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SAGES POSTER ABSTRACTS

**Hepatobiliary/Pancreatic Surgery – P405**

**GALLBLADDER POLyps: ULTRASOUND vERSUS PATHOLOGY REPORT CORRELATION.**, SERGIO DIAZ MD, CARLOS A LOPERA MD, ROGELIO MATALLANA MD, JUAN D MARTINEZ MD, CAROLINA BRAVO MD, MAURICIO MORENO MD, INSTI-TUTO DE CIENCIAS DE LA SALUD CES. PROFAMILIA CLINIC.

When laparoscopic cholecystectomy (LC) is indicated for gallbladder polyps (GP) found on ultrasound (US), at the time of surgery a different diagnosis is frequently made. Since the decision to operate depends on the US findings we wanted to assess the accuracy of US for diagnosing GP. We retrospectively compared the results of preoperative US with those of the pathology report for patients undergoing LC. Between January 2004 and June 2005, 338 patients had LC at our institution. 228 patients were female and 50 were male. Indication for surgery was cholelithiasis in 95.3%, polyps in 3.3% and functional disorders in 1.4%. Among 11 patients diagnosed with gallbladder polyps on ultrasound only 1 was confirmed at pathology (3.3% vs 0.3%), five other patients diagnosed preoperatively only as cholelithiasis actually had polyps in the pathology report. The sensitivity and specificity of US for the diagnosis of GP was 16.7% and 97.8% respectively (PPV: 9.1% CI: 0.6-37.7 NPV: 98.5% CI: 96.7-99.4). We conclude that despite being an excellent tool for diagnosing cholelithiasis, US alone is not acceptable for GP because of it's low sensitivity. Other diagnostic approaches are suggested

**Hepatobiliary/Pancreatic Surgery – P406**

**EVALUATION OF POSITIVE PRESSURE PNEUMOPERITONEUM EFFECT ON LIVER ENZYMES FOLLOWING F ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY,** Arieh Eitan MD, Alexander Weiar MD, Amitai Bickel MD, Department of Surgery (1) and Urology (2), Western Galilee Hospital, Nahariya, Israel, and the Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.

**Background:** Laparoscopic operations are usually associated with cardiovascular changes, as well as visceral perfusion, mainly attributed to the effects of CO2 pneumoperitoneum (pp). Studies made on a small number of patients have demonstrated significant modifications in liver function tests(LFT) following laparoscopic cholecystectomy. According to our experience, those findings were not confirmed.

**Aim:** To assess prospectively LFT in large group of patients undergoing laparoscopic cholecystectomy.

**Patients and methods:** During a 7-year period (1999-2005), 1720 patients were scheduled for laparoscopic cholecystectomy. In 1190 of them (study group), the surgery was elective. Exclusion criteria for that group included acute cholecystitis, acute pancreatitis, pre-operative ERCP, and LFT abnormalities. The remaining 530 patients underwent surgery for acute cholecystitis. Liver function tests were evaluated preoperatively and 20-24 hours postoperatively. The patients underwent surgery in the supine reverse-Trendelenburg position, and the intra-abdominal PP pressure was set on 14 mmHg.

**Results:** The mean value of liver function tests and amylase were within normal limits, and did not increase significantly post-operatively (LDH: 237.7 to 281 IU; ALT: 37.6 to 39.6; AST: 44.8 to 45.1; T.Billirubin: 0.65 to 0.54; Gamma GGT: 24.3 to 23.5 Alk. Phos: 55.2 to 55.5; Amylase: 48.9 to 48.1 IU). We observed post-operative mild enzyme increase in 40 patients (1 to 3 enzymes in each, 3.36%), only in 5 of whom, choledocholithiasis were found.

**Conclusions:** In contrary to previously published data, we have validated, in light of our large prospective study, that induction oc CO2 PP dose not deranged liver function enzyme functions. We suggest that liver enzymes will not serve as an indicator to adversees effects following PP induction. We concluded that the routine post-operative examination of LFT (in order to exclude choledocholithiasis etc.) is unnecessary, following elective and uncomplicated laparoscopic cholecystectomy.

**Hepatobiliary/Pancreatic Surgery – P407**

**TRANSPERITONEAL vERSUS TRANSHEPATIC PERCUTANEOUS CHOLECYSTOSTOMY AS A NON-SURGICAL TREATMENT FOR ACUTE CHOLECYSTITIS,** Arieh Eitan BA, Norman Loberant BA, Y Notes BA, Amitai Bickel MD, Department of Surgery and Invasive Radiology, Western Galilee Hospital, Nahariya, Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel

**Introduction:** Percutaneous cholecystostomy (PC) has become an accepted procedure in patients with acute cholecystitis who are not candidates for cholecystectomy. The procedure is performed under local anesthesia under image guidance.

**Objective:** To determine whether there is any difference in clinical outcome of gallbladder drainage based on anatomic approach to the gallbladder, that is, transhepatic versus transperitoneal.

**Patients and Methods:** Our study enrolled 132 patients who underwent PC for acute cholecystitis, as a temporary or permanent substitution to surgery, from January 1995 to December 2004. The patients were divided into two matched groups.

**Results:** Regarding hospital course, there were 7 deaths in the transperitoneal group and 5 deaths in the transhepatic PC group, due to the patient's underlying condition (superimposed sepsis and multi-organ failure) and not attributed to PC. Mean time from PC to hospital discharge was 9 days in the transhepatic group and 7 days in the transperitoneal group (P=0.055). Fluoroscopic examination following placement of the catheter revealed similar percentages of contrast leaks. One patient in each group had clinical evidence of localized bile leak with peritoneal irritation. Clinical improvement following PC was noted in 92% of the transperitoneal group and 88% of the transhepatic group.

**Conclusion:** We found no significant difference between our two study groups concerning complication rate, mortality and clinical sequela. We conclude that the transperitoneal route for PC is at least as safe as the transhepatic route. The physician who perform PC should base his decision on the anatomic route according to his personal experience and the patients' medical condition.

**Hepatobiliary/Pancreatic Surgery – P408**

**CONVERSION IN LAPAROSCOPIC CHOLECYSTECTOMY AFTER GASTRIC RESECTION: A 15 YEAR REVIEW,** Kathy Hsu, MD C/O: Shannon A Fraser MD, Harvey Sigman MD, Sir Mortimer B. Davis Jewish General Hospital, McGill University

**Background:** Gastrectomy or truncal vagotomy is known to increase the incidence of cholelithiasis. Many of these patients will become symptomatic and the adhesions from their gastric resection may make laparoscopic cholecystectomy much more difficult.

**Methods:** We prospectively assessed the data for the 15 year cumulative laparoscopic cholecystectomy experience of one surgeon at a university teaching hospital with respect to conversion and post operative outcomes, with particular attention to patients having had previous gastric resection.

**Results:** Patients with previous gastrectomy had similar operative times (81.1 (45-120) minutes), a significantly higher conversion rate (64.2%, p < 0.01) and a significantly higher complication rate (35.7%, p<0.05) than those patients who had had other previous upper abdominal surgery (73.2 (35-130) minutes, 25%, and 11.3% respectively) and those without previous abdominal surgery (66.5 (25-250) minutes, 2.7% and 4.5% respectively).

**Conclusion:** Pre-operative knowledge of the increased conversion rate and increased morbidity will inform surgical planning for both the surgeon and the patient.
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# Hepatobiliary/Pancreatic Surgery - P409

## ONE HAND LIVER HANGING METHOD: AN EFFECTIVE TECHNIQUE TO CREATE A GOOD VISUAL FIELD IN THE LAPAROSCOPIC HEPATECTOMY, Fumihiko Fujita

MD,Mitsuhisa Takatsuki MD,Susumu Eguchi MD,Hirotaka Tokai MD,Yuichiro Ito MD,Noritsugu Tsuneoka MD,Tamotsu Kuroki MD,Yoshitsugu Tajima MD,Takashi Kanematsu MD, Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences

**Introduction:** Unlike laparoscopic cholecystectomy, laparoscopic hepatectomy has not been widely accepted because of its technical difficulties sometimes caused by intraoperative bleeding or poor visualization. To overwhelm these intraoperative troubles, we need to contrive some method to create a good view during the operation.

**Objective:** We propose our normal technique, one hand liver hanging method (OHLH), which can create a good visualization on a transection plane of the liver parenchyma during laparoscopic hepatectomy.

**Patients:** From January 1996 to June 2005, there were 10 laparoscopic hepatectomies for treatment of primary and metastatic neoplasm of liver carried out at our large community of teaching hospital. Eight out of the 10 patients had tumors located in left lateral segment, while the others had in lower segment of the right lobe.

**Operative methods and results:** Laparoscopic left lateral segmentectomy using OHLH was carried out in 4 patients. We usually use 4 or 5 trocars inserted into the insufflated abdominal cavity. In the beginning, the location of tumors is confirmed by laparoscopic ultrasonography, and the transecting line is decided and previously marked on the surface of the liver. After dividing the falciform ligament, a small hole is made on the coronary ligament that is located on the extended transecting line. A tape that one side was fixed on the abdominal wall is passed through the divided coronary ligament and positioned behind the posterior surface of the lateral segment. The hepatic parenchymal dissection begins with pulling up the other end of the tape by one hand. This technique plays an important role in lifting the liver to be resected. None of the patients required blood transfusion during or after the operation. The operative margin was negative in all patients and there was no operative mortality and morbidity.

**Conclusion:** Our OHLH method, using a tape which lifts the liver to be resected, provided better exposure, resulting in easy control of bleeding of the transaction surface at the deep parenchyma of the liver. OHLH is a useful and effective technique in laparoscopic left lateral segmentectomy.

# Hepatobiliary/Pancreatic Surgery - P410

## THE PRESENT SITUATION OF LAPAROSCOPIC SURGERY FOR PANCREATIC DISEASE IN OUR INSTITUTION, SHOJI FUKUYAMA MD,KAZUHIKO SHIBUYA MD,MAKOTO SATO MD,SHIN-ICHI EGAWA MD,MICHIAKI UNNO MD, TOHOKU UNIVERSITY GRADUATE SCHOOL OF MEDICINE

**[Background]** Recently, indications of laparoscopic surgery have been spreading for various kinds of diseases. However, the number of laparoscopic surgery for pancreatic disease is still remarkably low compared to other abdominal diseases. The reason is considered that anatomy of the pancreas is rather complicated and highly trained surgeons are required to perform these operations because of the technical difficulties. We report summary of 17 cases of laparoscopic surgery for pancreatic disease that we experienced.

**[Patient]** From May 1998 to May 2006, a total of 17 patients underwent laparoscopic surgery for pancreatic disease at Tohoku University Hospital. Information regarding patient characteristics, preoperative workup, operative technique, complications, specimen features and clinical follow-up was collected and analyzed.

**[Result]** Of the 17 patients, 7 underwent enucleation, 4 underwent distal pancreatectomy (DP), 2 underwent cyst-gastrostomy (CG) and 4 underwent cystjejunostomy (CJ). The mean operation time was 339 minutes for enucleation, 322 minutes for DP, 322 minutes for CG and 203 minutes for CJ. Complications were 4 pancreatic fistulae and 1 postoper-

ative hemorrhage. Mean hospital stay was 27 days for enucleation, 19 days for DP and 19 days for CG and CJ.

**[Conclusion]** The operation time with complicated procedure tends to be longer, but regarding hospital stay, there is no difference among these operations. We will continue to perform laparoscopic surgery for pancreatic disease in order to collect the data and to confirm the safety and validity of these operations.

# Hepatobiliary/Pancreatic Surgery - P411

## LAPAROSCOPIC DISTAL PANCREATECTOMY, K FURUTA

PhD,K TABASHI PhD,H KATGIRI PhD,K ISHII PhD,H TAKAHASHI PhD,M WATANABE PhD, Department of Surgery, KITASATO UNIVERSITY

**INTRODUCTION:** A laparoscopic approach to pancreatic disease is increasingly performed although its ultimate benefit is yet to be confirmed. Laparoscopic distal pancreatectomy with or without splenectomy is gradually gaining acceptance as an alternative to open resection in selected patients. The aim of this study is to report our initial institution experience with laparoscopic distal pancreatectomy in 13 patients.

**METHODS:** A retrospective review of database was carried out. From July.2004- September.2006,We performed 13 distal pancreatectomies by the laparoscopic approach. These 13 patients were included in the study with varyingly preoperative diagnosis such as neuroendocrine tumors (4 patients), cystic lesions (5 patients), IPMT (3 patients), pancreatic cancer suspected tumor (1 patient). The median age was 63 years (33-74) with a female to male ratio of 5:8. In addition to 3 port, a hand port was placed in the midline to aid in dissection and the pancreas was divided with a endoscopic linear stapler.

**RESULTS:** Of the 13 patients, two were converted to an open procedure due to an uncertain adhesion and inadequate exposure.

The median operating time was 205 minutes (150-280) with a tumor size of 5cm (0.5-8).

The median time to resuming regular diet and converting to oral pain medications was 2.5 days and 4 days respectively. The length of stay was 10 days (5-15).These were no mortalities. Of the 9 patients that successfully underwent the procedure laparoscopically, and these were no morbidities. With a median follow up of 13.0 months (1-20), 5 patients with a diagnosis of malignancy have no evidence of recurrent disease.

**CONCLUSIONS:** A minimally invasive approach to pancreatic disease is safe and technically feasible with acceptable morbidity. Further large series studies with longer follow up are necessary to determine the role of laparoscopic surgery in the treatment algorithm of management of pancreatic disease.

And endoscopic linear staplers were feasible and safty for pancreatic resection.

# Hepatobiliary/Pancreatic Surgery - P412

## IATROGENIC COMPLICATIONS DURING LAPAROSCOPIC CHOLECISTECTOMY AND SIMULTANEOUS ERCP: THE SAFETY OF THE RENDEZ-VOUS PROCEDURE IN 74 CONSECUTIVE CASES, La Greca Gaetano PhD,Di Blasi Michele MD,Barbagallo Francesco MD,Sofia Maria MD,Gagliardo Salvina MD,Latteri Saverio MD,Lombardo Rosario MD,Russello Domenico MD, Department of Surgical Sciences, Transplantation and Advanced Technologies, University of Catania, Cannizzaro Hospital,Via Messina 829, Catania 95126. Italy

**Background:** The management of patients affected by gallstones and common bile duct stones is still a challenge as there are different successful available options. An alternative to both sequential approach or totally laparoscopic treatments consists of the simultaneous laparo-endoscopic "Rendez-Vous" (RV) procedure which combines laparoscopic cholecystectomy, intra-operative cholangiography and endoscopic common bile duct clearance.

**Method:** The authors report their experience with the "Rendez-vous" in a group of 74 consecutive patients. The
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SAGES POSTER ABSTRACTS

relevant technical features and the results concerning the effectiveness and the incidence of complications are analyzed especially concerning the incidence of post-procedural pancreatic damage directly related to intraoperative ERCP, ES and CBD clearance monitoring postoperatively amylase and lipase levels.

**Results:** The RV procedure was feasible in 72 patients (97,2%). The effectiveness of the procedure was 100% concerning the clearance of CBD. Minor morbidity affected 2,7% of the patients. The mean duration of the intra-operative endoscopic procedures was 16 minutes. Only one case of minor intra-operative complication occurred. 7 patients (9,4%) had increase of amylase levels after the RV but only (5,4%) had a pathologic increase. The main cause of pathologic increase of amylase levels was the retrograde transapillary injection of the contrast medium. The mean postoperative hospital stay was 3.3 days. All the patients were symptoms free up to last 6 month's follow-up. Only in one patient (1,6%) an asymptomatic recurrence of a common bile duct stone was diagnosed

**Conclusions:** This collaboration between endoscopist and surgeons for the simultaneous laparo-endoscopic RV approach is related to a very high effectiveness that seems to be better than those reported in the literature for the other available treatment's options. This high effectiveness and the related low morbidity and the data form the literature suggests that the procedure is also extremely safe and therefore. The main factor of iatrogenic pancreatic damage evidenced as hyperamylasemia is strictly and significantly related to retrograde injection of the contrast medium that should anyway avoided. If the mandatory collaboration between surgeons and endoscopists is guaranteed, it can be an usefull option for the patient, the surgeon, the endoscopist and the hospital.

## Hepatobiliary/Pancreatic Surgery - P413

LAPAROSCOPIC CHOLECYSTECTOMY FOR SYMPTOMATIC BILIARY HYPERKINESIA, Reza A Gamagami MD, Silver Cross Hospital, Joliet, IL

**Background:** This study aimed to evaluate the pathologic and clinical outcome of patients with symptomatic biliary hyperkinesia, defined as the presence of classic biliary colic symptoms, without evidence of cholelithiasis with CCK-HIDA>75% following laparoscopic cholecystectomy.

**Methods:** Retrospective review of 1024 patients who underwent cholecystectomy by a single surgeon between 2000-2006, identified 20 patients with CCK-HIDA>75%. Follow up for symptom improvement was assessed by telephone interview. Pathology specimens were reviewed.

**Results:** Follow up was achieved in all patients. Mean follow up was 16 months with a range of 1 month to 33 months. 17 patients (85%) were improved or cured. In 2 of 3 patients who failed to improve, no reproduction of symptoms occurred at the time of CCK-HIDA, and histopathology revealed normal gallbladder findings. Pathology demonstrated chronic cholecystitis in 17 (85%), cholelithiasis in 1 (5%) and normal finding in 3 (15%).

**Conclusion:** Patients presenting with classic biliary colic in presence of normal gallbladder ultrasound with CCK-HIDA>75% with reproduction of symptoms should be considered for laparoscopic cholecystectomy. Improvement and cure can be achieved in at least 85% of patients.

## Hepatobiliary/Pancreatic Surgery - P414

LAPAROSCOPIC CHOLECYSTECTOMY USING HARMONIC: NOT ONLY CLIPLESS, Roberta Gelmini MD, Alessia Andreotti MD, Chiara Franzoni MD, Nicola Quaranta MD, Massimo Saviano MD, Dept. of Surgery - University of Modena and Reggio Emilia - Italy

**Background:** Laparoscopic cholecystectomy is the gold standard treatment of gallstones. The ultrasonically activated scalpel (Harmonic Scalpel - Ethicon) may be used as sole instrument for both gallbladder dissection and section of cystic artery and duct with no need of further ligatures.

**Methods:** In a series of 30 consecutive patients, laparoscopic cholecystectomy was performed with Harmonic as sole instrument for dissection and section of cystic artery and

duct. In 4 patients an additional cystic duct ligature with clips was performed because of the large size of the duct (3 cases of associated common bile duct stones and 1 of gallbladder empyema). There were 20 females and 10 males and we have employed a four trocars technique. Indications were as follows: 17 simple gallstones, 3 common bile duct stones, 8 acute cholecystitis and 2 gallbladder empyema. In 8 cases associated procedures were performed.

**Results:** The mean operative time was of 72 minutes, intraoperative cholangiography was performed in 4 cases and common bile duct exploration in 3. A drainage was left in 16 patients. There were no conversions. No patients developed postoperative complications and the mean postoperative hospital stay was of 2,1 days.

**Conclusions:** Laparoscopic cholecistectomy performed with ultrasonically activated scalpel is feasible and effective. The advantages are represented by using a unique instrument both for dissection of the gallbladder form the hepatic bed and division of artery and duct. Furthermore, because of the minimal thermal dispersion, the use of Harmonic reduces the risk of injuries. The main limit of the procedure is represented by the cystic duct size: if more than 5 mm in diameter an additional ligature is necessary.

## Hepatobiliary/Pancreatic Surgery - P415

LAPAROSCOPIC CHOLECYSTECTOMY (LC) FOR THE PATIENTS WITH ACUTE BILIARY PANCREATITIS, Ke Gong MD, Wenyue Zhang, Beijing Shijitan Hospital

**Background:** The treatment of acute biliary pancreatitis is still a subject of debate. Objective: The aim of this study was to evaluate the feasibility and the right time of LC for treatment of the patients with acute biliary pancreatitis.

**Methods:** A retrospective analysis of 21 patients with acute biliary pancreatitis who underwent LC between January 1999 and August 2003 was performed. Data collection included pre-operative, intra-operative and post-operative.

**Results:** Among the total 21 patients, 12 males and 9 females underwent LC surgery. They had a mean age of 61 years (range 28°C76). All patients had a gallstone history. 12 patients were first acute biliary pancreatitis attack and the others were second or more third attack. All patients had abdominal pain, nausea, vomit, fever and 9 patients with jaundice. The serum and uric amylase of 21 patients were increased respectively 603.3 (+/-°C) 451.34(IU/L)(Normal 80°C220 IU/L), 1933.4 (+/-°C) 145.8(IU/L) (Normal 100°C1000 IU/L). The serum ALT of 18 patients were 111.1 (+/-°C) 37.2(IU/L)(Normal 45 IU/L) i£The serum AST of 15 patients were 77.7 (+/-°C) 14.5(IU/L) (Normal 35 IU/L) i£The serum TBIL of 11 patients were 41.7 (+/-°C) 9.5 (u mol/L) (Normal 17 u mol/L), the serum DBIL of these patients were 25.3 (+/-°C) 5.8 (u mol/L) (Normal 11 u mol/L) i£Ultrasound or CT scan showed gallstone in all patients and pancreatic swell in 18 patients when all patients had an acute biliary pancreatitis attack. 21 cases underwent LC successfully and 11 cases were put the abdominal drainage after the patients had acute biliary pancreatitis 20 °C 40 day. The mean operative time was 70min (45min °C 120min). The amount of intraoperative bleeding was 60ml (30ml°C 200ml). 19 cases recovered without any complication. Two cases had acute biliary pancreatitis again after LC and were cured by medicine soon. The mean overall period of hospitalization was 7 days.

**Conclusions:** LC is feasible and safe for the patients with acute biliary pancreatitis. The right operative time is between 20 to 40 day following an attack of acute biliary pancreatitis, the serum amylase, ALT, AST and TBIL level are approximately normal and no common bile duct stone has been showed by ultrasound or CT scan.

## Hepatobiliary/Pancreatic Surgery - P416

LAPAROSCOPIC LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA, Ho-Seong Han, Yoo-Seok Yoon, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

**Aim:** The aim of this study is to evaluate the role of laparoscopic liver resection in the treatment of HCC by reviewing our experiences of laparoscopic resection for HCC.
**Methods:** We retrospectively analyzed the clinical outcomes of 21 patients who had undergone laparoscopic liver resection for HCC among 70 cases of laparoscopic liver resection between May 2003 and February 2006.

