<figure><img src="image_93.png" /></figure>

**CONCLUSION:** This novel technique of gamma probe localization of the ureters is feasible and may offer a non-invasive approach for ureteral identification. A significant increase in gamma counts over the ureter could be consistently demonstrated for an extended period after a single injection of Tc-DTPA.

## Colorectal/Intestinal Surgery - P146

**LAPAROSCOPIC COLECTOMY FOR "BENIGN" COLORECTAL NEOPLASIA: A WORD OF CAUTION**, Marc Brozovich
MD,Thomas E Read MD,Salgado Javier MD,William Harb MD,Robert P Akbari MD,James T McCormick DO,Philip F Caushaj MD, Division of Colon and Rectal Surgery, Western Pennsylvania Hospital, Cinical Campus of Temple University School of Medicine. Pittsburgh, PA, USA.

**Purpose:** Endoscopically unresectable "benign" colorectal polyps are considered by some surgeons as ideal cases for their early laparoscopic colectomy experience. Our hypotheses were: (1) a substantial fraction of patients undergoing laparoscopic colectomy for "benign" colorectal neoplasia will have adenocarcinoma on final pathology; and, (2) in our practice, we perform an adequate laparoscopic oncologic resection for "benign" polyps as evidenced by margin status and nodal retrieval.

**Methods:** Data from a consecutive series of patients undergoing laparoscopic colectomy (on an intention to treat basis) for endoscopically unresectable neoplasms with benign preoperative biopsy histology were retrieved from a prospective database and supplemented by chart review.

**Results:** The study population consisted of 63 patients (mean age 67, mean BMI 29). 2/63 cases (3%) were converted to laparotomy because of extensive adhesions (n=1) and equipment failure (n=1). Colectomy type: right/transverse (n=49, 78%); left/anterior resection (n=10, 16%); subtotal (n=4, 6%).

Invasive adenocarcinoma was found on histologic analysis of the colectomy specimen in 14/63 (22%), standard error of the proportion 0.052. Staging of the 14 cancers: I (n=6, 43%); II (n=3, 21%); III (4, 29%); IV (1, 7%). Median nodal harvest was 12 (range 5-21) and all resection margins were free of neoplasm.

By univariate analysis, neither dysplasia on endoscopic biopsy nor lesion diameter was predictive of adenocarcinoma, although sample size may be too small to adequately assess these variables. 8/23 (35%) patients with dysplasia on endoscopic biopsy had adenocarcinoma on final pathology vs. 6/40 (15%) with no dysplasia (p=0.114, Fisher's exact test). Mean diameter of benign tumors was 3.2cm (range 0.5-10.0cm) vs. 3.9cm (range 1.5-7.5cm) for adenocarcinomas (p=0.189, t-test).

**Conclusions:** A substantial fraction of endoscopically unresectable colorectal neoplasms with benign histology on initial biopsy will harbor invasive adenocarcinoma, some of advanced stage. This finding supports the practice of performing oncologic resection for all patients with endoscopically unresectable neoplasms of the colorectum. The inexperienced laparoscopic colectomist should approach these cases with caution.

## Colorectal/Intestinal Surgery - P147

**ANAL PAP SMEAR IN HIGH RISK PATIENTS: A POOR SCREENING TOOL**, Neil Cambronero MD,Katia Papalezova MD,Cesar Santiago MD,Jason Penzer MD,Christian Hirsch MD,Scott Hanan MD, Cabrini Medical Center, NY, NY

Anal cancer and anal intraepithelial neoplasia is rare in the general US population, with an incidence of 0.8 per 100,000. However, the incidence is increased by 25 to 50 times in homosexual men, and even more so in those presenting with HIV and or AIDS. The association of HPV infection with cervical neoplasia in women has been well documented in the literature and it is from this experience that the association of HPV with anal cancer has been deduced. However, there are multiple other factors influencing the development of anal cancer- including HIV seropositivity, a history of sexually transmitted infections, and participation in anally per-

ceptive intercourse. The cotoversy surrounding routine cytological screening for intra-anal HPV stems from the unknown natural history of HPV infection, and the absence of any cure. This study was designed to assess the accuracy of Anal Pap Smears in predicting the histological grade of anal intraepithelial lesions and in detecting anal cancer. The literature suggests that anal cytology by has a sensitivity between 50 and 75 percent, with variations depending on the study, or the definitions of the staging classifications. Our study which includes 143 individuals, of whom 105 are HIV positive, shows a poor correlation between the cytological and the histological results in a high risk population. The sensitivity of PAP read as high grade intraepithelial neoplasia, condyloma, or squamous cell carcinoma on anoscopy and biopsy was 58%. The specificity of PAP read as normal or low grade intraepithelial neoplasia to exclude high grade neoplasia, condyloma, or squamous cell cancer was only 22%.

Anal PaP Smear in High Risk Patients? A poor tool

In the light of these findings, we advocate routine close surveillance of these high risk patients with anoscopy, excision, ablation, and biopsy of any suspicious visible lesions rather than screening with Anal PaP smear.

## Colorectal/Intestinal Surgery - P148

**AN INFECTIOUS COMPLICATION OF LAPAROSCOPIC APPENDECTOMY: FIFTH DAY SYNDROME**, SENOL CARILLI MD,AYDIN ALPER MD,AZIZ KAYA MD,ALI EMRE MD, VKF AMERICAN HOSPITAL GENERAL SURGERY DEPARTMENT

Appendectomy is the second most common general surgical procedure following lap cholecystectomy and the most common intra-abdominal surgical emergency with a life time risk of 6%. Traditionally infectious complications of appendectomy represented by wound infections and intra-abdominal abscess in many articles. Here, we describe another infectious complication with a historical cohort study of adult patients on for suspected appendicitis by open (OA) or lap appendectomy (LA).

**METHOD** Between 1996 to 2004 we have performed 582 emergency appendectomies in a private setting hospital. 162 of them were OA, 402 were LA and 18 started as LA and turned to open. Mean age was 30,87 (13-87) and 298 of them were male 284 were female. Pathological diagnoses of the specimens were; uninflammed appendix vermiformis 62, periappendicitis 8, carcinoid and metastatic tumors 6, perforated 14 and remaining diagnosis were changed from acute appendicitis to gangrenous appendicitis. Overall complication rate is 6.87%. Postoperative complications after OA were; 1 status epilepticus, 2 pneumonia, 13 extended ileus, 8 wound infection, 2 postop diarrhea. Complications following LA were; 4 pneumonia, 9 extended ileus, 3 postop diarrhea, 2 intra-abdominal abscesses, 5 fifth day syndrome (FDS). There was no mortality.

**CONCLUSION** FDS was originally described as a complication of traditional appendectomy in children. Typically the syndrome presented after an uneventful immediate postoperative course, the child would have a febrile painful small bowel obstruction with signs of localized peritonitis in the right iliac fossa. In medical literature there are only several articles and these are describing the syndrome on children. In our limited series we have experienced that the condition is not confined to pediatric population. Mean age of the patients with FDS was 36 (24-55). Their readmission dates were differed between 3-6th postop days. All they had abdominal pain, fever, localized peritonitis, paralytic ileus and leukocytosis. Its etiology is most probably perop fecal spillage. Radiological signs were air-fluid levels suggesting paralytic ileus on plain x ray, and ultrasound and CT scan reveal loculated fluid around the edematous ceacum. The importance of the syndrome is originated from its treatment which differs from an abscess. Cessation of oral feeding, starting IV fluid and parenteral antibiotic treatment with covering colonic flora are adequate treatment.
<figure><img src="image_94.png" /></figure>

SAGES POSTER ABSTRACTS

Colorectal/Intestinal Surgery - P149

THE MANAGEMENT OF PERFORATED APPENDICITIS:
LAPAROSCOPIC VERSUS OPEN APPENDECTOMY, Arthur M
Carlin MD,Sameeh Kawar MD, Henry Ford Hospital

**Introduction:** The purpose of this study is to compare the surgical outcomes of laparoscopic and open appendectomy in patients with perforated appendicitis. The literature has yielded conflicting results regarding the benefit of laparoscopic appendectomy in the management of perforated appendicitis. The primary concern is the potential for increased risk of infectious complications with the laparoscopic approach.

**Methods:** A retrospective review was performed to evaluate the outcomes of laparoscopic versus open appendectomy. Student's t-tests and X2 analyses were utilized to determine differences in continuous and nominal variables respectively, and significance assumed at p < 0.05.

