreas, biliary tract, liver, and transverse colon. Fifty-seven (21%) patients had prior lower abdominal surgery while 185 (70%) patients had no prior abdominal surgery. Morbidity analysis demonstrated one (4.2%) complication in the upper abdominal surgery group, seven (3.8%) complications in the no prior surgery group and one (1.8%) complications in the lower abdominal surgery group. Fisher's exact test did not reveal any statistically significant differences in complication rates between the prior upper abdominal surgery group and the other groups (p = 0.77, 0.51). There was no mortality directly attributable to PEG placement.

**Conclusions:** PEG may be performed safely in patients with prior upper abdominal surgery.

Complications of Surgery - P243

PERFORATED DUODENAL ULCER FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS,

Christopher W
Finnell MD,Atul K Madan MD,David S Tichansky
MD,Kenneth Sellers MD, The University of Tennessee at
Memphis

Perforated duodenal ulcers that result in massive intra-
abdominal contamination are generally thought to present
with abdominal pain, signs of sepsis and the hallmark sub-

<figure><img src="image_118.png" /></figure>
<figure><img src="image_119.png" /></figure>

SAGES POSTER ABSTRACTS

diaphragmatic free air.

We present a case of a 54 year old female who presented to the emergency room with a 3 day history of abdominal pain that had become worse and unrelenting. She admitted to alcohol use and was taking aspirin for her abdominal pain. Her past medical history was significant for a laparoscopic roux-en-y gastric bypass 2 years prior at an outside institution for morbid obesity from which she had lost over 100 pounds. Physical examination found her to be mildly febrile with a diffusely tender abdomen, laboratory analysis showed slightly elevated amylase level. A CT demonstrated perihepatic fluid with no evidence of free air.

Surgery was consulted after her pain was noted to have increased in the right lower quadrant and appendicitis was suspected. At this time, she was tachycardic, febrile, hypotensive, with a rigid abdomen. Following fluid resuscitation she underwent emergent laparotomy, where a massive volume of biliary acites was discovered along with a 1 cm perforated ulcer in the first portion of the duodenum. She was requiring high doses of vasopressors intraoperatively so a Grahm patch was preformed rapidly followed by copious irrigation of the abdominal cavity and facial closure. She had a stormy postoperative course but was ultimately discharged home.

The initial lack of free air had led her initial physicians down an erroneous diagnostic path. Patients who have undergone bariatric procedures that present with abdominal pain should have surgical consultation preferably by surgeons experienced in bariatric surgery

**Complications of Surgery – P244**

**INTESTINAL FAILURE: A RARE ERCP COMPLICATION,**
Patrick Gatmaitan MD, Celine Gisbert MD, Bruce Duke MD, Guilherme Costa MD, Kareem Abu-Elmagd MD, Conemaugh Memorial Medical Center; UPMC Montefiore Hospital

Endoscopic retrograde cholangiopancreatography (ERCP) is a relatively common procedure performed for both diagnostic and therapeutic purposes. Complications include pancreatitis, hemorrhage, perforation, and death among others. This case study illustrates a rare and unreported ERCP complication. Review of the MEDLINE literature from 1966 to August 2006 regarding ERCP did not yield any complication of extensive bowel ischemia and necrosis leading to intestinal failure. Our patient is a 63-year old female who presented with right upper abdominal pain, elevated LFTs, and dilated common bile duct. She was diagnosed with sphincter of Oddi dysfunction and ERCP with sphincterotomy had been performed. This was followed by a protracted, complicated and disabling post-operative course. She initially developed a severe necrotizing pancreatitis, then both retroperitoneal and intra-peritoneal abscesses, portal and superior vein thrombosis, small and large bowel necrosis leading to eventual enterectomy and colectomy. Almost a year after her ERCP, she remains on total parenteral nutrition awaiting bowel transplantation. This report demonstrates a unique case of intestinal failure as a complication of ERCP.

**Complications of Surgery – P245**

**THE PERFORATION OF THE GALLBLADDER IN CASES OF INCIDENTAL GALLBLADDER CANCER- AND THE DOUBTFUL PROTECTIVE EFFECT OF ISOLATION BAGS.,** Thorsten Goetze PhD, Vittorio Paolucci PhD, Clinic for general-, abdominal- and minimally invasive surgery of the Ketteler-Krankenhaus

**Introduction:** The accidental intraoperative perforation of the gallbladder is a problem of the laparoscopic surgery, if an incidental gallbladder carcinoma exists at the time of operation.

According to the literature this complication comes up to 30% of the laparoscopic operations. In order to prevent the dissemination of tumourcells the use of an isolation bag is proclaimed.

The question is if the intraoperative perforation of gallbladder carcinoma really leads to a prognostic deterioration and

if the patients which have been treated with an isolation bag have a prognostic advantage.

**Material and method:** To obtain data we are using the Register of the German Society of Surgery for incidental gallbladder cancer. We are collecting our data with a standardized questionnaire, which has been sent to all german and now to all austrian surgical clinics as well.

**Results:** 441 cases of incidental gallbladder carcinomas are registered.

239 were operated laparoscopically, 81 (34%) of them get a relapse of the tumour.

110 patients were treated with the support of an isolation bag, the rate of a relapse was 41% (n = 41).

129 of the laparoscopic group have treated without an isolation bag, the rate of an relapse was 28% (n = 36).

In 50 of 239 laparoscopic treated patients there was an intraoperative accidental opening of the organ, the rate of a relapse was 46% (n = 23).

In 33 of 50 cases an isolation bag was used, the rate of a relapse was 48% (n = 16).

The other 17 of 50 patients who were operated without an isolation bag have a rate of relapse of 41% (n=7).

The group without an intraoperative perforation (n = 189) have 31% (n=58) of tumour recurrence.

77 of this 189 were treated with the use of an isolation bag, 29 (38%) of them had a tumour recurrence, the other 112 of the 189 patients treated without a bag had a recurrence rate of 29% (n = 26).

**Discussion:** In our register, the intraoperative perforation leads to a significant prognostic disadvantage (p=0.046 Fisher's exact test).

The patients treated with an isolation bag have a tendency of a higher rate of tumour recurrences (p= 0,055 Fisher's exact test).

The isolation bag seems not to have a protective effect.

**Complications of Surgery – P246**

**INTRAABDOMINAL ABSCESS AS A COMPLICATION OF LAPAROSCOPIC APPENDECTOMY: REPORT OF A CASE,**
Hiromitsu Hoshino MD, Hiroshi Yano MD, Takushi Monden MD, NTT west osaka hospital

Many reports of laparoscopic appendectomy (LA) have been published since it was first performed in Germany in 1982. Because it is generally associated with a low complication rate, the risk of an intraabdominal abscess occurring as an early complication of LA has not been emphasized. We report a case of an intraabdominal abscess after performing LA that was cured conservatively. A 28-year-old woman was admitted to our department with right lower abdominal pain. After computed tomography (CT) and laboratory examination, a diagnosis of appendicitis was made and LA was performed. The mesoappendix was divided using a Laparoscopic coagulation shears (LCS). A simple ligation of the root of the appendix with an Endo-loop was performed and it was divided using a LCS. The appendiceal stump was not invaginated. A retrieval bag was introduced into the abdominal cavity to remove the resected appendix. After removing the appendix, the peritoneal cavity was irrigated with 1000ml of warm saline, and the Douglas pouch was drained with a Penrose drain. The appendiceal inflammation was macroscopically classified as phlegmonous. The patient was discharged on the 7th postoperative day in excellent condition with no wound infection and no intraabdominal abscess. The patient's body temperature increased to 38.1?? on 16th postoperative day and CT revealed a water-density pericecal mass, 3cm in diameter. We diagnosed it as a postoperative intraabdominal abscess. Because her abdominal pain didn't become severe, we managed with intravenous antibiotics. It subsided by 10 days. This case shows that intraabdominal abscess after LA occurred in spite of the use of a retrieval bag for extraction and irrigation of peritoneum with much saline. Although the cause of this complication was unknown, it may be necessary to invaginate the appendiceal stump or to divide the root of the appendix using laparoscopic linear stapler.
<figure><img src="image_120.png" /></figure>

## Complications of Surgery - P247

EARLY RE-LAPAROSCOPY FOR MANAGEMENT OF SUSPECTED POSTOPERATIVE COMPLICATIONS, Boris Kirshtein MD, Aviel Roy-Shapira MD, Sergey Domchik MD, Solly Mizrahi MD, Leonid Lantsberg MD, Department of Surgery A Soroka Medical Center, Faculty of Health Sciences Ben Gurion University of the Negev

**AIM:** To evaluate the role of early re-laparoscopy for diagnosis and treatment of patients who are progressing as expected following laparoscopic surgery.

**PATIENTS AND METHODS:** We performed a retrospective review of the patients underwent re-laparoscopy for suspected complications of laparoscopic surgery between January 2000 and July 2006.

**RESULTS:** During the study period, 7726 patients underwent laparoscopic surgery in our service. Of these 57(0.7%) patients underwent re-laparoscopy for suspected complications. 15 male and 42 female patients with mean age 51.9 years old underwent initial laparoscopic surgery for cholelithiasis (27), morbid obesity (11), incisional hernia (9), perforated viscus (4), acute appendicitis (3), end stage renal failure (1), infected urachal (1) and ruptured ovarian cysts (1). The primary operation was elective in 43 patients. Indications for re-laparoscopy were excessive postoperative pain in 21(37%), peritoneal signs in 18(32%), SIRS 8(14%), intestinal obstruction in 4(7%), bile leak in 3(5%), overt shock in 2(4%), and bleeding in 1(2%) patient. Median delay between operations was 2 days. Re-laparoscopy was negative in 18(32%) patients. In other patients, a firm diagnosis could be established. The identified pathology was treated laparoscopically in 50 patients, the rest were converted. 7 patients underwent more than one re-laparosopies. Three patients in this series died of their complications. Re-laparoscopy was not associated with additional morbidity.

**CONCLUSIONS:** A policy of early re-laparoscopy in patients with suspected complications enables timely management of identified complications, with expedient resolution.

## Complications of Surgery - P248

RETROPERITONEAL TROCAR INJURY IN LAPAROSCOPIC CHOLECYSTECTOMY, Subhasis Misra MD, Prasanta Raj MD, Fairview Hospital, Cleveland Clinic Health System

**OBJECTIVE:** Bowel injuries can be a major complication during abdominal laparoscopic procedures. Unfortunately, trocar injuries still happen in laparoscopic cholecystectomy. We present an unusual case of retroperitoneal right colon injury from trocar placement.

**METHODS:** 40-year-old female, with recent history of laparoscopic cholecystectomy two months back presented with intermittent right-sided abdominal pain since her surgery. Patient had right flank tenderness but had no peritoneal signs. CT scan showed asymmetric thickening of wall of the ascending colon with surrounding fat reaction suggestive of localized perforation possibly from colonic carcinoma. No history of ulcerative colitis, crohns disease, colon cancer in family. Gastroenterologist deferred colonoscopic exam due to localized perforation. Of note, bladeless trocars were used during the initial laparoscopic cholecystectomy surgery.

**RESULTS:** Patient underwent exploratory laparotomy and right hemicolectomy. Frozen section of mass showed fibrous serositis with fat necrosis and granulation tissue, with no malignant changes and an intact bowel mucosa. This finding was consistent with injury of the ascending colon bowel wall due to trocar insertion as it was involving the trocar entry site.

**CONCLUSION:** As a part of ascending colon is retroperitoneal, injury can go unnoticed and stay in the retroperitoneal location and can have delayed presentation of perforated colon injury with continued symptoms. We believe that bladeless trocar can cause traction injury during insertion, which may go unnoticed as the trocar travels in the retroperitoneal space and this injury may not be visible in the laparoscopic view. Hence, careful trocar placement under direct visualization and with minimal shearing is recommended.

## Complications of Surgery - P249

BILE DUCT INJURIES AFTER OPEN AND LAPAROSCOPIC CHOLECYSTECTOMIES AT DEPARTMENT FOR ABDOMINAL SURGERY, MARIBOR, SLOVENIA, andromako nikica, Department of abdominal surgery, Teaching hospital Maribor, Slovenia

**Results:** In 5 year period at Department for abdominal surgery in Maribor, 2799 cholecystectomies were performed. There were 15 bile duct injuries in this period what represents. Four injuries occurred after conventional operation and 11 after laparoscopic technique. Eight bile duct injuries were detected immediately and repaired immediately. Other were found up to 11*day postoperatively. Major signs were biliary leakage through abdominal drain, obstructive jaundice or acute abdomen which all demand operative treatment.

Our patients in Strasberg classification: Type A / 5 patients; Type B / 1 patients; Type C / 3 patients; Type D / 5 patients; Type E / 1 patients.

### Treatment

A type- In two cases we only ligated cystic duct and in three cases ligated superficial aberrant duct together with T-tube.

B type- injury was recognized intraoperatively and managed with bile duct ligature

C type- injures were immediately detected and repaired with bile duct ligatures.

D type- injures were repaired in four cases with direct sutures of bile duct with T-tube and in one case bilio-digestive anastomosis was performed.

E type- injury was immediately treated by biliodegutive anastomosis.

### Conclusion

? Laparoscopic cholecystectomy has become the standard method for the elective treatment of patients with symptomatic cholelithiasis

? It is a method of choice for patients in hands of experienced surgeon

? Conversion do not mean "bad surgeon" but on the contrary wised experienced and rational

? There is no easy cholecystectomy; all are identical and must be save for all patients

? It is of major importance to be absolutely sure of anatomic situation before cutting any structures in triangle Callot

? The highest aim is not harm any biliovascular structure

? All reparation of this structures are inherently connected to high risk of secondary stenosis, liver cirrhosis and shorter survival

## Complications of Surgery - P250

INTRAOPERATIVE COMPLICATIONS IN THE LAPAROSCOPIC TREATMENT OF ESOPHAGEAL DISEASES, Pablo E Omelanczuk MD, Jorge A Nefa MD, Sergio E Bustos MD, Walther Minatti MD, Department of General Surgery, Hospital Italiano de Mendoza. Argentina. Lateral Este 1015 Guaymallén, Mendoza. Argentina

**Objective:** Laparoscopic surgery is the approach of choice for the surgical treatment of benign esophageal disease. However, it is not free of operative complications. To show how different lesions are produced and how they are resolved.

**Materials and method:** Videos of laparoscopic surgeries of benign esophageal disease were assessed retrospectively over the period January 2001-April 2006, including 45 Heller procedures and 148 antireflux procedures using Nissen fundoplication laparoscopically.

**Results:** Intraoperative complications were the following: 1 pneumothorax, 2 liver lesions, 4 esophageal perforations (during myotomy for achalasia), 4 hemorrhagic lesions (1 lesion of the diaphragmatic vein, and three lesions of gastric short vessels). There was no morbidity or morbity. None required conversion.

**Conclusions:** Intraoperative complications of laparoscopic esophageal surgery are not frequent. In trained groups, they can be resolved laparoscopically without altering the final outcome of the surgery.
<figure><img src="image_121.png" /></figure>

# SAGES POSTER ABSTRACTS

## Complications of Surgery - P251

**LAPAROSCOPIC REMOVAL OF SEVERED, PARTIALLY RETAINED JACKSON-PRATT DRAIN FOLLOWING OPEN SURGERY,** Megan Palsa MS, Arthur Stanten MD, George Kazantsev MD, Ajay Upadhyay MD, Department of Surgery, Alta Bates Summit Medical Center, Oakland, California.

**Introduction:** Retained intra-abdominal Jackson-Pratt (JP) drain secondary to fracture during attempted removal is a rare complication. The management of this occurrence in the immediate post operative period has traditionally involved a return to the operating room and retrieval either by wound exploration or formal repeat laparotomy. A computed tomography guided wire localization and retrieval has been reported as another option, provided the drain end is still in the abdominal wall. We describe the use of laparoscopy in the immediate post operative period following open surgery as an alternative approach to this annoying problem.

**Case Report:** A 59 year old female underwent a distal gastrectomy with Roux-en-Y bypass for carcinoid tumor of the proximal duodenum and wedge resection of a solitary liver lesion. Ten days post operatively during Jackson Pratt drain removal, severance of the drain occurred leaving the perforated flat portion of the drain in the peritoneal cavity, beyond the reach for external probing and removal. An abdominal radiograph revealed the flat part of the drain lying in the right upper quadrant. Access to the abdomen was easily obtained by inserting a veress needle in the left sub costal region. The flat portion of the drain was deeply imbedded in omental adhesions over the right dome of the liver. There was no evidence of suture relating to drain severance or adherence. The adhesions were taken down and the retained portion of the drain was successfully removed via the 10 mm trocar. There were no adverse effects related to the laparoscopic removal.

**Conclusion:** A JP drain may fracture during removal if it is inadvertently sutured, pinched, over stretched, or wrapped by omental adhesions as in our patient. Severance of JP drain and partial retention is an unusual post-operative complication that can be successfully managed using different approaches if the drain is located in the subcutaneous tissue, theses include exit site exploration, CT guided removal or a formal laparotomy. However, an intra-abdominal retention can be best approached using a laparoscopic technique before considering laparotomy. Laparoscopic approach in the immediate post operative period following open surgery is a feasible and safe option.

## Complications of Surgery - P252

**ASSESSMENT OF ADHESIONS AT LAPAROSCOPY FOLLOWING OPEN AND LAPAROSCOPIC COLORECTAL SURGERY,** Henry m Dowson MD, Yuen Soon MD, Angela J Skull MD, Timothy A Rockall MS, Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK

**Introduction:** Reports have suggested that laparoscopic surgery results in the formation of fewer adhesions than equivalent open surgery. This pilot study aimed to evaluate the inter- and intra-observer reliability of an adhesion scoring system adapted for use at laparoscopy following general surgical procedures.

**Methods:** All patients who had previously had a colorectal procedure (either laparoscopic or open), and were referred for subsequent laparoscopy, were eligible for the study. The laparoscopies were videoed and scored for adhesion formation by 5 experienced general surgeons on 3 separate occasions. Adhesions were assessed at laparoscopy using an 8 point scoring system, based on the severity of adhesion formation at three separate sites (access wound, site of pathology and surgical resection, and any distant sites), the overall extent of adhesion formation (0-25%, 25-50%, >50%), and involvement of small bowel. Inter-observer variation was calculated using the lambda coefficient.

**Results:** 10 laparoscopies (7 prior to liver resection) were recorded and analysed. 7 patients had previously had open colorectal surgery, and 3 laparoscopic surgery. Lambda coefficient showed good reliability, and there was no significant in intra-observer variability.

**Conclusion:** This study has demonstrated that this adhesion scoring scale adapted for use in laparoscopic surgical procedures is both reliable and reproduceable. We plan to use this in a study comparing the incidence of adhesions following laparoscopic and open colorectal surgery.

## Complications of Surgery - P253

**VICERAL FAT AREA IS A USEFUL PREDICTOR OF SURGICAL OUTCOME FOLLOWING LAPAROSCOPIC COLECTOMY FOR COLON CANCER,** Shingo Tsujinaka MD, Yutaka J Kawamura MD, Fumio Konishi MD, Ken Mizokami MD, Takafumi Maeda MD, Jichi Medical University Omiya Medical Center

**Introduction:** Obesity may compromise surgical outcome following laparoscopic surgeries. The body mass index (BMI) is widely used as a definition of obesity, though individuals with large volume of muscle and/or bone can be misinterpreted as obese. Visceral fat area is another parameter of obesity that correlates with metabolic diseases. To date, no study has investigated upon the impact of visceral fat area on surgical outcome following laparoscopic colorectal surgery. Therefore, the purpose of this study was to evaluate whether visceral fat area is a predictor of surgical outcome following laparoscopic colectomy for patients with colon cancer.

**Patients and Method:** With the approval of the Institutional Review Board, a total of 167 patients who underwent laparoscopic colectomy for any stage of colon cancer between April 2001 and April 2006 were included. All patients had abdominal computed tomography preoperatively. Visceral fat area was measured at the level of umbilicus and individuals with the amount of >130 cm2 were classified into the obese patients (Definition I). Alternatively, the body mass index (BMI) was also calculated and the obese patients were defined as BMI >25 (Definition II), according to the criteria of the Japan Society for the Study of Obesity. For both of these definitions, patient characteristics, intraoperative variables, morbidity, and postoperative recovery were compared between the obese and the non-obese patients.