**Results:** The patients were composed of 19 men and 2 women, with a mean age of 59.3 years. Operation procedure included 13 cases of tumorectomy, 3 cases of left lateral sectionectomy, 2 cases of left hepatectomy, 3 cases of right posterior sectionectomy, and 1 cases of right hepatectomy. Mean size of tumors was 2.9 cm, and mean distance of safety margin was 1.3 cm. Intraoperative transfusion was needed in 6 patients (28.6%) with a mean amount of 1.3 units. Mean postoperative hospital stay was 11.9 days. Postoperative complications developed in 6 cases (28.6%), all of which was improved by conservative management. However, there was no postoperative mortality. Recurrence was detected in 5 cases (19.0%) after a mean period of 13.5 months from operation, of which 3 cases had multiple recurrences.

**Conclusion:** Our experiences confirmed that laparoscopic resection for HCC was an effective and safe treatment. Therefore laparoscopic liver resection, although its long term results are necessary, is expected to be a useful treatment modality for HCC in terms that it is less invasive than open liver resection and offers complete removal of the lesion compared to non-operative managements.

## Hepatobiliary/Pancreatic Surgery - P417

LAPAROSCOPIC ROUX-EN-Y CHOLEDCHOJEUNOSTOMY IN BENIGN BILIARY DISEASE, Ho-Seong Han MD, Yoo-Seok Yoon MD, Kwang-Sik Chun MD, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

**Aim:** Laparoscopic bilio-enteric bypass has been mainly performed as cholecystojejunostomy or choledochoduodenotomy. However, due to technical difficulties, few reports on laparoscopic Roux-en-Y choledochojejunostomy (LRYCJ) have been documented. Herein we present our experiences for LRYCJ for benign biliary disease.

**Methods:** We retrospectively analyzed the clinical outcome of 19 patients with benign biliary disease who had undergone LRYCJ in Seoul National University Bundang Hospital and Ewha Womans University Mokdong Hospital from February 1997 to June 2006. Except two laparoscopic assisted cases, all procedures were performed with totally laparoscopic methods.

**Results:** Indications were choledochal cyst in eleven patients, recurrent CBD stone in six and benign CBD stricture in two. The patients comprised nine men and ten women, with a mean age of 45 years. Mean operation time was 328.4 minutes. In one patient with type IVa cholecochal cyst, laparoscopic left hemihepatectomy was done simultaneously. Postoperative complications occurred in 3 cases, including aspiration pneumonia, bile leakage and intraabdominal bleeding. Mean hospital stay was 10.8 days. After a mean follow-up duration of 27.5 months, three patients developed the anastomotic stricture, which were managed by radiologic intervention in two patients and revision of anastomosis in one patient.

**Conclusion:** Our experiences indicate that LRYCJ can be a feasible option in the treatment of the benign biliary disease, but more accumulation of data may be needed for evaluation of long-term outcome.

## Hepatobiliary/Pancreatic Surgery - P418

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH AN ATTEMPT TO PRESERVE SPLEEN AND ITS VESSELS, Ho-Seong Han MD, Yoo-Seok Yoon MD, Kwang-Sik Chun MD, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

**Aims:** Although an increasing number of reports on laparoscopic distal pancreatectomy for benign and borderline malignancy in the pancreas have recently been documented, it has not achieved worldwide acceptance yet. The aim of this study is to analyze our experiences of laparoscopic distal pancreatectomy and evaluate its usefulness.

**Methods:** Twenty-four patients underwent laparoscopic dis-

tal pancreatectomy from May 2000 to June 2006 by one surgeon team in Seoul national University Bundang Hospital and Ewha Womans University Mokdong Hospital. The preservation of splenic vessels and spleen was tried unless the tumor was very close to splenic vessels or malignancy was suspected in preoperative radiologic studies. We retrospectively analyzed of the clinical outcome of these 24 patients.

**Results:** There were eight men and sixteen women, with a mean age of 46.3 years. Indications were eighteen cystic neoplasm, two pseudocyst, two islet cell tumor, one lymphoepithelial cyst and one traumatic laceration. There was no conversion to open surgery. Splenic vessels and spleen were successfully preserved in twenty cases (83.3%). The mean operation time was 265.8 minutes and transfusion was not necessary. Mean size of the lesion was 4.4cm. Postoperative complications occurred in 5 cases (20.8%), including 3 intraabdominal fluid collections, 1 pancreatic fistula and 1 pleural effusion, which were improved by conservative management. The mean hospital stay was 10.9 days.

**Conclusion:** Our experiences show that laparoscopic distal pancreatectomy is a relatively safe and useful option in the treatment of the benign or borderline malignant pancreatic disease.

## Hepatobiliary/Pancreatic Surgery - P419

AN ALTERNATIVE RECONSTRUCTION AFTER PANCREATICODUODENECTOMY, Michael G Wayne DO, Irving A Jorge MD, Cabrini Medical Center

Pancreaticoduodenectomy is the procedure of choice for tumors of the head of the pancreas and periampullary tumors. Despite advances in both surgical technique and postoperative care, the procedure continues to carry a high morbidity rate. One of the most common morbidities is delayed gastric emptying (DGE) with rates of 15-40%. We decided to alter our reconstruction, due to 2 cases of prolonged DGE attempting to avoid this complication. All patients underwent a classic pancreaticoduodenectomy with an undivided roux-en-y technique used for reconstruction.

**Methods:** We reviewed the charts of our last 13 Whipple procedures and evaluated them for complications, looking specifically for DGE. We compared this to our control group of 15 Whipple's performed with the standard reconstruction.

**Results:** There were no cases of delayed gastric emptying (0%). There was 1 wound infection (8%), 1 case of pneumonia (8%), and 1 case of bleeding from the gastrojejunal stable line (8%). The operative mortality was 0%.

**Conclusions:** Use of the undivided roux-en-y technique for reconstruction after Whipple procedure may decrease the incidence of DGE. It also has the added benefit of eliminating bile reflux gastritis.

<figure><img src="image_164.png" /></figure>

## Hepatobiliary/Pancreatic Surgery - P420

PREOPERATIVE EVALUATION OF THE CALOT TRIANGLE ANATOMY WITH THE 3-DIMENSIONAL CT IMAGE OF CHOLANGIOGRAM AND ANGIOGRAM COMPLEX (3D-DIC-CT-A) FOR THE SAFE LAPAROSCOPIC CHOLECYSTECTOMY, Minoru Kakihara MD, Eiichi Sugasawa MD, Yoshiki Kajiwara MD, Yoshitaka Kiyota MD, Toshimichi Takigawa MD, Taichi Satou MD, Kiyoshi Nishiyama MD, Hideki Asakawa MD, Kazuo Hatsuse MD, Hidetaka Mochizuki MD, Department of Surgery, National Defense Medical College, Japan.

**Introduction:** Laparoscopic cholecystectomy is less invasive procedure than open cholecystectomy. But there still remain some complications such as injury to arteries and biliary
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SAGES POSTER ABSTRACTS

systems. Especially, in cases with chronic fibrous inflamma-
tion, safe dissection and clear exposure at the Calot triangle
is difficult, although it is essential for cholecystectomy. For
the sake, we have been trying to figure out clear 3 dimen-
sional (3D) images of the Calot triangle by 3D-DIC-CT-A pre-
operatively.

**Materials and Methods:** For three months from June to August in 2006, we have succeeded to construct 3D images in 9 cases (5 cases without inflammation, 4 cases with chronic cholecystitis). Just after the drip infusion cholangiography (DIC), patients are transferred to the CT room. 3D-DIC-CT-A had been taken as follows; The applied CT system is AquilionTM 64 multislice CT (Toshiba Medical systems, 64-row Quantum detector). The software to make images is ZIOSTATION (ZIOSOFT, INC.).

The scan protocol is as follows; Pipe voltage is 120 KV and electric current is 400 mA. Turn speed of a signal bridge is 1 round per minute by 0.5 seconds, and photography condition is 64 lines of collection in 0.5 mm slice. For reconstruction, the image slice thickness is 0.5mm with reconfiguration space of 0.3mm, and quantum denoising filter is Toshiba original which reconfiguration function (factor) is 11. Contrasting procedure is as follows; as a vasodilatation agent, 2ml of alprostadil (Palux inj.) is injected and contrasting is started 30 second later. A hundred ml of lomeprol (lomeron350) is injected 4ml/second as the contrast media, and 30ml of omophagia water is injected afterwards. ROI (region of interest) is set in the celiac artery and start photography 8 seconds after CT value reaches 120 HU.

**Results:** Cystic arteries and biliary systems at the Calot triangle were clearly identified in both groups in 3D images, and they were safely devided and clipped without any injuries even in the group with chronic inflammation.

**Conclusions:** Preoperative evaluation of arteries and biliary systems at the Calot triangle by 3D-DIC-CT-A is effective especially in cases with complicated chronic fibrous change.

Hepatobiliary/Pancreatic Surgery - P421

URGENT CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS? SHOULD THIS BE PERFORMED BY SPECIALIST CENTRES ONLY?, Jim Khan, Ian Nordon, Saboor Ghauri
MD,Charles Ranaboldo MD,Nicholas Carty MD, Salisbury
District Hospital, Salisbury, UK

**Introduction:** Laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gall stone disease. However it place remains controversial in the management of acute cholecystitis due to a high reported incidence of bile leaks and conversion rate. Tertiary referral centres have reported good results. We present a series of cases after the introduction of an urgent cholecystectomy pathway in a district general hospital.

**Methods:** A practice of urgent cholecystectomy for acute cholecystitis was introduced by three consultant general surgeons. All prospective patients having an urgent laparoscopic cholecystectomy for acute cholecystitis, over a twelve month period were entered into a database. A dedicated ultrasound service was instituted to provide prompt diagnosis in these patients. Their demographic details, operative findings, laboratory results were recorded. Timing of ERCP, post operative complications and conversion rate and hospital stay were also noted.

**Results:** There were 64 patients in the study with a median age of 51 years (range 21-84). There were 27 males and 37 females. 03 patients had obstructive jaundice on admission. 11 patients had a pre op ERCP and 03 patients had on-table cholangiogram. There were no conversions. Post op ERCP was required in 06 patients. The median time interval between admission and operation was 3.5 days (range 2-7). There were 03 bile leaks but no CBD injury. There were no wound infections. One patient required re-operation for small bowel obstruction secondary to a port site hernia.

**Conclusion:** Urgent Laparoscopic Cholecystectomy for acute cholecystitis is a feasible treatment option in a DGH. A safe practice can be ensured by adherence to a care pathway and a multidisciplinary consultant delivered service. Urgent cholecystectomy service can be provided safely in a DGH with outcomes comparable to previosly published literature.

Hepatobiliary/Pancreatic Surgery - P422

LAPAROSCOPIC SPLEEN-PRESERVING DISTAL PANCREATE-
CTOMY FOR MUCINOUS CYSTIC NEOPLASM, Kee-Hwan
Kim MD,Sang-Kwon Lee MD,Ji-Il Kim MD,Chang-Hyoek An
MD,Jeong-Soo Kim MD,Keun-Woo Lim MD,Eung-Kook Kim
MD, Department of Surgery, Uijeongbu St. Mary's Hospital,
College of Medicine, The Catholic University of Korea,
Korea.

**BACKGROUND:** After splenectomy, many complications may occur. For example, there are changes in the peripheral blood count, infection, sepsis and even death. Therefore, many surgeons are attempting preservation of spleen in the lesion of distal pancreas during operation. Here, we described one case of a laparoscopic spleen-preserving distal pancreatectomy for mucinous cystic neoplasm. With increased familiarity with the laparoscopic anatomy of the pancreas and advances in minimally invasive techniques, surgeons have ventured further to operate on technically difficult cases such as pancreas cystic tumor that were until recently managed by laparotomy.

**PATIENTS AND METHODS:** We present our experience with one woman aged 34 years with cystic mass in the tail of the pancreas (about 4x4 cm) that was performed spleen-preserving laparoscopic distal pancreatectomy that preserved splenic vessels and hence splenic function.

**RESULTS:** The pathology was reported that the pancreatic mass was mucinous cystic neoplasm and the patient had an uneventful recovery, with no major morbidity. She was discharged by the 9th postoperative day.

**CONCLUSION:** Laparoscopic resection of pancreatic cystic neoplasm in adult patient is feasible. We feel that there is a considerable learning curve with the technique. Although long-term data are lack, we report that laparoscopic spleen-preserving distal pancreatectomy for mucinous cystic neoplasm may prevent complications of splenectomy and is safe and less invasive.

Hepatobiliary/Pancreatic Surgery - P423

LAPAROSCOPIC CHOLECYSTECTOMY BY COMBINED
METHOD, Fumito Kuranishi PhD,Yoshinori Kuroda
PhD,Toshio Noriyuki PhD,Masahiro Nakahara
PhD,Toshikatsu Fukuda PhD,Yasuyo Ishizaki PhD,Yasuo
Kawaguchi MD,Ryuichi Hotta MD,Etsushi Akimoto, MD,
ONOMICHI GENARAL HOSPITAL

**INTRODUCTION** We have introduced laparoscopic cholecys-
tectomy(LC) from 1992,and performed it about 900 cases. At
the beginning, we have adopted pneumoperitoneum(8
mmHg,8 liter/min), we have started combined method(peu-
moperitoneum : 4 mmHg,4 liter/min and abdominal wall lift-
ing method) from 1993. Combined method -@enables to
perform LC by low pressure. From the standpoint of body
temperature(BT) we report the effect of combined method.

**METHOD & OBJECT** LC was underwent in 879 patients from 1992 to 2005. We reviewed retrospectively these patients. We exclude 28 cases underwent combined operation(mastectomy etc.), 52 cases( open conversion), 18 cases (complication).We couldn?ft confirm the BT of 22 cases,so we also exclude them. BT change between pre and post operation was confirmed from the record of anesthesia.We devided them into three groups, BT increasing group A , BT no change group B and BT decreasing group C.

**RESULT** Between three groups(A,B &C) there was no signifi-
cant difference about first walking, first flatus, intestinal
murmur, first stool, laboratory data(WBC,CRP), pain killer
usage, post operative hospital stay and oral intake. However
in the Group C the degree of BT decrease showed signifi-
cant difference between pneumoperitoneum(0.56?)0.33 ??)
and combined method(0.44?)0.29 ??)(P<0.01).

**CONCLUSION** Physiologically speaking post operative high BT may be better. No remarkable effect of post operative BT change was seen. This study suggest that from the stand point of BT change, combined method is useful to lower the stress of long time operation, not only LC but also another laparoscopic surgery.
## Hepatobiliary/Pancreatic Surgery - P424

### ENDOSCOPIC ULTRASOUND EVALUATION OF PERI-AMPULLARY NEOPLASMS PREDICTS RESECTIONABILITY,

Margaret Lauerman BS, Mary DiGiorgi MPH, Aliye Bill BA, Stavros Stavropoulos MD, Peter Stevens MD, Beth Schrope MD, John Chabot MD, John Allendorf MD, Department of Surgery, Columbia University College of Physicians and Surgeons

**Introduction:** Endoscopic ultrasound (EUS) is frequently used preoperatively to evaluate the relationship of peri-ampullary malignancies to the mesenteric vessels and portal vein prior to surgical resection, and this study was conducted to evaluate the currently unclear role of EUS in a surgically eligible population. Our institution offers concomitant vascular resection during pancreatectomy, enabling us to compare EUS to intraoperative findings with respect to vascular invasion.

**Methods and Procedures:** Operative reports, EUS reports, and hospital records of all patients undergoing attempted resection of periampullary neoplasms at our institution over a three year period were reviewed, with vascular invasion status assessed both radiologically and intraoperatively. Patients that did not undergo surgical exploration were excluded. Fifty-seven patients were identified as eligible.

**Results:** The positive predictive value, negative predictive value, sensitivity, specificity, and accuracy were 55%, 83%, 43%, 88% and 77%, respectively for predicting vascular involvement, and 40%, 88%, 44%, 86% and 79%, respectively for determining the need for vascular resection.

**Conclusions:** EUS is an excellent pre-operative evaluation for excluding vascular invasion and identifying a majority of patients who do not necessitate vascular resection. This information facilitates preoperative planning and patient counseling at centers that offer concomitant vascular resection with pancreatectomy. Furthermore, EUS findings, in isolation, are inadequate to declare patients with periampullary lesions unresectable.

## Hepatobiliary/Pancreatic Surgery - P425

### SAFETY AND OUTCOMES OF 2 MM LAPAROSCOPIC CHOLECYSTECTOMY IN 837 CASES; THE NEXT EVOLUTION IN LAPAROSCOPIC CHOLECYSTECTOMY,

John Macoviak MD, Faris Al-Gebyor MD, Marc D Silverstein MD, Garth Davis MD, Robert Davis MD, Patrick R Reardon MD, The Methodist Hospital, Department of Surgery, Department of Public Health

**Introduction:** Cholecystectomy has advanced from primarily an open procedure to one that is primarily performed laparoscopically. The next step in the evolution of this procedure is diminishing the number and size of ports used. Just as with the last evolution, this one must occur without increased risks to the patient. This study of laparoscopic cholecystectomy (LC) compares operative time, length of stay, complications, conversions from two 2mm ports to adding a third 2 mm port, and conversion of 2 mm ports to larger ports.

**Methods:** This single surgeon cohort study includes consecutive LC's using 5 and 10 mm ports (Group I, 8/15/1990-6/30/1996) compared to consecutive LC's using 2 mm instrument ports (Group II, 7/1/1996-8/17/06). In both groups a 10 mm peri-umbilical camera port was used. Patient demographics, clinical characteristics and outcomes were collected prospectively and supplemented by medical record review for missing data.

**Results:** There were 279 patients in Group I and 837 patients in Group II. Group I patients were older (age 56 ± 18 vs. 53 ± 18, P = 0.008), less likely to be obese (BMI 26.9 ± 5.5 vs. 29.2 ± 13.3, P=0.01), less likely to have gallstone pancreatitis (1.8% vs. 5.3%, P= 0.01), less likely to have common bile duct stones (0% vs. 2.5%, P=0.008) and had longer pre-operative length of stay (1.8 ± 5.3 vs. 1.0 ± 3. days, P=0.002) than group II patients. The two groups were not significantly different by gender (58% vs. 62% female, P=0.21), presence of cirrhosis (0.4% vs. 1.8%, P =0.08) or perforation of a gan-grenous gallbladder (0% vs. 0.4%, P=0.25). There were 2 conversions to open cholecystectomy in group I (0.7% vs

0%, P=0.06). In 802 Group II patients with available port size data 262 (32.7%) were started and finished with two 2 mm ports, 336 (41.9%) required a third 2mm port, and a 5mm port was added or replaced a 2 mm port in 204 (25.4%). Operative time was not different (Group I 72 ± 61 minutes vs. 67 ± 44 minutes, P=0.14). Post-op length of stay was shorter in Group II (Group I 2.5 ± 3.5 days vs. 1.1 ± 3.2 days, P< 0.01). There was no difference in procedure-related complications (Group I 3.1 % vs. 3.2 %, P=0.92). Non-procedure-related major complications were less frequent in Group II (0.8% vs. 2.5%, P=0.03). There were 2 deaths in Group I and none in Group II (0.7% vs. 0%, P=0.06).

**Conclusions:** LC with 2 mm instrument ports is safe and effective compared to LC using 2 or 3 larger (5 mm and 10 mm) instrument ports.

## Hepatobiliary/Pancreatic Surgery - P426

### LAPAROSCOPIC ROUX-EN-Y CYSTOJEUNOSTOMY USING A CIRCULAR STAPLER - A NOVEL TECHNIQUE,

Jerad P Miller MD, Brent C Ziegler MD, Michael S Bauer MD, Phillip D Price MD, Mount Carmel Medical Center

**Background:** Pancreatic pseudocysts are seen in up to 10% of patients after an episode of acute pancreatitis. Surgical management is the mainstay of treatment for pancreatic pseudocysts. Minimally invasive surgical management ranges from endoscopic therapy to laparoscopic drainage.

**Methods:** 49 year old male with a 12.2 x 20 cm pancreatic pseudocyst underwent Roux-en-Y cystojejunostomy utilizing a 22 mm circular stapled anastomosis.

<figure><img src="image_166.png" /></figure>

**Results:** The pseudocyst was successfully drained laparoscopically. There was one minor (UTI) postoperative complication. The patient was discharged home on POD 5. Repeat CT scan 4 months postoperatively showed complete resolution of the pancreatic pseudocyst.

**Conclusions:** Laparoscopic Roux-en-Y cystojejunostomy using a circular stapling device is a safe alternative for minimally invasive surgical management of pancreatic pseudocysts.

## Hepatobiliary/Pancreatic Surgery - P427

### LEAKS FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY,

Peter Ojo MD, Steve Yood MD, Department of surgery, Hospital of Saint Raphael, New Haven, CT

**INTRODUCTION/OBJECTIVES:** Laparoscopic cholecystectomy is the most common surgical procedures performed in the US. Bile leaks remain a significant cause of morbidity for patients undergoing this procedure. The aim of this study is to determine the incidence and sites of leaks after laparoscopic cholecystectomy

**METHOD:** Retrospective review of all laparoscopic cholecystectomy performed at our institution from January 2000 to August 2006.

**RESULTS:** Laparoscopic cholecystectomy was performed in 2936 patients with a leak rate of 0.5% (15 leaks /2936). The male to female ratio was 1:2. Most leaks occurred from the cystic duct stump (53%). Other sites of leaks were duct of Luschka (33%) while 13% were unspecified. Patients with leaks from duct of Luschka presented within the first 4 days after surgery while those with leaks from the cystic stump tend to present after the fourth post operative day. Patients with leaks and significant collection were discharged earlier when drained surgically than by CT guidance.

**CONCLUSION:** With increasing laparoscopic experience, leaks after laparoscopic cholecystectomy occur more from
<figure><img src="image_167.png" /></figure>

# SAGES POSTER ABSTRACTS

the cystic duct and duct of Luscka than from the CBD injury. Operative drainage of significant bile collection may be associated with shorter hospital stay than CT guided drainage

## Hepatobiliary/Pancreatic Surgery - P428

**LAPAROSCOPIC CBD EXPLORATION WITHOUT T-TUBE, I.S. Choi PhD, C.H. Park MD, Y.M. Ra MD, D.K. Go MD, D.S. Yoon MD, W.J. Choi MD, Department of Surgery, Konyang University Hospital**

**Purpose:** Many modalities of common bile duct stones (CBDS) management evolved greatly for the past three decades. Among these techniques, Laparoscopic common bile duct exploration (LCBDE) is feasible and is becoming popular. LCBDE has traditionally been accompanied by T-tube drainage which has a 4.7-17.5% morbidity rate and increases hospital stay. Avoidance of T-tube drainage therefore should advantageously contribute to the ideal approach for LCBDE. Herein we are reporting the clinical outcomes in 57 patients who had undergone LCBDE without T-tube placement.