**Results:** Appendectomy was performed in 146 patients (age >= 15 years) with perforated appendicitis at our teaching institution from February 2000 through March 2006. The mean age was 47 ± 18 years with 86 male patients (59%). The mean operative time and length of stay were 88.5 ± 33 minutes and one week, respectively. Open appendectomy was performed in 119 patients. Laparoscopic appendectomy was attempted in 27 patients and completed successfully in 5. The operative time was significantly longer in the laparoscopic as compared to the open appendectomy group (109 ± 32 vs. 81± 31 minutes; p = 0.028). There were no differences in the rates of postoperative cardiovascular, respiratory, gastrointestinal, or renal complications. The rate of postoperative wound infections was similar between both groups (7.4% lap vs. 7.6% open). The rate of postoperative intra-abdominal abscess formation was significantly higher in the laparoscopic as compared to the open appendectomy group (26% vs. 8%; p = 0.019). There was no difference in length of stay between the open and laparoscopic appendectomy groups, however, postoperative intra-abdominal abscess was a significant predictor of increased length of stay (11.8 vs. 6.7 days; p = 0.003). There was no correlation between postoperative intra-abdominal abscess formation and age, sex, operative time, or presence of comorbidities including diabetes.

**Conclusion:** Laparoscopic appendectomy for perforated appendicitis is associated with a high conversion rate, prolonged operative time, and an increase in postoperative intra-abdominal abscess formation.

Colorectal/Intestinal Surgery - P150

A RESIDENT'S EXPERIENCE WITH HAND-ASSISTED VS. STRAIGHT LAPAROSCOPY FOR LEFT COLECTOMY: IS THERE REALLY A DIFFERENCE?, Bradley J Champagne
MD,Edward C Lee MD,Guy R Orangio MD,Wayne Ambroze MD,David Armstrong MD,Brian Valerian MD,Feustel Paul PhD, Case Medical Center, Albany Medical Center, Georgia Colorectal Clinic

**Background:** Several studies comparing the effectiveness of hand-assisted colectomy (HAC) and straight laparoscopic colectomy (SLC) have been published. It has been suggested that HAC may help residents progress along the learning curve but there is currently no evidence to support this claim. These previous studies include procedures performed by staff surgeons or residents at various skill levels and report operative times and conversion rates as their primary endpoints. Furthermore, the actual role of the resident or staff surgeon as either the first assistant or primary surgeon is routinely not addressed. We report the experience of a single resident, training with both techniques, HAC and SLC, during residency and fellowship. The percentage of cases completed by the resident as the operating surgeon was the primary endpoint.

**Methods:** All patients who underwent left-sided HAC or SLC by a single resident, starting as the primary surgeon, were included. When the assisting staff surgeon assumed the role of the operating surgeon during the procedure it was recorded as an incomplete case for the resident. Operative times and conversions were included as secondary end-

points. All values below are reported as mean (range).

**Results:** A single resident started 147 laparoscopic colectomies as the primary surgeon during residency and colorectal fellowship including 81 left sided procedures. There were 44 patients in the HAC group and 37 SLC patients. There were no differences in patient demographics, diagnoses, ASA class, number of previous surgeries, and type of surgery. Cases done by straight laparoscopy were more likely to be completed by the resident than those done by HAC (SLC 88%, HAC 72%; p=.06). There were also differences in operative time favoring SLC (HAC 142 min (100-170) vs. SLC 133 min (95-195); p = 0.04). Complications were similar in the two groups (HAC 19% vs. SLC 21%) as were conversions (HAC 5.6% vs. SLC 4.5%) and length of hospital stay (HAC 4.9 days (2-10) vs. SLC 4.4 days (2-13); p = 0.17).

**Conclusion:** We feel that the percentage of cases completed by the resident as the operating surgeon is the most appropriate primary endpoint in determining the most effective approach for teaching laparoscopic colectomy. Residents and colorectal fellows may have more success completing straight laparoscopic colectomy than adjusting to the novel hand-assisted approach

Colorectal/Intestinal Surgery - P151

LAPAROSCOPIC RESECTION FOR RECTAL CANCER : ONCOLOGIC OUTCOMES IN 139 CONSECUTIVE PATIENTS WITH A MINIMUM FOLLOW-UP OF 2 YEARS., GS Choi MD,IT Lee MD,MJ Jo MD,SH Jun MD, Division of Colorectal Surgery, Department of Surgery, Kyungpook National University Hospital,

**Background:** One of the most controversial areas of laparoscopic colorectal surgery is that of rectal cancer. The aim of this study was to assess oncologic outcomes of the patients with rectal cancer who underwent surgery by laparoscopic techniques with a minimum follow-up 2 years. Methods: Between December 2002 and September 2004, a single surgeon (GSC) performed laparoscopic resection for 139 unselected rectal cancer patients (male, 77) without distant metastasis. Pre- and post-operative chemoradiation was given in 5 and 17 patients, respectively. Operating time, length of postoperative hospital stay, complications, oncologic outcomes were evaluated. Results: Mean operating time was 251 minutes and mean length of postoperative hospital stay was 11 days. In 89.2% of the patients, a surgical procedure with sphincter preservation was performed. The rate of conversion to the open approach was 4.3%. Overall morbidity rate was 20.9% and anastomotic leakage occurred in 11.3% (14 of 124 patients in whom sphincter preservation was undertaken). There was no postoperative mortality. Mean distal resection margin was 2.8 cm. Mean numbers of harvested lymph nodes was 18. The circumferential resection margin was positive in 5 patients (3.6%). 84 patients (60.4%) had T3 (78)/T4 (6) lesions. Distribution of TNM stages was 0:I:II:III =3.6%:27.3%:30.2%:38.1%. With a mean follow-up of 32 months, the local recurrence rate was 4.3%. Systemic recurrence occurred in 12.9%. No portsite recurrence was observed. Overall and disease-free 3-years survival rates were 91.1%, 80.2% respectively.

**Conclusions:** Laparoscopic resection for rectal cancer could be safely performed in terms of operative parameters and oncologic outcomes. Randomized controlled trials and long-term follow-up are needed to confirm these results.

Colorectal/Intestinal Surgery - P152

ELECTIVE LAPAROSCOPIC LEFT COLONIC RESECTION FOR NON COMPLICATED DIVERTICULITIS: WHEN IS IT BEST TO OPERATE?, élie k chouillard BA,toufic j ata BA,abe l finger-
hut BA, From the Department of Digestive Surgery of the
Centre Hospitalier Intercommunal de Poissy, France
In non complicated acute diverticulitis, resection is indicated
after one or two episodes according to the patient's age
(more than 55 years) or associated comorbidities. However,
the exact timing of elective operation has not been deter-
mined with precision. As compared to open surgery, elec-
tive laparoscopic left colonic resection for non complicated
acute diverticulitis decreases post-operative complications.
However, the conversion rate to laparotomy is associated
with increased postoperative morbidity rates.

Patients operated within three months of the last episode of diverticulitis were compared to case-matched patients operated beyond the third month after the last spurt. We studied the impact of time interval to surgery on outcome parameters including operative incidents, postoperative complications and pathologic findings.

As compared to the results of patients who had early resection, the conversion rate as well as the overall abdominal morbidity rate was decreased. Outcome after early surgery is significantly hindered by marked residual inflammation in the first three months after the last episode of acute spurt. Laparoscopic left colonic resection for acute diverticulitis is best performed beyond the third month after the last acute episode.

## Colorectal/Intestinal Surgery - P153

### LAPAROSCOPIC TOTAL COLECTOMY FOR BENIGN

### COLONIC DISORDERS, Abhay Dalvi MS, Pinky Thapar

MS,Ramkrishna Prabhu MS,Avinash Supe MS,Mukta Bapat MD,shobhna Bhatia MD, Department of General Surgery, Surgical Gastroenterology* and Gastroenterology*, Seth G.S.Medical college & K.E.M Hospital, Mumbai, India.

Laparoscopic total colectomy (LTC) with ileal pouch anal anastomosis (IPAA) is an emerging option for diseases affecting the entire colon (ulcerative colitis and familial adenomatous polyposis). Due to compromised medical condition of patients with Inflammatory bowel disease, a staged procedure is often advised. Open surgery involves a long incision, and re-intervention during staged surgery makes operations difficult, prolongs in-hospital stay and has a high incidence of postoperative subacute intestinal obstruction (SAIO). We analyse our data of LTC with IPAA as a staged procedure in patients with refractory ulcerative colitis (UC) and familial adenomatous polyposis (FAP).

A total of 11 patients (5 men) with median age 27 years (range 18-35) underwent LTC with IPAA from March 2003 - Aug 2006. Seven patients suffered from UC and 4 patients had FAP. Three had three stage procedure - all UC (1ST stage LTC, 2nd stage IPPA with covering ileostomy and 3rd stage closure of ileostomy), 7 had two stage - 4 UC and 3 FAP (1ST stage LTC with IPAA and proximal ileostomy, 2nd stage closure of ileostomy). Only one patient of FAP underwent single stage LTC with IPAA.

Median to lateral colonic dissection was done using monopolar electrocautery in 6 patients and harmonic scalpel in 5 patients. Pfannensteil incision was used to deliver the specimen. All patients underwent stapled IPAA.

The operative time ranged from 150 - 300 min (median 180 min). Only patient with FAP required conversion due to bleeding. Blood loss in all other patients was minimum not requiring any transfusion. All patients were on full oral diet by 4th post-operative day. No major complications were encountered except one patient developed SAIO which settled with conservative treatment. Other 10 patients were discharged by 8th day. It was interesting to note that at second or third stage of interventions, minimum or no adhesions were encountered.