**Results:** There were 74 (44.3%) obese patients with Definition I and 33 (19.8%) with Definition II. Incidence of surgical site infection was significantly frequent in obese patients than non-obese patients in Definition I (16.2 vs. 4.3%, p=0.009), whereas not significant with those in Definition II (15.2 vs. 8.2%, P=0.317). Overall morbidity rate was significantly increased in obese patients than non-obese patients in Definition I (28.4% vs. 10.8%, P=0.004), while not significant with those in Definition II (24.2 vs. 17.2%, P=0.349). There was no significant difference in both definitions in days to flatus, stool, or ingestion of diet. The median postoperative hospital stay was significantly longer in obese patients than non-obese patients in Definition I (11 vs. 10 days, P=0.03).

**Conclusion:** Visceral fat area is more accurate than BMI in predicting surgical outcome following laparoscopic colectomy for colon cancer.

## Complications of Surgery - P254

**LAPAROSCOPIC MANAGEMENT OF RETAINED GALLSTONES PRESENTING AS A HEPATIC MASS,** Brent C White MD, Thadeus Trus MD, Department of Surgery, Dartmouth-Hitchcock Medical Center

**Introduction:** Retained gallstones are associated with 2-4% of laparoscopic cholecystectomies. Most reports describing the complications of these stones have used open surgery in their management. The aims of this case report are to demonstrate an unusual presentation of retained gallstones and the feasibility of laparoscopic management.

**Methods and Results:** An 85 year-old woman who had undergone a laparoscopic cholecystectomy one year previously developed right upper quadrant pain and mild nausea. Upon thorough workup, a 3x2cm solid mass in the posterior right hepatic lobe was found on CT scan suspicious for malignancy. A CT-guided needle biopsy of this lesion unexpectedly obtained very scant, thick purulent material which was culture positive for Klebsiella. A repeat CT scan failed to reveal any resolution of this lesion after an extensive course
# SAGES POSTER ABSTRACTS

of antibiotics for presumed hepatic abscess. Given the culture results and prior laparoscopic cholecystectomy, diagnostic laparoscopy was pursued. This was performed with the patient in a left lateral decubitus position using three ports: one infraumbilical and two right subcostal. The liver was mobilized medially and an isolated abscess cavity containing numerous gallstones was found. All stones were carefully extracted and removed with a laparoscopic bag before marsupializing the abscess cavity. A Jackson-Pratt drain was left in the space adjacent to the cavity after thorough irrigation. The drain was removed several days after her operation. On follow-up office visit after a course of post-operative antibiotics, her symptoms had resolved.

**Conclusion:** Retained gallstones can resemble a solid hepatic mass on CT scan. Use of a laparoscopic approach in this case allowed diagnosis of suspected retained gallstones as well as definitive intervention. Such an approach could likely be used in other carefully selected cases where retained gallstones are suspected.

## Complications of Surgery - P255

### INTRAOPERATIVE DIAGNOSIS AND REPAIR OF TRANSECTED RADIAL NERVE DURING ENDOSCOPIC RADIAL ARTERY HARVEST FOR CABG, JOSEPH WOLF MD, NICK PATEL MD, LOUIS BRITTON MD, JEROME CHAO MD, ALBANY MEDICAL CENTER

Endoscopic radial artery harvesting for coronary artery bypass grafting was introduced by Terada et al. in 1988 following the success of endoscopic saphenous vein harvesting. It has since become the procedure of choice for many cardiac surgery groups as the structural integrity and vasoreactivity of the endoscopically harvested radial artery has been shown to be preserved.

As with all surgical procedures, there are morbidities associated. Several studies in the cardiac surgery literature have described the neurologic morbidities associated with the open and the endoscopic approach. The incidence of neurologic sequelae with the endoscopic technique ranges from one to twenty seven percent in the literature. Between eight and eighteen percent of patients reportedly develop dorsal hand numbness at the twelve month follow up evaluation, suggesting that there has been direct thermal or mechanical damage to the radial nerve. Yet, this injury has never been reported to be visualized and repaired intraoperatively. The authors present a case report of an inadvertent transsection of the radial nerve that took place during the endoscopic harvest of a radial artery for coronary artery bypass grafting. The injury was visualized by the surgeon on the endoscopic monitor and a plastic surgeon immediately repaired the injured nerve with a NeuraGen nerve conduit. This is the only report in the literature in which a radial artery was harvested with the endoscopic technique and a peripheral nerve injury was diagnosed intraoperatively and immediately surgically repaired.

## Education/Outcomes - P256

### ACQUISITION OF LAPAROSCOPIC SKILLS: COMPARISON OF MEDICAL STUDENTS AND PA STUDENTS, J R Adkins MD, S G Barloco MD, V Sherman MD, N R Barshes MD, M Millie MD, S Kreml MD, J F Sweeney MD, Baylor College of Medicine, Michael E. DeBakey Department of Surgery

**Introduction:** In the era of the 80-hour workweek physician assistants (PA) are playing a more integral part in the operating room, especially assisting with laparoscopic cases. We sought to determine the baseline laparoscopic skills and trainability of PA students compared to medical students.

**Methods:** 81 second and third year medical students (MS) and 17 PA students (PAS) were timed at baseline and post training on laparoscopic trainers. Three commonly used laparoscopic skills tasks Slam Dunk (Bean), Cobra Rope (Rope) and Terrible Triangle (Triangle) were used for the study. Each student was timed initially on each task and then again after two 2-hour training sessions. The overall improvement on each task was compared between the two groups using student's t-tests.

**Results:** Both the medical students and PA students improved significantly on each task (* indicates p<0.01). However, the amount of absolute improvement between the groups was not statistically significant. The table shows the time of each group on each task performed in seconds (mean (SD)). The standard deviation decreased in each group after training representing an improvement to a more consistent level of performance.

<table><thead><tr><th rowspan="2">Task<br>Practice group</th><th colspan="2">Bean</th><th colspan="2">Rope</th><th colspan="2">Triangle</th></tr><tr><th>Pre<br>Score</th><th>Post<br>Score</th><th>Pre<br>Score</th><th>Post<br>Score</th><th>Pre<br>Score</th><th>Post<br>Score</th></tr></thead><tbody><tr><td>MS</td><td>127.3<br>(70.2)</td><td>77.3<br>(40.6)*</td><td>187.9<br>(71.1)</td><td>104.3<br>(34.3) *</td><td>100.9<br>(44.4)</td><td>51.3<br>(26.6) *</td></tr><tr><td>PAS</td><td>160.2<br>(81.8)</td><td>74.3<br>(58.0)*</td><td>205.5<br>(120.3)</td><td>105.1<br>(46.1) *</td><td>95.3<br>(56.1)</td><td>47.8<br>(15.5) *</td></tr></tbody></table>

**Conclusion:** Laparoscopic skills of PA students have been shown to improve comparably to that of medical students, after only two 2-hour training sessions. PA students can be trained using the same curriculum as medical students, thereby enhancing the ability of PA students to assist with laparoscopic surgery.

## Education/Outcomes - P257

### THE DEVELOPMENT OF A PROFICIENCY-BASED TRAINING CURRICULUM ON THE LAPMENTOR VIRTUAL REALITY SIMULATOR, R Aggarwal MD, A Dias, I Balasundaram MD, A Darzi MD, Imperial College London

**Introduction:** The implementation of a competency-based laparoscopic surgical skills curriculum necessitates the development of tools to enable structured training, with in-built objective measures of assessment. Simulation in the form of virtual reality has been proposed for technical skills training at the early part of the learning curve. The aim of this study was to determine the construct validity and training potential of a commercially available laparoscopic VR simulator with force (haptic) feedback (Lapmentor, Simbionix, USA). A subsequent aim was to derive a competency-based laparoscopic training curriculum based upon this evidence.

**Methods:** 20 general surgeons of varying levels of experience were recruited: 10 inexperienced (performed <10 laparoscopic cholecystectomies [LCs]), 5 intermediate (20-50 LCs) and 5 experienced (>100 LCs). The basic skills module has nine tasks which were performed twice by all surgeons recruited to the study. The 10 surgeons inexperienced in laparoscopic procedures continued to train on the simulator for a further eight sessions, making a total of 10 sessions. Performance was recorded objectively and instantly by the VR simulator for the parameters of time taken, economy of movement (path length, number of movements) and error/accuracy scores.

**Results:** All nine tasks demonstrated construct validity for time taken (Kruskal- Wallis test, p<0.05). The economy parameters were construct valid for six of nine tasks, though error scores did not validate, apart from for two of the tasks (cutting and object translocation). Analysis of the learning curves for novices revealed significant improvements in performance on the basis of quantitative metrics, i.e. time taken and economy scores (p<0.05). The median results of experienced surgeons for each task for each validated parameter enabled definition of benchmark levels of performance to achieve.

**Conclusion:** All tasks have been proven to be construct valid, and learning curve analysis proves that novice surgeons improve their performance with repeated practice on the simulator. The derivation of benchmark criteria from the performance metrics of experienced surgeons ensures that it is acquisition of technical skill, and not the length of time spent on the simulator that determines progression onto real cases. This can serve to ensure that junior trainees have acquired pre-requisite levels of skill prior to entering the operating room, where they can be put into practice.

<figure><img src="image_122.png" /></figure>
<figure><img src="image_123.png" /></figure>

# SAGES POSTER ABSTRACTS

## Education/Outcomes - P258

**THE EFFECT OF NATURAL DISASTER ON ROUTINE SURGERY, Jason A Breaux MD, Mark A French, Colleen I Kennedy MD, William S Richardson MD, Ochsner Medical Center**

**Introduction:** We undertook this study so that we could learn about the effect of hurricane Katrina on routine surgery, laparoscopic cholecystectomy (LC), in order to understand what happens with a large natural disaster.

**Methods:** We used our prospectively collected database for all data. All inpatients with (LC) (DRG 493 & 494) and outpatients with principal procedure code 51.23 LC were included in the study. The time periods used were for the seven months prior to Katrina and compared it to seven months starting three months after the storm, when operating room volumes were close to status quo. Costs and revenues are all hospital based.

**Results:** Total cases were 196 pre and 167 post storm (preS and postS) for outpatient and 62 preS and 64 postS for inpatient.

<table><thead><tr><th>Inpt ($)</th><th>preS</th><th>postS</th><th>Outpt</th><th>preS</th><th>postS</th></tr></thead><tbody><tr><td>Cost</td><td>2020</td><td>1977</td><td></td><td>5313</td><td>4077</td></tr><tr><td>Revenue</td><td>3705</td><td>3830</td><td></td><td>8330</td><td>7487</td></tr><tr><td>Profit</td><td>1684</td><td>1853</td><td></td><td>3016</td><td>2779</td></tr></tbody></table>

Decreased costs were largely due to loss of veteran (higher paid) staff and therefore overall decrease in salary even though lower level staff incurred wage gains due to high demand for these wage earners postS. Our better payers decreased by 10.5% and Medicare, Medicaid and private pay non-insured increased by 1, 3.5, and 6% respectively. Overall reimbursement declined from 43.7% to 41.4%. Total outpatient profits were $330,110 preS and $309,391 postS and inpatient were $186,990 and $117,876.

**Conclusions:** Hurricane Katrina opened the door to cost efficiencies for LC. However, revenue is down due to increases in uninsured and fewer outpatient LCs. In planning for this type of disaster, be ready for large staff turnovers, potential changes in payor mix, a diminished employment pool, and decreases in outpatient surgery.

## Education/Outcomes - P259

**LONG TERM FOLLOW UP FOR LAPAROSCOPIC CHOLECYSTECTOMY IN THE ELDERLY POPULATION, CK Chang MD, RC Liu MD, JC Choi MD, SK Liu MD, T MacPherson, Department of Surgery, Kaiser Permanente, Walnut Creek CA**

**Background:** The aim of this study was to review the long term outcome of the elderly population who underwent laparoscopic cholecystectomy (LC).

**Methods:** A retrospective review was undertaken to identify patients 80 years old or older who underwent LC at a Northern California Kaiser Permanente facility. All patients received their treatments between January 1996 and December 2005. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and Cox regression.

**Results:** Of the 269 patients who underwent LC, 23% (61 patients) underwent an open cholecystectomy. Mean overall survival (OS) was 79±3 months. Mean age was 85 years (range 80-100), with 13% (34 patients) over the age of 89. Mean follow-up was 44 months (range 1-121 months). Mean length of stay 4.3 days with 28% undergoing outpatient surgery. The 30 days, 6 months and 1 year mortality were 4.5%, 10.1% and 17.9% respectively. During the study period the number of patients undergoing outpatient LC remained the same while the number of inpatient admissions tripled. Patients who were admitted for inpatient LC had a decrease survival when compared to outpatient LC, 73 months versus 88 months, respectively. None of the outpatient LC died within 6 months or was converted to an open cholecystectomy.

**Conclusion:** Laparoscopic cholecystectomy can be performed safely in the geriatric population. However earlier diagnosis and surgical referral may improve survival before acute presentations.

## Education/Outcomes - P260

**MENTORING SURGICAL RESIDENTS ON LIVE ANIMAL MODELS IMPROVES THE SAFETY AND EFFICACY OF EGD, Yoav Mintz MD, John P Cullen MD, Alana Chock MD, David W Easter MD, Mark A Talamini MD, Michelle K Savu MD, University of California at San Diego**

**Objective:** Esophagogastroduodenoscopy (EGD) is a difficult task for surgical residents. Mentoring sessions using live animal models will significantly increase their expertise prior to performing EGD on human patients, thereby improving patient safety.

**Methods:** Following the approval of the UCSD IRB committee 12 surgical residents received an introductory lecture about endoscopy with an emphasis on operating the endoscope. Two 40 Kg pigs served as animal models. In order to simulate gastric lesions, one of the pigs was marked with methylene blue dye and mucosal clips in the fundus, body and antrum. The residents were randomly divided into a mentored group (n=7) and a non-mentored (NM) group (n=5). Each resident in the mentored group performed an EGD while being guided by an experienced surgeon. Following this session the residents went on to perform an EGD on the marked pig. The NM group performed the EGD on the marked pig without prior mentoring. Performances were graded on time and accuracy. Statistical analysis was performed using the unpaired t test.

**Results:** In the marked pig the z-line was identified correctly in both groups +/- 2 cm. The mean time to successfully intubating the stomach was 2.1 min for the non-mentored group and only 1.2 min for the mentored one (p = 0.0289). The mean total time for the procedures were 12.2 min and 8.7 min respectively (p=0.0460). Once in the stomach, the mean time to identify one lesion was 4.6 min for the NM group but only 1.1 min for the mentored group (p = 0.0256). Only one resident from the mentored group failed to identify a second and third lesion. In the NM group two residents failed to identify a second lesion and all quit prior to identifying a third lesion due to frustration. The anatomic locations of 15 of 19 lesions (79%) in the mentored group were identified correctly. Only one lesion was correctly identified in the NM group. All NM residents pointed out that the orientation in the stomach was the most difficult and challenging part of the test.

**Conclusions:** Mentoring session on live animal models significantly improves the time performance, the spatial orientation and overall increases the expertise of surgical residents for this task. The input by the mentor increases the value of the hands on experience and could be adopted as a method for shortening the learning curve and improving patient safety for EGD.

## Education/Outcomes - P261

**THE EFFECTS OF PRACTICE ORGANIZATION ON VISUOMOTOR MISALIGNMENT ADAPTATION, A Kurahashi BS, K Leeming BS, H Carnahan PhD, A Dubrowski PhD, Department of Surgery, University of Toronto**

The objective of this study was to examine the impact of how the organization of a practice session (practice scheduling) influences adaptations to visuo-motor misalignments (VMM) in novices. During laparoscopic surgery, visuo-motor misalignments occur when displayed endoscopic images conflict with the visual orientation of the actual movements. However, adaptation processes can be facilitated by manipulating the way practice sessions are organized to compensate for this misalignment. Typically when practicing several related versions of the same task, random practice has been shown to interfere with practice performance compared to blocked or drill type practice, but has been shown to be superior to blocked practice in the long term retention of simple motor skills (retention or transfer performance). Borrowing from this concept, 24 novices performed a pick-up-and-replace task using laparoscopic instruments in a box trainer; there were three angles of visual field rotation (AVFR): 0°, 60° or 90°. Participants were assigned to either the Blocked or Random practice groups and all performed the pick-up-and-replace task for 30 practice trials (10 at each
SAGES POSTER ABSTRACTS

AVFR). After 24 hours, retention tests were performed at each AVFR, followed by a transfer test to a new AVFR (45°). The acquisition, retention and transfer performance scores were analyzed using analyses of variance. Statistical analyses showed that the AVFR increased, task performance decreased in both practice groups. While both groups improved performance during practice, performance in the 90°AVFR condition never achieved the same level as other AVFRs. As well, during practice, the random group performed worse than the blocked group only for the first half of practice. For the 0° AVFR retention test, the blocked group again performed better than the random group, indicating better learning for this group. However, for the more difficult AVFR conditions (60° or 90° AVFR), and for the transfer test, there were no group differences. It was concluded that the typical random learning advantage seen for simple tasks was absent due to the inherent complexity of laparoscopic skills. Thus, in terms of time-efficiency, blocked practice is preferred for VMM adaptation acquisition in novices since fewer camera manipulations are required during practice

Education/Outcomes – P262

STEREOSCOPIC VERSUS TRADITIONAL TWO-DIMENSION-
AL VISUALIZATION FOR TRAINING MODULES, Ward J
Dunnican MD,Carrie Jahraus MD,Randall Kimball BA,T. Paul
Singh MD,Ashar Ata MPH,Suvranu De PhD, Albany Medical
College, Albany, NY USA

The use of three-dimensional vision may benefit perform-
ance of surgical tasks. Our previous research has utilized a
dual monitor based stereo vision system (Planar Systems,
Inc.). This dual monitor based stereo vision system allows
the observer to visualize three dimensional objects. We
examined the benefits of stereoscopic vision among trained
and untrained surgeons as to their performance of surgical
training procedures.

We prospectively enrolled 20 participants into two groups: untrained (medical students, PGY1 residents) and trained (PGY4, PGY5 residents and attendings). Participants were asked to perform five repetitions of a peg transfer task first using 2D vision, then using 3D vision. After both the 2D and 3D task performance, all participants completed a questionnaire. Data analyzed included time to completion of task, errors, the development of visual strain, resolution and brightness of images, and preference for 2D versus 3D. Twosample t-test was used to compare the means of average task completion times between trained versus untrained participants. Wilcoxon rank-sum test was used to compare the means of average times using 2D versus 3D task completion. Generalized Estimation Equations (GEE) were used to determine the effect of repetition on task completion for 2D, 3D, and transition from 2D to 3D.

When comparing 2D to 3D task performance, trained partici-
pants exhibited no overall improvement in task completion.
Untrained participants exhibited a significant improvement
in task completion using 3D (p=0.04). Trained participants
performed better than untrained participants using 2D
(p=0.02). There was no significant difference between
trained and untrained participant performance using 3D
(p=0.37). Most participants in each group preferred 3D visu-
alization.

Stereoscopic visualization facilitates performance in
untrained individuals. Trained individuals are able to adapt
to non-stereoscopic monitors: this learned ability may be
obviated by the use of stereoscopic visualization during sur-
gical training. This is evident in the similar performance of
both groups using 3D visualization. The use of stereoscopic
visualization may promote accelerated adaptation to
advanced minimally invasive procedures.

Education/Outcomes – P263

LAPAROSCOPIC APPENDECTOMY, SAGES OUTCOMES
STUDY, D S Edelman MD, Baptist Hospital of South Florida

Intro: The SAGES Outcomes Data base was queried for all Appendectomy (appy) data using CPT codes 44950, 44960 and 44970. The information was analyzed and outcomes reviewed.

Results: There were 644 patients entered into the data base.