**Methods:** Patients with dilated ductal systems exceeding 10mm in diameter or with CBD stones larger than 10mm in diameter or patients who had failed treatment by EST were the indications for LCBDE in this study. Between March 2001 and August 2006, 57 patients with CBDS underwent this approach. The age ranges from 57 to 87 years with an average of 71 years in 23 males and 34 females. One via a trans-scystic and the other 56 patients via a transductal (via choledochotomy) approach was undertaken. In choledochotomy group, we adopted internal endobiliary stents in 18 patients and performed primary closure for choledochotomy. The other 38 patients who had external drainage such as, endoscopic nasobiliary drainage (ENBD), percutaneous transhepatic biliary drainage (PTBD), were treated by LCBDE with primary closure. Each patient selected by the criteria above underwent LCBDE without T-tube drainage and their clinical outcomes, operating time, the duration before diet start, hospital days and complications were analyzed.

**Results:** Because of impacted large CBDS and biliary stricture, there were 4 cases (7.0%) of open conversion. The mean operating time was 135 minutes (65~290 min.). The mean time to diet and hospital stay were 1.9 and 8.1 days. The rate of successful stone removal was 97.8%. The complication rate was 8.7% and there were no mortalities. In all, there was 5 complications included two pleural effusions, one subhepatic seroma, one retained stone and one bile leakage.

**Conclusion:** LCBDE without T-tube is a safe and feasible technique. Further study and assessment of internal endobiliary stents should be warranted.

## Hepatobiliary/Pancreatic Surgery - P429

**LAPAROSCOPIC CBD EXPLORATION WITH A LITTLE HELP FROM UROLOGISTS, Sonali P Rao MS, Prashanth P Rao MS, P P Rao, Mamata Hospital And Research Centre, Mumbai, India**

**Introduction:** Single-stage laparoscopic treatment for patients with cholelithiasis and choledocholithiasis has gained wide acceptance because of the advantages offered in terms of improved patient comfort, reduced hospital stay and lower costs. Primary closure of the CBD over a biliary endoprosthesis further adds to these advantages and should be performed where feasible. We present some novel techniques of CBD exploration and closure using instruments at hand.

**Methods:** 45 patients over a six-year period underwent laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis demonstrated preoperatively or intraoperatively. Various endoscopic instruments were used to visualize and extract the stones. These were a rigid ureteroscope, a flexible ureteroscope, a 5mm telescope along the side of a suction cannula and a standard flexible videocholedochoscope. Closure of the CBD was performed over a T-tube in the initial 5 cases.

A laparoscopic bilio-enteric bypass was performed for one patient with a 30 mm CBD stone and a 20 mm CBD. In one patient the CBD was closed primarily without any stenting. In the remaining 38 cases, the CBD was sutured over a double-pigtailed stent (6F and 16cm) used commonly in urological procedures. The stents were placed using a glide wire under fluoroscopic guidance with the proximal end in the common hepatic duct and distal end in the duodenum.

**Results:** With regard to the CBD exploration, complete stone clearance was achieved in 43 of 45 patients. Of the two patients with retained stones, one was treated by post-operative ERCP and the other by relaparoscopy, stone removal and closure over a T-tube. With regard to the methods used for biliary decompression, the D-J stent was found to be easy to insert and worked effectively with lower morbidity than a T-tube. In 32 patients, the stent was passed spontaneously with a mean time of 9 days. In 6 patients the stents had not passed by six weeks and were removed endoscopically.

**Conclusion:** LCBDE can be performed with a variety of endoscopic instruments. The lack of a sophisticated flexible videocholedochoscope need not necessarily be a deterrent to performing this procedure. Biliary decompression can be effectively achieved with a simple D-J stent which is inexpensive, avoids the morbidity of a T-tube and in most cases does away with the need for endoscopic removal.

## Hepatobiliary/Pancreatic Surgery - P430

**LATERAL DISSECTION TECHNIQUE: TOWARDS SAFER LAPAROSCOPIC CHOLECYSTECTOMY, Ibrahim A Salama MD, Hesham M Abdeldayem MD, Mahmoud A Abuoshady MD, Samy a kashkosh MD, Amr a mostufa MD, Steven D Schwaitzberg MD, Amr M Helmy MD, Department of Hepatobiliary surgery, National Liver Institute, Menouphyia University, Shibin Elkom, Egypt 1Department of surgery, Cambridge Health Alliance, Cambridge, MA.**

**Background:** Laparoscopic Cholecystectomy has been quickly accepted worldwide. However, the incidence of bile duct injuries seem to be high.

**OBJECTIVE:** to evaluate the efficacy and safety of lateral dissection technique during laparoscopic cholecystectomy.

**METHODS:** Between 1 October 1995 and 30 September 2005. 1.645 laparoscopic cholecystectomies were performed in National Liver Institute and Mahmoud hospital by using lateral Dissection technique. Keeping close to gall bladder wall, dissection start at a safety zone identified at the lateral edge of the gall bladder neck. The peritoneum at the lateral Side of Hartman pouch is opened from above down to the junction with the cyst duct. The base of the gall bladder is freed off the liver bed until a window above the hepatic pedicle is opened. Then with minimal dissection the cystic artery and the cystic duct are clipped.

**RESULTS:** Out of 1.645 cases of laparoscopic cholecystectomies performed by lateral dissection techniques there were no mortality. 279 cases (16.9%) were acute cholecystitis Eight (0.48%) had significant bile leak (5 from cystic duct stump and 3 from accessory duct at the liver bed) 2 managed conservatively, 3 treated by endoscopic stenting and surgery was mandatory in 3 cases. Intraopertive Cholangiography (IOC) was performed in 213(12.9%). Missed CBD stones in 4 cases (0.24%) all successfully treated endoscopically. There were no bile duct injuries among our series. Port site hernia in 11 cases (0.66%). Port site wound infection in 18 cases (1.09%). Hospitals stay (1-12 days). Four cases (0.24%) were converted to open (2 had severe adhesions and inflammation and 2 had intraoperative bleeding).

**CONCLUSION:** improving the safety of laparoscopic cholecystectomy can be achieved by starting dissection at a safety zone lateral to edge of the gall bladder with minimum dissection at triangle of Calot (Dangerous zone).

**Key words:** Lateral dissection- Safety zone-Laparoscopic cholecystectomy
## Hepatobiliary/Pancreatic Surgery - P431

TIMING OF CHOLECYSTECTOMY AFTER ENDOSCOPIC SPHINCTEROTOMY FOR COMMON BILE DUCT STONES, A.H.W. Schiphorst MD,M.G.H. Besselink MD, D. Boerma PhD,R. Timmer PhD,M.J. Wiezer PhD,K.J. van Erpecum PhD,B. van Ramshorst PhD, St Antonius Hospital, Nieuwegein, the Netherlands

**Introduction** The goal of this study was to determine whether in patients with combined cholecystodocholithiasis, the timing of laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES), does affect the outcome of LC. According to the literature, conversion rate of LC after ES is as high as 20%, at least when performed after 6-8 weeks. It is hypothesized that early planned LC after ES reduces recurrent biliary symptoms and conversion rate.

**Methods** All patients who underwent LC after ES between 2001 and 2004 were evaluated. Recurrent biliary symptoms during waiting time for LC, conversion rate, postoperative complications and hospital stay were documented. Data were analyzed using the Student's t-test.

**Results** 167 consecutive patients (M:F=59:108, median age 54 years) were analyzed. The median interval between ES and LC was 7 weeks (IQR 2-13 weeks). During waiting time for LC, 33 patients (20%) had recurrent biliary symptoms. These consisted of cholecystitis (n=18, 11%), recurrent choledocholithiasis (n=9, 5%), cholangitis (n=4, 2%) and biliary pancreatitis (n=2, 1%). 15 of these patients underwent a second ERC. Median time between ES and development of recurrent complaints was 22 days (IQR 8-47 days). 76% of the biliary complications occurred more than 1 week after ES. Conversion to open cholecystectomy occurred in 13% of all patients. However in patients with recurrent complaints during the waiting period, conversion rate was 21% (versus 10% in uncomplicated patients; p=0.048). This concurred with a significant longer hospital stay (median 4 versus 2 days, p<0.001).

**Conclusion** In this study, during the waiting period for cholecystectomy after ES, 20% of all patients had recurrent biliary complaints. These recurrent complaints are associated with second ERC, a higher conversion rate and a significantly longer hospital stay. Presumably, earlier surgery after ES can prevent these negative results. A prospective randomized clinical trial has been initiated.

## Hepatobiliary/Pancreatic Surgery - P432

LAPAROSCOPIC TREATMENT OF PANCREATIC TUMORS: A SINGLE-CENTER EXPERIENCE IN BRAZIL, Antonio L

Macedo MD,Aureo L De Paula PhD, Vladimir Schraibman MD,Jaques Pinus MD, Albert Einstein Hospital, Brazil

The increasingly widespread use of minimally invasive surgery has allowed surgeons to exploit this approach for complex procedures, such as pancreatic resections, though its actual role outside simple operations remains debated. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery.

This is a study of 9 consecutive patients, 5 men and 4 women, with pancreatic tumors who were treated at our institution from 2004 to July 2006. All patients presented US, CT scan or MRI showing a pancreatic tumor and were good candidates for laparoscopic surgery. Preoperative diagnostic work-up, operating time, postoperative complication rate, length of hospital stay and clinical outcome were assessed.

**RESULTS:** Successful laparoscopic resection was performed in all patients: 9 distal pancreatectomies, among these latter 5 had spleen-preserving distal pancreatectomy. In 1 case a hand assisted port was used to close the main pancreatic duct. Mean operative time was 170 minutes. The median tumor size was 18 mm, and comprised: 3 mucinous neoplasms with free margins, 3 serous cistadenomas and 3 neuroendocrine tumors. Four complications were observed in this group (local non-infected collections) and the median hospital stay was 8 days. One patient died after 1 month due to an extensive bleeding from the gastroduodenal artery.

**CONCLUSIONS:** Laparoscopic approach proved to be feasible and safe, although the average operative time is longer and demanded good surgical skills as well as precise localization of the tumor and definition of its nature. Tumors located in the body or tail of the pancreas that are benign in nature can better benefit of laparoscopic approach.

## Hepatobiliary/Pancreatic Surgery - P433

EXPERIENCE WITH NEEDLESCOPIC CHOLECYSTECTOMY IN 145 PATIENTS, Masashi Tachibana MD,Nobumi Tagaya PhD,Akihito Abe MD,Keiichi Kubota PhD, Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan

**Background:** Laparoscopic cholecystectomy with needlescopic instruments has progressed. However, this refinement has several limitations to perform surgical procedure. We performed a consecutive study to evaluate the feasibility and safety of needlescopic cholecystectomy.

**Materials and Methods:** For 8 years we performed needlescopic cholecystectomy in 145 patients of cholecystolithiasis, gallbladder polyp or calculus cholecystitis. There were 58 men and 87 women with a mean age of 51.8 years (range: 27-79). After creation of pneumoperitoneum, three 2-mm or 3-mm ports were placed at the right upper quadrant and one 12-mm port at the umbilicus. The operation was performed in two manners. The operator manipulated dissecting forceps, electrocautery, clipping, cutting and intraoperative cholangiography (IOC) in the left hand and 2-mm needlescope in the right hand during all procedures. The assistant manipulated two grasping forceps from the right subcostal ports. In the other, the operator manipulated two dissecting or grasping forceps under 10-mm laparoscope. The assistant manipulated grasping forceps from the right subcostal port and 10-mm laparoscope from the umbilical port. When performing clipping or cutting of cystic duct and artery, IOC and removal of gallbladder, 2-mm needlescope is moved from the umbilical port to the epigastric port. We evaluated the feasibility and safety of needlescope or fine-caliber instruments from operative results

**Results:** IOC was successfully performed in all patients. The conversion to standard laparoscopic cholecystectomy was required in 8 patients (5.5%) due to the difficulty of continuing procedure. The conversion to open laparotomy was required in one patient (0.7%) due to the existence of aberrant bile duct. The mean operative time was 88 min and postoperative hospital stay was 5.3 days. Postoperative complication was an intra-abdominal abscess in one patient requiring long postoperative hospital stay. No other major intra and postoperative complications were found.

**Conclusion:** The use of needlescope and fine-caliber instruments was feasible and safe to perform laparoscopic cholecystectomies with low morbidity and no mortality.

## Hepatobiliary/Pancreatic Surgery - P434

INTERNAL BILIARY DRAINAGE; CHOLEDOCHODUODENOSTOMY OR SPHINCTEROPLASTY?, Safwan A Taha

MD,Hashim S Khayat MD,Akram A Hasan MD, University of Basrah College of Medicine

**Objectives:** Internal biliary drainage is the safety escape route that can save the day in a lot of biliary problems culminating in common bile duct (CBD) obstruction. This is a prospective study that was carried out to compare the two surgical alternatives to endoscopic sphincterotomy (ES) for CBD obstruction, namely choledochoduodenostomy and sphinctero-plasty, where ES is unavailable, like it is here in IRAQ.

**Methods and procedures:** The study group involved 85 patients who were operated on by a team of three surgeons. All the operations entailed CBD exploration along with an additional drainage procedure. Patients were divided into two groups according to the type of drainage procedure: The first, sphincteroplasty, group (42 patients) and the second, Choleduchoduodenostomy, group (43 patients). The explorations were carried out through either subcostal or right paramedian incisions. The former was primarily used for choledochoduodenostomy and the latter for transduode-
<figure><img src="image_168.png" /></figure>

SAGES POSTER ABSTRACTS

nal sphincteroplasty. Patients were followed up for 6 months postoperatively. The outcome was compared, in relation to each procedure, with regards to the postoperative course and its complications notably wound infection, pancreatitis and bile leak.

**Results:** Indications for drainage in the sphincteroplasty group were CBD stones, some of which presented with jaundice and/or cholangitis, dilated CBD, biliary-cutaneous fistula (consequent upon previous surgery), intrabiliary rupture of hepatic hydatid cysts and ampullary stenosis. In the Choleduchoduodenostomy group, drainage was performed for CBD stones, with/without jaundice, dilated CBD, cholangitis, intrabiliary rupture of hepatic hydatid cysts and tumor of the pancreas. Wound infection occurred in 6 patients in the sphincteroplasty group (14.8%) compared to 3 (7%) in the Choleduchoduodenostomy group. T-tubes were used in 11 patients, exclusively in the choledochoduodenostomy, group, still, not a single case of pancreatitis was reported. The same observation was made regarding mortality. On the other hand, biliary leak occurred in 5 patients, all in the Choleduchoduodenostomy group. It closed spontaneously with conservative treatment in 3 of them while the other 2 required re-exploration. One of them unfortunately died later.

**Conclusion:** In our experience, sphincteroplasty improves the postoperative course and gives fewer complications, notably with bile leak and is, therefore, preferred to choledochoduodenostomy.

## Hepatobiliary/Pancreatic Surgery - P435

HAND-ASSISTED LAPAROSCOPIC SPLEEN-PRESERVING DISTAL PANCREATECTOMY, Kyoichi Takaori MD, Nobuhiko Tanigawa MD, Tomoyuki Agui MD, Mitsuhiko Iwamoto MD, Yoshiharu Miyamoto MD, Dept of Gastroenterological Surgery, Osaka Medical College

[Background] Benign or non-invasive lesions in the body-tail of the pancreas appear favorable indication for laparoscopic distal pancreatectomy. However, some cystic lesions of the pancreas, typically mucinous cystic neoplasms, are so large that it is difficult to handle these tumors by purely laparoscopic approach. We carried out hand-assisted laparoscopic spleen-preserving distal pancreatectomy (HALSPDP) in two young women with large cystic lesions of the pancreas. [Case No. 1] A woman in her twenties presented with a cystic lesions measuring 7cm in the pancreatic tail on CT. A diagnosis of mucinous cystic neoplasm was made and she underwent HALSPDP. A 7.5-cm midline incision was made and a hand port was inserted. One 12-mm trocar and two 5-mm trocars were placed. Dissection was carried out with LigaSure. The pancreas was transected with ENDO-GIA. Splenic artery and vein were preserved. Operative time was 300 min and estimated blood loss was 250 ml. [Case No, 2] A woman in her twenties suffered from upper abdominal pain after menstruation period. CT, MRI and ultrasound revealed a large cystic lesion measuring 12 cm in the body-tail of the pancreas. With a suspected diagnosis of endometriotic cyst, HALSPDP was indicated. A 7.5-cm transverse incision was made in the upper abdomen and a hand port was inserted. Three 5-mm trocars were placed and a 5-mm laparoscope was used. The pancreatic neck was transected with TL-60 through the hand-port wound. Splenic artery was preserved while splenic vein was resected en bloc because the cystic lesion adhered to adjacent tissues including the splenic vein. Operative time was 495 min and estimated blood loss was 650 ml. Postoperative course was uneventful without complication.

[Conclusion] HALSPDP was practicable in patients with large cystic lesions of the pancreas, who were satisfied with better cosmetic outcome as compared to open surgery.

## Hepatobiliary/Pancreatic Surgery - P436

LAPAROSCOPIC SEGMENT III LIVER RESECTION FOR ISOLATED COLORECTAL METASTASIS: A DESCRIPTION OF TECHNIQUE, Janos Taller MD, Brett Langenberg DO, Jay Grove MD, Gordon Wisbach MD, Department of Surgery, Naval Medical Center, San Diego

Laparoscopic surgery is increasingly a viable approach for the treatment of both benign & malignant hepatic lesions. While the majority of studies have come from European institutions, publications from US centers are increasing. The objective of this case report is to demonstrate the feasibility and safety of a totally laparoscopic segmental liver resection at our institution.

Our patient is 64 y/o female with a T3N0M1 adenocarcinoma of the colon. 3 months prior to presentation, she underwent an open right colon resection for a cecal mass & core biopsy of a 2 cm solitary liver lesion. Her case was presented to our multidisciplinary tumor board which recommended segmental liver resection followed by adjuvant chemotherapy for best long-term survival. Pre-operative CT scan & PET imaging confirmed a single metastatic focus in segment III of the liver and the patient was offered a laparoscopic segment III liver resection.

In the supine position, pneumoperitoneum was achieved with Veress needle technique and insufflation pressure maintained at 12mmHg. 5 laparoscopic ports were placed. Moderate adhesiolysis & division of the falciform ligament were required to expose the upper abdominal field. Intraoperative US excluded any additional metastatic lesions. Electrocautery was used to score resection boundaries on the hepatic capsule and perform superficial parenchymal transection. Deeper dissection was completed by an ultrasonic dissector. Small biliary radicals and hepatic vessels were occluded with vascular clips while larger segmental hepatic veins were divided with an endoscopic stapler using 2.5mm loads. A portion of the anterior stomach, adherent to the tumor, was resected en bloc with the liver segment using the ultrasonic dissector. Operative time was 280 minutes and EBL was 250 mls. The patient was observed overnight in the ICU & transferred to the ward on POD#1. She was advanced to liquids on POD#3 & was discharged home on POD#5 tolerating a regular diet. There were no complications. Final pathology revealed complete excision of her metastasis with > 2cm margins.

Our report demonstrates that totally laparoscopic liver resection may be safely performed. While resection of left sided, small, peripheral lesions is technically easier to perform than right sided, larger lesions, continued development of technique will allow the application of laparoscopic resection to increasingly complex liver tumors. Further prospective evaluation is required.

## Hepatobiliary/Pancreatic Surgery - P437

PANCREATIC FISTULA FOLLOWING LAPAROSCOPIC DISTAL PANCREATECTOMY- ENDOSTAPLER VERSUS SUTURE +/- FIBRIN SEALANT, Craig j taylor MD, nicholas o'Rourke MD, leslie nathanson MD, george Hopkins MD, lan martin MD, laurent layani MD, michael ghusn MD, Royal Brisbane Hospital, Brisbane Queensland Australia

**Background** Pancreatic fistula (PF) is a frequent complication following laparoscopic distal pancreatectomy (LDP) that may be influenced by the management of the pancreatic stump. The ideal method of closing the pancreatic stump has not yet been determined.

**Method** The risk of PF according to various methods of stump closure was determined from a multi-centre retrospective study and a review of the published literature. Pancreatic fistula was defined as persistent lipase-rich drainage after 7 post-operative days, or the need for radiological drainage of a lipase-rich collection.

**Results** 46 consecutive LDP were performed between 1996 and 2006 in Brisbane Australia. The incidence PF following endostapled (30 cases) or sutured closure (16 cases) was 13% vs 19% respectively (p=0.43). The application of fibrin sealant to either the stapled (4) or sutured (8) stump, or oversewing the stapled stump (3), did not improve the risk
SAGES POSTER ABSTRACTS

of PF (25%, 25%, 33% respectively). 13 papers involving 220 cases of LDP were identified from the literature. The overall incidence of PF was 15%, with a trend toward fewer leaks following stapled closure. A lack of consistency in PF definition was revealed and made comparison difficult.

**Conclusion:** There is a trend toward fewer pancreatic fistula following stapled closure of the pancreatic stump in LDP. Fibrin sealant does not appear to confer additional benefit. A need exists for uniformity in the definition of PF when reporting results of LDP.

## Hepatobiliary/Pancreatic Surgery - P438

### EFFICACY OF FIBRIN SEALANT WITH OMENTAL PATCH IN DECREASING PANCREATIC FISTULA AFTER LAPAROSCOPIC DISTAL PANCREATECTOMY, Vic Velanovich MD,Ilan Rubenfeld MD, Henry Ford Hospital

**Background:** Both laparoscopic and open distal pancreatectomy have been plagued by pancreatic fistula despite different stump closure techniques. The purpose of this study was to determine if the use of a fibrin sealant with an omental patch will decrease pancreatic fistula formation after laparoscopic distal pancreatectomy.