Most of these patients require a staged procedure. Open surgery becomes morbid with repeated interventions prolonging the recovery as it involves long incision against Pfannensteil incision in LTC and adhesions in subsequent interventions. Laparoscopic intervention for colectomy offers a distinct advantage by lesser blood loss and faster recovery in the first stage, decreased difficulty in second and / or third procedure. We propose that LTC with stapled IPAA is a definite option for patients with diseases of the colon requiring pancolectomy.

## Colorectal/Intestinal Surgery - P154

### MINIMALLY INVASIVE TREATMENT OF RECTOVAGINAL

### FISTULA, Giancarlo D'Ambrosio MD, Luigi Solinas

MD,Luciana Barchetti MD,Angelo De Sanctis MD,Mario Guerrieri MD,Giovanni Lezoche MD,Adriana Rotundo MD,Emanuele Lezoche MD, Il Clinica Chirurgica - Policlinico Umberto I - University of Rome "La Sapienza"

**Introduction:** Rectovaginal fistulas (RVFs) represent a difficult matter. Surgical treatment of RVF may be accomplished through different surgical routes: transanal, transvaginal, perineal, transabdominal and a laparoscopic approach has been reported. The most employed techniques are direct suture, muscular flap or mesh with a success rate of 40-85%.

We present a new approach that utilize the T.E.M. to remove the fistula and the scar tissue around.

### Methods:

-Technique: the patient is placed in prone position on the operative bed. The fistula is clearly identified by the 3D TEM direct vision and a wide excision of the margins is performed. The dissection of rectovaginal septum orally and laterally is performed by TEM and the aboral part introducing the finger in the dissected area of the septum. The Buess rectoscope is introduced again and the suture of the vaginal edge is performed in order to obtain a longitudinal suture. The emostasy is carefully verified and a transverse suture line is performed in the rectal wall. No drainage was required.

-Patients: Four patients were operated on with this innovative technique in two years period. All the patients were referred us from other institutions and the fistula was related to transvaginal hysterectomy in 1 case and in the other 3 cases occurred after low anterior resection with stapler.

**Results:** Postoperative course was uneventful and the patients were discharged 2 days after operation. Very low dose of analgesics was required, oral intake started after 24 hours and mobilization was obtained at the same day of operation.All the patients had a previous stoma that was closed 30 days later after endoscopic and radiological examination.

### Conclusion:

We strongly recommended this approach in the treatment of RVFs that avoid any incision of perineal area with no risk to damage sphincter fibres and function.

## Colorectal/Intestinal Surgery - P155

### LAPAROSCOPIC-ASSISTED SIGMOID COLECTOMY FOR

VOLVULUS, Bastian Domajnko MD,Ahmed Ahmed MD,Thad J Boss MD, Department of Surgery, Highland Hospital, University of Rochester Medical Center

Sigmoïd volvulus (SV) is a disease of the elderly and debilitated that carries a high mortality. We report the case of a 70-year-old female patient presenting with a large bowel obstruction (LBO), whose radiographic findings suggested SV. The volvulus was decompressed with rigid sigmoidoscopy and a rectal tube was placed. Following bowel prep, the patient was taken for surgery. Pneumoperitoneum was achieved using a 5-mm optical trocar inserted at the umbilicus. A 2nd 5-mm port was inserted in the epigastrium. Initial laparoscopic examination revealed a lengthened redundant loop of sigmoid colon with little room in the abdominal cavity. We therefore modified our initial attempt of a fully laparoscopic sigmoid colectomy to a laparoscopic-assisted procedure. A 5 cm incision was made in the LLQ. The sigmoid was grasped at the apex and extracted in such a way as to splay out the redundant loop on the surface of the abdomen, with the proximal and distal parts of the loop aligned side by side. A stapled side-to-side anastomosis was performed.

<figure><img src="image_95.png" /></figure>

The intervening mesentery was then divided and the redundant loop of sigmoid colon resected using the linear stapler. The colon was returned to the abdominal cavity and the wound closed in layers. Total operative time was 51 minutes. The patient had an uncomplicated postoperative

<figure><img src="image_96.png" /></figure>
<figure><img src="image_97.png" /></figure>

SAGES POSTER ABSTRACTS

course and was discharged the following day. Colonic volvulus accounts for 5% of LBO in North America. The standard treatment for SV is sigmoid resection. Few reports exist in the literature of laparoscopic-assisted sigmoid colectomy in the setting of volvulus. The minimally invasive approach described here is ideal in the high risk or elderly patient who presents with acute SV when a totally laparoscopic resection is not technically feasible.

Colorectal/Intestinal Surgery – P156

LAPAROSCOPIC TREATMENT OF CROHN'S DISEASE: SINGLE SURGICAL TEAM EXPERIENCE, Ismail Hamzaoglu MD,Tayfun Karahasanoglu MD,Bilgi Baca MD, Ilknur Erenler Kilic MD, Department of Surgery, Istanbul University Cerrahpaşa Medical School, Istanbul, Turkey

**Background:** Surgical intervention is generally mandatory in Crohn's disease when the steroid refractory complications; recurrent bowel obstruction, intraabdominal abscess and internal or external fistula occured. Herein, we present the results of patients who had been operated on for Crohn's disease.

**Methods:** The patients who underwent laparoscopic and open surgical intervention for Crohn's disease were evaluated, retrospectively. Indications for surgery, intraoperative findings, postoperative complications, follow-up results were reviewed.

**Results:** Between January 2000 and August 2006, 49 patients with Crohn's disease were operated. There were 23 female and 26 male whose mean age was 36 (21-58) years. Indications for surgery were as follows; bowel obstruction (n=32), internal fistula (n=5), external fistula (n=2), anal stricture due to perianal involvement (n=4), liver abscess (n=1), ileum perforation (n=1) and tumor development (n=1). While 19 patients underwent laparoscopic surgery, 30 patients underwent conventional surgery. The performed laparoscopic operations were; ileocecal resection (n=13), partial small bowel resection (n=2), right hemicolectomy (n=1), left hemicolectomy (n=1), total colectomy (n=1), drainage of liver abscess (n=1). Mean hospital stay after laparoscopic surgery was 5 (2-10). There was no complication and mortality in laparoscopically operated patients. Mean follow-up time was 28 (3-59) months. Histopathologic examinations revealed that one patient had tuberculosis.

**Conclusions:** Laparoscopic treatment of Crohn's disease offered substantial advantages in terms of more rapid recovery, shortened hospital stay and better cosmetic advantages. There was no increase in complications, as compared with open surgery.

Colorectal/Intestinal Surgery – P157

SINGLE SURGICAL TEAM EXPERIENCE FROM TURKEY FOR ULCERATIVE COLITIS, Ismail Hamzaoglu MD,Tayfun Karahasanoglu MD,Bilgi Baca MD, Ilknur Erenler Kilic MD, Istanbul University Cerrahpasa Medical Faculty Department of General Surgery

**Background:** During follow up period of patients with ulcerative colitis, surgery may be necessary. In this study the results of the patients who were operated on by the same surgical team for ulcerative colitis were presented.

**Methods:** Patients underwent surgery for ulcerative colitis were reviewed, retrospectively. Operative data, postoperative complications, early and late outcomes were presented.

**Results:** Between January 1999 and August 2006, 44 patient underwent surgery for ulcerative colitis. There were 14 female and 30 male patients. Mean age was 38 (18-70) years. Surgical indications of patients were; pancolitis in spite of medical therapy (n=12), complications of medical therapy (n=6), uninterrupted steroid intake (n=6), subsequently occured sigmoid colon cancer (n=1), lower gastrointestinal bleeding (n=5), perforation (n=1), acute fulminant or toxic colitis (n=13). While 30 patients were operated on electively, 14 patients were operated on urgently. Elective surgical procedures were performed as single staged (n=17) and two staged (with loop ileostomy, n=13) operations, emergency procedures were performed as two (n=7) and three (n=5) staged operations. In two patients, total colectomy with end ileostomy were performed.

Laparoscopic resection was performed in 18 patients. Two of the elective surgical procedures were redo operations (pouch excision and new pouch reconstruction). Mean postoperative hospital stay was 11 (4-42) days. Mean mortality rate was 4% (n=2). Minor complication rate was 9% and major complication rate was 20%. Major complications were; pouch leakage (n=3), rectal stump leakage (n=1), acute mechanical intestinal obstruction (n=4), ileostomy complications (n=1). In one patient after the closure of the ileostomy, pouch leakage was occured and ileostomy was done. Mean follow up period was 35 (1-92) months. Average stool frequency was 4 (2-9) times/day. In 6% of the patients, chronic pouchitis developed.

**Conclusions:** When the functional and clinical outcomes were evaluated, the treatment choice in ulcerative colitis should be restorative proctocolectomy. In the cases of acute colitis or patients receiving high-dose steroid, we recommend two or three staged procedures. Totally (colon and rectum resection with intracorporeal anastomosis) laparoscopic restorative proctocolectomy is our preferred method.