Open appy were 210, open appy with perforation were 46
and laparoscopic appy were 388. There were 342 men, 299
women and 3 unlisted in the data base. Average age was 36
years (7 to 84). The majority of patients had general anes-
thesia but spinal anesthesia was used in 8 open appys and
local only was used in 3 open patients. Hospital stay ranged
from 0-10 days and averaged 1.5 days. One open appy
stayed 10 days, one perforated open appy stayed 9 days
and one lap appy stayed 7 days. Post-op abscess were doc-
umented in 14% of patients, 3 lap appy's and 1 open appy,
non-perforated. Only 28 patients (4.3%) had post op out-
come data entered.

**Conclusions:** There were many appendectomy patients entered into the data base. Post operative follow up data was sporadic and too few to draw any conclusions. It is suggested that by enhancing the Outcomes Data Base for Appendectomy useful outcomes data should be obtainable.

Education/Outcomes – P264

ON-Q PAIN MANAGEMENT SYSTEM DOES NOT REDUCE
HOSPITAL LENGTH OF STAY IN VENTRAL HERNIA REPAIR,
David A Edelman MD, Andre Nunn MD, Wayne State

University

**Background:** Pain after ventral hernia repair can be significant, and result in increased hospital length of stay. There have been several recent publications evaluating the On-Q pain management system following inguinal and midline laparotomy operations. However, there is a paucity of data in regards to ventral hernia repair. The aim of this study was to evaluate the effectiveness of the On-Q system. It was our hypothesis that the On-Q system would decrease the length of stay in patients with ventral hernia repair.

**Methods:** This is a retrospective study of all patients that underwent ventral hernia repair by a single surgeon from January 2002 through June 2006. Only patients whose operation was primarily due to their ventral hernia were included. Patients with small hernias, or umbilical hernias were excluded.

**Results:** There were a total of 63 patients included in this study. Of the 63, 45 (71%) patients underwent operation, did not receive a pump, and were considered control. The average length of stay for the 18 patients with the On-Q pain system was 3.2 days and not significantly different (3.3 days) than the patients without the pain system (p=0.9). Of the 63 patients, 41 (65%) had their ventral hernia repaired laparoscopically. Within this sub-group, no difference in average length of stay was seen between those patients with the pump (2.5 days) and those patients without the pump (2.7 days) (p=0.7).

Conclusions: In this study, we found that our hypothesis was incorrect. The use of the On-Q pain management system did not result in a shorter hospital length of stay for our patients that underwent ventral hernia repair. A prospective, randomized clinical trial is necessary to validate our results.

Education/Outcomes – P265

PANTOPRAZOLE UTILIZATION ANALYSIS, David A Edelman MD, Krupa R Patel, Lisa G Hall, James G Tyburski MD, Robert F Wilson MD, Detroit Receiving Hospital, Wayne State University, Detroit, Michigan

**Introduction:** There has been a rapid increase in the use of proton pump inhibitors in recent years. Recently, our institution has had several shortages of IV pantoprazole lasting 7-10 days each time. The purpose of our study was to evaluate in-patient usage of IV pantoprazole. We hypothesized that hospitalized patients with upper GIB or risk for stress ulcers inappropriately received IV pantoprazole based on current literature.

**Methods:** This was a retrospective study of 165 consecutive in-patients identified as receiving pantoprazole from December 2004 to March 2005. Only patients receiving IV pantoprazole were included (n=78). Data collected included demographics, indication and dosing of pantoprazole, admitting team (surgery vs. medicine), risk factors for stress ulcers, length of stay, and mortality. Pantoprazole IV was deemed appropriate for stress ulcer prophylaxis (SUP) in

<figure><img src="image_124.png" /></figure>
<figure><img src="image_125.png" /></figure>

# SAGES POSTER ABSTRACTS

the presence of mechanical ventilation > 48 hours or coagulopathy plus one of the following: refractory gastric pH despite being treated with histamine-2 blocker, if an adverse drug reaction to a histamine-2 blocker was known, or Helicobacter pylori suspected or documented. Pantoprazole was deemed appropriate for GIB if clear evidence was present (coffee ground emesis or guaiac positive stools). The dose of pantoprazole was considered correct if 80 mg IV q8 hours or 8 mg/hr infusion was given for SUP, or if 80 mg IV bolus followed by 8 mg/hr infusion was given for GIB.

**Results:** Our study population had a mean age of 54±17 years and 62% were males. Overall, 45% (35/78) of patients receiving IV pantoprazole had an appropriate indication, and 19% (15/78) received the correct dose. Of the 78 patients, 43 (55%) were treated with pantoprazole for SUP, and 35 (45%) patients were treated for GIB. We found that none of the 43 patients treated for SUP had an appropriate indication for pantoprazole, but all of the patients with GIB (35) had an appropriate indication. Of the 35 patients treated for GIB with pantoprazole, only 40% (14/35) received the correct dose. In all cases of incorrect dosing, patients were underdosed.

**Conclusions:** Pantoprazole is not being prescribed appropriately for stress ulcer prophylaxis in our patient population. Even the patients appropriately receiving pantoprazole, the majority were prescribed an incorrect dose. Appropriate indications and dosing of pantoprazole could eliminate the shortages seen at our institution.

## Education/Outcomes - P266

**A PROFICIENCY-BASED CURRICULUM FOR ROBOTIC TWO-LAYER HAND SEWN ANASTAMOSIS**, Makram Gedeon MD, Mouza T Goova MD, George Walker RN, Farid J Kehdy MD, Homero Rivas MD, Daniel J Scott MD, University of Texas Southwestern Medical Center, Dallas, Texas.

**Introduction:** Validated curricula are now widely available for laparoscopic skills but not for robotic surgery. The purpose of this study was to develop and evaluate a proficiency-based curriculum using an inanimate model for two-layer hand sewn anastomosis using the daVinci robot.

**Methods:** The model was developed by repetitive iterations using various materials; a Daisie model holding 2 parallel foam intestinal organs was selected. The anastamosis was created using the daVinci system with 2 needle drivers (primary arms) and scissors (4th arm), a 15mm bougie, and four 18cm braided sutures placed in a running fashion on 3cm premarked segments of foam. Objective scoring included time and errors based on a previously validated system; errors included suture fraying, breakage, or laxity, knot security, inaccurate bite size or travel, and anastamotic size and patency. A proficiency level was defined as the mean score of 3 repetitions performed by an expert with extensive robotic experience (score 55 or 35 minutes with no errors). After an orientation, robotic novices (n=3, PGY5-Fellow) performed 3-5 repetitions to determine feasibility, construct validity, and benefit of training. Workload was assessed after each repetition using the validated NASA-TLX visual analogue scale. Comparisons were by t-tests; values are mean ± s.d. (p<0.05 considered significant).

**Results:** The curriculum required 25 man-hours for development and the model was suitably durable for repetitive practice; materials cost less than $100 for the entire study with sutures donated. Baseline trainee and expert performance were significantly different (19.3 ± 12.1 vs. 54.7 ± 4.0, p=0.01), supporting construct validity. Trainees significantly improved after practicing 3.6 ± 1.3 hours, as indicated by baseline and final scores (19.3 ± 12.1 vs. 50.3 ± 3.0, p=0.01), but none reached proficiency in 3-5 repetitions. No difference in workload was detected between novices and experts (68 ± 23 vs. 66 ± 7, NS).

**Conclusions:** This model is cost-effective and suitable for proficiency-based robotic anastamosis training. With additional

training time, it is anticipated that novices may reach expert performance. Interestingly, robotic surgery seems to even the playing field from a workload standpoint while trainees are acquiring the skills necessary to perform a complex task. Such training may ultimately play a role in surgeon credentialing on robotics prior to proctorship or adoption into practice.

## Education/Outcomes - P267

**THE CONSTRUCT VALIDITY OF COMPUTER-DERIVED PERFORMANCE METRICS FOR SELECTED SIMULATED LAPAROSCOPIC TASKS**, J. A Oostema MD, Matthew Abdel BS, Jon C Gould MD, University of Wisconsin School of Medicine and Public Health, Department of Surgery

**Introduction:** A surgical skills assessment tool is said to demonstrate evidence of construct validity if users with more experience, and by inference more skill, perform better or more efficiently. Computer derived motion metrics such as smoothness (the number of times an instrument tip changes velocity during a task) and path length may be more sensitive measures of skill for a particular task than traditional metrics such as time.

**Methods:** Twenty-four medical students (third year), 19 surgical residents (PG1-5), and 3 attending surgeons were asked to perform four different tasks 3 times in a hybrid computer-based physical laparoscopic trainer (ProMIS, Haptica Inc., Dublin). The 4 tasks in order of complexity were laparoscopic orientation (Task 1), object positioning (Task 2), sharp dissection (Task 3), and intra-corporeal knot tying (Task 4). Metrics recorded were time, path length, and smoothness. Laparoscopic operative experience for each user was quantified using case logs. Correlations were determined using regression analysis and ANOVA.

**Results:** A statistically significant correlation was observed between experience and performance for all three metrics for tasks 2-4 (all p< 0.01). Smoothness was the only metric to correlate in the laparoscopic orientation task. Within tasks, time and smoothness correlate much more strongly with experience and to a similar degree. The strongest correlation was observed for the knot tying task (r2=0.60 for time and 0.59 smoothness). An r2=1.0 would represent a perfect correlation between experience and the specified metric.

**Conclusions:** The computer-derived metrics measured by the hybrid trainer correlate with laparoscopic experience. Further study is necessary to determine if specific metrics are better indicators of actual skill.

## Education/Outcomes - P268

**INSURANCE VARIATIONS IN DEMOGRAPHICS AND OUTCOMES FOR GASTRIC BYPASS SURGERY**, J Hagedorn BA, B Encarnacion BA, E Ketchum BS, I Liu BS, D Williams MD, J Morton MD, Stanford Departments of Surgery

**Introduction:** Bariatric surgery is now increasing recognized by insurers as an important therapy. Little is known regarding the variation in demographics, serology, and outcomes among different insurance groups. The purpose of this study to identify variations among different insurance groups.

**Methods:** A retrospective chart review of patients undergoing laparoscopic Roux en Y gastric bypass between July 20023 and June 2006 at the Stanford Hospital was conducted. Patient demographics, comorbidity resolution, cardiac risk factors, and weight loss in different insurance groups were compared using ANOVA and chi-squared analysis as appropriate. The patient population was divided into three groups: private insurance, Medicare, and Medicaid.

**Results:** 479 patients were identified with 74% having private insurance, 10% Medicare and 8% Medicaid. The remainder of the patients was excluded in this review. The statistically significant results are below.

<table><thead><tr><th></th><th>Private</th><th>Medicare</th><th>Medicaid</th></tr></thead><tbody><tr><td>% Female</td><td>81</td><td>92</td><td>97</td></tr><tr><td>% BMI&gt;50</td><td>28</td><td>84</td><td>37</td></tr><tr><td>Trigly preop</td><td>172</td><td>145</td><td>254</td></tr><tr><td>DM resolution</td><td>80</td><td>88</td><td>100</td></tr><tr><td>%BMI Loss-12 mo</td><td>32</td><td>34</td><td>38</td></tr></tbody></table>
SAGES POSTER ABSTRACTS

**Conclusions:** Patient demographics, serologics, and out-
comes differed among insurance groups. These differences
may be related to access to care and socio-economic status
for these different insurance groups. Recognizing that varia-
tion exists for insurance status among gastric bypass
patients may allow for targeted and tailored care.

**Education/Outcomes – P269**

A SYSTEMATIC REVIEW OF EDUCATIONAL INITIATIVES
DESIGNED TO IMPROVE LAPAROSCOPIC SKILLS, Fatima A
Haggar MPH,Eric C Poulin MD,Joseph Mamazza MD,Robin P
Boushey MD, The University of Ottawa, The Ottawa Hospital

**Introduction:** In the current era of cost containment, reduced training hours and schedule constraints, increased pressure has necessitated innovative training strategies for teaching surgical skills outside of the OR. Consequently, many alternative training methods have been proposed for teaching lap skills. However, the effectiveness of the existing training models in teaching lap skills has not yet been proven. We aim to determine the effectiveness of educational methods designed to improve the lap skills of surgical novices.

**Methods:** We searched the Cochrane Library, MEDLINE, Health Star, EMBASE, ERIC and the references list of related reviews and articles. From these, we identified studies of technical surgical skills training methods where educational strategies were used to determine their effects on improving the lap skills of surgical novices.

**Results:** From an initial 4251 abstracts, the review of full text identified 21 RCTs with 552 participants that described technical surgical skills interventions focused on improving lap skill performances of novices and reported objectives measures of surgical performance. The quality of reporting and methodology of included studies were generally poor by today' standards. These RCTs often lacked adequate sample size and baseline group comparability. The majority of interventions used computer simulations (CS) (10/21) or video box simulations (VBS) (5/21) to teach lap skills. Training on CS or VBS combined with structured didactic training helps novices adapt to the fulcrum effect and perform surgical tasks significantly faster. No economic evaluations comparing surgical educational strategies with standard training or other educational interventions were identified.

**Conclusions:** Certain elements appear to be consistently associated with improvement in basic lap skills. However, the design features of the studies make it unclear as to which characteristics are beneficial. Further research is needed to explore these elements.

**Education/Outcomes – P270**

COMPARISON AND VALIDATION OF TWO DIFFERENT SUR-
GICAL SKILLS SIMULATORS, Dieter Hahnloser MD, Rachel
Rosenthal MD, Christian Hammel, Daniel Oertli, Markus
Müller, Pierre-Alain Clavien, Department of Visceral and
Transplantation Surgery, University Hospital Zurich,
Switzerland

**Background:** Simulators are increasingly incorporated in surgical training and validation is important. The simulations need to resemble the task they are based upon (face validity) and the simulator should be able to differentiate between levels of experience (construct validity).

**Aim:** To assess two different types of computer-based simulators: the fully computerised virtual reality (VR) simulator Xitact LS500 (VR-simulator) and the hybrid ProMisTM simulator.

**Methods:** 146 participants (61%) of the 22nd Davos International Gastrointestinal Surgery Workshop performed on a voluntary basis three similar exercises (camera navigation, clip and cut, and dissection) on the two different simulators. Objective performance parameters recorded by either simulator and subjective evaluation by questionnaire were compared between beginner (n=73) and advanced participants (n=73).

**Results:** The camera navigation exercise was completed by 52% of the participants on the VR- and by 47% on the hybrid simulator with no difference in performance parameters between beginners and advanced trainees. The hybrid simulator was graded more realistic (70% vs. 20%, p=.001) and

more useful (65% vs. 36%, p=.043) than the VR-simulator. Participation was higher at the clip and cut exercise (75% VR- and. 52% hybrid simulator) and advanced trainees performed significantly better (shorter tool-tip-travel distance, smoother, quicker and with higher score) on both simulators compared to beginners. The clip and cut exercise was graded more realistic on the hybrid (81% vs. 44%, p=.007) and similar useful on both simulators (77% vs. 72%). The dissection exercise was completed more often on the hybrid simulator (47% vs. 23%, p=0.002). Only the hybrid simulator was able to distinguish between advanced trainees and beginners, with significantly higher scores for all performance parameters for the latter. The hybrid simulator was graded more realistic (70% vs. 33%, p=.016) and more useful (83% vs. 62%, p=.12). Overall, acceptance of requirement to train on and to be evaluated by such simulators is still low (53% and 50%, respectively).

**Conclusion:** Fully computerized VR- or hybrid simulator performance parameters can distinguish between beginner and advanced trainees for perceptual motor skills (proving construct validity), but not for visuo-spatial exercises such as the camera navigation.

**Education/Outcomes – P271**

GRADUATING LAPAROSCOPIC FELLOWS WOULD PER-
FORM MORE SOLID ORGAN AND BILIARY PROCEDURES IN
THEIR "IDEAL" FELLOWSHIP THAN THEY ACTUALLY PER-
FORMED IN FELLOWSHIP TRAINING, Jason Harper
MD,David S Tichansky MD,Atul K Madan MD, Division of
Minimally Invasive Surgery, Department of Surgery,
University of Tennessee Health Science Center, Memphis,
TN, USA

**Introduction:** With the increase in minimally invasive surgery (MIS) fellowships, the concept of the ideal and standardized training curriculum is important. We have previously presented data to support the hypothesis that the expected procedure mix in current MIS training is different from what current MIS fellows would call their "ideal" fellowship. We hypothesize that upon completion of MIS fellowship training, graduating fellows would have performed a higher volume of certain types of cases in their "ideal" fellowship.

**Methods:** A survey of recently graduated MIS fellows examined the case mix and volume they performed as fellows and the case mix and volume they would have performed in an "ideal" fellowship. Differences between actual and ideal case volume were analyzed by Wilcoxon test.

**Results:** To date, 12 questionnaires were returned. All but one participant completed a one-year fellowship. The average fellows per program were 1.8. Fellows performed an average of 269.5 procedures including 42.4 diagnostic and 3.3 therapeutic endoscopies. All participants were satisfied overall with the actual case load they performed. All but one participant were satisfied overall with the actual case diversity in their fellowship. All participants felt well prepared for practice. Graduating fellows believed their actual training was equivalent to "ideal" training in ventral and inguinal hernia repair, gastric bypass, lap banding, colectomies, antireflux, cholecystectomy, appendectomy, thoracoscopy, therapeutic and diagnostic endoscopy, and gastric, esophageal, adrenal, and kidney resections (p=ns). However, their actual training fell short of their "ideal" case volume in CBD exploration and spleen, liver, and pancreas resections (p<0.05).

**Conclusion:** In 4 of 19 (21%) MIS procedure types, recently graduated fellows performed less case volume than in an "ideal" fellowship. There is a continuing need to better define and standardize the ideal MIS fellowship curriculum.

**Education/Outcomes – P272**

EXPERT PERFORMANCE CHARACTERISTICS OF A NEW
VIRTUAL REALITY SURGICAL SIMULATOR, Michael C Hsu
MD, John R Romanelli MD, Jay N Kuhn MD, David B Earle
MD, Ron W Bush BS, Neal E Seymour MD, Baystate Medical
Center and Tufts University School of Medicine

**Introduction:** In order to define appropriate surgical performance objectives for criterion-based simulation training

<figure><img src="image_126.png" /></figure>
<figure><img src="image_127.png" /></figure>

# SAGES POSTER ABSTRACTS

of basic laparoscopic skills, expert performance characteristics of a new laparoscopic virtual reality (VR) surgical simulator were determined.

**Methods:** 5 expert laparoscopic surgeons repetitively performed 6 manipulative tasks (n=14 task trials) on a SurgicalSIM VR simulator (METI, Sarasota, FL; SimSurgery AS, Oslo, Norway) during distributed 1 hour sessions. VR tasks consisted of abstract object manipulation (4 tasks), and part-task laparoscopic cholecystectomy exercises (2 tasks) set at intermediate difficulty configurations. All tasks were scored for time, instrument tip path length, and errors with mean performance determined for 4 iterations of each task after stable performance was achieved.

**Results:** Performance improvement occurred for all tasks, and stable performance was achieved after a variable number of iterations (2-10 task trials). Expert performance data are shown (Table).

<table><thead><tr><td>Task</td><td>Time (sec)</td><td>Path Length(cm)</td><td>Errors</td></tr></thead><tbody><tr><td>Retract-Dissect</td><td>84±6</td><td>253±25</td><td>3±1</td></tr><tr><td>Traverse Tube</td><td>72±9</td><td>258±25</td><td>2±1</td></tr><tr><td>Place Arrow</td><td>92±11</td><td>201±20</td><td>3±2</td></tr><tr><td>Apply Clips</td><td>42±3</td><td>75±8</td><td>1±0</td></tr><tr><td>Dissect GB</td><td>100±14</td><td>121±11</td><td>4±1</td></tr></tbody></table>

**Conclusions:** Variability in number of tasks to achieve stable performance is an expected consequence of skills variations between subjects. At the selected difficulty configurations only very small additional incremental performance improvements appear possible after 14 task trials. To determine suitability of these configurations to train novice surgeons, comparisons to completed learning curves for novices must be made.