**Methods:** Retrospective review of laparoscopic distal pancreatectomy patients treated with fibrin sealant and omental patch compared to historical controls. Patients who underwent laparoscopic distal pancreatectomy with treatment of the pancreatic stump with fibrin sealant and omental patch were compared to patients who did not receive such treatment. After completion of the resection, 5 cc of fibrin sealant was applied to the cut edge of the pancreatic remnant. Omentum was placed over the pancreatic remnant to adhere to the stump. A drain was placed over the omentum. CT scans were obtained on postoperative day #3 to determine if any fluid collection was present. A pancreatic leak was defined as any amylase-rich fluid found in the drain or a fluid collection next to the pancreatic stump.

**Results:** A total of 16 patients underwent laparoscopic distal pancreatectomy with fibrin sealant and omental patch, whereas 13 patients did not. There were no patients in the fibrin sealant group who developed a pancreatic leak, compare to 3 (23%) in the no sealant group (p=0.05)

**Conclusion:** Although retrospective using historical controls, this series suggests that the use of fibrin sealant may reduce the incidence of postoperative pancreatic leak after laparoscopic distal pancreatectomy.

## Hepatobiliary/Pancreatic Surgery - P439

### INCOMPLETE LAPAROSCOPIC CHOLECYSTECTOMY - A CAUSE OF CONCERN, Satpal S Virk, Sundip Sidhu, Ajit Sood, Dayanand Medical College & Hospital, Ludhiana, Punjab, India

During Laparoscopic Cholecystectomy (LC) stress is laid on the identification of cystic duct and infundibulum junction rather than on the junction of cystic duct and common bile duct, as was in open technique. This leads on inadvertent incomplete cholecystectomy which becomes symptomatic later. We present five cases of incomplete cholecystomecties following LC. LC timing, presentation, investigations and demographic characteristics are given in the table.

<table><thead><tr><td>Age/Sex</td><td>Interval</td><td>Presentation</td><td>Investigation</td></tr></thead><tbody><tr><td>52/M</td><td>6 Years</td><td>Biliary colics</td><td>USG</td></tr><tr><td>60/M</td><td>3 Years</td><td>Biliary colics</td><td>CECT</td></tr><tr><td>45/F</td><td>2 Months</td><td>Jaundice</td><td>USG, ERCP</td></tr><tr><td>42/M</td><td>2 Years</td><td>Biliary Colics</td><td>USG</td></tr><tr><td>22/M</td><td>2 Days</td><td>Peritonitis</td><td>CECT</td></tr></tbody></table>

Clips far away from midline on the radiographs were seen. Three gall bladders were removed laparoscopically and in two patients by open technique because one had large associated bile duct stone and other was explored for pancreatic malignancy. Gall bladders were having well defined infundibulum and cystic duct. All patients had uneventful recovery. Histopathology revealed chronic cholecystitis except in one where it was xanthogranulomatous cholecystits. Staying away from common bile duct may reduce the incidence of bile duct injury but it may lead on to inadvertent incomplete cholecystectomy

## Hepatobiliary/Pancreatic Surgery - P440

### USE OF THE MULTIPLE INSTRUMENT GUIDE WITH 2.8 MM CHOLEDCHOHSCOPE TO REMEDiate BILE DUCT STONES, Donald E Wenner MD, James C Rosser, Jr. MD, Paul R Whitwam MD, David M Turner MD, Jason M Degani MS, Roswell Regional Hospital, Eastern NM Medical Center

**Objective:** This study was designed to assess the use of the Multiple Instrument Guide and the 2.8 mm flexible choledochoscope in laparoscopic remediation of bile duct stones. The ultimate aim is to develop safe, practical and effective LCBDE techniques that are applicable to all cases of choledocholithiasis. A secondary objective was to evaluate the incidence of pancreatitis as a result of bile duct instrumentation following LCBDE.

**Methods:** All cases of choledocholithiasis that presented to our surgical team were addressed using laparoscopic techniques. The Multiple Instrument Guide and the 2.8 mm flexible choledochoscope were used in all but the simplest cases. Both trans-cystic duct and choledochotomy methods were used. Balloon catheters, stone baskets, and laser lithotripters were employed under choledochoscopic guidance.

**Results:** 101 patients with choledocholithiasis underwent LCBDE. In 45 patients trans-cystic techniques were used to clear stones from the bile duct and in 56 a choledochotomy technique was used. A trend toward greater success using trans-cystic techniques (63%) was observed in the second half of the study. 9 patients had a pre-operative ERCP, 4 of these patients had an intact gall bladder, and 5 had undergone previous LC. All of these cases were successfully cleared using laparoscopic techniques. 3 patients had retained stones after the LCBDE procedure for a success rate of 97%. No cases of pancreatitis resulting from the LCBDE procedure were identified on clinical grounds or by laboratory testing.

**Conclusion:** LC/LCBDE can successfully clear stones from the bile duct in virtually all cases, even those following unsuccessful ERCP and having previous LC. Pancreatitis as a result of the LCBDE procedure using these techniques was not observed. The Multiple Instrument guide and the 2.8 mm choledochoscope allow for a safe, practical and effective LCBDE procedure.

## Hepatobiliary/Pancreatic Surgery - P441

### THE RENDEZVOUS TECHNIQUE IN MANAGING CHOLEDCHOLITHIASIS, Vaughn E Whittaker MD, Charles Fasanya MD, Sitaram Pillarisetty MD, College of Physicians and Surgeon Columbia University, Harlem

Common duct stones are present in 10-15% of patients having cholecystectomy. Common duct stones may be removed preoperatively by Endoscopic Retrograde Cholangiopancreaticogram (ERCP) based on radiographic and biochemical evidence. Intra operative and post operative stone removal is possible by ERCP. We describe an intraoperative ERCP technique using the rendezvous method.

We report our experience using the technique over an eight (8) month period March 2005 to December 2005. Patients were selected based on preoperative biochemical and radiologic evidence confirming common duct stones. Others were selected based on cholangiogram demonstrating common duct stones. The ERCP was performed by a skilled surgical endoscopist (SP). Intraoperative Cholangiogram (IOC) was performed during Laparoscopic cholecystectomy (LC). If common duct stones were confirmed, we then passed a transcystic duct Glide® wire into the duodenum under fluoroscopic control. Duodenoscope was then passed into the duodenum and the guide wire exiting through the papilla was identified. Using the glide® wire localization an adequate sphincterotomy was performed and the stones were extracted from the common bile duct (CBD). We then irrigated the CBD with transcystic duct catheter and visualized the effluent endoscopically in the duodenum until the effluent was free of debris.

There were a total of eight (8) patients with six (6) undergoing laparoscopic cholecystectomy and two (2) having an

<figure><img src="image_169.png" /></figure>
<figure><img src="image_170.png" /></figure>

# SAGES POSTER ABSTRACTS

open procedure. The patients had pathology varying from biliary pancreatitis two(2), common duct stones complicated by previous cholangitis one(1) and uncomplicated choledocholithiasis six(6). There was no failure of cannulation though one(1) case where the stone was impacted in the common duct required its opening and the guide wire passed through a choledochoscope.

In all cases the stones were removed and endoscopic sphincterotomy was achieved. The post operative course was uncomplicated during the immediate post operative period and several months after follow up.

Common duct stones can be removed with a high degree of success by endoscopists skilled in performing ERCP intra operatively. The rendezvous technique can be performed both laparoscopically or open. Patients benefit from one procedure, though lengthened. It reduces the failure rate of stone extraction in ERCP. Surgeons are encouraged to learn ERCP.

## Hepatobiliary/Pancreatic Surgery - P442

### SIGNIFICANCE OF SONOGRAPHIC GALLBLADDER WALL THICKENING IN CHRONIC CHOLECYSTITIS, Howard

Youngworth MD, Adam Kopelan MD, Jeffery Lautin MD, Newark Beth Israel Medical Center, Newark, New Jersey.

**Introduction:** The purpose of this study is to evaluate if ultrasound (US) can accurately diagnose chronic cholecystitis (CC). Since the evolution of laparoscopic cholecystectomy, gallbladder (GB) surgery has become more prevalent with less complication. Hence, the US finding of GB wall thickening in CC maybe less evident as a consequence of this.

**Methods:** We retrospectively reviewed the medical, US and pathology reports of 62 patients who underwent cholecystectomy for biliary disease during a one year period.

Patients were excluded if US or pathology reports were not performed, incomplete or missing, contracted gallbladders, computerized tomography used instead of US, or cholecystectomy was performed for non-primary biliary disease. In addition, only those patients with pathologically proven cholecystitis were included in this study. Each case was reviewed based on pathological and US findings. GB walls greater than 0.3 cm on pathological reports was considered thickened. US wall thickening was graded as mild and moderate, corresponding to 0.4 - 0.5 cm and 0.5 - 0.6 cm, respectively. All ultrasounds were reviewed by two separate reviewers. Of the 62 patients initially reviewed, 39 patients met the criteria for the study.

**Results:** Of the 39 patients in the study, 82% had normal appearing gallbladder walls on US. Only 18% of the patients had thickened GB walls on US alone and 10% of the patients had GB walls greater than 3 mm on US and gross specimen.

**Conclusion:** This study demonstrates that US can not accurately diagnose CC. We found that only 18% of patients had GB wall thickening on US and only 57% of these patients had true GB wall thickening based on pathology. We attribute this discrepancy on 2 possible factors. One, the edema within the gallbladder could have leaked out prior to pathological examination. Or second, the time interval between US examination and cholecystectomy could have been enough to allow the regression of the GB wall due to resolving inflammation. Pathological evaluation of CC depends more on lymphocytes, plasma cell and macrophage infiltration, rather than GB wall thickness. GB wall thickness on US does not appear to be an accurate noninvasive technique for diagnosing patients with CC.

## Hernia Surgery - P443

### LAPAROSCOPIC TECHNIQUE OF MAYO'S REPAIR FOR VENTRAL HERNIA WITH MESHPLASTY, B B Agarwal, S

Agarwal, M K Gupta, V R Saggar, K C Mahajan, Sir Ganga Ram Hospital & Lady Hardinge Medical College, India

**Objectives:** Laparoscopic technique of Mayo's repair with meshplasty to decrease incidence of seroma formation

**Method & procedures:** Endoscopic surgery for ventral hernias has become a standard procedure. It now has universal acceptance except for a significant morbidity due to early or delayed seroma formation.

Seroma formation has been attributed to the redundant parietal tissues and the space left by the reduced hernial contents. Measures such as compression dressings; closure of the defect and obliteration of the space by tissue glues are being tried, with the compression to obliterate the space being most widely practiced. For the compression to be effective, a flat, solid contraposing structure is required, which can be provided by the musculofascial continuity obtained on closure of the defect. A transverse closure without any mass of strangulated tissues between the closing sutures is desirable which is easily achieved by double-breasted, 'pants over vest' repair. This principle first enunciated by Mayo in 1901 remains the gold standard for closure of ventral hernia defects till date. However Mayo's repair had high recurrence rates in open surgery hence we reinforced the repair with an onlay intraperitoneal mesh.

We have applied this principle to the endoscopic surgery for ventral hernias by closing the defect by Mayo's principle and reinforcing the repaired defect with an intraperitoneal onlay meshplasty. The sutures for Mayo's closure are passed through the lumen of a spinal needle placed transcutaneously through the margins of the defect. The suture thread is picked up by a loop made from thread passed through another spinal needle. Once all the sutures are passed, the double breasting is confirmed by the slide of the flaps in a 'pants over vest' manner as seen on endovision. The sutures are then tied and buried subcutaneously.

**Results:** 23 patients have undergone laparoscopic Mayo's repair with meshplasty. We have not encountered any patient with seroma formation during a minimum follow up of 4 months.

**Conclusion:** Laparoscopic technique of Mayo's repair for ventral hernia with meshplasty is safe and feasible means to improve the results specially seroma formation. We are following our patients for its any benefit on recurrence.

## Hernia Surgery - P444

### PROCESS IMPROVEMENT REDUCES INFECTION IN LAPAROSCOPIC VENTRAL HERNIA REPAIR, John D

Angstadt MD, Oliver Whipple MD, Memorial Health University Medical Center

**Objective of the study:** We have experienced some postoperative infection in our laparoscopic ventral hernia repairs with mesh. On March 1, 2005, our medical center implemented a process improvement program that streamlined preoperative antibiotic administration. The objective is to assess the impact of this program on infection rates following laparoscopic ventral hernia repair.

**Methods and Procedures:** This is a retrospective chart review of 144 laparoscopic ventral hernia repairs performed by a single surgeon between February 2002 and July 2006. All patients received the same preoperative antibiotic care and same postoperative care. All patients were followed in the surgeon's office after discharge. Infection was diagnosed with any erythema or induration over the seroma that required treatment. The process improvement program mandated a streamlined antibiotic administration process by the nurse anesthetist upon entering the OR room. For analysis procedures were separated into two groups: those procedures performed before March 1, 2005 and those procedures performed after March 1, 2005. Statistical analysis was performed with Fisher's t test.

**Results:** Eighty-four patients underwent surgery before March 1, 2005 and 60 patients underwent surgery after March 1, 2005.

<table><thead><tr><th></th><th>Pre-March</th><th>After March</th></tr></thead><tbody><tr><td>Cases</td><td>84</td><td>60</td></tr><tr><td>Seromas</td><td>29 (30%)</td><td>16 (27%)</td></tr><tr><td>Infections</td><td>12 (14%)</td><td>2 (3%)</td></tr></tbody></table>

There was a statistically significant difference in infection rates (p<0.02).

**Conclusions:** Preoperative antibiotic administration is widely accepted as appropriate for laparoscopic ventral hernia repair. The timing of administration is critical to insure proper blood levels of antibiotics. In our institution process improvement almost eliminated postoperative seroma infection following ventral hernia repair
## Hernia Surgery - P445

LAPAROSCOPIC LUMBAR HERNIA REPAIR, Siddharth

Bhende MD, Keyur Chavda MD, Ali Ghellai MD, Guthrie Clinic Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital of acquired. They can occur anywhere between the 12th rib and iliac crest. Many surgical techniques for repair of lumbar hernias have been described including primary repair, local tissue flaps and conventional open mesh repair. Despite the various available methods, no repair has been adopted as the most favorable surgical approach. The reasons for this include the difficulty in defining the fascial edges of the defect and weakness of surrounding tissue. Furthermore, the boundaries of lumbar hernias inevitably include a bony structure further contributing to the difficulty of the repair. Laparoscopic lumbar hernia repair using a prosthetic mesh has become simple and logical by adopting maneuvers from the laparoscopic ventral hernia repair and modifying the technique to accommodate the anatomy of the lumbar hernia. Laparoscopy has afforded several advantages including reduced postoperative pain, decreased hospital stay and better cosmesis while accomplishing a complete reconstruction of the area.

We present a patient who underwent successful laparoscopic lumbar hernia repair with prosthetic mesh at a rural based community hospital. The patient had an uneventful postoperative course and was discharged on postoperative day two. Three month follow-up reveals the patient to be asymptomatic without any recurrence.

## Hernia Surgery - P446

DIFFERENCES IN RECOVERY TIME AND POSTOPERATIVE PAIN AMONG HERNIA PATIENTS: A COMPARISON OF KEY-HOLE TYPES, SENOL CARILLI MD, BURCAK KABAOGLU MD, ZEYNEP DÖRTBUDAK* PhD, AYDIN ALPER MD, VKF AMERICAN HOSPITAL GENERAL SURGERY DEPARTMENT, *KOC UNIVERSITY SCHOOL OF HEALTH SCIENCES

This study aims to investigate differences -if any- in postop pain and recovery time among two different surgical mesh application techniques used in hernia operations in a private medical facility in Istanbul, Turkey. We have randomly selected 100 patient records from a total of 773 inguinal hernia patients, 50 lateral keyhole (LK) and 50 down keyhole (DK) mesh applications, according to pre-defined subject selection criteria. Mean age among the patients was 50.22 years (sd 13.66), a statistically significant difference between the two groups was observed (DK means 45.86, sd 13.31; LK means 54.74, sd 12.56). We analyzed associations between surgical technique (LK vs DK) and a number of variables including hernia type, time since previous hernias, post-surgical time for resuming daily activities (RDA) and resuming work (RW), postop complications, postop pain on day one and seven (VAS1, VAS7), and number of analgesic pills administered after surgery. Bi-variate analyses using $\div$2 ad t-testing revealed that VAS1, VAS7 and number of analgesic tablets taken by the patients post-surgery were not associated with mesh-slit type ($p$>>.05). Pain scale results correlated positively with the number of analgesics taken by the patient ($r$=-.548, $p$=.01). However variables related to resuming activity were significantly different between DK and LK. Mean days to RDA was 1.63 (sd1.19) in the DK group and 2.63 (sd 1.51) in the LK group ($t$=-3.56, $p$=.001). Likewise, mean days for RW was 3.08 in DK (sd 1.80) as opposed to 5.38 (sd2.44) in LK patients ($t$=-4.67, $p$<.001). The distribution of single/double hernias among LK and DK groups presented a significant difference (chisq=10.61, $p$<.001). We used keyhole type as a proxy for the number of tacks used during surgery, a variable expected to be related to postop pain. Preliminary analysis of the dataset shows a shorter recovery among DK patients, but not significantly reduced postop pain. We believe that this discrepancy between recovery time and postop pain may be attributable to a statistically significant difference in mean age between the two groups. Mean age in the LK group is higher. Consistent with this, it is often beleived that pain perception may decrease

with age. The investigators aim to enlarge the random dataset to perform multivariate analysis of pain and recovery related variables, hernia types and number of tacks used while controlling for age, to explore the subject further.

## Hernia Surgery - P447

MESH OUTCOMES AND REDO SURGERY AFTER LAPAROSCOPIC TREATMENT OF VENTRAL AND INCISIONAL HERNIA. EXPERIENCE OF 57 SECOND LOOKS., Elie Chelala MD, Y. Debaerdemacker MD, F. Charara MD, M. Dessily MD, JL. Allé MD, Tivoli university hospital, La Louvière, Belgium

**Introduction:** This study discusses a minimally invasive approach by transabdominal fixation of an innovative composite mesh (Parietex®), associated to a musculofascial closure in moderate to large defects. This report aims to review the redosurgeries done after a large number of 537 LIVH. It demonstrates the minimal occurrence of the various complications encountered in intraperitoneal stapling (as major loop adhesion and mesh migration...) and redo surgery after LIVH.

**Methods:** All previous surgeries were performed laparoscopically with 3 trocars. All defects were closed before placement of the mesh, to avoid ultimately extrusion of the mesh and reduce the risk of seroma formation. In "second looks," the first trocar is always inserted on a lateral side externally to previous skin incisions of the transabdominal fixations. Meticulous adhesiolysis is undertaken by scissors and little coagulation in order to avoid damaging the mesh. If recurrence is observed, the defect is closed and a larger mesh of Parietex is implanted under the previous one with transparietal fixation by pulling the threads with the endoclose device.

**Results:** Between October 2000 and August 2006, 537 ventral and incisional hernias were included in this study. Size of defect: 3-14 cm. Recurrences appeared in 10 cases (1.8%) from 3 to 36 months. With a mean follow up of 36 months, 420 over 537 (78%) patients were controlled. A "second look" has been obtained on 57 patients (10.6%) from 3 to 36 months with "adhesion-free" for the majority (31), "Mueller I-II adhesion" of the omentum for others (22), and serosal adhesions easily cleavable for the rest (4). The absence of shrinking and wrinkling of the prosthesis in all these cases confirms its total peritonization of the anterior abdominal wall.

**Conclusion:** This suturing concept technique proves satisfactory both on the technical and the results fronts. The major difference and enhancement in the exposed method is highlighted by the absence of prosthesis migration and limited adhering side effects. It is an effective, safe and reproducible procedure, even so for redo surgery. Redo surgery after LIVH, could be applied with utmost care of unpredictable adhesion's risk on the midline. Adhesion risk is minimised with a lower rate of recurrency using the suturing concept and an efficient polyester protected mesh. Morbidity rate is low and mid-term outcomes are promising. Longer follow-up is mandatory.

## Hernia Surgery - P448

TEP REPAIR - SIR GANGA RAM HOSPITAL APPROACH, PRADEEP CHOWBEY MS, Chairman - Minimal Access & Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi (India)

TEP hernia repair is a technically demanding procedure. Once well versed with the approach we have found it an efficient method for groin hernia repair. To make the procedure cost effective & prevent hernia recurrences, we have modified innovated to simplify the procedure. Patients are placed in supine position. A 10mm incision is made below the umbilicus on the affected side. The anterior rectus sheath is incised, muscle retracted laterally & blunt finger dissection done caudally posterior to the rectus muscle. A sterile finger glove is tied around the tip of the suction cannula with silk thread, which is gently pushed into a plane posterior to rectus muscle towards symphysis pubis. About 150-200cc of sterile saline is injected in the balloon & left for 3-5 minutes. After balloon deflation, the suction cannula is
<figure><img src="image_171.png" /></figure>

SAGES POSTER ABSTRACTS

substituted by a blunt tip Hassan's cannula & space insuf-
flated to a pressure of 15mmHg. A 30deg. scope is used. Two
5mm trocars are placed in midline, one just above the sym-
physis pubis & the other midway between the two. The dis-
section is started after identification of the pubic bone in
midline. The entire posterior floor is dissected & the
anatomical landmarks -inferior epigastric,iliac & gonadal
vessels, vas deferens in males, round ligament of the uterus
in females & nerves are identified. The lateral dissection is
completed upon visualisation of psos muscle. Any direct
sac is dissected off the fascia transversalis.A small indirect
hernia is easily mobilised from the cord structures &
reduced. In cases of large sacs or in complete indirect her-
nia extending upto scrotum,the sac is divided just proximal
to the internal ring & the distal sac is left behind. The edge
of the peritoneum is pulled as far cephalad as possible, so
that the mesh that placed on the posterior floor is covered
by peritoneum, on desafflation. A standard polypropylene
mesh (15x15cm) is used for each side. The mesh is rolled
tightly upto 3/4th of its length & anchored with two catgut
knots to prevent unfolding. The mesh is pushed into the
preperitoneal space through the Hassan cannula & anchored
with 2-3 tacks to the Cooper's ligament medially(ProTack®)
through the mid port. After securing the mesh, the knots on
the folded mesh are cut to unfold the mesh over the peri-
toneum i.e. floor. The mesh is placed to cover all the hernial
defects (direct inguinal, indirect inguinal & femoral). The
results will be evaluated & compared with other well estab-
lished techniques.

Hernia Surgery - P449

LAPAROSCOPIC BIOLOGIC MESH REPAIR OR PROLENE
MESH REPAIR, D S Edelman MD, Baptist Hospital of South
Florida

Intro: Fibrin Glue to fix prolene mesh or extracellular matrix (ECM) biologic mesh during laparoscopic hernia repair was evaluated and compared over the past 6 months.