Colorectal/Intestinal Surgery – P158

LAPAROSCOPIC SURGERY IN COLORECTAL CANCERS: EXPERIENCE WITH 57 PATIENTS, Tayfun Karahasanoglu MD, Ismail Hamzaoglu MD,Bilgi Baca MD, Ilknur Erenler Kilic MD, Department of Surgery, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey

**Purpose:** The aim of this study was to evaluate the results of patients laparoscopically treated for colorectal cancer. Patients and methods: Between August 2001 and August 2006, 57 consecutive patients who had laparoscopic resection due to colorectal cancer were evaluated retrospectively on a prospective database. Histopathologic results, operative findings, postoperative complications and follow-up data were reviewed.

**Results:** Mean age of patients was 62 (32-91) years including 23 female and 34 male were operated on for colorectal neoplasms. Tumor localizations were: right colon (n=9), transvers colon (n=4), left colon (n=8), sigmoid colon (n=4) and rectum(n=32). There were 20 low anterior resection, 12 abdominoperineal resection, 10 left hemicolectomy, 9 right hemicolectomy, 4 anterior resection, 1 subtotal colectomy and 1 restorative proctocolectomy. Mean duration of operation was 160 (120-360) minutes. Mean postoperative hospital stay was 7 (3-24) days. Mean follow-up period was 14 (1-60) months. Mortality rate was 1% and morbidity rate was 14%. No local recurrence occured in the postoperative period. There were one patient developed carcinomatosis peritonei in the second year of follow-up and one patient with metachronous rectum cancer. Mean number of resected regional lymph nodes was 16 (6-48). According to AJCC, staging was as follows; 40% (Stage I), 21% (Stage IIA), 7% (Stage IIIA), 13% (Stage IIIB), 11% (Stage IIIC) ve 8% (Stage IV).

**Conclusion:** Laparoscopic surgery in the treatment of colorectal cancer is a safe method providing general benefits of minimal invasive surgery such as short hospital stay, minimal pain, faster recovery and early return to daily activities.

Colorectal/Intestinal Surgery – P159

VIRTUAL REALITY SURGERY SIMULATION SYSTEM FOR LAPAROSCOPIC ASSISTED COLORECTAL SURGERY WITH PATIENT-SPECIFIC ANATOMY, Ken Eto MD, Shigeyuki Suzuki PhD, Naoki Suzuki PhD, Asaki Hattori PhD, Makoto Kosuge MD, Akinori Oda MD, Masato Yokoyama MD, Michiaki Watanabe MD, Masaichi Ogawa MD, Hideyuki Kashiwagi MD, Sadao Anazawa MD, Katsuhiko Yanaga MD, Department of Surgery, The Jikei University School of Medicine

**Objective:** We developed a virtual reality surgery simulation technique for laparoscopic assisted colorectal surgery (LACS). We believe this system allows for a safer operation by enabling the surgical team to visualize the anatomy preoperatively, practice the specific surgical maneuvers for the specific patient, and decrease the potential for complications specific to LACS.
SAGES POSTER ABSTRACTS

<figure><img src="image_98.png" /></figure>

**Methods and procedures:** We have been creating a virtual reality surgery simulation system for LACS utilizing patient?lspecific anatomy. These computer simulated tissue models were created by utilizing the sphere-filled method that enables visualization of real-time deformations and is based on patient-specific data obtained from CT-angiograms. The model aims to simulate tissue deformation effects on the mesentery and blood vessels caused by manipulations during laparoscopic colectomy. We aimed to represent anisotropic deformations of these models by analyzing the direction of the vessel structures. The system allows surgeons to practice surgical maneuvers and mesenteric vessel ligation which require greater skill than in conventional surgery. It enables surgeons to know the anatomy of patients pre-operatively, and to anticipate variations in the vascular anatomy. Virtual laparoscopic instruments were controlled by manipulation of two PHANTOM devices. As a result, the surgical maneuvers of laparoscopic colectomy such as pushing and grasping of the mesentery and its vessels could be simulated. Additionally, surgeons can practice dissecting, isolating and dividing the vessels with virtual laparoscopic instruments.

**Results:** At this time, we present our virtual computer simulated model of right colon and mesenteric anatomy. Based on these models, we have performed 5 cases of laparoscopic right colectomy utilizing this simulation. Four cases were for ascending/cecal colon cancer and 1 case for diverticulitis. From our model, we knew in advance that 4 of the 5 cases did not have a right colic artery. There were no operative or post-operative complications.

**Conclusions:** We believe this virtual reality surgery simulation system for LACS with patient?lspecific anatomy helps to make LACS safer and easier. Additionally, it represents a novel and emerging technique for laparoscopic surgical training which can be used to teach residents as well as established surgeons without laparoscopic experience or training.

## Colorectal/Intestinal Surgery - P160

**PRESACRAL LYMPHANGIOMA: RARE CAUSE FOR CYSTIC PRESACRAL TUMOR, G. Peter Fakhre MD, Jeffrey Albright MD, Philip Metzger, Mayo Clinic Jacksonville**

Presacral tumors are rare lesions, typically categorized as congenital, inflammatory, osseous, neurogenic, or miscellaneous in origin. These cystic or solid neoplasms may be benign or malignant. Lymphangiomas are uncommon lesions, most commonly occurring in the neck, where they are known as cystic hygroma. Fewer than 5% of lymphangiomas occur intraabdominally, occurring in the omentum, retroperitoneum, and bowel mesentery. We report only the second reported case of a cystic lymphangioma presenting as a presacral mass. The lesion was identified incidentally on a CT scan in a 69-year-old man during evaluation for a pulmonary embolism. The patient underwent a successful resection via a posterior parascrococcygeal approach.

## Colorectal/Intestinal Surgery - P161

**LAPAPAROSCOPIC COLECTOMY FOR COLON CANCER. DOES CONVERSION AFFECT THE OUTCOME?, Mariano M Faresi MD, Michael Hellinger MD, Laurence Sands MD, Floriano Marchetti MD, Jackson Memorial Hospital**

**BACKGROUND:** Laparoscopic-assisted colectomy (LAC) has evolved as a technical option in the treatment of colorectal cancer, and has proven to have oncologic outcomes comparable to open colectomy (OC). The aim of this study is to analyze the results of a large LAC group from a single teaching institution, and the impact that conversion to OC has on the outcome.

**METHODS:** Since October 1995 to September 2005, 101 patients underwent laparoscopic-assisted colectomies for colorectal adenocarcinoma. The study group was divided into A) cases completed laparoscopically (83 patients) and B) patients who required conversion to OC (18 patients). All procedures were performed by senior residents supervised by board certified colorectal surgeons. A retrospective review of a prospective database was performed. Reasons for conversion were intraoperative complications (6

patients), unfavorable anatomy (11 patients) and equipment failure (1 patient). Outcome measures included short term morbidity and mortality, conversion rate, pain, length of hospitalization, local recurrence, metastasis and overall survival.

**RESULTS:** The 30-day mortality and overall morbidity were 3.6% and 16.8% for non-converted patients, versus 0% (P=1.0) and 50% (P<0.004) for the converted group. Analysis of the morbid groups showed an intraoperative complications incidence of 7% in group A, and 44% in group B (P=0.056). Mean length of stay was 5.2 days in group A, and 9.1 days in group B (P=0.0006). Overall local recurrence was 2.4% and occurred only in non-converted patients; however this difference was not statistically significant (P=1.0). Kaplan-Meier survival analysis showed no differences between study groups (log-rank test P=0.25).

**CONCLUSION:** The LAC technique for colorectal cancer can be taught to surgery residents in a controlled and safe manner. Conversion to open negatively affects morbidity, however, early mortality and overall survival are not altered. Conversion does not increase the incidence of local recurrence or abdominal wall implants.

## Colorectal/Intestinal Surgery - P162

**PROSPECTIVE EVALUATION OF FUNCTIONAL RESULTS AFTER LAPAROSCOPIC COLECTOMY FOR DIVERTICULAR**

**DISEASE, A. Forgione MD, J. Leroy MD, M. Simone MD, C. Bailey MD, F. Rubino MD, D. Mutter MD, J. Marescaux, IRCAD-EITS/ University Louis Pasteur, Strasbourg, France**

**Introduction:** The aim of this study was to evaluate quality of life (QoL), sexual and urinary function after laparoscopic colectomy for diverticular disease.

**Materials and methods:** A prospective clinical study was carried out from March 2005 to May 2006. All patients undergoing elective laparoscopic sigmoid resection for diverticular disease were included. Age, sex, BMI, ASA status, comorbidities, number of episodes of diverticulitis and operative data were recorded. Functional results were evaluated before and 3, 6 and 12 months postoperatively: quality of life using the Gastrointestinal QoL Index (GIQLI); sexual and urinary function using the International Index of Erectile Function (IEEF-5) and International Prostate Symptom Score (IPPS-6) for male and the Urogenital Distress Inventory (UDI-6) for female patients.