## Education/Outcomes - P273

SHOULD HAND SUTURED GASTROJEJUNOSTOMY BE THE GOLD STANDARD - LESSONS LEARNT IN OVER 970 CONSECUTIVE LAPAROSCOPIC GASTRIC BYPASS CASESWITH-OUT LEAK., Ashutosh Kaul MD,Thomas Sullivan BS,Dominick Artuso MD,Edward Yatco MD,Thomas Cerabona MD, New York Medical College

Aim of this presentation is to communicate our series of 970 consecutive laparoscopic gastric bypasses done at a single center without any leak from gastrojejunostomy (GJ).

This is a retrospective analysis of prospectively maintained data from a tertiary care center. Data was analyzed from Jan 2001 till June 2006. Redo cases, sleeve gastrectomies, lap bands and biliopancreatic diversions were excluded. All cases were done by four bariatric surgeons and by fellowship trainees under their guidance.

Our technique for creation of the GJ is a four layered hand sutured (inner absorbable and outer non absorbable) sized over an 18 French orogastric tube. The roux limb is brought up in a retrocolic retrogastric route. We test the anastamosis intraoperatively using air injection and by gastrograffin swallow the next day. 970 cases were done. 81 of these cases were done with Da vinci robotic assistance. Average BMI was 49 (range 35 to 87) and average age was 41 years (range 16 to 75 years). 30 of these cases were over 65 years old. There were 3 conversions to open and 3 mortalities.

One in a patient who threw an emboli to small bowel, one with PE at 27 days after surgery and third with aspiration pneumonia at 29th day after surgery). The 30-day readmission rate was 6.1%. Stricture rate was less than 2% with all being managed by endoscopic dilation. Both marginal ulcer and wound infection rate were under 1%. Median length of stay was 2 days.

On comparison of other series in literature we find that the hand-sutured method has the least reported incidence of leak and stricture rate. Though technically challenging it seems to have excellent results. This presentation and those in literature seem to suggest that sutured techniques may have value in preventing leaks. Further randomized multi-institutional studies may be needed to better define the gold standard in creation of gastrojejunostomy in laparoscopic gastric bypass.

## Education/Outcomes - P274

SYSTEMATIC REVIEW OF THE DATA PROVIDED FOR REGULATORY APPROVAL OF NOVEL ENDOLUMINAL GERD THERAPEUTICS., Pavi S Kundhal MD,David R Urbach MD, University Health Network, Toronto, Canada.

**Background:** GERD is a common medical condition, for which a variety of medical and surgical therapies are available. Recently, several endoluminal devices for treatment of GERD have entered the marketplace. While approval of new pharmaceuticals requires a substantial body of evidence of effectiveness and safety from large controlled trials, the amount of medical evidence required for approval of medical devices is typically much smaller.

**Methods:** Our objective was to review the data submitted for approval of new endoluminal technologies for GERD by the Food and Drug Administration (FDA). Commonly used endoluminal therapies were identified through literature review and consultation with local experts. Applications to the FDA were than reviewed using the electronic versions available on the FDA website. When the evidence for clinical approval was based on a predicate device, that data was used.

**Results:** Currently, there are 5 devices on the market (one was recalled in 2005), and we were able to find information on 4. In three cases approval of the current form of the therapy was based on effectiveness and safety data from a predicate device, with approval based on being 'substantially equivalent.' In terms of assessing clinical safety and effectiveness, single prospective multiple centre trials were used. The average number of patients in each study was 65.3. The longest follow-up of these four devices was 12 months. In all devices, biocompatibility and long term potential toxicity were evaluated in animal models. One device was subsequently recalled by the FDA in 2005, due to reports of adverse events.

**Conclusion:** Endoluminal GERD therapeutics are commonplace. However, very little human data on long term safety and effectiveness are available prior to their approval for public use. This is in contrast to the large randomized controlled studies that are typically required for new pharmaceuticals.

## Education/Outcomes - P275

IMPROVEMENT OF LAPAROSCOPIC SKILLS USING SIMULATORS FOR MEDICAL STUDENTS, Masashi Kurobe

MD,Kazuhiko Yoshida MD,Katsuhiro Yanaga MD, Department of Surgery, Jikei University School of Medicine

**INTRODUCTION:** For safe performance of laparoscopy, surgeons must learn differences between open and laparoscopic surgery for which a training system should be developed to improve laparoscopic skills. The purpose of this study was to evaluate the effects of laparoscopic training by simulators for medical students who have "0" experience in laparoscopic surgery.

**METHODS:** For a task to assess laparoscopic skills, we tested "intracorporeal knot" which requires needle transferring, placement of a suture, and knot tying. Fifteen medical students were enrolled in this study. None of them had previous laparoscopic experience. These students were divided into two groups; training group (n=9) or non-training group (n=6). Training group was given the task to practice the laparoscopic simulators for 5-10 minutes per day for one month. Speed of performance was measured before and after the training in each group.

**RESULTS:** Training group showed a significant improvement in performance after practice as compared to before (240.1 ?) 84.9 to 87.6 ?) 64.5 sec. [Mean ? SD]) (p<0.05). Non-training group showed no difference (239.0 ?) 53.7 to 210.0 ?) 59.8 sec.). The training group after practice exhibited significantly better performance as compared to the non-training group (p<0.05).

**CONCLUSIONS:** The laparoscopic simulators showed a significantly positive effect or improving laparoscopic skills even to the medical students. This study demonstrates that the development of training system is crucial to laparoscopic surgeons and that the motivation for persistent practice is important. These simulators may also help to recruit medical students to surgery.
## Education/Outcomes - P276

**MINIMALLY INVASIVE SURGERY FELLOWSHIP - A 6TH YEAR OF RESIDENCY?**, A Park MD, B T Heniford MD, S M Kavic MD, T H Lee MD, University of Maryland, Baltimore, MD; Carolinas Medical Center, Charlotte, NC

**Introduction:** With the expanding breadth and acceptance of Minimally Invasive Surgery (MIS) in general surgery, the acquisition of advanced laparoscopic skills is becoming increasingly important for residents. Minimum standards have been set for American graduates by the Accreditation Council for Graduate Medical Education (ACGME). Our aim was to assess the evolving experience of MIS fellows and compare it to the ACGME requirements, as well as the fellow's own perception of the number of cases required for competence.

**Methods:** A survey was designed and distributed to 80 MIS fellows. There were a total of 54 responses. Results were compared to a similar survey distributed in 2003 (before the advent of the 80-hour work week) for which there were 31 responses, and to the ACGME statistics for 2004-2005. Fellows were asked to detail their operative experience during residency, as well as to specify the minimum number of cases they felt were needed to achieve competence. Other questions probed expectations and motivations for applying to fellowship.

**Results:** Competence estimates were similar from 2003 to 2006. Current ACGME guidelines call for a total of 25 advanced and 60 basic cases. Although these numbers were easily attained by most fellows, they still describe graduating from residency with competence in only the most basic laparoscopic cases, despite some overall increase in the number of advanced cases performed (see table).

<table><thead><tr><th></th><th>ACGME<br>2004-5<br>average</th><th>Mean #<br>performed as<br>resident by 2003<br>MIS fellows</th><th>Mean #<br>performed as<br>resident by 2006<br>MIS fellows</th><th>Mean # estimated<br>by 2006 fellows as<br>needed for<br>competence</th></tr></thead><tbody><tr><td>Cholecystectomy</td><td>100.6</td><td>115.0</td><td>109.9</td><td>34.4</td></tr><tr><td>Colecectomy</td><td>6.5</td><td>5.9</td><td>16.0</td><td>27.1</td></tr><tr><td>Fundoplication</td><td>4.7</td><td>8.3</td><td>7.1</td><td>21.8</td></tr></tbody></table>

**Conclusions:** Residency programs do not appear to have kept pace with the growth of MIS as an accepted or preferred operative approach to surgical problems. MIS fellowship has been a popular choice among surgical residents, as fellows feel they are not competent to perform advanced procedures based on their resident experience alone. Interest in research or an academic career is at best a secondary consideration. It is not unreasonable to suggest that the MIS fellowship has simply become, for many, a sixth year of surgical residency.

## Education/Outcomes - P277

**PATIENT PERCEPTION OF MEDICARE FEE SCHEDULE OF LAPAROSCOPIC PROCEDURES**, Atul K Madan MD, David S Tichansky MD, Jason Harper MD, University of Tennessee Health Science Center

**Introduction:** It seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient perception and opinion of Medicare reimbursements to surgeons related to laparoscopic surgery. Our hypothesis was that patients think the surgeon Medicare fee schedule is higher than actuality.

**Methods:** Patients filled out an IRB exempted survey. The survey included a written description of laparoscopic gastric bypass (LGB), laparoscopic band placement (Lap Band), laparoscopic cholecystectomy (Lap Chole) and Initial Patient Visit for 30 minutes (IPV). All participants were asked to give their thoughts of what Medicare currently reimburses for these procedures as well as what the payment should be. The survey also asked other questions about reimbursement related to Medicare.

**Results:** There were 96 participants in the investigation with 43% of patients not filling in reimbursements for at least one procedure. Table demonstrates what the perceived mean reimbursements by each procedure. 88% of patients looked at their bills from physicians and insurance companies carefully. 98% thought Medicare should pay more for more difficult cases. 85% thought Medicare should pay

more if the patient visits the surgeon more times during the global period. 32% feel Medicare pay physicians well and 91% thought that Medicare should increase fees. 42% patients felt that private insurance companies pay more than Medicare.

<table><thead><tr><th>Procedure</th><th>Perceived Fee</th><th>Suggested Fee</th><th>P value</th></tr></thead><tbody><tr><td>LGB</td><td>$14,963</td><td>$16,877</td><td>= 0.26</td></tr><tr><td>Lap Band</td><td>$11,971</td><td>$14,572</td><td>= 0.23</td></tr><tr><td>Lap Chole</td><td>$8,746</td><td>$10,555</td><td>= 0.19</td></tr><tr><td>IPV</td><td>$144</td><td>$181</td><td>= 0.10</td></tr></tbody></table>

**Conclusion:** Most of our patients overestimated what Medicare currently pays for some laparoscopic procedures. Surgeons need to do a better job in educating patients about the Medicare fee schedule.

## Education/Outcomes - P278

**ENDOSCOPIC SURGICAL SKILL QUALIFICATION FOR LAPAROSCOPIC CHOLECYSTECTOMY IN JAPAN**, Sumio MATSUMOTO PhD, Hiromi TOKUMURA PhD, Yuichi YAMASHITA PhD, Taizo KIMURA PhD, Toshiyuki MORI PhD, Masaki KITAJIMA PhD, ESSQS Committee of the Japan Society for Endoscopic Surgery

The Japan Society for Endoscopic Surgery (JSES) started Endoscopic Surgical Skill Qualification (ESSQS) in 2004, and carried out second examination in 2005. Assessment was performed by reviewing documents, which included laparoscopic surgery experiences, and qualifying unedited video tape by two independent referees. We adopted two criteria to evaluate surgical skills, as common and procedure-specific criteria to each gastrointestinal organ. Common criteria were given 60 points regarding basic endoscopic practice, and procedure-specific criteria were given 40 points to evaluate specialized skills of the practice. Laparoscopic cholecystectomy was evaluated by ten practice steps and degree of difficulty in completion. The proper skill evaluation was by the following items, elevating gall bladder (GB), retracting duodenum and transverse colon, exposing layer around cystic duct, identifying cystic artery and right hepatic artery, identifying common bile duct, transecting cystic duct, layer of dissecting from liver bed, bleeding control at liver bed and retrieval of GB. Each step was given three points respectively, and further points were added by referee, from neither for easy case to 10 points for difficult case according to the difficulty to complete.

In 2004, 110 surgeons were qualified among 170 candidates (66%). In 2005, 62 surgeons were qualified among 139 candidates (45%). To assess inter-rater agreement between referees, Cohen's weighted kappa value was calculated. It was 0.18 in 2004, up to 0.32 in 2005. These results were accomplished by revision of criteria and frequent meeting to make consensus among referees. We hope that this ESSQS will secure good outcome to decrease the number of complications and incidences of endoscopic surgery in Japan.

## Education/Outcomes - P279

**AUTOMATED PROMIS SIMULATOR METRICS PREDICT READINESS FOR FLS CERTIFICATION**, Anthony L McCluney MD, J Cao, G N Polyhonopoulos MD, D Stanbridge, L S Feldman MD, G M Fried MD, Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, QC, Canada

**INTRODUCTION:** SAGES Fundamentals of Laparoscopic Surgery (FLS) tasks are validated measures of technical skills. Certification requires travel to a testing site and a fee, thus a reliable method of predicting readiness for the exam would be advantageous. The ProMIS simulator (Haptica) provides automated scoring. FLS tasks can be placed in the ProMIS simulator and scored using time (TT), as well as motion analysis metrics: instrument path length (PL) and instrument smoothness (IS). This study was designed to evaluate these automated ProMIS metrics and their ability to predict readiness for FLS certification.

**METHODS:** 33 subjects (12 students, 16 residents PGY 1-4, and 5 experts) performed FLS tasks in the standard simulator and in ProMIS. Tasks were scored by FLS and ProMIS metrics. For each ProMIS metric, the total score was calcu-
<figure><img src="image_128.png" /></figure>

# SAGES POSTER ABSTRACTS

lated by summing the scores for the 5 FLS tasks. Pearson's correlations were calculated for ProMIS metrics versus standard FLS scores. Multivariate regression analysis identified independent predictors of standard FLS performance. These variables were then used for sensitivity and specificity calculations in order to establish a ProMIS pass-fail score for predicting readiness for FLS certification. Significance was defined as p<0.05.

**RESULTS:** TT (r = -0.82), PL (r = -0.56), and IS (r = -0.75) all correlated significantly with standard FLS score. Multivariate regression analysis identified TT as the strongest predictor of FLS score. A TT score of 1000 maximizes sensitivity and specificity and was identified as the pass-fail for reliably predicting FLS performance.

**CONCLUSIONS:** Automated ProMIS metrics correlate well with standard FLS performance. In this study sample, a TT score less than 1000 reliably predicted a passing FLS certification score.

## Education/Outcomes - P280

**INTER-RATER AGREEMENT IN ENDOSCOPIC SURGICAL SKILL QUALIFICATION SYSTEM IN JAPAN**, Toshiyuki Mori MD, Taizo Kimura MD, Tatsuro Yamakawa MD, Masaki Kitazima MD, Kyorin University, Fujinomiya Municipal Hospital, Teikyo University, Keio University

As we previously reported, the Japan Society of Endoscopic Surgery (JSES) has founded the Endoscopic Surgical Skill Qualification System (ESSQS) in an effort to encourage sound advances in techniques and more widespread use of endoscopic procedures in Japan. In addition to paperwork, applicants were requested to submit unedited videotapes that recorded laparoscopic procedures. For objective analysis of the skill level of each applicant, criteria was made for general and organ specific skills, sharing 60 and 40 points, respectively. Submitted tapes were evaluated with these criteria in a double blind fashion. When two judges scored more than 70 points, sanction was given, and when the decision split, the tape was subjected to the third judge or discussion by the working group of each organ. In the first year of 2004, a total of 422 surgeons applied, 212 surgeons were qualified (53%). In addition to the fact that granting rate varies widely in organs, ranging 28% in the esophagus to 65% in the biliary tract, inter-rater agreement (weighted kappa value, Cohen) of the two judges was as low as 0.31, ranging 0.18 in the biliary tract to 0.40 in the stomach. Toward the 2005 qualification, consensus meetings were held to improve inter-rater agreement. In the stomach group, decision was made to limit the procedure to laparoscopic distal gastrectomy for the better agreement. In 2005, a total of 275 surgeons applied, 128 surgeons were qualified (47%). Inter-rater agreement of the two judges improved to 0.40, most remarkably in the stomach group from 0.37 in 2004 to 0.59 in 2005. Preliminary calculation shows that the complication rate of qualified surgeons compares significantly better than the others. In the process of revision of criteria and consensus discussion, procedures are much standardized. ESSQS is the first system to certify technical aspect of endoscopic surgery, run by an academic body. We believe this system will enhance the surgical skills of endoscopic surgeons and thus decrease adverse outcome. It may also play an important role in the education system of endoscopic surgery.

## Education/Outcomes - P281

**SELF-REPORTED LEARNING PREFERENCE IS NOT RELATED TO GAINS IN SELF-CONFIDENCE LEVELS OF TRAINEES UNDERGOING BASIC SKILLS TRAINING IN MINIMALLY INVASIVE SURGERY WHEN COMPARED TO TEACHING METHOD EMPLOYED**, J T Paige MD, T Yang MD, Y Tang MS, R Hoxsey MD, A Marr MD, S Weintraub MD, J Hunt MD, S Chauvin PhD, Departments of Surgery, Obstetrics and Gynecology, Office of Medical Education, Research and Development Louisiana State University Health Sciences Center, New Orleans, LA

**Background:** Teaching basic skills in minimally invasive surgery (MIS) has become an essential component of general surgery residency curricula. It can be a time intensive

endeavor for busy faculty. Optimizing learners' ability to acquire such skills efficiently, therefore, is desirable. Increased self-confidence is the first step toward skill acquisition. We examined if trainee self-reported learning modality preference and method of teaching corresponded to improved self-confidence in MIS basic skills training.

**Methods:** From March to July, 2005, a total of 108 medical students, general surgery residents, and ob/gyn residents underwent instruction in three basic tasks (two-handed peg transfer, one-handed peg transfer, key threading) on an inanimate box trainer during a single session. Instruction was either video-based (n = 39), text-based (n = 34), or faculty-tutored (n = 32). Participants provided pre-session information regarding self-reported learning modality preference (aural, visual, written). They also completed pre- and post-session attitudinal questionnaires using a 5-point Likert-type scale focusing on self-confidence in performing various targeted basic MIS skills. Total mean scores and mean gains were calculated from the questionnaires. ANCOVA analysis was used to determine the effect of learning modality and teaching method on self-confidence.

**Results:** Self-confidence ratings were complete in 105 forms. Although participants demonstrated a significant mean gain in self-confidence following the session (delta = 0.65, p < 0.0001 paired t-test), mean gains were similar comparing participants receiving instruction compatible with their preferred learning modality (e.g. video-based with visual learning preference) and those who did not (e.g. video-based with written learning preference).

**Conclusion:** Self-reported learning modality preference was not related to the mean gain in self-confidence of trainees undergoing MIS basic skills training. Compatibility between teaching method and preferred learning modality did not influence self-confidence for performing targeted skills. Further investigation is necessary to determine whether accommodating trainees' preferred learning modalities by teaching method plays a role in enhancing actual skill performance.

## Education/Outcomes - P282

**SELF-REPORTED VIDEO GAME EXPERIENCE IS ASSOCIATED WITH INCREASED SELF-CONFIDENCE LEVELS OF TRAINEES PRIOR TO BEGINNING BASIC SKILLS TRAINING IN MINIMALLY INVASIVE SURGERY**, J Paige MD, T Yang MD, Y Tang MS, R Hoxsey MD, A Marr MD, S Weintraub MD, J Hunt MD, S Chauvin PhD, Departments of Surgery, Obstetrics and Gynecology, Office of Medical Education, Research and Development Louisiana State University Health Sciences Center, New Orleans, LA

**Background:** Reduced tactile sensation, two-dimensional depth, and the fulcrum effect make minimally invasive surgery (MIS) a challenge both to teach and learn. Video game experience appears to enhance MIS skills acquisition, but the reason for this observation is far from clear. We examined if prior gaming experience helped with MIS skills acquisition by boosting self-confidence in learners.

**Methods:** From March to July, 2005, a total of 108 medical students, general surgery residents, and ob/gyn residents underwent instruction in three basic tasks (two-handed peg transfer, one-handed peg transfer, key threading) on an inanimate box trainer during a single session. Participants provided pre-session information regarding video game experience. They also completed pre- and post-session attitudinal questionnaires using a 5-point Likert scale focusing on self-confidence in performing various objectives-related basic MIS skills. Total mean scores and mean gains were calculated from the questionnaires. ANOVA and ANCOVA analysis was used to determine the effect of prior video game experience on these scores.