**Methods:** A retrospective review of patients operated upon during the same time period by the same surgeon and at the same institution were analyzed. A pre-peritoneal technique securing a 10 x 15 cm soft prolene mesh or an ECM mesh with fibrin glue was used. Occassionally, 4-6 tacks were needed to secure the mesh.

**Results:** 20 patients were collected in each group. ECM patients averaged 37 years (16-65) and Prolene averaged 51 years (26-72). Operative time averaged 30 minutes in both groups. ECM mesh was used in 24 indirect and 5 direct repairs. Tacks were needed in 2 instances. Prolene mesh was used in 16 indirect and 7 direct repairs. Tacks were needed in 8 instances. Patients were seen at 2 weeks, 8 weeks and 6 months. There were 3 patients in each group with mild, temporary groin pain. No recurrences were noted in either group.

**Conclusion:** The biologic extracellular matrix hernia repair with fibrin glue compared equally to soft prolene mesh repair using glue and an occasional tack. Long tern follow up and a randomized-prospective trial comparing the 2 techniques are needed.

Hernia Surgery - P450

ROBOTIC ASSISTED VENTRAL HERNIA REPAIR—A FEASI-
BILITY STUDY, Barry N Gardiner MD,William Hamstra
DO,Carol Alvord MS, San Ramon Regional Medical Center,
San Ramon, California

**OBJECTIVES:** Adoption of laparoscopic ventral hernia repair has been limited by the severity of pain associated with transfascial sutures and hernia staples. This retrospective study tests the feasibility and consequences of eliminating these fixation techniques by suturing the mesh directly underneath the abdominal wall with robotic assistance.

METHODS: Between 10/05 through 8/06, 14 consecutive ventral/incisional hernias suitable for a standard laparoscopic approach were repaired with robotic assistance. A polypropylene mesh was used in each case, overlapping the edges of the defect by 3-5cm. The sole means of fixation was a continuous non-absorbable suture placed around the

periphery of the mesh. No transfascial sutures or clips were
used for fixation of the mesh in any of these repairs. Length
of stay and use of intravenous narcotics in this group (RA)
were compared retrospectively to the previous 14 patients
who had undergone conventional laparoscopic repair (LR)
using transfascial sutures and staples. All p values are 2-
sided by the Wilcoxon's rank sum test (due to skewed data
distributions).

**RESULTS:** The two groups were well matched for age, sex, weight, and co-morbidities. The robotic approach was successfully completed in all 14 patients in the study group. Size of the implanted mesh was comparable between the two groups (RA median=300 cm?; LR=310 cm?, p=0.70). Compared to conventional laparoscopy, however, operating times in the study group were longer (RA median=124 min.; LR=70 min., p=0.004), and length of stay was shorter (RA median=4 hrs.; LR=31 hrs., p=0.01). The need for parenteral narcotics (expressed as morphine equivalents in mgs.) was substantially different between the two groups: in the recovery room (RA median=9 mg.; LR=20 mg. p=0.02), following recovery room up to the time of discharge (RA median=0 mg.; LR=32mg., p=0.001).

**CONCLUSIONS:** Repairing ventral/incisional hernias with robotic assistance is feasible, although technically challenging. This approach eliminates the need for both transfascial sutures and hernia staples, reduces much of the pain associated with conventional laparoscopic repair, and significantly lowers length of stay. A larger, prospective randomized study is warranted to explore the advantages of this minimally invasive approach to ventral and incisional hernia repairs.

Hernia Surgery - P451

LAPAROSCOPIC PARASTOMAL HERNIA REPAIR, Kevin L Huguet MD, Elisabeth C McLemore MD, Kristi L Harold MD, Mayo Clinic Scottsdale

**Background:** Parastomal hernias represent a common complication of stoma creation. Surgical repair has traditionally been performed through an open technique with unacceptably high recurrence rates. Laparoscopic ventral hernia repair is widely accepted for the repair of incisional hernias. There is a limited experience with laparoscopic parastomal hernia repair.

**Methods:** A retrospective review of parastomal hernia repairs from January 2004 to August 2006 was performed. All hernias were repaired with mesh using the Sugarbaker or Keyhole technique. Patient demographics, operative time, mesh and fascial defect size, complications, length of hospitalization, and recurrence rates were recorded.

**Results:** Twenty patients underwent laparoscopic repair of parastomal hernias (9 urostomy, 6 ileostomy, and 5 colostomy). Mean defect size measured 130 cm2 (range, 25 - 416cm2) and the mean mesh size was 440 cm2 (range, 240 - 780 cm2). All repairs were successfully completed laparoscopically. Mean operative time was 210 mins (99-326 mins). Follow-up ranged from 1-17 months (mean, 4 months). There have been no recurrences. There were 9 major post-operative complications. One patient required laparoscopic re-operation for obstruction of the urostomy. Two patients required mesh removal due to infection. Other complications included: C. difficile colitis (1), pneumonia (2), acute renal failure (1), surgical site infection (1), and 2 re-admissions for small bowel obstruction which resolved with conservative management.

**Conclusions:** Laparoscopic parastomal hernia repair is a feasible technique. There is a low incidence of recurrence in short term follow up.

Hernia Surgery - P452

LARGE HIATAL HERNIA WITH INCARCERATION OF THE OMENTUM MIMICKING A MEDIASTINAL TUMOR, Hitoshi Idani MD, Shinichiro Watanabe MD, Hiroki Nojima MD, Masahiko Muro MD, Takashi Ishikawa MD, Tatsuaki Ishii MD, Shinya Asami MD, Masanobu Maruyama MD, Shinichiro Kubo MD, Takashi Yoshioka MD, Hitoshi Kin MD, Department of Surgery, Fukuyama City Hospital

We present a rare case of large hiatal hernia with incarcera-
tion of the omentum mimicking a mediastinal tumor, which
<figure><img src="image_172.png" /></figure>

was successfully treated by laparoscopic surgery. A 74-year-
old woman presented to our hospital with a chief complaint
of general fatigue. Chest X ray photo showed an abnormal
shadow in the mediastinum. CT showed round low density
area (5X5cm) in the mediastinum. Only a small hiatal hernia
was observed by gastroesophagoduodenoscopy. No evi-
dence of malignancy was detected by those examinations
and the tumor was diagnosed as a lipoma of the medi-
astinum. However, the patient developed dysphagia and
chest pain one year later. Enhanced CT showed enlargement
of the tumor and fine blood vessels in the tumor, which was
diagnosed as hiatal hernia with incaeceration of the omen-
tum, then laparoscopic repair was performed. Laparoscopic
view showed the omentum herniated into the thorax and
completely covered the hiatus, by which the stomach was
almost in normal position. The omentum was pulled out
from the thorax and the hernia was repaired with modified
Toupet fundoplication. Operation time was 142 min. The
patient allowed a soft diet on the first POD and discharged
on the seventh POD. The mediastinal tumor was disap-
peared after the surgery. Five months after the surgery, dur-
ing her last visit to the outpatient department, she remained
well and symptom free.

Hernia Surgery – P453

LAPAROSCOPIC LATERAL COMPONENT SEPARATION IN PATIENTS WITH INFECTED MESH, Judy Jin MD, Michael J Rosen MD, Case Medical Center, Case Western Reserve University, Department of Surgery, Cleveland, Ohio, USA

INTRODUCTION A single staged approach for resection of infected mesh, component separation, and definitive abdominal wall reconstruction has been successfully reported by our group. The extensive subcutaneous dissection and division of perforator vessels can result in skin flap necrosis and complex postoperative infections. We report our initial experience with a minimally invasive component separation during resection of infected prosthetic mesh.

METHOD Two patients with infected Composix mesh under-
went surgical excision of the mesh. The resultant defect
averaged 205 cm2. A laparoscopic component separation
was performed through a 10mm incision over the external
oblique. The potential space between the internal and exter-
nal oblique was created with a balloon dissector. The exter-
nal oblique fascia was incised 2 cm lateral to the rectus from
the costal margin to the inguinal ligament. The fascia was
closed primarily with Alloderm underlay reinforcement.

RESULT The average operative time was 255 minutes and the bilateral laparoscopic component separations were performed in 45 minutes. Primary fascial closure was achieved in both patients. Both patients were discharged home on postoperative day 5 without complications. One patient developed a minor midline wound infection that did not involve the lateral compartments and was treated with local measures and resolved within three weeks. At two months follow up both patients are back to full activity without evidence of recurrence or infection.

CONCLUSION This preliminary experience demonstrates that laparoscopic component separation can be safely performed with excellent short term results. While wound infections are not uncommon in the resection of infected prosthetic material, the complexity of these infections are greatly reduced with a laparoscopic component separation.

Hernia Surgery – P454

A NOVEL REPAIR OF RECURRENT PERINEAL HERNIA, Ali F Mallat MD, Jessica D Lemmons MD, Pleas R Copas, Jr. MD, Hobart E Akin MD, University of Tennessee Medical Center

Background: Secondary Perineal Hernia (PH) is an incisional hernia caused by a protrusion of intraabdominal organs through a defect in the pelvic floor. This is a rare complication after abdominoperineal resection (APR), hysterectomy or other pelvic procedures. It is usually discovered within 1 year of surgery and occurs mostly in females.

Case presentation: Our patient is a 69 year old gentleman who presented with a large PH two years after an APR for low rectal cancer. Patient underwent a laparoscopic repair

where the Levator Ani Muscles (LAM) were approximated together. Unfortunately he had recurrence less than five month later and was treated by an open hernia mesh repair to be diagnosed six month later with a second recurrence. Due to significant LAM thinning and pelvic wall scarring, it was thought that LAM approximation along with mesh reinforcement would not provide enough perineal floor support.

**Treatment and outcome:** A Prolift® mesh was modified by sewing an additional piece of Ultrapro® mesh to widen it in its most narrow portion posteriorly. The arcus tendineus fascia pelvis (ATFP) was identified. The superficial strap of the anterior segment was passed medially through the obturator membrane, then through the obturator internus muscle approximately 1 cm from the prepubic end of the ATFP. The deep strap of the anterior segment emerged through the obturator internus muscle behind the ATFP, approximately 1 cm from the ischial spine. The Posterior Segment was positioned in the ischioanal fossa and secured by passage of the straps through the sacrospinous ligament and coccygeus muscles. The sacrospinous ligament was then sutured to the Prolene mesh for added lateral support. Patient recovered well without complication and has been PH free for 1 year.

**Conclusion:** The choice of the best approach in PH repair must take into account pelvic anatomy as well as the use of appropriate synthetic materials to provide support to the damaged pelvic floor.

Hernia Surgery – P455

OBTURATOR HERNIA; A MORE COMMON ENTITY IN THE LAPAROSCOPIC ERA?, Arun A Mavanur MD, Scott J Ellner MD, Ibrahim M Daoud MD, Saint Francis Hospital / University of Connecticut

**Objective:** The incidence of obturator hernia is reported to be rare at about 0.1%. We present a single surgeon's experience with the presentation and laparoscopic approach to these hernias.

**Methods and Procedures:** A retrospective chart review was performed from 1992 to date. Details of patient demographics, symptoms and details of surgery were collected and analyzed.

**Results:** A total of 10 patients were identified to have an obturator hernia amongst the 2400 patients with herniae that underwent laparoscopic repair (incidence of 0.41%). All were female with a mean age of 58.5 years (range 15-93). None of our patients were diagnosed with an obturator hernia preoperatively, but were identified to have one at laparoscopy. 4 presented with recurrent hernia after a previous open repair, 3 with groin pain, and 3 with femoral hernia (1 incarcerated). 9 had TEP repairs. The patient with incarcerated femoral hernia had a TAP repair. No postoperative complications were encountered in our cohort. All except the patient with incarcerated femoral hernia were performed as day cases.

**Conclusions:** In our experience, obturator hernia is more common than reported in the literature. A laparoscopic approach allows easier intra-operative recognition of these hernias and is the probable explanation for the higher incidence in our study. These can be successfully repaired with either TEP or TAP repair.

Hernia Surgery – P456

A NOVEL APPROACH TO EXTRACTION OF INCARCERATED OMENTUM AND MESH INSERTION IN LAPAROSCOPIC VENTRAL HERNIA REPAIR, Kyle A Perry MD, Keith W Millikan MD, Jonathan A Myers MD, Rush University Medical Center

During laparoscopic ventral hernia repair (LVHR), it is not always possible to reduce incarcerated omentum through a tight defect and it may tear or require transection within the abdomen. This leaves an ischemic mass of tissue within the hernia sac which can cause pain, infection, or the appearance of hernia recurrence postoperatively. We describe a technique which allows extraction of any retained omentum within the hernia sac, mesh insertion, and laparoscopic completion of the procedure using only 5 mm trocars. After obtaining access to the abdomen with a 5 mm optical
<figure><img src="image_173.png" /></figure>

SAGES POSTER ABSTRACTS

trocar in select patients, lysis of adhesions is performed as needed. When incarcerated omentum that cannot be safely reduced is discovered, it is transected at the level of the abdominal wall using electrocoagulation or ultrasonic dissection. At this point, we make a 2-3 cm skin incision overlying the retained omentum, open the hernia sac, and remove the amputated omentum. The rolled up piece of mesh utilized for the repair is then inserted through this opening. The hernia sac is closed with absorbable suture, allowing reinsufflation of the abdomen and completion of the laparoscopic repair.

The aforementioned method enables us to safely remove any retained omentum from the hernia sac and utilize the same incision for mesh insertion. We utilize only 5 mm trocars without the need for a larger port through which to place the mesh into the abdomen. This reduces the risk of postoperative trocar site hernias as the opening for mesh insertion is covered by the mesh after it is fixed in place. This technique may also decrease the need for conversion to open hernia repair by allowing an alternative approach to reduce incarcerated omentum.

## Hernia Surgery - P457

TEP IN INCISIONAL AND VENTRAL HERNIA REPAIR, Bojan Radovanovic MD, Nenad Davidovic MD, Department of surgeru General hospital Pozarevac

During last twenty years Rives-Stoppa repair has become standard for repair of incisional hernias. This approach offers good mesh position easy and chip way of fixation, and possibility of implantation of broad spectrum of meshes. Endoscopic retromuscular approach has same benefits and offers advantages of minimal invasive surgery. During last two and a half years we performed 28 operations using this approach. From April 2003 to September 2005 we performed 28 operations in selected cases. We operated patients with hernia diameter less then 10 cm. Patients with symptoms of chronic and acute incarceration were excluded, but some of operated patients had irreducible hernias. The age of patients was between 42 and 78 years. We had eight umbilical,five epigastric hernias. Incisional: eight after upper medial laparotomy, two after medial infraumbilical lap., two after lateral and three after supra and infraumbilical lap. We used lateral approach in all cases. Three ports on the level of semi lunar line. Ten mm for laparoscop, and two 5mm for working instruments. The trocars are inserted under the rectus muscle and working space is created by insufflations and blunt dissection. We closed peritoneum with continuous suture. After opposite retro muscular space is created we placed mesh of adequate size. Mesh was fixed with suture passer transcutaneusly in all corners. We always put a drain. There were no intraoperative complications. One conversion, (second case) with addition of small incision for correction of mesh position.Two recurrences. Asymmetric defect with inadequate overleaping of the mesh. There was no infection. Weary low postoperative pain and discomfort. Although we are still in the learning curve, we can say that this approach can be used in all cases of small and medium sized hernias. We can use broad spectrum of meshes, and fixations is easy and chip, and avoid complications connected with intra-abdominal position.

## Hernia Surgery - P458

COMBINED LAPAROSCOPIC VENTRAL HERNIORRHAPHY WITH CHOLECYSTECTOMY USING ALLODERM TISSUE MATRIX, Michael Sawyer MD, Janice Strange, Darla Vardeman RN, Videoendoscopic Surgical Institute of Oklahoma and Great Plains Surgical Institute, Lawton, Oklahoma

A 57 year od man with a history of gallstone pancreatitis was referred for cholecystectomy. Physical examination demonstrated a large ventral hernia as well. The patient was counseled for laparoscopic cholecystectomy and ventral herniorrhaphy using Alloderm regenerative tissue matrix. The patient recovered uneventfully. He has had no postoperative complications at eight months of follow up. This is the first report of combined laparoscopic cholecystectomy with ventral herniorrhaphy using Alloderm tissue matrix.

<figure><img src="image_174.png" /></figure>

## Hernia Surgery - P459

LAPAROSCOPIC REPAIR OF FORAMEN OF MORGAGNI HERNIA IN A MORBIDLY OBESE PATIENT USING ALLODERM TISSUE MATRIX, Michael A Sawyer MD, Janice Strange, Darla Vardeman RN, Videoendoscopic Surgical Institute of Oklahoma and Great Plains Surgical Clinic, Lawton, Oklahoma

A 45 year od man with a BMI of 47.5 kg/m2 presented with signs and symptoms of complete gastric outlet obstruction. Nasogastric tube decompression afforded significant relief of symptoms. Radiologic studies revealed a foramen of Morgagni hernia with incarceration of the distal stomach, pylorus and proximal dodenum and attendant gastric outlet obstruction. Using a four trocar array, adhesions were lysed, and the incarcerated contents were reduced. The defect was repaired with an Alloderm regenerative tissue matrix, secured with laparoscopic tacks. The patient recovered uneventfully. He was discharged on the third postoperative day in good condition, tolerating a regular diet. He is doing well and remains symptom free at nine months of postoperative follow up. This is the first reported case detailing laparoscopic repair of a foramen of Morgagni hernia in a morbidly obese patient using Alloderm regenerative tissue matrix.

<figure><img src="image_175.png" /></figure>

## Hernia Surgery - P460

CHANGES IN BLADDER PRESSURE IN MORBIDLY OBESE PATIENTS 1-YEAR AFTER GASTRIC BYPASS SURGERY, T M Schmelzer BA, B L Paton BA, W L Newcomb BA, W W Hope MD, J H Norton PhD, T S Kuwada MD, K S Gersin MD, B T Heniford MD, Carolinas Medical Center

Morbidity obese people have been shown to have elevated intraabominal pressures, as measured though bladder pressure, when compared to people with a normal body mass index (BMI). We hypothesize that morbidly obese patients that experience weight loss after bariatric surgery will have decreases in their intraabdominal pressure. This study is a prospective study in which morbidly obese patients scheduled to undergo bariatric surgery had their bladder pressures measured preoperatively while doing sixteen different maneuvers. The measurements were then repeated one year after their operation. Mean bladder pressure was compared for each patient at the two time periods using a paired t-test. A p-value of <0.05 was considered significant.

Four patients completed the two phases of the study. The mean weight loss for the 4 patients was 44.98 kg (±14.76) corresponding to a decrease in mean BMI from 44.52kg/m2 (±3.49) to 29.09 kg/m2 (±2.13). The mean bladder pressure decreased in all of 15 maneuvers performed. The changes in pressure were statistically significant in 7 of 15 maneuvers performed. These included coughing (p = 0.0007), abdominal crunch (p = 0.0004), standing (p = 0.01), sitting (p = 0.02), valsalva while standing (p = 0.0005), lifting 10 pounds (p =
<figure><img src="image_176.png" /></figure>

0.01), and climbing stairs (p = 0.0001). The remaining maneuvers demonstrated decreased pressure postoperatively which trended towards significance. The percentage change in pressure for the various maneuvers ranged from -7.02% to -70.19%.

This study demonstrates that weight loss has an impact on intrabdominal pressure. We demonstrated significant decreases in pressure despite having a small study size. With continued enrollment in this study, we anticipate showing significant decreases in bladder pressures for all of the maneuvers we evaluate. Since it has been hypothesized that higher intra-abdominal pressures may increase the risk of hernia formation, this study suggests that weight loss may be a valuable method for prevention of hernia formation or recurrence in the morbidly obese patient population.

## Hernia Surgery - P461

THE NOVEL USE OF DIAGNOSTIC LAPAROSCOPY IN AN INCARCERATED FEMORAL HERNIA, Adam T Silverman MD, Sandip Maru MD, Mark Schwartz MD, Monmouth Medical Center

Femoral hernias account for only 2-8% of all hernias. Femoral hernias are more common in females with a preponderance of 4:1. The reason for this preponderance is the wider bone structure of the female pelvis. A typical presentation is an elderly frail female with a bulge in the groin. Patients can present with a varying array of complication sequela from irreducibility through intestinal obstruction to frank gangrene of strangulated bowel. The incidence of strangulation in femoral hernias is high at 40%. Femoral hernias can either be repaired via an open approach or laparoscopically. The authors present an interesting case of a female with an incarcerated femoral hernia that was repaired by an open procedure. To assess the viability of the bowel a diagnostic laparoscopy via the femoral canal was performed. The bowel was viable so a subsequent repair with mesh was performed. We present the literature utilizing diagnostic laparoscopy in hernia repairs and a novel approach in the evaluation of an incarcerated femoral hernia.

## Hernia Surgery - P462

IS EXPLANTATION OF INFECTED MESH AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR THE ONLY ASNWER?, N E Terry MD, Oliver C Whipple MD, Carl R Boyd MD, John D Angstadt MD, Memorial Health University Medical Center, Mercer University School of Medicine — Savannah Campus

**Introduction:** Laparoscopic ventral hernia repair has become the preferred technique for hernia repair in many institutions. Despite a significant decrease in the incidence of mesh infection with the laparoscopic approach, mesh infection remains a difficult problem that historically has demanded explantation of the mesh. We present a series of two cases that were managed initially without explantation of the mesh.

**Methods:** Parietex® dual mesh or Proceed® mesh were used in all of our ventral hernia repairs over the past two years. During that time, two patients developed mesh infections associated with a large abscess or exposed mesh. One was successfully managed without mesh explantation. One patient developed a bowel obstruction after laparoscopic ventral hernia repair. An incision was made through the mesh after an enterotomy, and the mesh was sewn closed. This patient went on to develop a wound infection that was treated open with exposed mesh. The wound granulated in and has remained closed for 12 months without further infection. The second patient developed a large intraabdominal abscess below the mesh 2 weeks after the laparoscopic ventral hernia repair. The abscess was treated with computed tomography scanning guided drainage. The cultures were positive for E. coli. A second collection anterior to the mesh was drained through an open incision. This patient had complete resolution of her leukocytosis and other symptoms for four weeks. She then developed cellulitis, and mesh explantation was performed.

**Results:** Both patients had resolution of fever, leukocytosis,

and all other symptoms, but only one of the two has completely cleared the infection. The mesh was salvaged in this particular case, without the need for removal and repeat hernia repair.