**Results:** Laparoscopic sigmoidectomy was carried out in 41 patients (21 males, 20 females). Mean age was 58 years (37-78), BMI 27 (21-38) and the average episodes of acute diverticulitis 2. ASA status of the patients was I (25), II (12) and ASA III (2). Conversion occurred in 1 case (2.4%) and postoperative complications in 3/41 (7%). Mean follow-up was 12.6 months (4-18). Postoperatively, QoL was significantly improved at 3, 6, 12 months without changes in sexual and urinary function (Table).

<table><thead><tr><td></td><td>Pre-op</td><td>3 months</td><td>6 months</td><td>12 months</td><td>p value</td></tr></thead><tbody><tr><td>GIQLI</td><td>100 (55-135)</td><td>113 (66-137)</td><td>112 (56-138)</td><td>112 (56-138)</td><td>&lt;0.05</td></tr><tr><td>IEEF-5</td><td>19 (10-25)</td><td>20 (6-25)</td><td>19 (13-25)</td><td>18 (8-25)</td><td>ns</td></tr><tr><td>IPPS-6</td><td>6.4 (0-21)</td><td>5 (0-11)</td><td>5.3 (1-9)</td><td>8 (1-23)</td><td>ns</td></tr><tr><td>UDI</td><td>3 (0-11)</td><td>2 (0-6)</td><td>3.6 (0-9)</td><td>1.6 (0-3)</td><td>ns</td></tr></tbody></table>

**Conclusion:** Laparoscopic approach for sigmoid disease does not affect sexual and urinary functions and appears to improve QoL. The use of QoL indexes might help in the decision to operate on patients after uncomplicated episodes of diverticulitis.

## Colorectal/Intestinal Surgery - P163

**ANOTHER WAY TO TREAT THE APPENDICEAL ROOT IN LAPAROSCOPIC APPENDECTOMY, Miguel Garcia-Oria MD, J. Domingo MD, F. Gomez MD, E. Piedrafita MD, M. Bolarin MD, C. Segendorf MD, Department of Surgery, Hospital de Figueres, Girona, Spain.**

**Background:** One of the important technical details in laparoscopic appendectomy (LA) is the treatment of the appendiceal root. LA can be performed applying endostalkers or endoloops at the appendiceal root, or with extracorporeal appendectomy.

**Methods:** All patients with suspected acute appendicitis (AA) submitted by the first author to exploratory
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# SAGES POSTER ABSTRACTS

laparoscopy during the period from June 2003 to august 2006 were analyzed. We report data of patients with laparoscopic intracorporeal knotting of the appendiceal root. Outcomes including length of stay, intraoperative blood loss, operative time and complications were prospectively registered.

**Results:** 69 surgical procedures were performed for suspected AA, 29 open approach, 40 by laparoscopy (L). 5 cases were exclude for the analysis (1 perforated appendicitis with lack of appendiceal root, 1 appendiceal phlegmon treated with drainage, 1 endostapler appendectomy, 1 perforated ulcer, 1 internal hernia). Data of the 35 LA with intracorporeal knotting of the appendiceal root were as follow: Mean age was 27.2 years (range, 10-49), females 20 (57.1%), postoperative LOS 3.2 days (1-9), surgical blood loss 20 (1-200) ml, there were 28 (80%) ASA 1 cases, and 7 (20%) ASA2. Operative time 70 (37-170) min, conversion rate 1 (2.8%). AA with peritonitis or abscess were 9 (25.7%), regular AA 19 (54.3%) and 7 (20%) were not AA in histological analysis. Complications were 1 (2.8%) case of small intraabdominal abscess not requiring drainage, 2 (5.5%) minor infections of the umbilical port, and 1 (2.8%) urinary tract infection. Reoperation, readmission or UCI were not required in any case. There was no Mortality.

**Conclusion:** The intracorporeal knotting of appendiceal root in cases of laparoscopic appendectomy is feasible and seems to have similar results than other establishes techniques.

## Colorectal/Intestinal Surgery - P164

**LAPAROSCOPIC TOTAL PROCTOCOLECTOMY AND LAPAROSCOPIC TOTAL ABDOMINAL COLECTOMY: SINGLE SURGEON EXPERIENCE**, Kelly A Garrett MD, Nitin G Malhotra MD, Edward C Lee MD, Department of General Surgery, Albany Medical Center, Albany, NY, USA

**INTRODUCTION:** In the minimally invasive era, laparoscopic total proctocolectomy (LTPC) and laparoscopic total abdominal colectomy (LTAC) have presented a challenge to the general surgeon due to longer operative times, high conversion rates and steep learning curves. This paper analyzes a single surgeon's (ECL) experience with LTPC and LTAC in the treatment of inflammatory bowel disease (IBD), familial polypsis syndromes (FPS), colonic inertia (CI) and colon cancer.

**METHODS:** 48 patients who underwent LTPC and LTAC were identified from a single surgeon's database (ECL) from March 2001 to July 2006. Data for this population of patients was collected by chart review and analyzed retrospectively.

**RESULTS:** Of 48 patients identified, there were 31 females and 17 males. Mean age was 33 with a range of 10-71. 38 cases were done electively and 9 were done emergently. LTPC and LTAC were performed on a total of 30 and 18 patients respectively. Of the 30 patients that had LTPC, 29 had creation of an ileo-anal J-pouch and one had an end ileostomy. 15 of the 18 patients that underwent LTAC had creation of an ileorectal anastomosis and 3 had an end ileostomy. 31 patients had a preoperative diagnosis of IBD, 8 patients had FPS, 7 had CI and 1 had colon cancer. The overall mean surgical time was 258.9 minutes (range 137-330) for LTPC and 194.3 minutes (range 155-259) for LTAC. Average length of stay was 8.6 days for LTPC and 9.2 days for LTAC. Average return of bowel function was 3.3 days for LTPC and 4 days for LTAC. Open conversion was required in 2 patients undergoing elective LTPC and 2 undergoing LTPC on an emergent basis. A total of 7 (14.6%) patients had early complications which included SMV thrombosis (1), ileus (3), wound infection (2) and DVT (1). 12 (25%) patients had late complications which included bowel obstruction (3), pouch leak (1), abscess (1), colitis (1) and readmission for dehydration (5). There were no mortalities.

**CONCLUSIONS:** When performed by an experienced colorectal surgeon, we believe that LTPC and LTAC have equivalent outcomes when compared to open approaches. In our experience, these procedures can be safely performed in the elective as well as the emergent setting with no difference in conversion rates. The laparoscopic approach for the management of colorectal diseases has become the standard of care at our institution.

## Colorectal/Intestinal Surgery - P165

**LAPAROSCOPIC APPROACH TO ACUTE SMALL BOWEL OBSTRUCTION: REVIEW OF 1047 CASES.**, B. Ghosheh MD, J. R Salameh MD, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi

**BACKGROUND:** Acute small bowel obstruction has been a relative contraindication for a laparoscopic management approach. However, as experience with laparoscopy grows, more surgeons are attempting it for this indication. The exact success rate, benefits, as well as risk of bowel injury and other complications have been unclear. The purpose of this study is to define the outcomes of laparoscopy for acute small bowel obstruction though a metaanalysis of published cases.

**METHODS:** A literature search of the Medline database was performed using the key words: laparoscopy, adhesiolysis, and bowel obstruction. Further articles were identified from the reference lists of retrieved literature. Only English language studies were reviewed. We excluded studies that included patients with chronic abdominal pain and/or chronic recurrent small bowel obstruction and/or gastric or colonic obstruction, when the data specific to acute small bowel obstruction could not be extracted. Data was analyzed with an intention to treat.

**RESULTS:** Eighteen studies from 1994 to 2005 were identified. Laparoscopy was attempted in 1047 patients for acute small bowel obstruction. The most common etiologies of obstruction included adhesions 83.0% (815/982), abdominal wall hernia (3.1% or 31/982), malignancy (2.9% or 29/982), internal hernia (1.9% or 19/982) and bezoars (0.8% or 8/982). Laparoscopic treatment was possible in 693 cases with a conversion rate was 33.8%. Causes of conversion were dense adhesions (27.1% or 58/214), need for bowel resection (23.3% or 50/214), unidentified etiology (13.1% or 28/214), iatrogenic injury (10.3% or 22/214), malignancy (7.5% or 16/214), inadequate visualization (4.2% or 9/214), hernia (3.3% or 7/214) and other causes (11.2% or 24/214). Morbidity was 15.5% (150/967) and mortality was 1.5% (16/1032). There were 45 reported recognized intraoperative enterotomies (6.7%), but less than half resulted in conversion. There were however 9 missed perforations, including one trocar injury, often resulting in significant morbidity. Early recurrence (defined as recurrence within 30 days after surgery) occurred in 2.1% (22/1032).

**CONCLUSION:** Laparoscopy is a safe and effective procedure for the treatment of acute small bowel obstruction with acceptable risk of morbidity, bowel injury and early recurrence.