**Results:** Three participants failed to complete a pre-session questionnaire, leaving 105 individuals for which self-confidence values could be determined. Participants with prior video game experience within the last year had higher pre-session self-confidence levels compared to those without such experience (2.32 ± 1.01 vs. 2.15 ± 0.86, p = 0.01). Additionally, participants with self-reported expertise in video game use had higher pre-session self-confidence lev-
# SAGES POSTER ABSTRACTS

els compared to those who self-reported as novices (2.34 ± 0.93 vs. 2.08 ± 0.91, p = 0.04). Mean gains in self-confidence post-session, however, were similar between those participants with video game experience with those who had little experience.

**Conclusion:** Prior video game experience within the last year and self-reported expertise in video game use give learners in MIS skills acquisition increased levels of self-confidence prior to training. Such increased self-confidence may predispose individuals to be more receptive to learning.

## Education/Outcomes - P283

**METASTATIC BREAST CARCINOMA INITIALLY PRESENTED AS ACUTE CHOLECYSTITIS. CASE REPORT AND REVIEW OF THE LITERATURE.**, Nikolaos Pararas PhD, Michael Genetzakis MD, Emmanuel Lagoudianakis MD, Georgios M Philippakis PhD, Artemisia Papadima MD, Andreas Manouras PhD, Ioannis Bramis PhD, First Department of Propaedeutic Surgery, Hippocrateion Hospital, Athens Medical School, Athens, Greece.

**Introduction:** Breast cancer mostly metastasizes to the liver, bones and the lungs. Less frequently, metastatic breast cancer is found in the central nervous system, the skin, endocrine organs (ovary, adrenal, pituitary), the pericardium and the peritoneum. The gallbladder is an infrequent site of metastatic malignant disease although malignant melanoma, renal cell carcinoma and cervical carcinoma have been documented.

**Methods and Procedures:** Because metastasis of breast carcinoma to the gallbladder has rarely been reported, we describe such a case that was incidentally recognized after cholecystectomy for acute cholecystitis, in an otherwise disease free 46 years old female who had undergone modified radical mastectomy for breast cancer two years ago. The patient, being considered as one with metastatic breast carcinoma, was subjected on adjuvant chemotherapy consisting of doxorubicin, cyclophosphamide and 5-FU. A year later she died because of generalized peritoneal seeding of the tumor.

**Conclusions:** Metastatic gallbladder involvement is rare, especially with primary breast carcinoma. It usually leads to symptoms of pain abdomen, mimicking acute or chronic cholecystitis. Its prognosis is poor after the development of gallbladder metastases. Thus, pain abdomen in a patient with breast carcinoma should be suspicious of metastatic gallbladder and treated aggressively as it portends a poor prognosis

## Education/Outcomes - P284

**ABSTRACT VIRTUAL REALITY TRAINING DEVELOPS CORE LAPAROSCOPIC SKILLS COMPARABLE TO EXPERIENCED LAPAROSCOPIC SURGEONS: RESULTS OF A PROSPECTIVE RANDOMIZED TRIAL COMPARING TWO VIRTUAL REALITY TRAINERS.**, E. Matt Ritter MD, Elisabeth A Pimentel BA, Ryan E Earnest BS, Randy S Haluck MD, Mark W Bowyer MD, National Capital Area Medical Simulation Center, Uniformed Services University, Bethesda, Maryland / Department of Surgery, Pennsylvania State College of Medicine, Hershey, Pennsylvania

**Introduction:** While simulation is becoming more widely accepted in surgical training, comparative trials on the training effectiveness of these simulators are lacking. We sought to compare the effectiveness of two abstract virtual reality trainers to train laparoscopic skills as assessed by the Fundamentals of Laparoscopic Surgery (FLS). We then compared the post training performance of the novice subjects with a group of experienced surgeons.

**Methods:** 20 novice medical students were recruited. Each subject performed a pre-test consisting of 3 FLS tasks - Peg Transfer (PT), Pattern Cut (PC) and Intracorporeal Suture (IS) - placed in the ProMIS augmented reality simulator (Haptica, Ireland). They were then randomized to train to predetermined levels of proficiency on 3 tasks of the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) (Mentice, Sweden) or the Rapid Fire/Smart Tutor (RFST) (Verefi, Elizabethtown, PA). After reaching the proficiency levels, both groups then took a post test consisting of 3 trials of the

same tasks used for the pre-test. Post test performance by both groups was then compared to a control group, composed of 10 experienced surgeons who had completed the same post test.

**Results:** MIST-VR and RFST groups demonstrated statistically significant improvement from the pre-test to the post test on all 3 FLS tasks (p < 0.0001). There was no significant difference in post test performance between the MIST-VR and RFST groups. When the simulation trained groups were compared to experienced controls there was no significant difference in performance with respect to PT. The experienced controls did significantly outperformed the MIST-VR group in PC (p<0.01) and IS (p<0.05), but differences between the experienced controls and the RFST group did not reach statistical significance.

**Conclusion:** Simulation based training on either the MIST-VR or the RFST simulator improves the skill level of novices as assessed by FLS. The post training skill level of these novices compares favorably with a group of experienced surgeons. Virtual Reality trainers, such as RFST and MIST-VR, train fundamental laparoscopic skills equally and to a level comparable to a group of experienced practicing surgeons.

## Education/Outcomes - P285

**A SINGLE MASSED SKILLS COURSE FOR SURGERY TRAINEES DOES NOT CONVEY LONG TERM PERFORMANCE BENEFIT.**, Scott T Rehrig MD, Kinga Powers

MD, Daniel Jones MD, Beth Israel Deaconess Medical Center

**BACKGROUND:** Promotion in our residency program is contingent on achieving minimal performance criteria for partial tasks and passing Fundamentals of Laparoscopic Surgery (FLS). Basic Endolaparoscopic Surgery Tasks (BEST) are the checkerboard, bean drop, terrible triangles, endostitch, and intracorporeal suturing. Top Gun Laparoscopic Skills and Intracorporeal Suturing Course (TG) uses similar tasks with feedback and consistently improves skill acquisition in videotrainers. The aim of our study was to determine whether a structured TG course augments performance on FLS two years later.

**METHODS:** We retrospectively compared FLS scores among resident trainees who took TG course to residents who did not participate in TG. In addition to clinical duties, all residents were provided performance criteria expectations for BEST and one-hour per month protected practice time in the skills lab for two years. Data where analyzed using Mann Whitney t tests and Spearman correlation.

**RESULTS:** No difference was noted between those trained on the TG system versus no TG training in terms of FLS cognitive or manual skill performance scores (mean+/-SD; p < 0.05; manual skills p = NS, cognitive skills p = NS.) Only moderate correlation was observed between TG intracorporeal suturing training performance and overall FLS manual skills scores (Spearman r = 0.6, P = 0.35)

<table><thead><tr><th></th><th>TG + BEST (n=5)</th><th>BEST (n =7)</th></tr></thead><tbody><tr><td>FLS</td><td></td><td></td></tr><tr><td>Cognitive</td><td>500+/-56</td><td>474+/-85</td></tr><tr><td>Manual skills</td><td>471.6+/-68</td><td>496+/-96</td></tr></tbody></table>

**CONCLUSIONS:** All residents participating in a mandatory integrated laparoscopic skills curriculum passed the FLS examination. Prior partial task training on the TG system did not improve cognitive or manual skills performance on the FLS examination compared to colleagues. An intensive course may convey no advantage to clear proficiency expectations, posted benchmarks and ample interval opportunity to practice.

## Education/Outcomes - P286

**INSTITUTIONAL ACTIONS AND PROBLEMS FOR EDUCATION SYSTEM ESTABLISHMENT IN AN ENDOSCOPIC SURGERY DEVELOPING AREA IN JAPAN.**, Mitsuo Shimada MD, Nobuhiro Kurita MD, Tomoharu Yoshizumi MD, Satoru Imura MD, Yuji Morine MD, Masanori Nishioka MD, Hidenori Miyamoto MD, Department of Surgery, The University of Tokushima

**Introduction:** We herein report institutional actions and problems for system establishment in an endoscopic surgery

<figure><img src="image_129.png" /></figure>
<figure><img src="image_130.png" /></figure>

# SAGES POSTER ABSTRACTS

developing area in Japan.

**Actions and Results** (1) Preoperative surgical simulation?F In case of cholecystectomy, complete checking of local anatomy and variations is performed by 3-D visualization of vessels inside and outside of the liver using MD-CT and biliary system using MRCP and/or DIC-CT. As a result, no complication of biliary tract has occurred, and the rate of young surgeon as a operator has increased. In case of gastrointestinal surgery, surgical simulation consisted of 3-D CT including virtual colonography and accurate assessment of lymph-node metastasis using diffusion-weighed MRI and PET-CT made operation time shorter and operative blood loss smaller. (2) Periodical educational seminar and training in animal laboratory: Educational seminars were held 3 times per year by experienced endoscopic surgeons. Furthermore, training courses in animal laboratory were held twice per year for young surgeons including young residents. Both actions succeeded in raising surgical spirit and skill up of young surgeons. One of ideal training methods using computer-enhanced surgical simulation is too expensive to receive its benefit. (3) An institutional policy?F The rate of endoscopic surgery for gastrointestinal cancer dramatically increased after changing institutional policy in 2004 (9.3% in 2001-2003 versus 52.5% in 2004-2006).

**Conclusions** Above-mentioned actions are necessary to establish safe and secure educational system in endoscopic surgery developing area under strong leadership as a whole of Department of Surgery, instead of a part of surgeons who are interested in endoscopic surgery.

<figure><img src="image_131.png" /></figure>

## Education/Outcomes - P287

**ESTABLISHMENT OF HIGH-QUALITY INTERACTIVE TELESURGERY SYSTEM IN ASIA-PACIFIC AREA USING SUPERFAST INTERNET CONNECTIONS**, Shuji Shimizu MD, Naoki Nakashima MD, Koji Okamura PhD, Masao Tanaka MD, Kyushu University, Fukuoka, Japan

**Background:** Endoscopic surgery has revolutionized the field of surgery, and now much attention is being paid to the effective method of adequate education and training. With rapid development of information and communications technology, we established a high-quality telesurgery system between Japan and Korea without any loss of image quality during transmission using high-speed Internet connections (Surg Endosc 20:167-170, 2006). The aim of this study was to extend this new system to other Asia-Pacific regions.

**Methods:** Kyushu University Hospital in Fukuoka, Japan, was linked to 20 institutions and 13 meeting venues in 18 cities in Korea, China, Taiwan, Thailand, Singapore, Vietnam, Hawaii, and Australia over Asia-Pacific Advanced Network (APAN), an international research and education consortium. Digital video transport system (DVTS), free software which transforms digital video signals directly to Internet Protocol, was installed in a regular personal computer with network bandwidth of 30 Mbps per channel. Security software was used to protect patients?Eprivacy. Questionnaires were performed to evaluate the system.

**Results:** Between February 2003 and July 2006, 36 international teleconferences on endoscopic surgery were performed, 13 of which were real-time demonstration of surgery and 23 were interactive teleconferences using videos or PC presentations. Multiple stations were connected in nine events. The frame rate of transmitted pictures was 30/sec, and the time delay was restricted in the range of 0.3-1.0 sec between the stations. With reply rate of 59% (409/713) and 57% (398/713), 295 (72%) answered the image quality to be very good and 95 (23%) good, and 307 (77%) answered the sound to be very good and 71 (18%) good, respectively.

**Conclusions:** This is the first time to establish the advanced telesurgery system in such a wide range of international scale, which provides remote audience with the same quality of surgical streaming just as in an actual operating room. Because it is economical and easy to set-up, and high-speed R&D network is also available in western countries, we believe our cutting-edge system based on superfast Internet will facilitate the prevalence of newly developed, less invasive surgical procedures effectively and beyond geographic borders to whole world.

## Education/Outcomes - P288

**OBESITY AS A FACTOR IN LAPAROSCOPIC SURGERY,** Ramandeep S Sidhu MD, Prasanta Raj MD, Mario Scarpino MD, Shannon M Tarr MD, Richard Treat MD, Fairview Hospital

**Background:** Laparoscopic cholecystectomy is considered the standard of care for most symptomatic gall bladder diseases. Obesity has been a documented independent predictive factor for conversion to open cholecystectomy. This study investigates whether or not obesity is a major factor in determining the outcome of laparoscopic cholecystectomy.

**Methods:** Retrospective chart review of 603 patients scheduled for laparoscopic cholecystectomy. Three BMI groups (normal, overweight and obese) were compared.

**Results:** There was no statistically significant difference in the conversion rate, intraoperative and postoperative complication rates, or length of stay. The only statistically significant difference was in the duration of surgery.

**Conclusions:** Laparoscopic cholecystectomy is a safe and effective treatment for gall bladder disease among obese patients. Use of long trocars, instruments, open insertion of umbilical port, meticulous dissection, subxiphoid port placement and additional 5mm port to retract the liver or push down the omentum for better visualization of anatomy is recommended.

**Key words:** laparoscopic cholecystectomy, obesity, BMI, conversion rate

## Education/Outcomes - P289

**ROBOTIC SUTURING ON THE FLS MODEL POSSESSES CONSTRUCT VALIDITY, IS LESS PHYSICALLY DEMANDING AND IS FAVORED BY MORE SURGEONS COMPARED TO LAPAROSCOPY,** Dimitrios Stefanidis MD, Anahita Mostafani, Chris Bell MD, Lee Ann Lau MD, Marc Zerey MD, Makram Gedeon MD, Andrew Harrell MD, George Walker RN, Amanda Walters BS, B Todd Heniford MD, Daniel J Scott MD, Department of Surgery, Carolinas Medical Center

**Background:** The value of robotic assistance for intracorporeal suturing has not been well defined. The objective of this study was to compare robotic with laparoscopic suturing on the FLS model in a large cohort of surgeons. Construct validity for the simulated tasks was examined and surgeon performance, workload and suturing preference was assessed.

**Methods:** Attendees (n=117) of the Robotic Station at the SAGES 2006 Learning Center placed intracorporeal sutures on the FLS box-trainer model using conventional laparoscopic instruments and the DaVinci robot. Participant performance was recorded using a validated objective scoring system with a cut-off time of 5 minutes. A questionnaire regarding demographics, task workload and suturing modality preference was completed. Construct validity for both tasks was assessed by comparing the performance scores of subjects with various levels of experience. The validated NASA-TLX questionnaire, which rates the mental, physical and temporal demand of a task as well as the performance, effort and frustration of the subject, was used for workload measurement. For all statistical comparisons p<0.05 was considered significant.

**Results:** 84% of participants had prior laparoscopic and 10% prior robotic suturing experience. Within the allotted time, however, 83% of participants completed the suturing task laparoscopically compared to 72% with the robot. Construct validity was demonstrated for both simulated tasks accord-
ing to the participant's advanced laparoscopic experience, laparoscopic suturing experience, and self reported laparoscopic suturing ability (p<0.001 for all) and according to the prior robotic experience, robotic suturing experience and self reported robotic suturing ability (p<0.001 for all), respectively. While participants achieved higher suturing scores with standard laparoscopy compared to the robot (84 ± 75 vs. 56 ± 63, respectively; p<0.001), they found the laparoscopic task to be more physically demanding (NASA score 13 ± 5 vs. 10 ± 5, respectively; p<0.001) and favored the robot as their method of choice for intracorporeal suturing (62% vs. 38%, respectively; p<0.01).

**Conclusions:** Construct validity was demonstrated for robot-ic suturing on the FLS model. Robotic assistance decreases the physical demand of intracorporeal suturing compared to conventional laparoscopy and, in this study, was the preferred suturing method by most surgeons. Curricula for robotic suturing training need to be developed.

## Education/Outcomes - P290

### TRAINING SEMINAR SPECIALIZED IN FUNDAMENTAL SKILLS OF ENDOSCOPIC SURGERY IN JAPAN, Kazuo

Tanoue PhD, Satoshi leiri PhD,Kozo Konishi MD,Ken Okazaki PhD,Shouhei Yamaguchi MD,Daisuke Yoshida MD,Kenoki Ohuchida PhD,Takefumi Yasunaga,Hideaki Nakashima PhD,Makoto Hashizume PhD, Advanced Medicine and Innovative Technology, Kyushu University Hospital

(BACKGROUP) Recently, development of an endoscopic surgery in Japan is remarkable, but surgical complications by lack of technique and recognition for an endoscopic surgery has become a social problem. Since a professional education / training for the purpose of medical safe standard improvement is very important, we regularly perform the seminar that is specialized in a fundamental manual skill for young surgeons, at our training center for endoscopic surgery.

(SUBJECTS and CONTENTS) By August, 2006, 255 surgeons attended in 21 times of the seminars. Training contents are as follows; 1: A basics lecture about endoscopic surgery, 2: The box training for space perception, coordinated movement of right/left forceps and a suture/ligation, 3: Virtual reality training by a simulator, 4: Practical training using an animal, such as dissection of lymph nodes and vessels, hemostasis with clipping, ultrasound activated devise or vessel sealing system, and a repair suturing for injured organ. Before/after training, we perform our original technical evaluation for trainee. The technical evaluation task using the box trainer and the rubber sheet that a circle with eight dots inside/outside were printed is as follows; a trainee sutures between certain dots, and performs the remaining seven places of continuous sutures along the circle successively. At last, the trainee ligates twice with an edge of initial ligation and finishes the task. In each trainee, a time to finish the task and a trace of both forceps were recorded, and the distance that was out of needle entry from the point, a tear of rubber, and a slack of a thread were recorded as errors.

(RESULTS) By skill evaluation before/after training, the trainee who were able to accomplish all the task increased to ten from 0, and the trainee who were able to accomplish initial suture ligature increased to 97% from 71%. The time to finish the initial suture ligature was significantly shortened, and average of the continuous suture number increased significantly. In a trace of forceps, movement distance decreased with right and left, and speed increased. However, the average of errors of a tear and a gap increased after the training.

(CONCLUSION) The individual training system for skill-up and the evaluation system of fundamental skills are necessary for establishment of education in endoscopic surgery. Therefore, our training seminar is important as education of basics stage.

## Education/Outcomes - P291

POOR PREOPERATIVE JOB PERFORMANCE AND CAREER ADVANCEMENT SECONDARY TO OBESITY IS ASSOCIATED WITH GREATER WEIGHT LOSS FOLLOWING LAPAROSCOPIC GASTRIC BYPASS, David S Tichansky MD, Whitney Orth BS, Atul K Madan MD, Division of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA

**Background:** Patient motivating factors to be compliant and maximize weight loss vary greatly. Each patient represents a unique web of intrinsic and extrinsic motivators, some more effective than others. Multiple tools continue to preoperatively attempt to determine patients' motivation to do well postoperatively and predict outcomes. Most have limited success. Herein, we study the effectiveness of a preoperative Impact of Weight on Quality of Life (QOL) Questionnaire in predicting weight loss outcome after laparoscopic gastric bypass (LGB).

**Methods:** 100 consecutive patients were enrolled by completing the pre-operative questionnaire. Percent excess body weight loss at one year (EBWL) was analyzed against the score of each section of the questionnaire and the total score of the questionnaire using Pearson's correlation coefficient test.

**Results:** Complete questionnaire results and one year weight loss data were available on 81 patients. Negative Work-related QOL section scores reflecting poor job performance and career advancement were associated with greater EBWL (p = 0.047). No other single test section score (Health-related QOL, Social-related QOL, Mobility-related QOL, Self Esteem-related QOL, Sex-related QOL, Activity-related QOL, and Eating-related QOL), nor the total test score, had a statistical correlation with EBWL.

**Conclusion:** Preoperative poor job performance and career advancement are associated with greater EBWL after LGB. Perhaps extrinsic motivators (i.e.: from a job) are the strongest of all.