**Conclusions:** Despite minimally invasive techniques to repair ventral hernias, mesh infection still remains a complication often requiring a large incision with removal of the mesh. With the advent of the lower molecular weight prostheses, greater tissue ingrowth may allow mesh salvage in select cases. This case demonstrates the ability to manage this complication nonoperatively with the aid of intravenous antibiotics, abscess drainage, and close surveillance.

## Hernia Surgery - P463

CHRONIC POSTERIOR SEROMA WITH NEOPERITONEUM FOLLOWING LAPAROSCOPIC VENTRAL HERNIA REPAIR: TREATMENT ALGORITHM, Zurab Tsereteli MD, Archana Ramaswamy MD, Bruce Ramshaw MD, Department of General Surgery, University of Missouri-Columbia, Columbia, MO

**Introduction:** Laparoscopic ventral hernia repair is now widely performed. Seromas frequently occur following laparoscopic ventral hernia repair. Most seromas usually form anterior to the mesh and resolve with conservative management. In rare cases, some patients develop pseudo-neoperitoneum deep to the mesh which secrets fluids forming a collection. We present the group of 9 patients with delayed seroma posterior to mesh and a possible treatment algorithm for this situation.

**Methods:** All nine patients underwent laparoscopic ventral hernia repair with mesh the last 3 years. The patients developed persistent abdominal pain and/or abdominal wall mass between 1 month and 1 year postoperatively. CT scan revealed a fluid collection posterior to the mesh. Five patients presented with an asymptomatic mass and have been followed without any intervention. Three patients had severe symptoms and underwent laparoscopic exploration which demonstrated a large fluid collection posterior to the mesh bounded by a thick neoperitoneum. A small window was created in the neoperitoneum to allow for free drainage into the peritoneal cavity. They experienced significant improvement. One patient following two attempts of percutaneous drainage of posterior seroma underwent laparoscopic drainage in same fashion. Three weeks later the fluid reaccumulated with recurrence of symptoms, and following an attempt of replacement with a hydrophilic mesh, the patient required a biologic mesh.

**Result:** Based on this experience a treatment algorithm is presented for management of a persistent posterior seroma following laparoscopic ventral hernia repair. The first step is simple follow up without any intervention. Patients without improving symptoms should be considered for laparoscopic internal drainage of the fluid collection. The final option for patients who fail drainage procedure is mesh removal with or without new mesh placement.

**Conclusion:** Persistent seroma posterior to the mesh following laparoscopic ventral hernia repair is a rare problem. The above algorithm may help guide management of this complex situation.

## Hernia Surgery - P464

TRANS ABDOMINAL PRE-PERITONEAL MESH (TAPP) REINFORCEMENT OF POSTERIOR LOWER ABDOMINAL WALL IN-PATIENTS WITH SPORTSMAN'S GROIN; IS IT WORTH-WHILE?, Y Viswanath MS, C Munipalle MS, James Cook University Hospital, Marton Road, Middlesbrough, Cleveland, UK

**AIM:** Management of groin pain in the absence of a clinically palpable hernia in young athletes is challenging to the attending surgeon. We evaluated the role of laparoscopic reinforcement of posterior abdominal through the Trans Abdominal Pre-Peritoneal (TAPP) route.

**METHODS:** All patients suspected to have Sportsman's groin after initial assessment by a muskulo-skeletal specialist and failed conservative measures underwent TAPP reinforcement of lower abdominal wall using an non-absorbable
<figure><img src="image_177.png" /></figure>

SAGES POSTER ABSTRACTS

mesh. All patients had plain radiology, Dynamic Ultrasound Scan of Groin and or MRI.

**RESULTS** Among a total of 20 patients who underwent TAPP mesh reinforcement over a period of 24 months, 12 (Group A) had bilateral and 8 had unilateral groin pathology. Four (20%) among 20 (Group B) had associated other pathology (adductor enthesopathy in three and one has osteitis pubis). Preinjury level of activity to 100% in all 17 athletes in-group A and 70% improvement in all four in-group B was attained within 6-8 weeks. One patient in group A and one in Group B developed recurrent symptoms after 12 months and subsequent investigations were unrevealing.

**CONCLUSION** TAPP mesh reinforcement in symptomatic athletes with Sportsman's groin should be considered as an option and the success rate in-patients with isolated groin pathology is higher than ones with multiple pathology.

## Hernia Surgery - P465

### LAPAROSCOPIC VERSUS OPEN COMPONENT SEPARATION: A COMPARATIVE ANALYSIS IN A PORCINE MODEL

Christina P Williams MD, Michael J Rosen MD, Judy Jin MD, McGee F Michael MD, Steve J Schomisch BS, Ponsky Jeffrey MD, Case Medical Center, Case Western Reserve University, Department of Surgery, Cleveland, Ohio, USA

**Background:** The ideal surgical treatment for complicated ventral hernias remains elusive. Traditional component separation provides local advancement of native tissue for tension free closure without prosthetic materials. This technique requires an extensive subcutaneous dissection with division of perforating vessels predisposing to skin flap necrosis and complicated wound infections. A minimally invasive component separation may decrease wound complication rates, however the adequacy of the myofascial advancement has not been studied.

**Methods:** Seven 20 kg pigs underwent bilateral laparoscopic component separation. A 10 mm incision was made lateral to the rectus abdominus muscle. The external oblique fascia was incised, and a dissecting balloon was inflated between the internal and external oblique muscles. Two additional ports were placed in the intermuscular space. The external oblique was incised from the costal margin to the inguinal ligament. The maximal abdominal wall advancement was recorded. A formal open component separation was then performed and maximal advancement 5cm superior and 5cm inferior to the umbilicus was recorded for comparison.

**Results:** The laparoscopic component separation was completed successfully in all animals in an average of 20 minutes per side. Laparoscopic component separation yielded 3.7cm (sd 1.0) of fascial advancement above the umbilicus, while 4.2cm (1.1) was obtained after open release. Below the umbilicus, laparoscopic release achieved 4.8cm (1.2) of advancement while 5.6cm (1.1) was gained after open release.

**Conclusions:** The minimally invasive component separation achieved 86% of the myofascial advancement as compared to a formal open release while avoiding the risks of skin necrosis, large wound infection, and seroma formation resulting from extensive subcutaneous dissection. Laparoscopic component separation should be considered the procedure of choice for providing local myofascial advancement flaps in repairing complicated ventral hernias.

## Minimally Invasive Other - P466

### VARICOCOLECTOMY BY ENDOSCOPIC EXTRAPERITONEAL ROUTE (VEER), B B Agarwal MS, M K Gupta MS, S

Agarwal MS, K C Mahajan MS, Sir Ganga Ram Hospital & Lady Hardinge Medical College, India

**Aims:** To perform safe Varicocoelectomy endoscopically by extraperitoneal route.

**Materials & Methods:** From April 2004 to May 2005, 8 patients were operated for symptomatic varicocoele. 6 of them had primary infertility with oligo-asthenospermia and 2 were advised surgery for scrotal pain.

All of them had clinically manifest varicocoele. Ultrasound and doppler were done to determine the testicular size and reflux velocity.

Laparoscopic ligation with division of testicular veins is widely accepted treatment for varicocoele. Better endoscopic surgical understanding of extraperitoneal space has paralleled the evolution of totally extraperitoneal repair (TEP) for inguinal hernia. With our experience of TEP repair, we are now performing ligation and division of testicular veins close to deep inguinal ring, extraperitoneally. This not only avoids the violation of peritoneal cavity, but also ensures the venous disconnection in a more precise manner.

**Results:** There have been no recurrences after a mean follow up of 18 months. Semen parameters improved in all the 6 patients.

**Conclusion:** Varicocoelectomy Endoscopically by Extraperitoneal Route (VEER) is a safe technique for symptomatic varicocoele.

## Minimally Invasive Other - P467

### FLUOROSCOPY GUIDED LAPAROSCOPIC REMOVAL OF INGESTED FOREIGN BODY (SEWING NEEDLE) FROM THE ABDOMINAL CAVITY AFTER 9 YEARS AND TWO FAILED LAPAROTOMIES, RAMESH AGARWALLA MS, OM TANTIA MS, ILS MULTISPECIALITY CLINIC

Ingested foreign bodies pass out spontaneously with stool or are removed by endoscopic methods or surgically. In few cases, the foreign bodies cannot be removed and they lie in the abdominal cavity without any symptoms. We report a case where a sewing needle was accidentally ingested 9 years ago. The patient had 2 failed laparotomies at the district hospital for its removal. The patient was having non specific abdominal pain which she attributed to the needle in her abdomen.

She had developed severe anxiety as a result and had repeated admissions to the hospital for the same. The needle which had broken into two parts over a period of 9 years and had migrated out of gastrointestinal tract was removed by fluoroscopy guided laparoscopic surgery.

## Minimally Invasive Other - P468

### LAPAROSCOPIC PD CATHETER INSERTIONS Jannet

Anderson RN, Wing So RN, Diane Watson MSc, Todd Penner MD, University Health Network - Toronto Western Hospital

Good placement of a catheter for peritoneal dialysis (PD) is of utmost importance for an individual undertaking PD for end stage renal disease (ESRD). Traditionally, PD catheter insertion was carried out by surgeons using an open insertion (OI) under general anesthesia (GA), which results in a blind placement and risk of bowel injuries and catheter misplacement. Commencing May 2006, PD catheters are inserted using a laparoscopic insertion (LI) method at UHN, Toronto Western Hospital, Toronto, Canada. LI has the benefits of direct visualization of placement, decreased trauma and immediate recognition of intra-abdominal adhesions. This paper reviews the experience of PD catheter insertions by one surgeon during 2006, with 15 OI and 15 LI PD catheters.

We utilize a 5mm VersaStep® dilator and cannula with radially expandable sleeve to insert a 5mm telescope, then a 7-8mm dilator and cannula with radially expandable sleeve to place the PD catheter (Quinton Swan Neck®) at the suitable site. Insufflation has been previously carried out by Carbon Dioxide (CO2), which can be uncomfortable, thus used only with GA. We use Nitrous Oxide, which is not painful, and can be used with local anaesthetic (LA). Patients with ESRD are medically compromised so LA is preferable, provides faster recovery time and has potentially less risk.

We found 2 (13%) instances of catheter misplacement in the OI group, but none in the LI group. There were no immediate leaks in either group, however, there were 3 instances (20%) of late leak (after 2 weeks) in the LI group. In the OI group, there was one incident (7%) of wound abscess, and one incident (7%) of scrotal leak, which resulted in discontinuation of PD for both patients. Significantly, in the LI group, adhesions were visualized in 6 individuals (40%), and lysed in 4 (27%) of these cases, with two omentopexy carried out. Adhesions and omental wrapping are known complications, which can lead to peritoneal dialysis failure, thus
recognition and prophylactic treatment can have considerable benefit.

Laparoscopic PD catheter insertion under local anaesthetic has been shown to be efficient, and can provide prophylactic benefit, and is well accepted by patients requiring Peritoneal Dialysis.

## Minimally Invasive Other - P469

### PRE OPERATIVE ANGIOGRAPHIC SPENIC ARTERY EMBOLIZATION BEFORE LAPAROSCOPIC SPLENECTOMY

### FOR GIANT SPEENS: IS IT OF ANY BENEFIT?, Barak Bar-

zakai MD, Uri Rimon MD, Dan Rosin MD, Oded Zmora MD, Jihan Obeid MSc, Yaron Munz MD, Moshe Shabtai MD, Amram Ayalon MD, Department of Surgery and Transplantation, Sheba medical center, Tel Aviv university, Tel hashomer, 52621, Israel.

**Objective:** Preoperative splenic artery embolization is recommended before splenectomy for giant spleens, in order to reduce the intraoperative blood loss and the need for blood transfusion.

The goal of this study was to assess the possible benefit and safety of angiographic splenic artery embolization before laparoscopic splenectomy for giant spleens.

**Methods and procedures:** retrospective chart and computer data of patients who underwent preoperative angiographic splenic artery embolization prior to splenectomy in our department was collected.

Preoperative embolization was performed using both micro coils and gelatin sponge fragments, the morning of the operation.

**Results:** Between may 2001-May 2006, 20 patients underwent splenic artery embolization prior to splenectomy in our department.

In 7 patients laparoscopic approach was attempted, in 4 of them conversion to open approach was needed due to either bleeding or major difficulties during dissection. In 3 cases the laparoscopic approach was completed uneventfully.

The mean spleen weight was 1713 grams and the mean length of spleen was 23 cm.

The mean operative time, mean blood loss and mean volume of blood transfused were lower in the converted group (96 min. vs.185 min; 267 cc vs. 350 cc; 167 cc vs.427 cc).

The mean postoperative hospitalization was longer in the converted group (11 days vs. 4 days).

Among the converted group 3 patients developed post operative complications (pancreatic fistula, F.U.O, aspiration pneumonia), while in the laparoscopically completed group 1 patient developed post operative complications (thrombophlebitis).

No complications related to the embolization were recorded.

**Conclusions:** Although preoperative angiography is safe procedure and should be considered before open splenectomy for giant spleens, the benefit in laparoscopic splenectomy for giant spleens is doubtful as the conversion rate of such procedures in this cases is high (more than 50%), and puts under scrutiny the utility of laparoscopic splenectomy for giant spleens.

## Minimally Invasive Other - P470

### GALL STONE PANCREATITIS AFTER ROUX-EN-Y GASTRIC BYPASS: A TECHNIQUE OF LAP-ASSIST ERCP VIA THE GASTRIC REMNANT DURING LAPAROSCOPIC CHOLECYSTECTOMY,

Steven J Binenbaum MD, Frank J Borao MD, Steven A Gorcey MD, Monmouth Medical Center, Long Branch, NJ

Roux-en-Y gastric bypass surgery eliminates access to the second portion of the duodenum during the upper endoscopy. An ERCP may be required in evaluation of patients with symptomatic choledocholithiasis after having had gastric bypass surgery. Laparoscopically assisted ERCP during laparoscopic cholecystectomy is a safe technique for accessing biliopancreatic limb via the gastric remnant.

We describe a technique of performing an ERCP during laparoscopic cholecystectomy in two patients who presented with gall stone pancreatitis after the Roux-en-Y gastric

bypass operation. The first patient was diagnosed with gall stone pancreatitis many years after the operation and the second only six months after surgery. An ERCP was performed using a 15 mm laparoscopic port via the gastric remnant. Following extraction of stones from the common bile duct and sphincterotomy, laparoscopic cholecystectomy was successfully carried out as planned.

An ERCP performed through one of the laparoscopic ports is a safe and easy alternative to preoperative access to gastric remnant using interventional radiology techniques. Lap-assist ERCP is a one stage procedure executed at the same time as laparoscopic cholecystectomy which spares the patient the expense and the risk of complications from additional preoperative testing.

## Minimally Invasive Other - P471

### THE USE OF ELECTROTHERMAL BIPOLAR VESSEL SEALING SYSTEM (LIGASURE?) IN MINIMALLY INVASIVE VIDEOASSISTED THYROID SURGERY, Gianlorenzo

Dionigi, Luigi Boni PhD, Francesca Rovera, Veronica Bianchi, Patrizia Castano, Francesca Villa, Matteo Annoni, Department of Surgical Sciences, University of Insubria

Minimally invasive video-assisted thyroidectomy (MIVAT) has been practiced in our Department since 2005. It has some advantages over conventional surgery in terms of postoperative pain and cosmetic result. The aim of this study was to evaluate the use of the electrothermal bipolar vessel sealing system (Ligasure Precise, Valleylab, USA) on the performance of this procedure.

Between October 2005 and August 2006, 30 patients underwent MIVAT. The device was used for the last 13 operations. We compared this group of patients (LP) with a control group (CG) using Ultrasonic coagulating-dissection system (Ultracision CS-14C, EthiconEndo-Surgery, Cincinnati, USA) of 10 patients who had undergone MIVAT before the introduction of the LP. The following parameters were considered: age, gender, preoperative diagnosis, size of the lesion, type of operation (lobectomy or total thyroidectomy), incision length (at the start of the procedure and at the end), operative time, complication rate, and postoperative hospital stay.

**RESULTS** The two groups were well matched for age, gender, preoperative diagnosis, lesion size, and type of operation. The mean operative time and postoperative stay were for both lobectomy and total thyroidectomy not significant different. One patient in CG group experienced a transient recurrent nerve palsy. No cases required conversion to open surgery and none involved significant intraoperative complications. No patients complained of hypesthesia or paresthesia of the neck region or discomfort while swallowing 5 months after surgery. All patients were satisfied with the cosmetic results. As for the incision length (at the start of the procedure and at the end) there was not significant differences in the two groups.

This study showed that the utilization of the Ligasure for MIVAT is safe. Ligasure for MIVAT is feasible and provides excellent cosmetic results with a minimal degree of postoperative complaints. A reduction of the rates for such complications such as hypoparathyroidism and recurrent nerve injuries was not possible to demonstrate in the present study. Much larger series are needed for further evaluation of this instrument.

## Minimally Invasive Other - P472

### TROCHARLESS LAPAROSCOPIC CAPD CATHETER PLACE-MENT. A 2 YEAR REVIEW OF A NEW TECHNIQUE, Esmond Chi MD, Jukes Namm MD, Michael Chi BA, Antonio Robles MD, Loma Linda University, Jerry L. Pettis VAMC

**INTRODUCTION:** We describe a new technique for placing laparoscopic continuous ambulatory peritoneal dialysis (CAPD) catheters for end stage renal disease without the use of trocars.

**PROCEDURE:** A 5 mm left periumbilical incision is made. The abdomen is insufflated to 14 mmHg using the veress needle. The same incision is extended 4 cm transversely into a muscle splitting incision to expose the posterior rec-
<figure><img src="image_178.png" /></figure>

# SAGES POSTER ABSTRACTS

tus abdominus fascia. Here a purse-string suture is placed. A 16-french Bard introducer peel-away catheter (cath#0601520) is inserted through the purse-string and manually guided into the pelvis. Through this catheter a 5 mm, peritoneoscope visualizes the pelvis by identifying the bladder, sigmoid and pelvic bones. The catheter held firmly in place, and the scope is removed. A 57 inch Quinton CAPD catheter (cath #5c4160) is placed through the peel-away catheter into the pelvis. The peel-away sheath is removed and the CAPD catheter is left in the pelvis. The external end of the CAPD catheter is brought through a separate stab incision 3 cm cephalad. One liter of dialysate is infused and immediately retrieved to confirm of the catheter's function and location.

**RESULTS:** 10 consecutive patients who underwent a laparoscopic CAPD catheter placement over a 2 year period were reviewed. The trocharless technique (TL) was used in 4 patients. The single trochar technique (ST) was used in 6 patients. The mean follow-up was 12.3 months. Operative time, catheter long and short term function(fx), complications and removal were compared with both groups (table 1).

**CONCLUSION:** The trocharless technique for placing CAPD catheters is safe and effective compared to the single trochar technique

<table><thead><tr><th></th><th>TL(n=4)</th><th>ST(n=6)</th></tr></thead><tbody><tr><td>op time (min)</td><td>52</td><td>70</td></tr><tr><td>% short term fx</td><td>100</td><td>100</td></tr><tr><td>% long term fx</td><td>80</td><td>30</td></tr><tr><td>removed CAPD(%)</td><td>0</td><td>50</td></tr><tr><td>infection (%)</td><td>25</td><td>33</td></tr></tbody></table>

## Minimally Invasive Other - P473

### LAPAROSCOPIC REMOVAL OF A RETAINED LAPAROTOMY SPONGE - A CASE REPORT AND LITERATURE REVIEW, Ravi

J Chokshi MD, Mohammed I Khan MD, Samer Sbayi MD, Derick Christian MD, St. Francis Medical Center

A dreaded complication of surgery is a retained sponge or instrument. It is estimated that there is at least one sponge or instrument left in the body for every 8,000 to 18,000 cases. The standard of care has been to subject the patient to a repeat laparotomy and removal of the foreign body. We present a case of a 63 year old morbidly obese male who underwent an open cholecystectomy for acute cholecystitis. Difficult dissection and the patient's size caused the case to be prolonged with extensive bleeding. During final sponge and instrument counts, the sponge count was incorrect. An extensive exploration combined with multiple abdominal films failed to show evidence of the missing sponge. A computed tomography the following morning demonstrated the sponge ribbon. Later the same day, the patient underwent a diagnostic laparoscopy with removal of the sponge. The patient's hospital course was unremarkable and was subsequently discharged on the third post-operative day. We suggest the use of laparoscopy for the removal of foreign bodies is successful and minimally invasive when compared to a laparotomy.

## Minimally Invasive Other - P474

### DIAPHRAGMATIC HERNIAS FOLLOWING SEQUENTIAL VENTRICULAR ASSIST DEVICE EXPLANTATION AND ORTHOTOPIC HEART TRANSPLANTATION: EARLY RESULTS OF LAPAROSCOPIC REPAIR WITH PTFE, Shawn S Groth MD, Bryan A Whitson MD, Kenneth K Liao MD, Rafael S Andrade MD, Michael A Maddaus MD, University of Minnesota Department of Surgery

**Introduction:** Patients who undergo orthotopic heart transplantation (OHT) following ventricular assist device (VAD) explanation are at an increased risk of developing diaphragmatic hernias. Traditionally, repair of these hernias has been performed through an open approach. The aim of this study was to evaluate the safety, post-operative length of stay (LOS), and short-term efficacy of laparoscopic repair of diaphragmatic hernias post-VAD explantation.

**Methods and Procedures:** Single institution retrospective review of patients who underwent laparoscopic post-VAD

diaphragmatic hernia repair. Using a prospectively-maintained data base, patient demographics, operative details, and results of early follow-up were collected and analyzed. Failure of the repair was defined by chest x-ray or CT evidence of recurrence.

**Results:** Between January 2004 and February 2006, four men, mean age of 46 years (range 18 to 65), underwent laparoscopic post-VAD diaphragmatic hernia repair. The mean time to presentation following OHT was 30.8 months (range 9 to 63). The mean size of the defect was 9.5 cm (range 6 to 15). Three of the hernias contained omentum. One hernia, the only one which required emergent repair, contained transverse colon. All repairs were completely performed laparoscopically. Because it would have resulted in significant tension due to the size of the defects, none of the hernias were repaired primarily. Instead, a PTFE patch was secured over each patient's defect with pledget-reinforced, braided, nonabsorbable, hand-sewn mattress sutures and was reinforced with laparoscopic tacking screws. The mean LOS was 2.3 days (range 1 to 4). There were no peri-operative complications. At a mean follow-up period of 15.5 months (range 6.5 to 31), there have been no recurrences.