## Colorectal/Intestinal Surgery - P166

**LAPAROSCOPIC MANAGEMENT OF SMALL BOWEL OBSTRUCTION: ANALYSIS OF THE SALTS DATABASE.**, Dieter Hahnloser, Markus K Mueller, Markus Schaefer, Departemtn of Visceral and Transplantation Surgery, University Hospital Zurich, Switzerland

**Background:** Laparoscopy for small bowel obstruction (SBO) is not well established. The aims of this study were to review the outcomes of a nationwide prospective multicenter study.

**Methods:** Analysis of all patients operated from 1995-2004 for SBO based on the prospective database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS).

**Results:** 460 patients with a mean age of 52 years (±19) underwent either emergency operation within 24 hours (n=283, 62%) or elective laparoscopy (n=177, 38%) after a mean of 2.2 days (±5.8). 82% of operations were performed by surgeons with experience of >100 laparoscopies. Adhesions (61%) or an isolated band (31%) were the main causes of SBO. Intraoperative complications occurred in 15.2%, 36% of them could be managed laparoscopically. The conversion rate was 30% (39% inability to visualize the site of obstruction, 30% small target incision for resection, 22% complication, 9% various). Local surgical complications were noted in 44 patients (9.6%) including 16 wound infec-
tions and 6 missed perforations (1.3%). General (caridac and pulmonal) postoperative complications occurred in 7.6%. 10 patients (2.2%) were readmitted within 30 days and overall mortality was 0.4%. Emergency operations were significantly shorter (87% <120 minutes vs. 71%, p<0.001) with a higher conversion rate (38% vs. 17%, p<0.001), but without increased intraoperative (17% vs. 12%, p=0.1) or total post-operative complication rate (18% vs. 16%, p=0.8). However, conversion regardless the time of surgery was associated with significant increased morbidity (49% vs. 23%, p<0.001) and prolonged hospitalization (13.5 vs. 6.5 days, p<0.001).

**Conclusion:** Laparoscopic management of small bowel obstruction is safe and feasible in experienced hands and is not associated with increased morbidity in an acute situation. However, conversion should be preemptive and not reactive. Patient selection remains crucial.

## Colorectal/Intestinal Surgery - P167

**HAND-ASSISTED LAPAROSCOPIC TOTAL COLECTOMY FOR ULCERATIVE COLITIS WITH SIGMOID COLON CANCER, Shigeoki Hayashi MD, Minoru Matsuda MD, Motoo Yamagata MD, Tadatoshi Takayama MD, Division of Digestive Surgery, Nihon University School of Medicine**

**Background and Aim:** The laparoscopic procedure has been successfully used to perform colonic resections. Inflammatory bowel diseases like ulcerative colitis (UC) appear as an indication for laparoscopic surgery. We performed Hand-assisted Laparoscopic Total Colectomy (HALTC) for an UC patient with sigmoid colon cancer.

**Methods:** First six trocars were inserted, one 12 mm beside the umbilicus (laparoscope), two 5 mm trocar in the right side abdomen, two 12 mm trocars in the left side abdomen, and one 12 mm trocar in the middle lower abdomen. After lymphnode resection around inferior mesenteric artery, the artery was ligated with the medial approach. Sigmoid colon was mobilized. And the proximal rectum was transected using ENDOGIA. 7 cm Gelport incision was made at the umbilical incision. Under manual guidance mobilization of the large bowel, the mesenteric dissection by Ligasure was performed from cecum to sigmoid. The lower rectum was cut off and sleeve mucosal resection of residual lower rectum was done. The hand-port was removed and the colon was taken out through the middle wound. The terminal ileum was transected and ileocolonic artery was preserved. Then, J-pouch of terminal ileum was made with ENDOGIA. The ileal pouch-anal anastomosis was done and temporary covering ileostomy was made at the right lower abdomen. Therefore the HALTC was completed.

**Results:** HALTC was done for 68 years old man as UC with sigmoid colon cancer. He was discharged without complication. Four months later, the covering ileostomy was closed.

**Conclusion:** HALTC with systematic resection of lymphnode for sigmoid colon cancer is possible, safe and efficacy.

## Colorectal/Intestinal Surgery - P168

**CHANGES IN ANORECTAL PHYSIOLOGY AFTER ANAL SPINCHTER RADIOFREQUENCY REMODELING (SECCA PROCEDURE), Roman M Herman MD, Piotr Walega MD, Michal Nowakowski MD, Jerzy Salowka MD, Marcin Nowak MD, Jacek Sobocki MD, 3rd Department of General Surgery Jagiellonian University, Krakow, Poland**

The main doubt reducing enthusiasm for the radiofrequency remodeling technique (secca) was based on lack of physiological studies, which may explain the possible pathomechanism of improvement of symptoms. The aim of this study was clinical physiological evaluation of the anorectal function prior and during 6 months follow-up after the secca procedure.

14 fecal incontinence (FI) patients (2 male and 12 female, mean age 52,9 ranged 41-78 years) have been enrolled into the study. The standard technique and secca device was used (Curon Medical, Freemont, CA USA). The following parameters were evaluated at baseline, 3 and 6 months after the procedure: continence (CCF-FI, FI-SI scores), improvement (FI-QoL, patient diary, VAS), electromyography (EAS-superficial, IAS-needle), rectal electro- and thermosensitivity,

barostat, anal manometry, morphology (endoanal ultrasound).

Comparing to baseline, 3 and 6 months average results were as follows: CCF-FI 12,0-9,0-9,4; FI-SI 35,6-34,7-35; compliance 5,1-3,8-4; manometry BAP 30-39-40, SAP 65-87-95; electrosensation 16-51-45, thermosensation 0,7-0,25-0,3, respectively. In FI-QoL scale significant improvement in 3 of 4 measures was observed, as well as IAS and EAS electromyography improvement.

Secca remodeling is safe and seems to be effective method of FI treatment. It reduces the frequency and severity of FI symptoms, and improves patient's quality of life. This effect seems to be related to restored anorectal sensitivity and recto-anal coordination, however effect on IAS morphology and function is also detectable.

## Colorectal/Intestinal Surgery - P169

**EVALUATION OF LAPAROSCOPE-ASSISTED COLECTOMY FOR THE PATIENTS WITH ACUTE ABDOMEN, Eiji Ikeda MD, Okayama Red Cross General Hospital**

With 3-years experience of laparoscope-assisted colectomy (LAC), we have expanded its indication to the patients with acute abdomen from April 2002. Among 330 cases of LAC for 7 years and 9 months, 33 cases of acute abdomen were treated with LAC, which included 27 cases of intestinal obstruction and 6 of peritonitis. The indication of LAC for acute abdomen has been decided to be localized peritonitis or intestinal obstruction which is decompressed before operation to obtain enough working space for LAC. The patients who underwent emergency LAC were retrospectively compared with 54 cases of colonic acute abdomen which underwent open surgery or 297 cases of elective LAC. The proportion of the patients who were built colostomy, the amount of intraoperative bleeding and postoperative complication were significantly lower in emergency LAC group compared with open surgery group. Though 19 complications occurred in open surgery group, mild wound infection was seen in 2 case and no operative mortality was seen in emergency LAC group. The conversion rate to open surgery and incidence of complication of emergency LAC is as much as elective LAC cases. The cases of colon cancers were included in emergency LAC group, but all patients have passed without recurrence during median postoperative period of 26 months. LAC is useful for selective cases of acute abdomen.

## Colorectal/Intestinal Surgery - P170

**LAPAROSCOPIC EXCISION OF A MALIGNANT MESENTERIC CYST IN A 22 YEAR-OLD FEMALE, William A Jakobleff MD, Jonathan Reich MD, Carlos Martinez MD, Alexander Abkin MD, Nicholas Bertha DO, Morristown Memorial Hospital, Morristown, NJ**

**Background:** Mesenteric cysts are a rare entity occurring in about 1 of every 140,000 hospital admissions. Sixty percent of these occur in the small bowel mesentery, while 24% occur in the large bowel mesentery. Although rare, their malignant transformation has been reported.

**Methods:** We present the case of a 22 year-old female who presented to our institution with complaints of right upper quadrant abdominal pain. A mass was palpable on exam. A confirmatory CT scan demonstrated a mesenteric mass in the region of the hepatic flexure. The patient was taken to the operating room for a diagnostic laparoscopy and excision of the mass. The mass was enucleated laparoscopically and removed from the peritoneum in an Endocatch device.