## Education/Outcomes - P292

A SIMPLE AND EFFECTIVE SELF-TRAINING METHOD FOR LAPAROSCOPIC KNOT TYING, Kazunori Uchida MD,Naoki Haruta MD,Kazurou Okada MD,Masazumi Okajima MD,Manabu Yamamoto MD, Takanobashi Central Hospital Endoscopic Surgery Center

<< Intracorporeal suturing and knot tying is absolutely required for recent advanced laparoscopic surgery. Square knot is the ideal choice, however, it is not always easy and comfortable even for experienced laparoscopic surgeons. In order to complete the laparoscopic square knot without hectic effort, we developed a simple and effective self-training sheet to achieve the goal. To complete the square knot tying easily, making a "C" loop is the most important point and the core of this technique. Our innovative self-training sheet was developed based on a handwriting learning strategy. Practice with this sheet helps easy and smooth square knot tying with the correct sequence by operating 2 forceps and the thread.

## Education/Outcomes - P293

CLINICAL AND SEROLOGIC PREDICTORS OF GASTRIC BYPASS COMPLICATIONS, DB Williams MD, J Hagedorn MS, B Encarnacion BS, E Ketchum BS, I Liu BS, M Curet MD, J Galanko PhD, J Morton MD, Stanford Department of Surgery

**Background:** Roux en Y Gastric Bypass (RNYGB) is a highly effective intervention for morbid obesity. There has been recent concern regarding the incidence of complications associated with RNYGB. The purpose of this study is to identify predictors of complications in this patient population.

**Methods:** From August 1, 2003 to March 1, 2006, 487 patients underwent RNYGB at a single academic institution. Patient records were reviewed for preoperative demographic, comorbidity, and serologic data and post-operative complications at 12 months. A liberal inclusion criteria for complications was employed including Intra-abdominal Abscess, Anastomotic Leak, Arrhythmia, Bleeding Requiring
<figure><img src="image_132.png" /></figure>

SAGES POSTER ABSTRACTS

Transfusion, Bowel Obstruction, Cerebro-Vascular Accident, Deep Venous Thrombosis/Pulmonary Embolus, Myocardial Infarction, Pneumonia, Ulcers/Strictions, Urinary Tract Infection, Micronutrient Deficiencies, Wound Infections/Dehiscences/Hernia, Readmissions, and Reoperations.

**Results:** Overall patient demographics and comorbidities were: mean age (43), mean BMI (49), sex (83% female), previous abdominal surgery (56%), diabetic (34%), hypertensive (51%), hyperlipidemia (40%), sleep apnea (36%), and mean number of comorbidities (4). There were 0% mortality, 5% reoperation, and 21% overall complication rates. An abbreviated complication list is as follows, %: anastomotic leak (2), GI Bleeding (4.6), Bowel Obstruction (3), PE/DVT (1.5), and Ulcers/Strictions (3.5).

The patient population was divided into the two cohorts of those with and without complications. Patients with and without complications were similar respectively for the following preoperative variables: %, age>50 (27 vs. 27), %, female (83 vs. 83), % previous abdominal surgery (57 vs. 56), hemoglobin A1C (6.3 vs. 6.4), and number of comorbidities (4 vs. 4). The two groups did differ for two variables: % BMI >50 (39 vs. 28, P=.05) and Triglycerides/HDL ratio (5.2 vs. 3.7, P=.04).

**Conclusion:** Bariatric surgery is the only effective enduring and enduring treatment for morbid obesity. Identifying predictors of bariatric surgery complications can aid in risk modification and stratification. Complications in this population were partly predicted by BMI>50 and an elevated Triglycerides/HDL ratio, a novel marker of the metabolic syndrome.

Education/Outcomes - P294

THE DEVELOPMENT OF A VIRTUAL REFERENCE MANUAL FOR PERI-OPERATIVE NURSES WORKING IN A MINIMALLY INVASIVE SURGICAL SUITE, Shirley Yeung RN, Julie L Harnish MSc, David R Urbach MD, University Health Network, Toronto, Ontario, Canada

**Introduction:** Continuing education is necessary for peri-operative nurses to maintain their skills within the dynamic environment of minimally invasive surgery (MIS). It is becoming more common for hospitals to provide training and orientation for nurses online. In December 2005, the Toronto Western Hospital asked the MIS nurse specialist to create a reference manual for laparoscopic procedures which could be made available 24/7 via the hospital's Intranet site.

**Methods:** A virtual reference manual was created using web-based publishing software. The manual contains information on 4 laparoscopic procedures: cholecystectomy, appendectomy, adrenalectomy, and ventral herniorrhaphy.

**Results:** For each of the above surgical procedures there are 8 sections encompassing: anatomy/physiology, anesthesia, patient positioning and preparation, draping, procedure description, medication, surgeon preferences, and postoperative care. Prior to publication all sections were reviewed by experts in the field. The manual also contains synoptic videos of the procedure for nurses to review, along with images of equipment, room set up, and draping procedures. Special attention is paid to the set up of instruments and the step-by-step use of laparoscopic equipment.

**Conclusion:** The creation of a virtual reference manual was a collaborative effort of OR personnel, surgeons, and administration. Having an online resource should reduce the uncertainty and "fear" nurses experience when working in a MIS suite with unfamiliar equipment. This will be particularly helpful for the novice OR nurse, or the nurse from another service who is asked to fill in. The virtual reference manual will be available online in Fall, 2006. Once the manual is formally launched, further research is planned to assess the impact online resources have on nursing.

Education/Outcomes - P295

95.5 % PRACTICING PHYSICIANS RECOGNIZE THE SIGNIFICANCE OF HANDS-ON COURSE FOR LAPAROSCOPIC SKILL IN PEDIATRIC SURGERY, Jyoji Yoshizawa MD, Shinsuke Ohashi MD, Keiichirou Tanaka MD, Masashi Kurobe MD, Masaki Kanai MD, Naruo Kuwaashima MD, Syuichi Ashiduka MD, Kazuhiko Yoshida MD, Takao Oki MD, Jikei University school of medicine

**Introduction:** Laparoscopic skill is an increasingly important part for pediatric surgeons. We offered 1.5 day laparoscopic hands-on course for practicing physician in pediatric surgery. Assessment of the requirements and contents for the hands-on course was achieved by surveying the participants of the course.

**Materials and methods:** One time per year for six years, hands-on courses for laparoscopic surgery were held from 1999 to 2004. 123 practicing physicians in pediatric surgery attended the course. The course included a lecture about basic skill, the box training for a suture and practical training using an animal. At the conclusion of the course, the course evaluations were used to survey its success. The survey consisted of assessment of the requirements, length of the course, necessities of demonstration, the number of procedure and the number of practicing physicians per one table, et al.

**Results:** We achieved a 78% response rate from 123 participants. 95.5 % of the attendee felt that the course improved their skills or made difference in their training. The adequate length would be one day (48%), on the other hand 1.5 day was 25%, and 2 days was 30%. 41 attendees (42.7%) expected several demonstrations, but 55 attendees (57.3%) did not expect any other demonstrations except Nissen?fs procedure. Emphasis of the attendee was placed on practical training using an animal. Two attendees per one table (71%) were more popular than three attendees.

**Conclusion:** This hands-on course for pediatric surgeons should be significant to develop the basic and advanced skills for pediatric laparoscopic surgery.

Education/Outcomes - P296

MEASURING SURGICAL TEAM QUALITY USING A BENCH MODEL SIMULATION: CONSTRUCT VALIDITY OF LEGACY INANIMATE SYSTEM FOR ENDOSCOPIC TEAM TRAINING (LISETT), Bin Zheng PhD, Danny V Martinec, Peter M Denk MD, Prekash Gatta MD, Yashodhan S Khajanchee MD, Mark H Whiteford MD, Lee L Swanstrom MD, MIS program Legacy Health System

Efficient and safe performance of surgery requires dedicated collaboration amongst the surgical team. Up to now, surgical team skills, such as communication and cooperation, have mainly been developed in the OR at the potential cost of the patient safety. This project examines the construct validity of using an inanimate simulation to improve team skills outside the OR.

The Legacy Inanimate System for Endoscopic Team Training (LISETT) formulates two team-obligated tasks on a commercially available laparoscopic training box. The first task requires an individual to manipulate the laparoscope appropriately while his/her teammate transports an object between 3 pegs located separately. The second task demands an individual to remove an obstacle above a suturing site and control the laparoscope while his/her teammate performs an intracorporeal suture.

The dyad teams were assembled of staff surgeons, laparoscopic fellows, senior and junior surgical residents, or medical students. Tasks were video and audio recorded with both surgical site and room view. Performances were assessed using a comprehensive score system on team's movement speed and efficiency (penalty given as errors were made). Participants? surgical experiences were obtained by a pre-test survey and a team performance self evaluation was conducted subsequently to each trial.

LISETT scores correlated positively with surgeon's experience (r = 0.776, p < 0.001), which supported our hypothesis. Teams constructed by experienced surgeons (staff surgeons and fellow, n = 5) performed significantly better (89.1 +/- 4.3)
than intermediate (fellow and senior residents 77.3 +/- 9.3, n = 8) and inexperienced group (junior residents and medical students 40.2 +/- 17.8, n = 9). Data was further differentiated by the team performance score to examine the impacts of team quality on the LISETT score. The top-rated teams perform better (81.3 +/- 10.8; n = 6) than the intermediate (62.2 +/- 26.3; n = 12) and the low-rated teams (58.6 +/- 19.9). The LISETT scores increased progressively with the increasing surgical experience and self-rated team quality, revealing strong evidence for construct validity of using the LISETT program for team training outside the OR.

## Endolumenal Therapies - P297

**DIAGNOSTIC DILEMMA:** ERCP STATUS POST ROUX-EN-Y GASTRIC BYPASS, Lewis A Diulus BA, Bipan Chand BA, Suthep Udomsawaengsup BA, Cleveland Clinic Foundation

**1. Objective of the study/technique:** With an ever increasing patients population who have undergone Roux-en-Y gastric bypass surgery, a new diagnostic dilemma occurs when a sub-set of these patients require upper endoscopy to evaluate the bilopancreatic system. The anatomical changes created during by the bypass procedure make standard methods for this evaluation difficult. We describe the technique used to combine laparoscopic and endocopic evaluation and treatment in two such patients.

**2. Description of the methods** Two patients presented with recurrent pancreatitis after cholecystectomy. The first underwent a HIDA scan revealing sphincter of Oddi dysfunction. Preoperatively a PTC catheter was placed. Laparoscopy was then performed with lyses of adhesions freeing the gastric remnant. A gastrotomy was made and a trocar was placed directly into the remnant. An on-table ERCP was performed with a sphincterotomy. The gastrotomy was closed with a stapler. The second patient had an MRCP which demonstrated a dilated pancreatic duct with a possible stricture. Laparoscopy was again performed and the gastric remnant was freed in a similar fashion. Three sutures were placed in the anterior surface of the remnant using a suture passer and this was brought to the anterior abdominal wall. A trocar was then placed into the remnant. An ERCP was performed. Incomplete drainage of the biliary system was found and a sphincterotomy was performed to allow drainage. The trocar when then removed and replaced with a Malecot catheter. The sutures placed in the remnant were then used to secure it to the abdominal wall.

**3. Preliminary results** Both patients had resolution of their symptoms postoperatively. The patients have been followed for one year, and three months, respectively without any complications from the procedures.

**4. Conclusions/Expectations.** We demonstrated a novel approach to evaluate the bilopancreatic system via laparoscopically assisted ERCP in patients who have previously undergone Roux-en-Y gastric bypass surgery. With cooperation and communication between surgery, radiology and gastroenterology, this combined procedure can successfully be performed in the operative room.

## Endolumenal Therapies - P298

**SUCCESSFUL COMPLETION OF NEOADJUVANT CHEMORADIATION AND R0 RESECTION AFTER MALIG-NANT ESOPHAGEAL PERFORATION: A CASE FOR ENDO-SCOPIC STENTING**, Jonathan M Hernandez MD, Scott T Kelley MD, James S Barthel MD, University of South Florida Department of Surgery and the H. Lee Moffitt Cancer Center and Research Institute

**INTRODUCTION:** Perforation of the esophagus at the site of malignancy secondary to instrumentation is an uncommon but often catastrophic complication that presents a formidable challenge to the surgeon. Particularly challenging is the management of locally advanced (T4) tumors with aortic involvement. We describe for the first time a case in which a Polyflex® Esophageal Stent, a covered, self-expanding, sili-cone-coated stent was used as a bridge to allow the patient to receive neoadjuvant chemoradiation with subsequent minimally invasive R0 resection.

**METHODS AND PROCEDURES:** A 74-year old female was found to have adenocarcinoma at the gastroesophageal junction. Endoscopic ultrasound was undertaken, demonstrating AJCC stage T4N0 with invasion of the aortic wall at 40cm. After the procedure, a barium study demonstrated a free perforation at the level of the tumor. We elected to cover the perforation with a Polyflex® stent and a subsequent study showed complete sealing of the leak. The patient was discharged within 48hours and maintained nutrition orally. She completed neoadjuvant chemoradiation therapy with cisplatin, 5 fluorouracil (5-FU), and external beam radiation (50 Gy). Restaging revealed significant tumor regression and the patient underwent minimally invasive esophagectomy.

**CONCLUSION:** We report the first case of endoscopic stenting of a locally advanced perforated esophageal cancer for the purposes of administering neoadjuvant chemoradiation. The use of covered plastic stents is particularly useful since they do not interfere with subsequent radiation therapy. At the time of surgery, the stent was in good position despite significant tumor downstaging. Although definitive conclusions cannot be drawn from a single case, this study would suggest chemoradiation does not preclude the use of endoscopically placed covered stents.

## Endolumenal Therapies - P299

**TRANSANAL ENDOSCOPIC RESECTION OF CARPET-LIKE ADENOMAS OF THE RECTUM**, Pasquale Spinelli, MD, Giuseppe Calarco MD, Xiaoguang Ni MD, Andrea Mancini MD, Departement of Diagnostic and Surgical Endoscopy, National Cancer Institute, Milan, Italy.

The management of large rectal adenomas encompasses a variety of procedures including conventional both endoscopic or surgical approaches. In recent years endoscopic transanal resection using a urological resectoscope has been proposed as an alternative treatment modality. From October 1995, 72 patients with carpet-like adenoma of the rectum have been submitted to transanal endoscopic resection by urological resectoscope. The technique was similar to Trans-Urethral-Resection. We used a continuous flow resectoscope, 27 Fr external diameter, (Olympus A2614) which provides clear visualisation of the operative area, through a 4 mm diameter telescope, 12°.

An adequate follow-up is available for 58 patients (21 male and 37 female with a mean age of 67 yrs range 18-88).

Severe dysplasia, malignant adenomas and invasive carcinomas were treated in 12, 7 and 2 patients, respectively. Complete eradication was obtained in 55 patients; in the remaining 3 patients, initially treated for malignant adenomas, an invasive adenocarcinoma was observed during the follow-up and treated by RT (1 pt) or surgery (2 pts). The mean number of treatment sessions was 2,5 (range 1-7). The mean time between the first treatment and the complete eradication was 6 months (range 1-18).

Complications were 5 intraoperative bleeding treated with local injection of epinephrine (1:20.000) and 4 early postoperative bleeding, one controlled with local injection of epinephrine (1:20.000) and three spontaneously recovered. One perforation below the peritoneal reflexion occurred and it was treated conservatively.

No early or late mortality was reported.

Our experience shows the efficacy of transanal endoscopic resection by means of urological rectoscope in the treatment of carpet-like adenomas and for pT1 cancer, in patients unfit for major rectal surgery.

## Ergonomics/Instrumentation - P300

**BARBED SUTURE FOR CLOSURE OF MIDLINE ABDOMINAL INCISIONS: A PROSPECTIVE COMPARATIVE TRIAL**, Fatemeh Abtahi MD, Spencer Brown PhD, Christopher Bell MD, Rod Rohrich MD, UT SouthWestern Medical Center at Dallas

**Objective:** The purpose of this study is to identify the properties of these barbed sutures while performing closing the abdominal midline incision and compare that to standard sutures using the same materials without barbs.

**Introduction:** Surgical sutures are the most frequently used

<figure><img src="image_133.png" /></figure>
<figure><img src="image_134.png" /></figure>

# SAGES POSTER ABSTRACTS

biomaterial for wound closure and tissue approximation; however wound closure depends on the surgeon's ability to tie a secured knot. A knotless (self-anchoring) suture has been developed, in which bidirectional barbs are introduced into an absorbable monofilament suture that eliminates the need for tying a knot to obtain suture closure. The barbs are designed to grip tissue and obviate the need for tying a knot during tissue approximation. They can pass easily through tissue in one direction, but can not be reversed, therefore providing knot security.

**Goals:** The purpose of this study is to identify the properties of these barbed sutures while performing closing the abdominal midline incision and compare that to standard sutures using the same materials without barbs. Those properties that are being measured are; tensile strength, tissue reactivity, and cosmetic result of the midline incision closure at different time points (day 0, week 1, week 2, week 6). Also this study will show that, the time needed to close a midline incision with barbed suture is shorter than using standard sutures.

**Study design:** This is a prospective, comparative study of abdominal midline incision closure in the porcine model which is being evaluated for suturing time, tensile strength, and histopathology related to wound healing, and cosmesis after surgery.

**Study design:** Fifty-four (54) pigs? large adult pigs will be used to address similar stresses on midline closures as observed in human. Each animal will have an abdominal midline incision and closure. Three groups are defined by time of animal harvest.

**Preliminary Results:** The barbed suture is a faster and reliable closure technology based on our initial data. This novel barbed suture, based on the same material as standard sutures, is safe and will provide surgeons a superior alternative for closing the midline incisions.

## Ergonomics/Instrumentation – P301

A "ONE SIZE FITS ALL" APPROACH IS NOT MEETING THE NEEDS OF A GROWING PERCENTAGE OF WOMEN SURGEONS WHO ARE USING DISPOSABLE LAPAROSCOPIC INSTRUMENTS, Danielle Adams MD, Stephen J Fenton MD, Bruce Schirmer MD, David M Mahvi MD, Peter F Nichol MD, University of Utah, University of Virginia and University of Wisconsin

**Introduction:** An increasing number of women are entering the field of general surgery. Surgical devices have traditionally been targeted at men. We hypothesized that due to a smaller hand size, female general surgery residents would have significantly more difficulty utilizing the "one size fits all" handles of disposable laparoscopic instruments when compared to male residents.

**Methods:** General Surgery Residents were surveyed at three large, academic, general surgery training programs (University of Utah, University of Virginia and University of Wisconsin). Training year, gender, glove size and laparoscopic case experiences were recorded. Participants were asked to evaluate 4 disposable laparoscopic instruments (stapler, ultrasonic shears, Ligasure® and laparoscopic retrieval bag) and asked if each instrument required one hand only, one hand with some assistance or two hands to use properly. Additionally, participants were asked to subjectively assess each instrument by rating it as easy, occasionally awkward or always awkward. Data were tabulated and analyzed (chi square & Mann-Whitney analysis) comparing male to female residents for each instrument.

**Results:** A total of 81 residents were asked to participate. There were 51 anonymous responses (23 women and 28 men). Women's glove size was significantly smaller than men's (6.5 vs. 7.5, p<0.0001), whereas, the clinical year and number of laparoscopic cases were not significantly different between the two groups. Women reported the following instruments to be more awkward than their male counterparts: stapler (p<0.0003), ultrasonic shears (p<0.0143) and Ligasure® (p<0.023). Women were also more likely to use more than one hand only when operating an instrument (stapler p<0.0001, ultrasonic shears p<0.0006, Ligasure® p<0.0111) as opposed to men. Interestingly, the majority of

both male and female residents found the laparoscopic retrieval bag required more than one hand to use (86% v 67%, p =0.098).

**Conclusions:** Current disposable laparoscopic instruments are not designed for individuals with small glove sizes. Women have significantly more difficulty with the "one size fits all" laparoscopic instrument handles. With the increasing number of women entering general surgery programs, this problem will persist until instruments are designed to target surgeons with small hand sizes.

## Ergonomics/Instrumentation – P302

USE OF CAVITATION LESS ULTRASONIC SHEARS TO REDUCE AMOUNT OF INTRAOPERATIVE SCATTER, Prakash Gatta MD, Nathaniel E Uecker MD, Lee L Swanstrom MD, Legacy Health System

**PROPOSITION:** With the widespread use of ultrasonic dissection in Laparoscopic Surgery, cavitation and scatter have become more common problems. In order to address this, we have trialed a prototype ultrasonic device with minimal cavitation effects. The goal of this study was to measure the amount of cavitation, scatter, laparoscope contamination and compare it with regular ultrasonic coagulation shears.