**Conclusions:** This report, the only series of laparoscopic repair of diaphragmatic hernias which developed following VAD explantation, demonstrates that laparoscopic repair with PTFE can be performed with minimal morbidity, with a brief LOS, and with excellent short-term results.

## Minimally Invasive Other - P475

### EARLY RETURN TO PERITONEAL DIALYSIS FOLLOWING LAPAROSCOPIC REVISION OF MALFUNCTIONING

CATHETERS, J Gutierrez MD, A. Ney MD, M Odland MD, C Richardson MD, HCMC

**Introduction:** Laparoscopic revision of Peritoneal Dialysis Catheters (PDC) is an accepted technique to identify and manage the common causes of malfunction. In our series the use of a two millimeter telescope and three millimeter ports allowed early return to dialysis following revision.

**Methods:** Between 2005-2006, eight patients underwent laparoscopic revision of PDC. Patient age, diagnosis and time to catheter revision were analyzed. In seven patients the PDC exit site was used to insufflate the abdomen, in one patient the catheter was plugged and the Veres technique was used for insufflation. All patients had a 2mm telescope placed, two patients had one additional 3mm port placed, six patients had 2 additional working ports placed. All patients had the PDC secured to the anterior abdominal wall to direct the catheter into the pelvis.

**Results:** All catheters were initially implanted using the open technique. Laparoscopic findings at time of revision were migration (four) and omental wrapping (four). Four patients started using their catheters two to seven days from revision and two patients in two weeks. Complications included a postoperative partial small bowel obstruction treated medically. This patient was unable to use the PD catheter secondary to pain and inadequate dialysis. One patient had chronic pain with peritoneal dialysis runs and asked to have the catheter removed. The remainder of the catheters continue to function.

**Conclusion:** Laparoscopy is highly effective in the management of peritoneal dialysis dysfunction. With the smaller ports early return to peritoneal dialysis is safe. None of our patients had port site leakage problems. Securing the catheter to the abdominal wall directed toward the pelvis has prevented catheter migration and omental plugging in our series. We recommend laparoscopic technique be used for revision of malfunctioning peritoneal dialysis catheters.

## Minimally Invasive Other - P476

### LAPAROSCOPIC SURGERY FOR PERSONS OF ADVANCED

AGE, Ken Hagiwara MD, Minoru Matsuda MD, Motoo Yamagata MD, Shigeoki Hayashi MD, Tadatoshi Takayama MD, Division of Digestive Surgery, Nihon University school of Medicine

**Introduction:** The average life span of Japanese people is extending year and year, a person of advanced age is increasing. So, the opportunity of performing surgical oper-
ation for parson of advanced age will be increase. It is the important point of surgical operation for patient of advanced age to perform minimally invasive operation and to prevent of postoperative complication. We investigated on safety and feasibility of laparoscopic surgery for old age. Patient selection; Eighteen cases of gastrointestinal malignancies (include 10 cases of gastric cancer and 8 cases of colorectal cancer) were selected. the average of age was 85.1 y.o. (81-96). Male : female= 1:1, 2 cases of local resection except lymphadenectomy, 7 cases of distal gastrectomy, 1 case of total gastrectomy, 2 cases of ileocecal resection, 1 case of Rt. hemicolectomy, 2 cases of sigmoidectomy, and 3 cases of anterior resection.

The Performance Status (P.S.) before operation were grade 0= 1 case, grade 1= 5 cases, grade 2= 8 cases, grade 3= 2 cases and ASA were PS 1= 6 cases and PS 2= 12 cases.

They have preoperative complication (11 cases of hypertension, 1 case of Diabetes, 1 case of cerebral infarction, 3 cases of renal failure, 2 cases of heart disease, 4 cases of anemia and 1 case of COPD)

**Result:** we performed operation laparoscopically in all cases. Average duration of operation is 194.5 min. Average blood loss is 117.5 ml. There is no intraoperative complication. One case of renal failure, 1 case of pneumonia and 1 case of pseudomembranous enterocolitis were observed as postoperative complication. All patient recovered and discharged by conservative therapy and average of hospital stay was 21.7days. As a result, laparoscopic procedure was able to perform safety in old age.

**Conclusion:** laparoscopic procedure is feasible and safety for parson of advanced age and some benefits were given the patients.

## Minimally Invasive Other - P477

LAPAROSCOPIC APPENDECTOMY PERFORMED IN OUR INSTITUTION, Yuzo Hirata MD, Jiro Okiyama MD, Yasuhiro Imaoka MD, Chiaki Inokuchi MD, Inokuchi hospital

**Methods** Here we present the results of a study carried out on 83 patients diagnosed with pathologically confirmed appendicitis from January 2002 to June 2006 in our institution. Patients ages ranged from 11 to 81 and the male:female ratio was 51:32. They were divided into three different groups for surgery, with 22 patients undergoing laparoscopic surgery (LA group); 57 patients subject to open appendectomy (OA group); and 4 patients converted to open appendectomy (CO group). Following a post-operative examination for cancer, the extent of appendicitis in patients was then examined for this study.

**Results** We found no cases of superficial (S) inflammation in the LA group, although there were 9 phlegmonous (P), and 13 gangrenous cases (G). The OA group contained 5 cases of S, 34 cases of P, and 20 cases of G. Among the CO group there were 4 cases of G. Although we found that there was no difference in duration of surgery among P cases from either the LA or OA groups, we did find that significantly longer surgery was required for G cases from the LA group. Furthermore, three cases from the OA group were observed as suffering from wound infection, while there were no such cases in the LA group. Although there was no difference in the total number of hospitalized days required in either LA or OA groups, the period of admittance in the CO group was considerably longer than either of these two groups.

**Conclusion** An increase in the number of cases of laparoscopic appendectomy being performed has been accompanied by an improvement in surgical outcome. This technique can be seen as being particularly beneficial to the patient in terms of cosmetic considerations and a lack of complications. In the event of patients developing an intestinal obstruction or having a highly inflamed appendix, however, the subsequent difficulties encountered in performing laparoscopic manipulation means that it is extremely important to consider an intraoperative change to open appendectomy.

## Minimally Invasive Other - P478

A CASE OF KAPAROSCOPIC PERSISTENT URACHAL RESECTION, K Ishii MD, K Katagiri MD, Y Takahashi MD, K Itabashi MD, K Furuta MD, M Watanabe MD, KITASATO University
A 23-year-old female with persistent urachal with lower abdominal pain is reported.

She had this episode from the period of elemental school student and had at the period of senior high school and 21-year-old. She searched disease with a similar symptom in internet and suspected persistent urachal. At admission, a induration was palpated in the midline of her lower abdomen. We approached with laparoscopic operation. Three ports was inserted in abdominal cavity at left lateral abdomen. A fold of urachal in lower abdomen was searched and excised with laparoscopic operation. The cut-end near the bladder was ligated with a endoloop. ?? ? ter operation, She had no symptom with no complication. As 6 months after operation, it is uneventful.

Laparoscopic persistent urachal resection is feasible and safety operation.

## Minimally Invasive Other - P479

GEOGRAPHIC VARIATION IN ADOPTION OF LAPAROSCOPIC CHOLECYSTECTOMY, Jason A Kemp MD, Samuel R G. Finlayson MD, Dartmouth-Hitchcock Medical Center

**Introduction:** For many general surgeons, the professional isolation of rural practice serves as an obstacle to the adoption of new techniques. Whether this obstacle impeded the dissemination of laparoscopy in rural settings is not known.

**Methods:** Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, American Hospital Association data, and Rural-Urban Commuting Codes, we identified all laparoscopic and open cholecystectomy procedures performed in rural and urban hospitals for each year from 1988 to 1997. We then examined the trends in adoption of laparoscopic cholecystectomy in rural versus urban hospitals.

**Results:** 4,683,343 cholecystectomies were performed nationwide from 1988 to 1997. Overall, the proportion of procedures done laparoscopically increased from 2.9% to 81.9% for elective cholecystectomy, and from 1.1% to 71.8% for urgent cholecystectomy. The proportion of elective procedures done laparoscopically increased sharply from 1990 to 1992 from 2.9% to 73.7% and remained high for both rural and urban areas, with negligible difference in timing of adoption. Use of the laparoscopic approach for urgent cholecystectomy increased sharply from 1990 to 1992 (1.1% to 55.4%), and since 1992, has continued to increase steadily in both rural and urban areas (to 69.6% and 74.0% respectively). These trends were not substantially different across geographic regions of the US.

**Conclusions:** Although very small differences in the use of laparoscopy in rural vs. urban settings are evident, the timing and rate at which rural surgeons adopted laparoscopic cholecystectomy mirrored that of urban surgeons from 1988 to 1997. These data suggest that most rural surgeons managed to learn and adopt the laparoscopic approach to cholecystectomy despite the obstacle of professional isolation.

## Minimally Invasive Other - P480

TITLE: LAPAROSCOPIC PLACEMENT OF AN ABSORBABLE MESH TO PROTECT SMALL BOWEL DURING PELVIC RADIOTHERAPY., F M Kiernan MD, M Joyce MD, C K Byrnes MD, N Davarinos MD, P Thirion MD, P Neary MD, F B Keane MD, Division of Colorectal Surgery, Department of General and Vascular Surgery, Adelaide and Meath Hospital, Tallaght, Dublin 24, and Department of Radiation / Oncology St Lukes Hospital, Rathgar, Dublin 6, Ireland

**Introduction:** Radiotherapy has significantly improved the outcome for patients with pelvic malignancies. The response to treatment is dose dependent but the presence of small bowel in the radiation field is a limiting factor. Intestinal slings have been developed to suspend the bowel above the pelvis facilitating the delivery of radiation thus improving the potential for oncological cure. These have traditionally been inserted using an open technique. We herein
<figure><img src="image_179.png" /></figure>

# SAGES POSTER ABSTRACTS

describe the placement of a mesh using a minimally invasive technique.

**Methods:** The medical reports of three patients, who were diagnosed with prostate cancer, were reviewed. Pre-radiotherapy Cat Scans identified small bowel in the radiation field. The 3 patients had small bowel extracted from the pelvis with the insertion of an absorbable mesh using a minimally invasive technique. Patients were rescanned following radiotherapy.

**Results:** There were no complications from laparoscopic mesh placement, and elevation of small bowel from the pelvis. All patients were discharged surgically within 48 hours. All patients received the optimal dose of radiotherapy (70 GY) with a check CT scan confirming dissolution of the mesh at 6 weeks.

**Conclusion:** Elevation of the small bowel from the pelvis allows dose escalation of radiation, and improved survival from pelvic malignancies. This case series indicates that the use of laparoscopic surgery for mesh placement is feasible. In addition the early recovery and minimal morbidity from the laparoscopic approach allows early initiation of radiotherapy in contrast to an open technique. The use of an absorbable mesh reduces potential for mesh associated complications.

## Minimally Invasive Other - P481

**A "REVIVED" TESTICLE DURING LAPAROSCOPIC INGUINAL HERNIA REPAIR: A DIFFICULT INTRAOPERATIVE DECISION**, Gaetano La Greca PhD, Saverio Latteri MD, Francesco Barbagallo MD, Salvina Gagliardo MD, Emanuele Grasso MD, Maria Sofia MD, Domenico Russello MD, Department of Surgical Sciences, Transplantation and Advanced Technologies University of Catania, Cannizzaro Hospital,

Intraoperative surprises are not so rare and every surgeon is trained to overcome different problems and choose the best solution for the patient and for himself. These unexpected "surprises" are mostly related to unknown diseases, anatomic abnormalities or particular technical problems sometimes also extremely difficult to solve. This report concerns about a common case of a 44 years old male patient who was operated laparoscopically for the third recurrence of a left inguinal hernia in which however the intraoperative surprise was unique. The patient was father of two sons (24 and 21 years) and had been operated 20 years prior because of left inguinal hernia. The patient referred, and physical examination confirmed it, that the left testicle was removed by the surgeon because of intraoperative complication during that first operation. The patient had other two operation for recurrence of left inguinal hernia and also an operation for right inguinal hernia. During the laparoscopic hernia repair (TAP) the "surprise" was the following. Inside the abdomen, just near the inner inguinal ring and laterally to the hernial sac a normal testicle was found. This "surprise" carried relevant discussion between surgeons and the called urologists concerning medical, legal and psychological problems. These relevant legal problems were also related to the need to respect the privacy and to the difficult decision to maintain or resect the testicle that resulted normal at intraoperative US. The problems were related also to the fact that patient's girl-friend was young and did not had children but was also not legally married and also that the real function of the right testicle was unknown. The team decided to save the "revived" testicle gently preparing the spermatogenic cord and performing an orchidopexy. The technique for the hernia repair had to be modified. The day after surgery the patient was informed of the singular situation and also about his increased oncological risk due to the fact that the "revived" testicle was for 20 years intraabdominal. The patient was extremely happy to have again two testicle and refused the proposed orchiectomy accepting anyway a follow-up. The case is in our opinion really singular and interesting for different technical, surgical, legal, psychological and ethical aspect.

## Minimally Invasive Other - P482

**FAREWELL TO MCBURNEY'S INCISION: SHOULD LAPAROSCOPIC APPENDECTOMY BE THE GOLD STANDARD FOR APPENDICITIS?,** Peter Lalor MD, Samuel Szomstein MD, Raul J Rosenthal MD, Cleveland Clinic Florida

**Background:** Appendicitis can be treated successfully by open or laparoscopic appendectomy. In the era of minimally invasive surgery, laparoscopic appendectomy is arguably a better procedure when assessing wound complications, technical feasibility, and diagnostic advantages. Open appendectomy via traditional McBurney's incision may not be the optimal treatment for appendicitis. The aim of this study was to examine the standardized laparoscopic treatment of all cases of appendicitis by a minimally invasive-trained surgeon.

**Methods:** We retrospectively studied 125 consecutive patients undergoing laparoscopic appendectomy by a single surgeon between July 17, 2001 and August 21, 2006. All patients that presented with suspected appendicitis clinically or radiologically were surgically treated by the laparoscopic approach. Intraoperative findings and postoperative complications were reviewed.

**Results:** Of the 125 patients who underwent laparoscopic appendectomy for appendicitis, 100% of patients were successfully treated with a minimally invasive surgical approach without a single conversion to an open procedure. 11% (n=14) of patients had a perforated appendix, 5% (n=6) had gangrenous appendicitis, and 2% (n=3) had abscesses. Morbidity including wound infection, ileus, and abscess was 17% (n=21). There were no major complications and no re-operations for any reason. 11% (n=14) of patients had a normal appendix at operation. Length of stay averaged 2.4 days for all patients.

**Conclusions:** Although the literature has not shown a statistical advantage to laparoscopic versus open appendectomy, at our institution laparoscopic appendectomy is the gold standard for the treatment of appendicitis. Since conversion from laparoscopy indicates mid-line laparotomy, open appendectomy via McBurney's incision appears obsolete.

## Minimally Invasive Other - P483

**MANAGEMENT OF CHOLEDochOLITHIASIS AMONG THE UNITED STATES ARMY GENERAL SURGEONS,** Sukhyung Lee MD, Kyle N Remick MD, John P Schriver MD, William Beaumont Army Medical Center, El Paso, TX, USA

**BACKGROUND:** Laparoscopic cholecystectomy is the procedure of choice for removal of the diseased gallbladder, but controversy exists over various treatment methods for choledocholithiasis suspected preoperatively or discovered during surgery. The goal of this study is to determine if continuity in the diagnosis and treatment of choledocholithiasis exists among the United State(US) Army general surgeons.

**METHODS:** Web based survey was sent out to the US Army general surgeons to address the indications for pre-operative Endoscopic Retrograde Cholangiopancreatography (ERCP), laparoscopic intra-operative cholangiogram(IOC), and laparoscopic common bile duct exploration (LCBDE).

**RESULTS:** Forty six surgeons with average age of 44.35 years (Min 33 to Max 63) and average years in practice of 10.4 years responded to our web survey. Ninety two percent (36/39) of the US Army general surgeons perform selective pre-operative ERCP versus 8 percent (3/39) that do not perform pre-operative ERCP. ERCP services are available to all but one surgeon (25 at the same hospital and 16 by referral out of 42 responses). All but one surgeon perform selective IOC. Only one surgeon performs routine IOC. Fifty two percent of the surgeons (22/42) perform LCBDE. Average age, LCBDE training during residency, and laparoscopic training during residency did not differ between the group of surgeons who performs LCBDE and do not perform LCBDE. Some of the reasons for not performing LCBDE are lack of experience (11/20) and the availability of instrumentation (4/20).

**CONCLUSIONS:** Selective pre-operative ERCP and IOC are the preferred methods of managing choledocholithiasis among the US Army General Surgeons. Fifty two percent of the US Army General Surgeons do not perform LCBDE due to the lack of experience and the availability of instrumentation.
<figure><img src="image_180.png" /></figure>

## Minimally Invasive Other – P484

**IS COMPLETING A LAPAROSCOPIC FELLOWSHIP AFTER RESIDENCY WORTHWHILE?**, Rockson C Liu MD,CK Chang MD,Thomas Rolle MD, Kaiser Permanente Medical Center, Walnut Creek, CA

**BACKGROUND:** Many residents seek laparoscopic fellowship training to overcome the steep learning curve associated with advanced laparoscopic procedures. Few studies have documented the impact of laparoscopic fellowship training on a surgeon's 1st year in practice. This study details the experience of a single surgeon (RCL) who completed a 1 year advanced laparoscopic digestive fellowship (80% bariatric) after finishing residency.

**METHODS:** A prospective case log of the lead author's 1st year cases in a community hospital was reviewed. A total of 224 cases were performed as primary surgeon, of which 141 (63%) cases were laparoscopic. Of these laparoscopic cases, 65 (46%) were complex (defined as not appendectomy, cholecystectomy or diagnostic). Seven types of minimally invasive procedures, totaling 15 cases -- esophagectomy, splenic artery aneurysm resection, distal pancreatectomy, gastrojejunostomy, liver resection, SLiC, trans腔ary biliary stenting, and adrenalectomy -- were performed for the 1st time at the hospital, thus avoiding the need for open surgery or outside referral. In all complex laparoscopic cases, there was 1 (1.5%) conversion during a laparoscopic sigmoid colectomy for diverticulitis. There were no mortalities and 2 (3%) major complications of bleeding after laparoscopic colectomy requiring re-exploration. An additional 37 complex laparoscopic cases, mostly laparoscopic colectomies (19) and low anterior resections (5) were performed as teaching assistant.

**CONCLUSION:** Formal post-residency laparoscopic fellowship training provides a rapid means of foundation building and skills acquisition for a broad range of advanced laparoscopic operations. The impact of fellowship training is immediately evident in the 1st year of practice.

## Minimally Invasive Other – P485

**LAPAROSCOPIC MECKEL'S DIVERTICUCTOMY IN PATIENT WITH MECKEL'S DIVERTICULUM COMPLICATED BY SMALL BOWEL OBSTRUCTION:** A CASE REPORT, Sopark Manasnayakorn MD,Chadin Tharavej MD, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND

Intestinal obstruction caused by Meckel's diverticulum is rare and is usually associated with the fibrous cord attached between the diverticulum and the abdominal wall. We report herein the intestinal obstruction caused by an internal herniation of the distal ileum through the loop formed by an adhesion between the inflamed diverticulum and the ileal mesentery.

**A Case report:** A 15 year-old male presented with a clinical of intermittent intestinal obstruction. The patient had no previous abdominal surgery. On physical examination, no visible hernia was detected. Acute abdomen series revealed dilated small bowel loops. CT scan of the abdomen showed multiple dilated small bowel loops with collapsed distal ileum without any identifiable cause. Diagnostic laparoscopy demonstrated an internal herniation of distal ileum through the loop formed by an adhesion between the inflamed Meckel's diverticulum and the ileal mesentery. The authors proceeded to laparoscopic Meckel's diverticulectomy with Endo GIA 45-2.5mm (Tyco Healthcare). Postoperative course was uneventful. The oral intake was started on the following day and he was discharged from the hospital on the 3rd postoperative day.

**Conclusion:** Laparoscopy may serve as a useful diagnostic tool in patients with intestinal obstruction without previous abdominal surgery. Furthermore, the cause of intestinal obstruction, for example that associated with Meckel's diverticulum, can be successfully managed laparoscopically.

## Minimally Invasive Other – P486

**HIRING PRACTICES IN MINIMALLY INVASIVE SURGERY: A NATIONAL SURVEY OF SURGICAL CHAIRS,** Guillaume Martel MD,Eric C Poulin MD,Joseph Mamazza MD,Robin P Boushey MD, Department of Surgery, Minimally Invasive Surgery Group, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada

**INTRODUCTION:** An increasing number of surgical departments emphasize advanced minimally invasive surgery (MIS) within their institution. The objective of this study was to qualify the status of MIS within academic surgical programs, and to quantify its growing importance with respect to surgical hirings.

**METHODS:** A questionnaire was mailed to surgery department chairs and general surgery division heads at all 16 Canadian academic institutions. Non-responders were identified and contacted directly. Data pertaining to MIS were collected, including demographics, perceptions of MIS, and hiring data.

**RESULTS:** Overall, 77% of chairs responded (n=23/30), with representation from 94% of departments (n=15/16). Among surveyed chairs, 91% intend to increase the importance of MIS at their institution within 5 years, of which 90% intend to do so with new hirings. Networking (74%) and retaining one's graduates (87%) were cited most frequently as recruitment strategies in hiring new MIS surgeons. Among hiring goals, strengthening the division, strengthening subspecialties, research, and education were considered important or extremely important by >90% of chairs. Strengthening MIS was considered important or extremely important by 59% of chairs. Within 5 years, chairs intend to hire a median of 4 general surgeons, of which 51% will have formal MIS training. In comparison, over the last 10 years, significantly fewer new recruits (26%, p<0.001) had formal MIS training. Chairs (>90%) considered formal MIS fellowship, MIS fellowship plus a second fellowship, and proctorship to be adequate or completely adequate training for advanced MIS. Residency training (48%), week-end/long courses (65%), and self-teaching (74%) were considered inadequate training. Lack of OR time and costs/resources issues were considered most limiting in hiring new MIS surgeons.

**CONCLUSIONS:** Minimally invasive surgery is growing in importance within academic surgical departments, but it remains an intermediate priority for chairs and recruiters. It does not appear to substitute for traditional hiring goals. Formal MIS training appears important in recruiting new surgeons, while traditional training methods are considered inadequate.