**Results:** Pathology confirmed the diagnosis of mesenteric cyst with moderate-poorly differentiated adenocarcinoma.

**Discussion:** Data supports the use of both laparoscopic and open techniques for excision of mesenteric cysts. This case demonstrates the potential malignant transformation of a usually benign entity. Four lymph nodes included in our specimen were all negative for malignancy. The currently available literature does not advocate for further treatment.
<figure><img src="image_100.png" /></figure>

# SAGES POSTER ABSTRACTS

## Colorectal/Intestinal Surgery - P171

STAPLED HEMORRHOIDOPEXY IS ASSOCIATED WITH A HIGHER RECURRENCE RATE OF INTERNAL HEMORRHOIDS COMPARED TO CONVENTIONAL EXCISION SURGERY: FOLLOW-UP TO A META-ANALYSIS, S Jayaraman MD,P

Colquhoun MD, Department of Surgery, University of Western Ontario

In a recently published Cochrane Meta-Analysis of 12 randomized controlled trials (RCTs) comparing stapled hemorrhoidopexy (SH) to conventional hemorrhoidectomy (CH), we demonstrated that SH was associated with a greater risk of hemorrhoid recurrence (OR 3.85) and the symptom of prolapse (OR 2.96) in studies with long term follow-up. The purpose of this study is to update the analysis with more recently published trials.

A systematic review of RCTs comparing SH and CH with long-term results was performed using the Cochrane methodology. Included studies had a minimum follow-up of 6 months and compared circular stapled hemorrhoidopexy to excisional hemorrhoidectomy. Studies were analyzed for clinical and statistical heterogeneity. Primary outcomes were hemorrhoid recurrence, hemorrhoid symptom recurrence, complications and pain. A random effects model was used to calculate a meta-analysis.

An additional 3 RCTs were added to the original 12 trials. The results show that patients are even more likely to have recurrent internal hemorrhoids in long term follow-up (OR 3.97, 95% CI 1.64-9.59, p<0.002). Similarly, patients are even more likely to complain of prolapse (OR 3.60, 95% CI 1.51-8.56, p<0.004). Patients who received SH were more likely to have external anal skin tags (OR 1.62, 95% CI 1.00-2.62, p<0.05). Non-significant trends favoring CH continue to be seen in the proportion of asymptomatic patients, bleeding, soiling/difficultly with hygiene/incontinence, and the need for further surgery. Non-significant trends favoring SH are still seen in pain, pruritis ani and symptoms of anal obstruction/stenosis.

Patients receiving SH continue to experience a higher likelihood of hemorrhoid recurrence and are more likely to complain of prolapse in long-term follow-up compared with CH.

## Colorectal/Intestinal Surgery - P172

OUTCOMES OF LOCAL EXCISION OF T1 RECTAL CANCERS: OPEN TRANSANAL VS ENDOSCOPIC MICROSURGICAL, O

Jazaeri MD, E Schochet MD,J Obuch BA,R Riether MD,S Eid MS,J Matulay BA,R J Sinnott DO, Lehigh Valley Hospital

**Introduction:** Recent reports have questioned the adequacy of local excision (LE) for early rectal cancers. Transanal Endoscopic Microsurgery (TEM) allows for increased exposure, magnification, and more precise tissue handling over conventional transanal excision (TA). We propose that TEM may improve recurrence and survival outcomes in T1 patients due to the inherent advantages over TA with regard to adequacy and handling of specimens.

**Methods:** A retrospective review of all rectal cancers treated at our institution since 1990 was undertaken with IRB approval. 58 patients with T1 adenocarcinoma of the rectum who underwent TEM (n=19) or TA (n=39) were included. Mean follow-up was 4.9 and 7.7 years while mean age at the time of surgery was 68.1 and 67.4 years in the TEM and TA groups, respectively. Kaplan-Meier survival analysis and univariate linear regression were used to examine factors affecting local recurrence and survival.

**Results:** For TEM and TA, overall local recurrence rates were 21% and 15.4%, respectively, 5-year overall survival rates were 89.5% and 84.6%, respectively, and 5-year disease-specific survival rates were 100% and 97.4%, respectively. None of these differences reached statistical significance. Univariate analysis failed to identify any significant predictors of recurrence including lymphovascular invasion, tumor grade, distance from anal verge, mucinous features, or margin status. There were four local recurrences in the TEM group occurring between 1.1 and 4 years. Two were salvaged with no evidence of disease at years 5 and 6. One patient died from other causes 3 years after his recurrence. One patient died from bulky disease resistant to treatment at year 6, 18 months post recurrence. The six local recurrences in the TA group occurred between 3 months and 9 years post surgery. Three were salvaged with no evidence of disease at years 2, 14, and 15. Two patients failed salvage therapy and died 3.5 and 1.5 years following their recurrences. One patient died from other causes 3 years after his recurrence.

**Conclusion:** TEM appears to offer no significant survival advantage over TA in the treatment of early rectal cancers. For properly selected early-stage patients, the role of local excision remains an option, although close surveillance for up to 5 years remains obligatory. The roles of adjuvant and neoadjuvant therapies are evolving and may ultimately confer additional benefits to this patient population.

## Colorectal/Intestinal Surgery - P173

LAPAROSCOPIC ASSISTED DIVERTICULAR RESECTION FOR SITUS INVERSUS TOTALIS, Sanjay Jobanputra MD,Bashar

Safar MD,Steven D Wexner MD, Cleveland Clinic Florida, Weston, FL

**Background:** Situs inversus totalis is a rare condition where the abdominal and thoracic cavity structures are opposite of their usual position. Laparoscopic colonic surgery for this patient population is not well described. There are only two reported cases of laparoscopic sigmoid resection for diverticulitis. Methods: We present a third case of laparoscopic colectomy for diverticulitis in a patient with situs inversus totalis and a description of the operative procedure. Results: Our patient was a 62 year old female with a history of situs inversus totalis who had been hospitalized for multiple episodes of diverticulitis in the past and three episodes over a one month period. She was subsequently scheduled for laparoscopic sigmoid colectomy. The procedure included the use of four trocars, one umbilical, and the others on the left side of the abdomen, opposite our normal placement for sigmoid colectomy. The sigmoid colon was noted on the right side and a large phlegmon was also noted. The colon was mobilized and an incision was made through the patient's prior C-section incision to allow removal of the large phlegmon. Conclusion: Patient tolerated the procedure well and was discharged home on postoperative day 5 without complications.

## Colorectal/Intestinal Surgery - P174

A TECHNIQUE FOR LAPAROSCOPIC FEEDING JEJUNOSTOMY USING A BALLOON-TIP CATHETER, Amit RT Joshi

MD,Eugene Rubach MD,Gary R Gecelter MD, North Shore-Long Island Jewish Health System

**BACKGROUND:** Many techniques of totally laparoscopic jejunostomy have been described. Most use needle-catheters or T-tubes. We describe a technique that allows use of an ordinary 16-French catheter (red rubber or equivalent) to maximize versatility of post-operative feeding and medication administration. We find that the pre-placement of trans-abdominal sutures allows easy introduction of a catheter.

**METHODS:** We use three 5-mm trocars (for one flexible laparoscope and two operating instruments). After identifying the ligament of Treitz, an appropriate segment of proximal jejunum is chosen. We place two intra-corporeal 3-0 sutures just proximal and distal to the proposed enterotomy. We then pull the ends trans-abdominally using a suture passer. By placing traction on the proximal suture, the bowel is correctly oriented so that the proposed enterotomy site faces the camera and the distal jejunum is in a straight line. The enterotomy is made using a harmonic scalpel. The catheter is introduced through the abdominal wall using one of the trocar sites and fed into the distal jejunum while the distal jejunum is kept on traction. An air-insufflation test is performed to ensure intra-luminal positioning. The balloon
<figure><img src="image_101.png" /></figure>

SAGES POSTER ABSTRACTS

ic group (14.4%; p < 0.001). Wound infection was significantly more common in the open group (incidence, 31%) than in the laparoscopic group (7.2%; p < 0.001). Intraabdominal infection was equally common in the two groups. Hospital stay was significantly shorter in the laparoscopic group (p < 0.001). Amount of intraoperative bleeding was significantly higher in the open group (p < 0.001).

**[Conclusion]:** Our findings indicate that LA is safe and useful even for the treatment of appendicitis with perforation or abscess formation

## Colorectal/Intestinal Surgery - P179

**LAPAROSCOPIC RIGHT HEMICOLECTOMY FOR INTESTINAL INTUSSUCEPTION**, F M Kiernan MD,M Joyce MD,C K Byrnes DO,W Torregiani MD,P Neary MD,F B Keane MD, Division of Colorectal Surgery, Department of General and Vascular Surgery, and department of Radiology Adelaide and Meath Hospital, Tallaght, Dublin 24

**Introduction:** Adult intussusception is rare and usually associated with carcinoma in 50% of cases. These have traditionally been managed using an open technique. We herein describe a laparoscopic extended right hemicolectomy in a 64 year old lady with an intussusception secondary to a transverse colonic tumour.

**Methods:** The patient presented with a 6 week of crampy, colicky, abdominal pain. Her CT scan reported intussusception of the proximal large bowel. She underwent an extended laparoscopic right hemicolectomy with primary anastomosis.

**Results:** Her post-operative was uneventful and the histology reported a large bowel adenocarcinoma with none out of 25 nodes involved.

**Conclusion:** When operative intervention is required, intussusception may be managed using a minimally invasive technique. However large bowel intussusception in adults may have a malignant cause thus laparoscopic resection should only be performed by surgeons experienced in laparoscopic resections for colorectal malignancies as oncological safety must be the primary concern. This laparoscopic approach facilitates rapid recovery and earlier time to chemotherapy if required.