**METHODS:** A total of 4 devices were used to compare the effect of scatter in an in vitro setting. The new Cavitation Less Device (CLD) was compared to three other commonly used commercially available devices. The primary parameter measured was the distance of scatter of ink over a large sheet of blotting paper. The data collected was analyzed utilizing the Analysis of Variance. In vivo assessment was performed in animals to measure laparoscope contamination and coagulation capability

**RESULTS:** A total of 25 occurrences were recorded for each device, with scatter distance varying between 0mm to 1200 mm. The average distance of the CLD was 66mm, and those of the other three ranged between 339mm to 919mm. The Analysis of Variance showed a statistically significant difference between the CLD and the remaining 3 devices, with a p value of <0.001. All devices coagulated tissue equally well. Laparoscope contamination was less with the CLD but did not achieve statistical significance.

**CONCLUSIONS:** The CLD is a new device that reduces the amount of intra-operative scatter. This reduces the incidence of scope contamination during dissection and potentially reduces operating time

## Ergonomics/Instrumentation – P303

PROSPECTIVE ANALYSIS OF VISUAL CANNULA ENTRY IN LAPAROSCOPY: ENDOTIP, Karen B Glass MD, Artin M

Ternamian MD, George Tolomiczenko MD, Violine Marcoux MD, Miran A Ternamian MD, University of Toronto: Women's College Hospital and St. Joseph's Healthcare

**Objective:** Describe safe application of the threaded visual cannula, review efficacy of this method, and determine incidence of complications.

**Design:** Prospective observational cohort study (Canadian Task Force classification II-1).

**Setting:** University affiliated teaching hospitals.

**Subjects:** Authors' AT and KG's patients, May 1994 - 2006, having laparoscopic procedures for different gynecologic conditions were entered. Data sheets indicate demographics, number and kind of previous abdominal or pelvic surgery, primary and ancillary port particulars, complications, findings, and surgical procedures performed.

**Intervention:** Most primary port applications were pre-insufflated to a variety of initial intraperitoneal pressures. After three failed attempts to secure adequate pneumoperitoneum, or when patients were assigned pre-operatively for no pre-insufflation, then the visual cannula was applied directly.

**Measurements and results:** No failed primary or ancillary port insertion encountered, irrespective of BMI, location of primary port insertion, number of previous surgeries, and existence of peritoneal adhesions. No major port complications were encountered. Port slippage was infrequent, port infection rare, and port competence well maintained.
Trainees unfamiliar with the visual cannula's application, lacked ability to interpret monitor entry images, and the method's predictive value were lost.

**Conclusions:** Laparoscopic primary and ancillary port creation continues to be associated with serious yet avoidable complications. Use of visual entry methods allows surgeons to document port dynamics during port insertion and removal. The ability to observe the interaction of tissue, instrument and force will enhance our understanding of accident causation, eliminate hindsight bias, and allow error analysis to improve patient safety.

## Ergonomics/Instrumentation - P304

**A NEW AND SIMPLE "WRIST BAND" TECHNIQUE OF HAND ASSITED LAPAROSCOPIC SURGERY,** *Jyotsna S Kulkarni MD, Sanjay B Kulkarni MD, Deepti V Kamat MD, Kulkarni Endo Surgery Institute*

Today hand assisted laparoscopic surgery is used by novice surgeons as a learning step. It is useful for experts to perform complex solid organ surgery with reconstruction. Many devices are available for hand assisted laparoscopy. These devices are at times cumbersome to use. They are disposable and expensive.

We have used a new, simple and effective "Wrist Band" technique for hand assisted laparoscopic surgery for six years. A 7cm(surgeons glove size) muscle splitting incision is made at the pre-planned site. Two gauze pieces are wrapped around the surgeons non dominant wrist, above the sleeve of the gown but below the glove. A blue gauze is inserted in the abdomen. This gauze is used for mopping. The surgeons glove is lubricated with jelly for easy insertion in to the abdomen through the incision. The "Wrist Band" is adjusted to prevent CO2 leak through the incision. The rest of the trocars are inserted by palpation or under vision.

We have used this technique for hand assisted laparoscopic donor nephrectomies (105 cases), nephroureterectomy (10 cases), colectomies (4 cases), splenectomies for very large spleens (6 cases), Whipples procedure (3 cases).

The advantages of hand assisted laparoscopic surgery are many. It gives surgeon the tactile feel and 3D spatial orientation. It facilitates finger dissection and helps to control bleeding. This gives more confidence to the surgeon. The gauze is used to clean the telescope tip. Extraction of large specimen is quick and easy. The overall operative time is reduced.

Our new and simple "Wrist Band" technique is a very useful tool. This is specially applicable in developing countries, where the total surgical cost at times is less than the expensive hand port device.

## Ergonomics/Instrumentation - P305

**ASSESSMENT OF TABLE HEIGHT CHANGE WITH LAPAROSCOPIC INSTRUMENT CHANGE,** *Gyusung Lee PhD, David Dexter II MD, Tommy Lee MD, J. Scott Roth MD, Patricia Turner MD, Stephen M Kavic MD, Adrian E Park MD, University of Maryland*

Surgeons seldom change the set height of an operating table once beginning a case and never do so to accommodate difference in instrument handles. Previous studies sought to determine optimal table height without taking into account the influence of different instrument handles. We gave surgeons different styles of instrument handles and free range to choose optimal table height, based on comfort. Board-eligible, Board-certified general surgeons were recruited to complete two FLS tasks: peg board transfer (task 1) as well as intracorporeal suturing and knot tying (task 2). All tasks were conducted on a training stand with adjustable operating table and monitor height (Stryker).

Subjects for task 1 were given 2 disposable pistol grip (PG) dissectors (USSC) and 2 inline (IL) needle drivers (Ethicon) for task 2. Nineteen reflective markers were placed on each subject's upper body, and 4 markers were placed on each instrument. A motion capture system (Vicon) used these

markers to calculate upper-body joint angles and instrument shaft angles. For both PG and IL instruments, the table height was adjusted until maximum comfort was achieved. Kinematic measurements were made while instrument tips were in the center of the operative field. When using PG instruments, optimal table height averaged 98.1cm. When using IL instruments, a significant change was found as the table height lowered by 6.4cm to average of 91.7cm (p<0.005). Multiple changes in joint kinematics were observed when surgeons changed to IL instruments.

Notable changes were in shoulder and wrist joint excursions while there was no significant change in elbow angle. With the IL instruments, elevation angle decreased from 45 to 33 degrees (p<0.005). Optimal table height differs when surgeons work with PG versus IL instruments. A table height change based on instrument change faces limitations, such as drape and stand rearrangement and time consumption.

Given such difficulties, ergonomic factors warrant further analysis to determine if a standard optimal table height for different instrument handles exists or if an ergonomic redesign of handles is warranted. Additionally, our data suggests that wrist position in addition to elbow position significantly impacts surgeon comfort and optimal table height. Further investigation will be conducted as part of our comprehensive research, including imaging, display, surgical ergonomics using whole body analysis, and human factors.

## Ergonomics/Instrumentation - P306

**USE OF OXIMETRY-CAPABLE INSTRUMENTS FOR THE DIFFERENTIATION OF VASCULAR AND NON-VASCULAR STRUCTURES DURING LAPAROSCOPY,** *Ozanan R Meireles, Eric J Hanly MD, Lia R Assumpcao MD, Takintope Akinbiyi MS, Marcin Balicki BS, Gregory S Fischer PhD, Sunipa Saha MS, Samuel Shih MD, Russell H Taylor MD, Mark A Talamini MD, Michael R Marohn DO, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD*

**Introduction:** Decreased tactile sensation and two-dimensional visualization are limitations in laparoscopic surgery. These disadvantages can be critical when attempting to distinguish between vascular and non-vascular tubular structures in laparoscopic surgery. We hypothesize that oximetry-capable laparoscopic graspers can discriminate vascular from non-vascular structures based on differential oximetry wave form patterns.

**Methods:** A laparoscopic grasper was fitted with built-in oxymetry capability. Two pilot experiments were performed in adult swine. In the 1st study, known vascular and non-vascular structures were grasped at random with the prototype instrument while a second investigator blinded to the physical structures being grasped interpreted the wave form of the oximetry readings. In the 2nd study, readings were obtained in the distal renal vessels while the proximal renal artery was intermittently clamped, causing momentary blood flow interruptions toward the instrument sensors. Again, a second blinded investigator interpreted the oximetry patterns over time.

**Results:** Investigators reliably (100% accuracy) distinguished oximetry patterns of vascular from non-vascular structures. Arterial structures showed characteristic high-amplitude oximetry waves compared to semi-flat waves from non-arterial structures. This characteristic wave form disappeared when blood flow was interrupted with vascular clamping, but promptly returned after blood flow was restored.

**Conclusions:** Oximetry-capable instruments can distinguish vascular from non-vascular tubular structures during laparoscopy, and may have clinical utility. Such "smart" instruments are now being tested clinically and may help compensate for some of the limitations inherent in laparoscopy. Oximetry-capable instruments may improve patient safety by aiding in proper identification of tubular structures during laparoscopic surgery.

<figure><img src="image_135.png" /></figure>
<figure><img src="image_136.png" /></figure>

# SAGES POSTER ABSTRACTS

## Ergonomics/Instrumentation - P307

A COMPUTERIZED ANALYSIS OF STANDARD VERSUS HIGH DEXTERITY LAPAROSCOPIC INSTRUMENTATION IN TASK PERFORMANCE, V K Narula MD,K M Reavis MD,D R Renton MD,D J Mikami MD,B J Needleman MD,J W Hazey MD,K E Hinshaw BS,W S Melvin MD, THE OHIO STATE UNIVERSITY HOSPITAL, CENTER FOR MINIMALLY INVASIVE SURGERY

**Introduction:** Minimally invasive surgery is becoming the standard of care for the majority of abdominal procedures. Laparoscopic instrumentation is constantly undergoing improvements to give surgeons an advantage. Articulated instrumentation provides a distinct advantage in the field of robotic surgery. Applying the same principles to standard laparoscopic instrumentation could offer increased degrees of freedom to make complex laparoscopic tasks easier to perform. We utilized a novel computerized assessment system to objectively evaluate task performance comparing Standard and High Dexterity (HD) laparoscopic instrumentation.

**Methods:** Advanced laparoscopic surgeons (2-12yrs experience) performed 3 unique task modules utilizing Standard and HD laparoscopic instrumentation (Novare Surgical Systems, Cupertino, CA). Performance was evaluated using a computerized assessment system (ProMIS, Dublin, Ireland) and results were recorded as time (sec), path (mm), and precision. Each surgeon had an initial training session followed by two testing sessions for each module. A Paired Student's T-Test was used to analyze the data.

**Results:** Nine surgeons completed the study. Objective assessment of the data is presented in the table below. Module 1 was statistically significant, whereas Module 2 and 3 showed no difference in task performance with the HD instrumentation.

<table><thead><tr><th colspan="4">Standard L/S vs. HD Instrumentations</th></tr><tr><th>Module</th><th>Time (sec)</th><th>Path (mm)</th><th>Precision</th></tr></thead><tbody><tr><td>1- Suturing *</td><td>201 vs. 326</td><td>12895 vs. 18035</td><td>1419 vs. 2134</td></tr><tr><td>2-Needle Pass</td><td>112 vs. 131</td><td>6517 vs. 6213</td><td>787 vs. 913</td></tr><tr><td>3-Needle Transfer</td><td>39 vs. 36</td><td>2140 vs. 2164</td><td>261 vs. 236</td></tr></tbody><tfoot><tr><td colspan="4">*p < 0.05</td></tr></tfoot></table>

**Conclusion:** HD instrumentation is in its infancy. Results showed no advantage using HD instrumentation. This could be due to the learning curve associated with new instrumentation and technology. With future developments in HD technology and training, the user interface will improve and may offer an advantage over standard laparoscopic instrumentation.

## Esophageal/Gastric Surgery - P308

**ROBOTIC-ASSISTED SURGERY FOR GASTRIC MALIGNANCIES:**
SHORT TERM RESULTS, C A Anderson MD,M Hellan MD,V Trisal MD,K Kernstine MD,J Ellenhorn MD,A Pigazzi MD, City of Hope

**Background:** Minimally-invasive surgery has been described for benign diseases of the foregut, however there is limited literature reporting its use in malignant diseases.

**Methods/Participants:** Between 8/30/04 - 7/28/06, 20 patients, with a median age of 61.7 (37-80) years, underwent minimally invasive resections with a combination of robotic and laparoscopic techniques for gastric cancer. The study group consisted of 6 females and 14 males with a median BMI of 25.8 and an ASA score of 3. 11 patients had GE junction tumors that required combined gastric and esophageal resection, 8 patients received a subtotal gastrectomy, and 1 patient had a wedge resection. Surgical procedures were performed for adenocarcinoma in 17 patients and three for a GIST tumor, a squamous cell carcinoma, and a highly dysplastic adenoma. 89% of the GE tumor patients received neoadjuvant chemoradiation therapy.

**Results:** 18 procedures were performed with robotic assistance and 2 with only conventional laparoscopic techniques. Conversion rate was 5%. The median operating time was 432 minutes. There was one intraoperative complication requiring colonic resection. The median number of nodes harvested was 24 (6-42). Patients were hospitalized a median of 9 days (3-64). The median time to patients resuming a solid diet was 6 days.

30-day mortality was 0%. There were 2 anastomotic leaks after esophagogastrectomy resections. Three patients were stage zero after resection, eleven were stage I, four were stage II, and one was stage III. Median follow-up time was 9 months (0-21) with no recurrences.

**Conclusion:** This early experience suggests that minimally invasive surgery is safe and feasible in patients undergoing oncologic procedures for gastric cancer. Due to the short-term follow-up no conclusions can be made about recurrence or survival yet. Further research is needed to demonstrate an advantage of either robotic or laparoscopic techniques over open procedures for gastric cancer.

## Esophageal/Gastric Surgery - P309

**SINGLE CENTER REVIEW OF TREATMENT OF ZENKER'S DIVERTICULUM:**
OPEN VS. TRANSORAL, Shahin Ayazi MD,Steven R DeMeester MD,Bethany J Lehman BA,Satish Kesavaramanujam MD,Christian G Peyre MD,Nuttha Ungnapatanin MD,Jessica M Leers MD,Andrew L Tang,Jeffrey A Hagen MD,John C Lipham MD,Tom R DeMeester MD, Department of Surgery, Keck School of Medicine of the University of Southern California

**Background:** The traditional approach to surgical therapy for a Zenker's diverticulum is an open cricopharyngeal myotomy with excision or suspension of the diverticulum. A more recent endoscopic alternative is a transoral stapling of the diverticulum, but reports have suggested a higher recurrence rate with this technique. The aim of this study was to compare the outcome of these two techniques focusing on relief of the major symptoms and the incidence of perioperative complications with each.

**Methods:** A retrospective review of 32 patients with primary surgical intervention for a Zenker's diverticulum at our center from 1998-2006.

**Results:** There were 21 males and 11 females with a mean age of 71. Dysphagia was present in 28 (87.5%), bland regurgitation in 14 (43.7%) and both symptoms were present in 10 (31.2%). The mean pouch size by endoscopic measurement was 2.5 cm (Range 2-4.5) in the open group and 3.7 (Range 3-4.7) cm in the endoscopic group. An open procedure was performed in 18 (56.2%) and in 14 (43.8%) an endoscopic procedure was performed. Median follow-up was 62.5 days in the open group and 98.1 days in the endoscopic group. Complete symptom relief was noted in 64.5% of the open group and 62.5% of the endoscopic group, with improvement in symptoms noted in 93.7% and 92.8% respectively. One patient in each group needed another intervention for persistent troubling symptoms. There were two reoperations in the early postoperative period, both in the open group for drainage of a neck hematoma.

Conversion to an open approach was performed in two patients due to inability to satisfactorily complete the endoscopic procedure.

**Conclusion:** In this series, patients were selected for an endoscopic approach only if their Zenker's diverticulum measured greater than 3 cm in size, and with this criterion the successful relief of dysphagia and regurgitation was similar to patients treated with an open approach. Further, no patient in the endoscopic group required early reoperation for a surgical complication. We conclude that an endoscopic approach is as effective as an open approach for relief of dysphagia and regurgitation symptoms during short-term follow-up in appropriately selected patients.

## Esophageal/Gastric Surgery - P310

**DAY CASE LAPAROSCOPIC ANTIREFLUX SURGERY:**
A PROSPECTIVE STUDY, NS Balaji,K Moorthy,Raj Nijjar,A Eisawi,CVN Cheruvu, University Hospital of North Staffordshire

**Background:** Laparoscopic Antireflux surgery (LARS) is the gold standard for the surgical treatment of Gastro oesophageal reflux disease (GORD). It is traditionally performed as an inpatient procedure.

**Aims:** To prospectively analyse the practicality of the provision of a Day case (DCLARS) provision of LARS and assess clinical outcomes.
SAGES POSTER ABSTRACTS

**Methods:** DC LARS was performed on ASA 1-2, fully independent patients with a carer at home. The preoperative work up included endoscopy and oesophageal pH manometry. Perioperative protocol included preoperative counselling, standardised anaesthetic, antiemetic and analgesic regimes. A loose floppy 360 degree fundoplication was performed in all patients. The primary end points were achievement of discharge as a day case, length of hospital stay (hours) and readmission rates. Secondary endpoints were the postoperative complications, pain, nausea and dysphagia scores in the first week after surgery. MVSS (Modified Visick Symptom Score) and global satisfaction profiles were assessed at a later follow-up to evaluate the effectiveness of DCLARS in symptom control related to GORD.

**Results:** 42 consecutive patients (M: F - 33:9) with a median age of 43(IQR 32-48) and BMI of 27(IQR 25-29) formed the study group. The preoperative % time pH< 4 was 14(IQR 10-20) and DeMeester score 58(IQR 39-81). The median postoperative stay in hospital was 6.75 hours (IQR 6-8) and all 42 (100%) patients were discharged on the day of surgery. There were no readmissions, although there were two reattendances with gas bloat.

Median post operative pain, nausea and dysphagia scores (Visual analogue scale of 0 -10) were assessed at discharge, 3, 5 and 7 days after surgery. The pain score was 5, 3, 2 and 2 at days 0, 3, 5 and 7 after surgery. The dysphagia score was 3, 1.5, 0 and 0 at days 0, 3, 5 and 7 after surgery. Post operative nausea pain score was 0 on all these days (0, 3, 5 and7).

The global satisfaction score was 9.5/10 recorded at the first follow up clinic visit (6 weeks). MVSS scores of 1 or 2 (good result) was recorded in 39/40, 38/40 and 39/40 patients for reflux, dysphagia and gas bloat respectively. 2 (4.5%) patients had an MVSS of 3 or 4 (unfavourable outcome) for dysphagia and needed conversion to partial fundoplication at a later stage.

**Conclusion:** Our study demonstrates that DCLARS is feasible with good clinical outcomes in patients with symptomatic GORD.

Esophageal/Gastric Surgery – P311

THE INFLUENCE OF LAPAROSCOPIC ANTIREFLUX SURGERY ON DIETARY AND POSTURAL TRIGGERS OF GASTRO-OESOPHAGEAL REFLUX, NS Balaji, K

Moorthy, Vasanth Dipesh BA, M Deakin, CVN Cheruvu, University Hospital of North Staffordshire

**Background and Aim:** (GOR) symptoms are known to be precipitated by specific diet and posture acting as triggers. The aim of this study is to assess the benefit of laparoscopic Antireflux surgery (LARS) on significant triggers of GOR identified preoperatively.