## Minimally Invasive Other – P487

**SEROMASCOPY: NON-ANATOMIC SPACE EXPLORATION WITH LAPAROSCOPE,** VINEY K MATHAVAN MD,JOHN GUSZ MD, Robinson Memorial Hospital, Ohio

**Abstract:** The advent of Minimally Invasive Surgery has allowed access into body cavities with similar to superior results when compared to traditional open surgery. Heretofore, the overwhelming majority of reported procedures dealt with access into, and maneuvers in defined anatomic spaces. We are introducing a new thought process in that we used a video telescope to diagnose and treat a chronic condition in a non-anatomic space.

**Case History:** A 49-year-old morbidly obese male with an enormously thick abdominal wall presented with a non-healing abdominal wound subsequent to infected mesh removal after a hernia repair. Local probing in the office revealed a long subcutaneous tract and no foreign body.

**Operative Procedure:** Under minimal intravenous sedation, the midline wound was examined. The small 3-4 mm hole was probed. It extended approximately 6-8 cm inferiorly and terminated in the subcutaneous tissue. A 5mm trocar was advanced through the hole and a video telescope was inserted. The anterior abdominal wound was insufflated to a low pressure and its contents visualized. The tract terminated in a large cavity anterior to the fascia. The cavity contained mostly healthy granulation tissue. A strand of knotted prolene suture with white fibrous material caught in the
<figure><img src="image_181.png" /></figure>

# SAGES POSTER ABSTRACTS

interstices of the suture was seen at the base. The camera was removed and an irrigator was used to copiously lavage the cavity. The camera was reinserted, a Kelly clamp was introduced into the cavity via a counter-incision and the suture was grasped. The suture was brought through the incision and was incised and removed. There was white foreign material, (cotton swab) caught in the suture. The wound was irrigated, cleaned and dressed. After this wound and sinus tract completely healed. At three years there is no evidence of recurrence.

**Discussion:** The uses of video telescopes are numerous. The use of a laparoscope in the exploration of a seroma cavity has not been reported. Here in was an example of the use of laparoscopic instruments and skills for non-anatomic space exploration (seromascopy). The technique is quick, relatively easy for a surgeon with basic laparoscopic skills and requires minimal sedation. This application allowed us to treat the condition expeditiously. If it is not helpful, standard open technique is not jeopardized. The choledochoscope may be used as an alternative to blind probing of suture sinuses.

## Minimally Invasive Other - P488

**LAPAROSCOPIC ASSISTED VENTRICULOPERITONEAL SHUNT EXPERIENCE IN URBAN CENTER, Kellie McFarlin**
MD,John Webber MD, Wayne State University Department of Surgery

**Introduction:** Several techniques have been described for laparoscopic assisted ventriculoperitoneal (VP) and lumbar peritoneal (LP) shunt placement. Single port placement with a Seldinger catheter and mini-laparoscopy with a 2mm laparoscope have been described for uncomplicated abdomens. This study reviews all lap assisted shunt cases in an urban hospital applying a two to three port technique.

**Methods:** All cases of laparoscopic assisted VP and LP shunts were reviewed from Harper University Hospital from January 2004 to August 2006. All procedures were performed by single general surgeon with neurosurgery department staff. A total of 30 cases were performed. 24 patients underwent VP shunt placement and 6 had LP shunt placement, ages 17 to 84. An umbilical port was placed followed by left upper quadrant and/or left lower quadrant ports under direct visualization. Alternative port placement was directed by previous abdominal surgery, scars from prior shunt revision or patient position (i.e. lumbar shunts).

**Results:** All cases had successful catheter placement and no intra-abdominal injury. 33% of patients had previous abdominal surgery or morbid obesity. Lysis of adhesions to facilitate optimal catheter placement was required in 30% cases. The indication for surgery in 23% cases was for distal shunt revision.

**Discussion:** Laparoscopy assisted VP and LP shunt insertion maintains the advantage of direct visualization for optimal catheter placement and function assessment during the procedure. Our technique of using two to three ports added no additional complications and was necessary to optimize catheter positioning in a complicated abdomen. This technique is applicable to most urban centers with a high volume of complex patients transferred to a tertiary care center for either shunt revision or malfunction.

## Minimally Invasive Other - P489

**A NOVEL TECHNIQUE FOR BILATERAL LAPAROSCOPIC ADRENALECTOMY, Matthew A Metz**
MD,Walter L Pegoli MD,Luke O Schoeniger MD, University of Rochester Laparoscopic adrenalectomy is described in the literature as a procedure performed through either a lateral decubitus or a posterior exposure. These techniques, while extremely effective, are cumbersome in patients requiring bilateral adrenalectomy. We describe a trans-peritoneal approach to both adrenals. The left adrenal gland is accessed through a window in the mesentery, inferior to the pancreas, and lateral to the inferior mesenteric vein. The procedure is performed entirely with the patient in a supine position, thereby eliminating the need for re-positioning.

**Two patients:** An obese six-year-old with adrenogenital syndrome, and an eighteen-year-old with congenital adrenal

hyperplasia underwent bilateral laparoscopic adrenalectomy using this technique. Operative time was ~270 minutes, respectively, and estimated blood loss was less than 50 cc for each patient.

## Minimally Invasive Other - P490

**FUNDUS-FIRST LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND REDUCES THE CONVERSION RATE, Shahram Nazari**
MD,Semira Mousavi khosroushahi MD,Abolfazl Jamal-Abbasi MD,Mohammad Ali Mohammadzadeh MD, Department of General and Laparoscopic Surgery, Milad Hospital, Tehran, Iran.

**Summary**

**OBJECTIVES:** Laparoscopic cholecystectomy (LC) is the "gold standard" in surgical management of symptomatic cholecystolithiasis. Isolation of the cystic duct is the first dangerous technique in laparoscopic cholecystectomy. Nearly all of the laparoscopic surgeons are now popular with standard laparoscopic cholecystectomy, in which dissection begins at Clot's triangle. In conventional open cholecystectomy, the fundus-down approach is a well recognized safe procedure during difficult cholecystectomies because it minimizes the risks of damage to the structures in or around Calot's triangle. In spite of this, fundus-first dissection (FFD) is not widely practiced in LCs.

**METHODS:** The purpose of this study is to evaluate the facility of FFD in difficult LCs. The study included 500 patients treated over 25 months. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of common bile duct stones, or carcinoma of the gallbladder. The grade majority were difficult cases, so we also reviewed the safety aspects of this approach and evaluated whether the fundus-first technique can prevent conversion in difficult cases.

**RESULTS:** The fundus-first approach was started in 35 patients; 30 procedures were completed laparoscopically. Five of the cases were further converted to open surgery. The mean operative time was 95-130 minutes (mean 112.5), which is significantly greater than conventional laparoscopic standard cholecystectomy (range 20-40 minutes, mean 30). Fundus-first laparoscopic cholecystectomy (FFLC) was performed without immediate or late complications.

**CONCLUSION:** FFLC appears to be safe procedure, and has the potential to reduce the conversion rate in difficult cases and may decrease the risk of injury to bile ducts.

**RECOMMENDATION:** FFLC could be started in difficult LCs. The surgeon should have adequate laparoscopic experience. If in spite of FFD, the anatomy of Calot's triangle is still obscure, he must convert to open exploration to prevent bile duct injuries.

## Minimally Invasive Other - P491

**LAPAROSCOPIC RESECTION OF GIST, WHEN MIGHT IT NOT BE APPROPRIATE, Gary P Neale**
MD,Ajay Upadhyay MD,George Kazantsev MD,Rupert Horoupian MD,Steven Stanten MD,Arthur Stanten MD, Alta Bates Summit Medical Center, Oakland, California

**Background:** Gastrointestinal stromal tumors (GIST) are rare tumors of the GI tract. Modern surgery is moving towards increased application of laparoscopy in abdominal surgery. We present here our surgical experience with GIST and the manner in which the surgery was performed.

**Methods:** Retrospective chart review of all patients diagnosed with GIST between April 2003 and June 2006 for a private surgical group. Patients were identified by an electronic search of Department of Pathology records. Charts were reviewed for presenting complaint, pre-operative work up, operation performed, outcome, and length of stay.

**Results:** Fifteen patients underwent surgery during this period. The location of these GIST included one in the distal esophagus, eleven in the stomach, one in the small bowel, one in the rectum and one 17.5 cm tumor in the pelvis of in determinant origin. Seven (46%) were 10cm in size or larger. Patients ranged in age from 33 to 83, and tumor size was from 1 to 22.7cm. Nine surgeries were performed open, two laparoscopic, two robotic, one laparoscopic assisted and one trans anal. Discharge was from 3 to 41 days after surgery.
**Conclusions:** While GIST may be operated upon laparoscopically, many of the patients in our series had a tumor of such a size that would preclude them from receiving the benefits of minimal invasive surgery, particularly when considering specimen removal. We conclude minimal invasive surgery has a role, but is not to be the goal for every patient diagnosed with GIST.

## Minimally Invasive Other - P492

**BILATERAL PNEUMOTHORACES FOLLOWING ERCP AND SPHINCTEROTOMY**, Haridimos Markogiannakis
MD,Konstantinos G Toutouzas PhD, Nikolaos Pararas
PhD,Andreas Romanos PhD,Dimitrios Theodorou
PhD,Ioannis Bramis PhD, 1st Department of Propaedeutic
Surgery, Hippocratio Hospital, Athens Medical School,
University of Athens, Athens, Greece

**Objective:** An extremely rare case of bilateral pneumothoraces following ERCP with endoscopic sphincterotomy is reported.

**Case report:** A 56-year-old woman was admitted to our department due to acute cholangitis. The patient presented with right upper quadrant pain, fever, chills, and vomiting of 24 hours duration. Clinical examination revealed jaundice and right upper quadrant tenderness with guarding but no rigidity or rebound. Chest x-ray on admission was normal. Blood tests revealed leukocytosis and elevation of á-GT, ALP, and bilirubin levels. Abdominal ultrasound demonstrated cholelithiasis along with two large stones in a dilated common bile duct. At ERCP, dilatation of the common bile duct and two common bile duct calculi were confirmed. Endoscopic sphincterotomy was performed and the stones were extracted. Post-sphincterotomy cholangiogram showed no extravasation of contrast. Over the ensuing 20 minutes, the patient developed marked subcutaneous emphysema with crepitus extending to the neck, upper abdominal pain, and shortness of breath. Clinical examination demonstrated tachycardia, tachypnoea, decreased oxygen saturation, bilaterally diminished breath sounds, mild abdominal distension and epigastric tenderness without peritoneal signs. Radiograph of the chest and abdomen revealed bilateral pneumothoraces, pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, and free air in the retroperitoneum. Bilateral chest tubes were placed and the patient was managed with nasogastric suction and broad-spectrum antibiotics. Esophagogram and upper gastrointestinal series demonstrated no extravasation of contrast. Chest and abdominal CT, performed on the next day, revealed subcutaneous emphysema, pneumomediastinum, pneumoperitoneum along with free retroperitoneal air. Neither any intra-abdominal or retroperitoneal fluid collection or abscess nor contrast extravasation from the gastrointestinal tract was demonstrated. Liver function tests were normalized on the 2nd post-ERCP day while resolution of bilateral pneumothoraces was confirmed on chest x-ray on the 4th day and both chest tubes were removed. The patient had an uneventful recovery and was discharged on the 10th day.

**Conclusion:** Bilateral pneumothoraces is a very rare complication of ERCP/endoscopic sphincterotomy. Despite the dramatic physical and radiographic findings, the patient responded to early treatment and conservative management with a favourable outcome.

## Minimally Invasive Other - P493

**LAPAROSCOPIC APPROACH OF MATURE SOLID TERATOMA OF FALLOPIAN TUBE:** **CASE REPORT**, Valentina Ratkajec
MD,Josip Bakovic MD,Toni Kolak PhD,Igor Stipancic
PhD,Zeljko Busic PhD,Petar Marusic MSc, Department of
abdominal surgery, University Hospital Dubrava

**Introduction:** We report a laparoscopic resection of mature solid teratoma arising in the fallopian tube. The mass was noted on MSCT prior to surgery for a mature cystic teratoma. The incidence of a mature solid teratoma of the fallopian tube is extremely low.

**Case report:** A 43-year-old nulligravida female, was seen at the emergency room because of worsening right lower quadrant abdominal pain, nausea and vomiting.

The physical examination showed tenderness on palpation of the right lower abdominal quadrant with rebound tenderness and a freely movable mass in cecoascendens projection. Bowel sounds were hypoactive. Preoperative laboratory data showed mycrocytic anemia, serum concentration of cancer markers CA 19-9 were increased (79.6) and CA 125 (9.40) were within normal limits. No leukocytosis was noted. High resolution ultrasound examination was inconclusive. First MSCT revealed inhomogeneous tumor (size 9, 5 x11cm) with calcification and sharp border to surrounding structures on the right side of lower abdomen. Colonoscopy findings did not reveal any pathology. Repeated MSCT scan showed tumor on the opposite side. Preoperatively, we considered that these findings represented acute abdomen due to probable bowel obstruction caused by small intestine tumor. The patient was taken to surgery, and the abdominal cavity was laparoscopically explored. Laparoscopy demonstrated a solid-appearing mass, approximately 10 - 11 cm in diameter, located at the ampullary segment of the right fallopian tube. Teratoma was attached by a pedicle to the tubal mucosa. Laparoscopic excision was performed, and the mass of the right fallopian tube and right ovary were resected. Pathology revealed mature cystic teratoma of the fallopian tube. The patient improved and was discharged 2 days after surgery.

**Conclusion:** Laparoscopic teratoma treatment in emergency condition combines two major advantages of laparoscopy: it is highly valuable in achieving the diagnosis when other diagnostic modalities don't give us clear picture in resolving the problem; laparoscopy approach presents the last frontier in teratoma treatment and is more acceptable method in comparison with classical surgery.

## Minimally Invasive Other - P494

**LAPAROSCOPIC PLACEMENT OF VENTRICULOPERITONEAL SHUNT CATHETERS USING MODIFIED SELDINGER TECHNIQUE**, Michael Sawyer MD, Janice Strange, Darla Vardeman
RN, David Pagnanelli MD, Videoendoscopic Surgical Institute of Oklahoma and Great Plains Surgical Institute, Lawton, Oklahoma

**Introduction:** Ventriculoperitoneal (VP) shunts are employed to treat hydrocephalus, or increased intracranial pressure. The abdominal terminus of the shunt is typically placed via a relatively large incision and dissection to expose the peritoneum. This is invasive and affords limited visualization of the peritoneal cavity.

**Methods:** We have placed six VP shunts using a modified Seldinger technique with a single trocar. Abdominal access is obtained with a 5 mm trocar at the umbilicus. The abdomen is insufflated to 15 mm Hg with CO2. A separate 5 mm abdominal skin incision is made to tunnel the shunt catheter inferiorly onto the abdomen. An 18 gauge needle and guide wire are passed into the abdomen via this incision. The needle is withdrawn and a peel-away catheter - introducer set is placed into the peritoneal cavity over the guidewire. It is used to advance the catheter into any desired location in the abdomen under direct visualization.

**Results:** This approach has been uniformly successful. Operative trauma and scarring are minimized. Patients recover rapidly with minimum discomfort. All catheters are functioning well at a mean of 9 months' postoperative follow up. There have been no wound infections or other postoperative complications.

**Conclusions:** Laparoscopic placement of VP shunt catheters using a modified Seldinger technique offers several advantages over open approaches. This should be the preferred technique for placement of such catheters.

## Minimally Invasive Other - P495

**UNINSURED PATIENTS ARE OFFERED LAPAROSCOPIC HERNIA REPAIR LESS OFTEN**, Susanna H Shin MD, Rebecca C Britt MD, Eastern Virginia Medical School, Department of Surgery, Norfolk, Virginia, USA

**Introduction:** Laparoscopic hernia repair has become more common as increasing data has shown a shorter hospital stay (LOS) and an earlier return to work. The uninsured patient population at our institution is evaluated and scheduled.
<figure><img src="image_182.png" /></figure>

# SAGES POSTER ABSTRACTS

uled for surgery at a resident-run clinic. We hypothesized that the uninsured population was offered laparoscopic repair (LAP) less often than the private insured population.

**Methods:** A retrospective chart review was performed of patients undergoing hernia repair (incisional (VHR) and inguinal (IHR)) on a single general surgery service. The patients included insured patients seen by attending surgeons at their private office and uninsured patients seen at the resident-run clinic. Data collected included age, gender, type of hernia, LAP vs Open (OP) repair, LOS and post-operative complications, including recurrence.

**Results:** From 7/02-6/06, 244 patients were scheduled to undergo elective hernia repair. 227 subjects had full records available for review. Subjects were then separated into insured (INS, n=177) and uninsured (UN, n=50) populations. These cohorts were similar in mean age (INS=48.5yrs, UN=44.7yrs, p=0.12) and male gender (INS=71.2%, UN=70%, p=0.87). A significantly greater proportion of the insured population underwent laparoscopic repair (INS=37.9%, UN=20%, p=0.02). The OP (n=150) and LAP cohorts (n=77) were similar in mean age (OP=46.6yrs, LAP=49.4yrs, p=0.20), male gender (OP=72.7%, LAP=67.5%, p=-0.42) and rate of post-operative complications (OP=10%, LAP=14.3%, p=0.34). The LOS between those VHR subjects that underwent OP vs LAP (OP=1.4days, LAP=1.8days, p=0.23) was not significantly different.

**Conclusions:** In our practice, the uninsured patient population is offered minimally invasive surgery less often than the insured. Given that this patient population can ill afford the lost wages from missed work, an effort must be made to educate surgical residents on indications for laparoscopic hernia repair so the uninsured will be offered the same care as the insured.

## Minimally Invasive Other - P496

**PARTIAL CHOLECYSTECTOMY FOR MIRIZZI SYNDROME: A MINIMALLY INVASIVE APPROACH**, Enrique M Sta.Ana MD,Uthaiah Kokkalera MD,Josh Felsher MD,Richard A Perugini MD,Demetrius E Litwin MD,John J Kelly MD, University of Massachusetts School of Medicine

**Introduction:** Mirizzi Syndrome is an uncommon complication of longstanding cholelithiasis resulting in compression of the common hepatic duct by either chronic inflammation or an impacted stone in the cystic duct. The inflammation engendered by chronic gallstone impaction in the gallbladder neck may distort the biliary anatomy, thereby making dissection in Calot's triangle perilous. Treatment of Mirizzi's Syndrome involves removal of the impacted stones, partial cholecystectomy and wide drainage, with repair or bypass of the biliary tree rarely necessary. As a result of the chronic inflammatory changes of the anatomy and the technical demand of the procedure, many authors have advocated an open traditional approach. We present two cases of Mirizzi's Syndrome which were successfully managed laparoscopically.

**Methods:** This is a series of two patients, a 77 year old male and a 47 year old female. Both presented acutely with jaundice and signs of cholangitis. The first also had a cholecystocolonic fistula. Laparoscopic partial cholecystectomy was performed following successful stabilization with endoscopic retrograde cholangiopancreatography and placement of a biliary stent.

**Results:** Both individuals were managed initially with ERCP, placement of biliary stent, and a course of antibiotics. After intervals of 12 and 8 weeks, respectively, they underwent laparoscopic partial cholecystectomy. The first patient also underwent takedown of cholecystocolonic fistula. Both patients did well postoperatively.

**Conclusion:** Mirizzi Syndrome is an uncommon disorder requiring a high degree of suspicion. ERCP is a valuable tool for both diagnosis and as an adjunct to treatment. In experienced hands, laparoscopic partial cholecystectomy is a technically feasible and safe approach.

## Minimally Invasive Other - P497

**A CASE PRESENTATION: PNEUMATOSIS INTESTINALIS**, Naizy Selim MD, Benjamin H Stone MD, University of Kansas Medical Center

**Objective:** We describe the utilization of laparoscopy and intraperitoneal to-air drain placement in a patient whose CT scan revealed massive pneumatosis intestinalis (PI), pneumoperitoneum, and pneumomediastinum.

**Methods:** A 22 year old female presented with recurrent acute abdominal pain, abdominal distention, pneumoperitoneum, and pneumomediastinum.

<figure><img src="image_183.png" /></figure>

Exploratory laparoscopy demonstrated intraperitoneal air with no evidence of bowel perforation or ischemia. Diffuse PI was noted throughout the bowel wall. An open to-air suction drain was placed in the peritoneal cavity providing peritoneal decompression. **Results:** Resolution of both pneumoperitoneum and pneumomediastinum was observed in the early postoperative period. The intraperitoneal drain was removed prior to discharge from the hospital. The patient was followed for one year postoperatively without evidence of complications or further manifestations of PI. **Conclusions:** Although a rare disease, laparoscopic exploration with open-to-air venting of the abdomen may provide an efficient diagnostic and therapeutic intervention in symptomatic patients presenting with pneumatosis intestinalis

## Minimally Invasive Other - P498

**LAPAROSCOPIC CYST EXCISION AND SPLENOPEXY FOR HEMORRHAGIC SPLENIC PSEUDOCYST AND WANDERING SPLEEN**, Christy M Lawson MD, Ali F Mallat MD, Matthew L Mancini MD, University of Tennessee, Knoxville

Wandering spleen is a rare diagnosis, especially when found in conjunction with a splenic pseudocyst. We describe here a 19 year old female who developed a subcapsular hematoma during an episode of mononucleosis, subsequently developing a large psuedocyst and wandering spleen. She was treated with laparoscopic cyst excision and splenopexy with good result. A review of current literature suggests that laparoscopic splenopexy achieves similar results as splenectomy with less adverse outcomes in patients with wandering spleen.

<figure><img src="image_184.png" /></figure>

## Minimally Invasive Other - P499

**BILIARY INJURIES IN LAPAROSCOPIC CHOLECYSTECTOMY - AN EXPERIENCE OF 13305 OPERATIONS**, Om Tantia MS,S. K. Bandyopadhyay MS,S Khanna MS,B Sen DO, ILS Multispeciality Clinic

Biliary injuries at Laparoscopic Cholecystectomy (LC) is a complication better avoided than treated. Our retrospective study analyzes Biliary complications (BC) in 13305 LC over 14 years by a single surgical team. The data was stored in a M.S Excel based software. Out of 52 cases of BC, 32 were detected per operatively and 20 post operatively. Of the per operative Bile Duct Injuries (BDI) 6 were complete transec-