**Methods:** A pilot phase 1 study prospectively identified the preoperative dietary and postural triggers of GORD. These were used as the trigger specific evaluation tool in the current phase 2 study. The triggers included different food varieties (chocolate, spicy and fatty foods), beverages (citrus juices, coffee, tea), alcohol, smoking and posture (supine, bending and exercise), The severity of symptoms related to these stimuli were graded prior to surgery as severely incapacitating (SI), moderately incapacitating (MI) or having no effect (NE). The effect and extent of relief after surgery were graded as complete relief (CR), significant relief (SR) or no effect (NE).

**Results:** Our study comprised of 43 patients (M: F - 29:14) with a median age of 46(IQR 35-54) who were assessed preoperatively and at a median of 8 months following LARS for trigger specific relief of reflux.

Spicy food and alcohol were the most severe preoperative dietary triggers in 37/43 (86%) followed by citrus juices 36/43(83%) and fatty food 34/43(79%) respectively. Supine posture was the worst postural preoperative precipitant in 37/43 (86%) (SI reflux-29 (78%) or MI reflux-8(22%)) of patients while bending and exercise affected 34/43(79%) and 25(58%) of patients. However smoking appears to have little effect (SI reflux-0, MI reflux-2)

Complete relief of reflux after LARS was seen in 95% (33/37) and in 79% (27/34) of patients after spicy and fatty food

intake respectively. 92% (34/37) of patients enjoyed reflux free alcohol intake following surgery. Complete relief from supine reflux was seen in 89% (33/37) and significant relief in the rest.

**Conclusion:** Our results conclude that LARS provides significant postoperative symptom relief of specific trigger provoked reflux. Trigger based assessment tools could be of value in evaluating post operative outcomes.

Esophageal/Gastric Surgery – P312

RETROSPECTIVE REVIEW OF RESULTS OF LAPAROSCOPIC PARAESOPHAGEAL HERNIA IN 106 PATIENTS WITHIN A RURAL POPULATION OPERATED BY A SINGLE SURGEON, MURALIDHARAN R BASKER MD, YASIR AKMAL MD, UMOH

J NSIKAK MD, RYAN HARDY MD, CARLY WHITEHEAD MD, STEPHANIE DUNKLE-BLATTER MD, ALLIE SCHUESS, ANTHONY T PETRICK MD, GEISINGER HEALTH SYSTEM

**OBJECTIVE:** Controversy remains over optimal management of the crura during repair of paraesophageal hernias (PEH). The objective of our study was to compare outcomes of laparoscopic PEH hernia repair (LPEHR) with primary crural closure (PC) versus crural closure with mesh reinforcement (MC).

**METHODS:** We retrospectively reviewed data that was prospectively collected for 106 consecutive patients (M:F=1:2.5; mean age, 60.6; age range=33-91) undergoing initial LPEHR between November 2001 to June 2006. Pre and post operative evaluation included a standardized GERD symptom questionnaire, assessment of antacid use, UGI, and EGD. Manometry and esophageal pH testing were done selectively. LPEHR included Collis gastroplasty (n=94) and Nissen fundoplication (n=105). PC was performed in 67 patients and MC was utilized in 39 (Crurasoft® n=29; Surgisis® n=9; Alloderm® n=1)). Statistical analysis was done using Chi-square test.

**RESULTS:** All cases were completed laparoscopically. Mean LOS was 2.3 days (Range 1-22 days). 90-day and in-hospital mortality rate was 1.8%. The 90-day major complication rate was 6.6% (4 leaks, 1 MI, 1 Gastric necrosis, 1 Acute recurrence). There was no significant difference between PC and MC groups. The minor complication rate was 10.8%. One patient had esophageal erosion of mesh 5 months postop. 83% of patients utilized PPI's preoperatively while only 23.5% of patients required PPI therapy postoperatively (p<.001) at mean follow up of 22.7 months. 84.9% judged their outcomes good/excellent. Overall in both PC and MC groups resolution of heartburn, emesis, dysphagia, respiratory symptoms, and abdominal pain were all statistically significant (p<.001) with no difference between groups. All patients had postop UGI and 15% had EGD to objectively assess recurrence rates. There were no recurrences in the MC group with a mean follow up of 6.2 months. In the PC group, the recurrence rate was 5.6% with a mean follow up period of 8.9 months (p >0.05).

**CONCLUSIONS:** Laparoscopic repair of PEH was safe and results in significant clinical improvement and diminished use of antacids in those patients experiencing heartburn. Our study utilizes rigorous objective follow up. Early analysis suggests recurrence rates are low in both groups with a nonsignificant trend toward better recurrence outcomes in the MC group than the PC group. We recommend the use of biologic mesh due to our experience with erosion of synthetic mesh in one patient.

Esophageal/Gastric Surgery – P313

EFFICIENT CLIPLESS MINILAPAROSCOPIC CHOLECYSTECTOMY? A STUDY OF 641 CASES, Gustavo L Carvalho

PhD, Elizabete M Andrade, Luis H Lira, Alexandre W Dantas, Flavia F Queiroga, Gilvan Loureiro MD, Frederico W Silva MD, Carlos H Ramos MD, Pernambuco State University, School of Medicine, Recife, Brazil

**INTRODUCTION:** With the advances in minimally invasive surgery, it has been possible to use more accurate equipment with a reduced diameter, which has led to state-of-the-art 2-mm instruments (needle trocars). Nevertheless,

<figure><img src="image_137.png" /></figure>
<figure><img src="image_138.png" /></figure>

# SAGES POSTER ABSTRACTS

because of the increased cost of this procedure it has not been described in the literature with a large patient series.

**OBJECTIVE:** To present modifications to the laparoscopic technique which may make it possible to conduct mini-lap procedures safely and effectively, thereby considerably reducing the cost of this type of surgery and showing that it can improve the life quality of the patient.

**METHOD:** From Jan 2000 to Aug 2006, 641 consecutive patients underwent minilaparoscopic cholecystectomy (MLC). The patients were suffering from chronic lithiastic cholecystitis at various stages of the disease or gallbladder polyps and were submitted to MLC, including acute cholecystitis and intraoperative cholangiography. Tech - After the pneumoperitoneum at the umbilical site, 4 trocars are inserted; 2 of 2-mm (support trocars), 1 of 3-mm (work trocar) and 1 of 10-mm diameter, through which a 10-mm 30-degree laparoscope is inserted. Neither the 3-mm laparoscope, nor clips, nor expensive endobags are used. The cystic artery is safely sealed by electrocautery, near the gallbladder and the cystic duct is sealed with surgical knots. Removal of the gallbladder is carried out, in a bag made with a glove wrist, through the 10-mm umbilical site.

**RESULTS:** MLC was attempted in all 641 patients (75.7% fem; mean age, 46.6 yr; range 14-94 yr). The total operative time was 32 min; range 13-105 min. The average hospital stay was 18h (96% were discharged within 24h). There was no conversion to open surgery; 3.3% of patients (underwent conversion to standard (5-mm) lap-chole because of difficulty with the procedure; there were 2.3% minor umbilical site infections and 1.7% incisional herniations. There was no mortality, no bowel injury, no reoperation, no bile leakage, no bile duct injury and no postoperative hemorrhage.

**CONCLUSION:** MLC is a safe and effective procedure which results in a better esthetic effect for the patients, when compared with conventional laparoscopy. The modifications to the technique allow for a considerable reduction in costs, associated with the original MLC procedure, since neither clips, nor endobags, nor mini-loops are used. Furthermore, no 3-mm laparoscope is used, which is the most expensive component of the mini-lap instruments.

## Esophageal/Gastric Surgery - P314

**NISSEN FUNDOPERLICATION IS EFFECTIVE FOR THE TREATMENT OF THE NUTCRACKER ESOPHAGUS - PRELIMINARY DATA**, Gustavo L Carvalho PhD, Thiago G Vilaça, Ana Beatriz T Ramos, Flavia F Queiroga, Luis H Lira, Carlos Brandt, Renata F Vieira, Pernambuco State University, School of Medicine, Recife, Brazil

**Introduction:** The nutcracker esophagus (NE) is a primary motor disorder characterized by esophageal peristaltic contractions of high amplitude. There is relationship between gastroesophageal reflux disease (GERD) and NE but, in spite of this, there is no consensus on the use of surgery in this association of diseases. The purpose of the present investigation was to evaluate the treatment of NE by laparoscopic anti-reflux surgery (LARS) in carriers of NE associated with GERD.

**Patients and Method:** From January 2000 to August 2006, 256 patients with GERD underwent LARS, of whom six presented NE. The diagnosis of GERD was confirmed by upper gastrointestinal endoscopy and 24-h esophageal pH monitoring when necessary. NE was confirmed by esophageal manometry. Follow up evaluation with endoscopy and esophageal manometry were performed in all 6 patients.

**Results:** There was no need for conversion to open surgery and there were no deaths or major complications resulting from the procedure. Five patients are asymptomatic and one is oligosymptomatic. The amplitude of peristalsis in the distal esophagus decreased from 251.4 ± 28.8mmHg to 192.2 ± 58.5 (t=2.221-p=0.050). Although the lower esophageal sphincter pressure increased from 8.9 ± 4.2 to 11.6 ± 7.1 (t=0.791-p=0.4472), the difference was not statistically significant.

**Conclusion:** Laparoscopic Nissen was shown to be safe and effective for the treatment of nutcracker esophagus in patients with associated GERD. Besides the improvement in esophageal motility and control of the gastroesophageal reflux, improvement or disappearance of NE symptoms was observed in all patients.

## Esophageal/Gastric Surgery - P315

**ECONOMIC BENEFITS OF THE PROVISION OF DAY CASE LAPAROSCOPIC ANTI-REFLUX SURGERY**, Krishna Moorthy MD, NS Balaji MD, A Samee MD, CVN Cheruvu MD, Upper Gastrointestinal Unit, Department of Surgery, University Hospital of North Staffordshire, Keele University, Stoke-on-Trent, UK.

**Introduction:** The feasibility of performing day case Laparoscopic Anti-Reflux Surgery (LARS) is well recognised. However, the economic benefit of such a strategy has not been previously explored. In this study we aim to assess the cost effectiveness of day case LARS.

**Methods:** All the procedures were performed by one surgeon over a 2 year period (2003-05). Patients in both cohorts (Day Case- DC and Inpatient- IP) were discharged on a standard schedule of post-operative analgesia and anti-emetics. A post-operative follow-up protocol consisting of telephonic follow up by the Day Surgery unit and 3 visits by the district nurse (DN) was established for the DC group. Data on readmissions, re-attendances, additional DN visits and visits to the General Practitioner (GP) was collected. Short-term direct costs up to the first post-operative follow-up appointment at 6 weeks were analysed. Pre-operative costs were similar in both cohorts. Thus the study variables include the operative and post-operative costs. Costs of hospital stay and the procedure including the theatre time, the disposables used and staffing were obtained from the trust's financial directorate. Costs for GP visits and DN visits were acquired from standard National Health Service cost sources.

**Results:** There were 20 patients in the IP group and 26 in the DC group. The IP patients were operated in the period between 12/03 and 12/04 while the DC patients were operated in the period between 10/04 and 12/05. Both groups were well matched for clinical presentation, endoscopy, manometry and pH findings. The total operative costs were higher in the IP group [(830 (IQR-240.2) v 768.6 (232.5); p=0.01]. The median hospital stay in the IP group was 1 day (range 1-3). There were no readmissions in the DC group. There were median 3 (range 3-4) DN follow-up visits and 1 (range 0-1) GP visit in the DC group. The median post-operative costs were significantly higher in the IP group (£352 (IQR- 352) vs £317 (IQR- 24); P=0.001). The total short-term costs were also significantly higher in the IP group [1368.6 (522.5) vs 1085.6 (244.7); P=0.001]. The clinical outcomes were comparable in both groups with no major complications.

**Conclusion:** The results of this study show that the provision of laparoscopic LARS on a day case basis, in comparison to inpatient practice, is associated with comparable clinical outcomes, high patient satisfaction and significant short term direct cost benefits.

## Esophageal/Gastric Surgery - P316

**EARLY EXPERIENCE WITH LAPAROSCOPIC GASTRIC RESECTION**, William C Conway MD, John D Webber MD, Detroit Medical Center/Wayne State University

**Introduction:** Laparoscopic gastric surgery has gained acceptance for benign disease, while this technique in malignant disease remains controversial. Laparoscopic approaches are less invasive, leading to reduced post-operative pain, reduced length of stay, and an overall increase in quality of life. An early experience with laparoscopic gastric resection is presented.

**Methods:** From 1/05 to 4/06, four patients underwent gastrectomy via the laparoscopic approach at Harper University Hospital. Procedures included two distal gastrectomies, one proximal gastrectomy, and one laparoscopic-assisted total gastrectomy, all with Roux-en-Y reconstructions. Medical charts and operating room records were reviewed in these cases.

**Results:** The indications for gastrectomy in our series included prophylactic gastrectomy due to genetic positivity for E-Cadherin in the setting of a family history of gastric cancer, distal gastric adenocarcinoma, pyloric stricture, and submucosal mass, which was identified as a GIST tumor on pathologic exam. Operative times ranged from 4.5 to 7.5
hours, and no cases were converted to an open procedure. Average blood loss was 112.5cc. Morbidity included an abdominal wall hematoma and iatrogenic hypotension; no mortality was noted. Average post-operative length of stay was 4.75 days. In the case of known adenocarcinoma, four nodes were obtained, one of which was positive.

**Conclusions:** Laparoscopic gastric resection is safe, well-tolerated, and may improve post-operative length of stay as well as post-operative debility. This technique is especially suited for benign disease and prophylactic resection in patients with E-cadherin positivity. In light of the minimal number of nodes obtained, more experience needs to be obtained before applying this technique to patients with gastric adenocarcinoma.

## Esophageal/Gastric Surgery - P317

### INCIDENCE OF FAMILIAL ACHALASIA OR ACHALASIA-TYPE SYMPTOMS AMONG RELATIVES OF PATIENTS UNDERGOING HELLER MYOTOMY WITH DOR FUNDOPLICATION,
Sebastian G de la Fuente MD,Eric J DeMaria MD,Joshua E Roller MD,Aurora D Pryor MD, Duke University Medical Center

**Objective:** Allgrove syndrome is a rare familial autosomal recessive disorder characterized by achalasia, alacrima, and adrenal insufficiency (triple-A syndrome). Genetic mutations responsible for this syndrome have been identified; however, the incidence of the disease, or of familial Achalasia in general, in patients undergoing surgery for Achalasia is unknown. In the present study we evaluated the incidence of Achalasia-type symptoms in family members of patients undergoing surgery for manometry-confirmed Achalasia.

**Methods:** A retrospective review was performed of all consecutive patients undergoing laparoscopic Heller myotomy with Dor fundoplication by a single surgeon at Duke University Medical Center. Basic demographics including age, sex, race, operative technique, family member affected, and length of stay were collected.

**Results:** A total of 54 patients were operated on by the one surgeon (AP) from 2003-2006. Of these, 5 patients (9%) had a family member with Achalasia-type symptoms. Sixty percent of patients with relatives affected were males and all were white. The mean age was 57 years old. All patients underwent preoperative evaluation including barium swallow as well as manometry that confirmed the diagnosis. Three of the patients underwent preoperative esophageal dilations at other institutions and one had Botox injection prior to surgery. One patient had both Botox injections and multiple esophageal dilations before referral. Three patients had first-degree relatives affected (son, sisters) and the remaining two had second-degree family members (aunts) with Achalasia-type symptoms. All underwent laparoscopic Heller myotomy with Dor fundoplication. No patients reported dry eyes (alacrimia) or had clear symptoms of adrenal insufficiency. There were no intraoperative or postoperative complications. The mean length of hospital stay was 23 hr.

**Conclusions:** Approximately 9 percent of patients with Achalasia have a relative affected with Achalasia or Achalasia-type symptoms. Of these, the majority are first-degree family members. For this reason, the initial work up for patients presenting with Achalasia should include assessment of the presence of Achalasia-type symptoms in their families. It is possible that another genetic variation exists that is associated with familial Achalasia and further investigation into this population is warranted.

## Esophageal/Gastric Surgery - P318

### CLINICAL EXPERIENCE WITH PROPHYLACTIC STENTING OF HIGH RISK ESOPHAGEAL ANASTOMOSES,
Peter M Denk MD,Yashodhan Khajanchee MD,Lee L Swanstrom MD, Legacy Health System, Portland, OR

Esophageal surgery has improved significantly through advances in technique and technology. It has now become routine and even "safe" in experienced centers. Mortality from anastomotic leaks has improved however anastomotic complications including leak and stricture remain common

and represent significant immediate and late morbidity. Leaks lead to wound infections, increase pain, prolong hospital stays and delay recovery or adjuvant therapy. Late sequelae typically present as dysphasia that frequently requires endoscopic dilatation and adds to cost, discomfort and associated risks.

Based on our studies of prophylactic stenting of flawed esophageal anastomoses in an opisthm model which documented leak prevention and reduced anastomotic strictures, we applied this technique to five selected patients undergoing laparoscopic total esophagogastrectomy.

**Methods:** Five male patients diagnosed with either Barrett esophagus with high grade dysplasia (1), or esophageal adenocarcinoma (4), had removable stents placed across the anastamosis at the time of esophagectomy. Three patients had laparoscopic transhiatal esophagogastrectomy with cervical anastomoses and two had laparoscopic/thoracoscopic approaches with thoracic anastomoses. All patients had laparoscopic feeding jejunostomies. Anastomoses were done with either two staple or staple / hand sewn technique. EGD was performed and Polyflex esophageal stents were placed under fluoroscopic guidance. Transmural sutures were placed at the proximal ends of the stents to secure them. Follow-up EGD with stent removal or subsequent intervention was based upon the patient's symptoms.

**Results:** Stents remained in place a mean 31 days (range 17 to 43). OR time averaged 7.1 hours. Length of stay averaged 23 days (range 7 to 45). 2 of 5 stents migrated, one of these patients developed a stricture but the other did not. One patient had a leak and after healing and stent removal went on to develop a stricture requiring several dilations. 3 of the 5 patients developed a stricture. Patients have had an average of 2.1 dilations per year postop (range 0 to 5.7) with a mean follow-up of 10 months (range 3-18).

**Conclusion:** Prophylactic stenting of esophageal anastomoses has the potential to prevent anastomotic leaks and decrease the incidence of strictures in selected high risk patients.

## Esophageal/Gastric Surgery - P319

### ARE MANOMETRIC STUDIES AND CALIBRATION REALLY NECESSARY FOR THE PROCEDURE OF LAPAROSCOPIC FLOPPY NISSEN FUNDOPLICATION?, Erhun Eyupoglu MD,Turgut Ipek MD,Metin Kapan MD,Adem Karatas MD, Ilknur Erenler Kilic, Department of Surgery, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey

**Background:** There are several surgical methods in gastroesophageal reflux disease (GERD) and the common aim is to minimalize the postoperative complaints. We want to show if preoperative investigations have an effect on the choice of surgical procedure and postoperative results or not.

**Material and methods:** We treated 540 patients with GERD with laparoscopic Nissen fundoplication. Preoperative endoscopy, pH meter and passage graphy were performed on all patient. Manometric studies were not performed. In 17 patients classically Nissen fundoplication was done and calibrated with bougie. In 523 of these patients floppy Nissen were performed.

**Results:** The mean duration of operation was 60.0 (50-200) minutes.. The overall duration of the hospital stay was 1.7 (1-8) days. In the postoperative period dysphagia occurred in 60 patients at the end of the first month, in 15 (2 %) patients at the end of the third month, in 3 (0.5 %) patients at the end of the first year and in 1 (0.1%) patient after 1 year. Gas bloating occurred in 65 (12 %) patients. Local ischemia of the spleen occurred in 3 (0.5 %) patient, and pneumothorax in another. Recurrence of the GERD occurred in 7 (1%) patients. Type 1 disruption occurred in 1 patient (0.2%) and type 4 disruption (0.2%) in another. Mortality rate was 0.1% (1 patient) due to esophageal perforation and pulmonary vein disruption during peroperative calibration.

**Conclusion:** In the postoperative period dysphagia is an important complaint which effects the life quality of the patients who underwent surgery for GERD. Decreasing the ratio of postoperative dysphagia is closely related with the type of the surgery. Laparoscopic floppy Nissen fundoplication

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