## Colorectal/Intestinal Surgery - P180

**THE EFFECT OF ROTATABLE LAPAROSCOPIC VIDEO MONITOR ON THE CAPABILITY OF LAPAROSCOPIC PROCEDURE**, Jae Hwang Kim MD,Tae Hwan Ghil MD,Sang Hun Jung MD, College of Medicine, Yeungnam Univ, Daegu, Korea

**Background:** The main difficulty with laparoscopic colorectal surgery, a difficulty is that assistors perform the procedures are performed with an uncomfortable image that is rotated up to 180 degrees left either right or left sides from their own normal view. This is one of major reasons why surgeons need require more training and experience to overcome this difficult view.

**Aim:** To evaluate the improvement of in the laparoscopic performance with using the normalized video image as compared with the previous rotated upside down image.

**Methods:** Surgical residents (inexperienced group; n=8) and surgeons (experienced group; n=8) who have experience treating more than 50 cases of with laparoscopic surgery experience performed a simple laparoscopic procedure using the a laparoscopic training kit with a newly developed rotatable laparoscopic video monitor (patent pending) that could be controlled by pushing a button on the floor. The monitor rotates 180 degrees on both the right and left side on a central axis of the image. We the named the 'Normalized view' as refers to the best image for performing the procedure and it can be made by rotating the image with the performer's by foot control. The study procedure was to hook a rubber band onto 2 standing bars in 3 minutes each with a 180 degree 'rotated view' and 'normalized view' in a cross-over design. We compared the number of successfully hooked rubber bands in both situations was compared.

**Results:** The number of successful results in the inexperienced group with the 'rotated image' and the 'normalized

image' was 0.4 ± 0.49 and 6.4 ± 0.51, respectively (p<0.001), and the number of successful results in the experienced group was 1.4 ± 1.01 and 9.4 ± 1.99, respectively (P<0.001). In comparison with the experienced group, the success rate with the 'normalized image' in the inexperienced group was low (p<0.05). However, the success rate of the inexperienced group with the 'normalized image' was significantly higher than the success rate of the experienced group with the 'rotated image' (p<0.001).

**Conclusion:** Compared with We confirmed that changing the 'rotated' laparoscopic video image, to the an easy 'normalized' image (the normal eye view) allows a dramatic improvement for in the laparoscopic performance. Using the use of a rotating laparoscopic video monitor could can maximize the capability of the assistants for to performing major laparoscopic surgery at any location of the body.

## Colorectal/Intestinal Surgery - P181

**INFLAMMATORY BOWEL DISEASE:OPEN VERSUS LAPAROSCOPIC SUBTOTAL COLECTOMY**, Dr.Rachel E Kirby MD,Mr. Colman K Byrnes MD,Mr. Myles Joyce MD,Keane B Professor Frank,Mr. Paul Neary, Department of Surgery,Adelaide and Meath Hospital Dublin ,Tallaght ,Dublin 24.

**Introduction:** Failure of medical treatment for ulcerative or Crohn's colitis necessitates surgical intervention,typically a subtotal colectomy.Laparoscopic surgical techniques to treat colonic disease are increasingly recognised as an alternative to open surgery.We compare a a minimally invasive with an open approach to subtotal colonic resection in severe IBD.

**Methods:** Consecutive patients having required a subtotal colectomy for IBD over a 5 year period were identified retrospectively.Charts were retrieved and analysed for demographics,clinical presentation,operative details,complications rates and clinical course.

**Results:** Nine patients underwent an open and nine a laparoscopic subtotal colectomy.There were no significant differences between age,sex,nutritional and ASA status.Mean time from diagnosis was seven years.Urgent or emergency surgery was required in 3 of the laparoscopic and 4 of the open group.Mean time from diagnosis was 7 years.Laparoscopic mean operating time tended to be longer (3 hrs 40min) than open (2hrs 50min:p=0.16):but there were no conversions.Early complications in the laparoscopic group were one ileostomy prolapse,one extraction site wound infection,one lateral space hernia requiring surgery.There was one intra abdominal collection in the open group requiring a second laparotomy.Average time to IV analgesia discontinuation (1.4 days laparoscopic vs 3.3 days open p<0.01) and full diet (2.4 vs 5.3: p<0.05) were significantly shorter in the laparoscopic group.Median lengths of stay (10 vs 14) tended to be less in the laparoscopic group p=0.13.

**Conclusion:** A minimally invasive surgical approach to both the elective and emergency surgical management of severe colitis is feasible with no conversion in this series.Complication rates are similar,with a more rapid early recovery but post operative lengths of stay are similar possibly due to stomal care issues.

## Colorectal/Intestinal Surgery - P182

**PERFORATED DIVERTICULAR DISEASE:LAPAROSCOPIC HARTMANN'S PROCEDURE AND SUBSEQUENT LAPAROSCOPIC REVERSAL**., Rachel E Kirby MD, Lucy M Soden MD,Colman K Byrnes MD,Prof.Frank B Keane,Mr.Paul Neary, Department of Surgery,Adelaide and Meath Hospital ,Tallaght ,Dublin 24 ,Ireland.

**Introduction:** Surgical treatment for perforated diverticular disease classically involves a sigmoid resection with primary anastomosis or Hartmann's procedure,depending on the degree of faecal contamination.Previous laparoscopic approaches described in this acute context describe the use of peritoneal washout,without resection.

**Methods:** We report a case of perforated diverticular disease,requiring a Hartmann's procedure,performed and subsequently reversed laparoscopically.
**Results:** A 59-year old female presented with left sided abdominal pain, sepsis and left iliac fossa peritonitis. Investigations were consistent with perforated diverticular disease. Laparoscopy confirmed the diagnosis. The perforation and degree of local contamination necessitated a resection, but precluded a primary anastomosis. A laparoscopic sigmoid resection was performed to the upper rectum with the perforated segment removed via the end colostomy site. Intestinal continuity was re-established laparoscopically five months later using a trans-anal stapling device. She remains well on routine follow up.

**Conclusion:** Laparoscopic Hatmann's procedure and reversal is feasible in carefully selected patients with perforated diverticular disease requiring surgery.

## Colorectal/Intestinal Surgery - P183

### ASSESSMENT OF A LAPAROSCOPIC APPROACH IN THE MODERN MANAGEMENT OF PERFORATED PEPTIC ULCER DISEASE.
Dr. Rachel E Kirby MD, Mr. Colman K Byrnes MD, Ms. Helen O'Grady, Mr. Musallam Al Akash, Prof. Frank B Keane, Mr. Paul Neary, Department of Surgery, Adelaide and Meath Hospital, Tallaght Dublin 24 Ireland.

**Introduction:** Open exploration and repair is the gold standard for the treatment of perforated peptic ulcer disease. More recently a minimally invasive approach has been described. We retrospectively analysed consecutive patients presenting to our unit during an evolution to a laparoscopic approach.

**Methods:** Patients presenting with a perforated peptic ulcer were identified over a 2 year period. Charts were retrieved and analysed.

**Results:** A total of 13 patients, 6 female and 7 male patients presented with a perforated peptic ulcer. 6 patients proceeded directly to a traditional laparotomy and open repair of the perforation. This was based on surgeons' preference. 7 patients underwent an initial diagnostic laparoscopy. Based on this evaluation, a formal laparoscopic omental patch repair was performed in 4 cases and an open approach performed on 3 cases. All patients underwent a formal repair with omentoplasty and commenced on empirical triple therapy post operatively.

There was no significant difference between the laparoscopically assessed and open cases (age p=0.89; and nutritional status p=0.70).

Laparoscopically assessed patients had an increased incidence of smoking, alcohol and NSAID consumption. The cases assessed laparoscopically and performed in an open fashion had a significantly delayed emergency presentation compared to those repaired laparoscopically (22 hours vs. 52 hours; p = 0.04). There was no additional morbidity associated with initial laparoscopic evaluation and subsequent open repair. These patients had a similar postoperative course to those that proceeded to open surgery directly. Patients assessed and repaired laparoscopically tended to have a shorter length of stay (7 vs. 14 days), a shorter operative time (1.3hrs vs 1.4hrs), earlier nasogastric tube removal (p =0.07) and shorter time to resume oral intake. Complications occurred only in cases completed by open procedure. These included a relaparotomy and washout in one instance, three cases by acute renal failure, 2 CVA?, an abdominal collection requiring drainage and these resulted in mortality in 2 cases.

**Conclusion:** Cases with prolonged duration of symptoms prior to surgical intervention are more likely to necessitate an open approach due to excessive peritoneal contamination. An initial laparoscopic assessment however adds no additional morbidity, and when a laparoscopic repair is performed may lead to a quicker recovery with fewer postoperative complications.

## Colorectal/Intestinal Surgery - P184

### THE PROBLEMS OF LAPAROSCOPIC LOW ANTERIOR RESECTION FOR RECTAL CANCER.
Yukihito Kokuba MD, Takeo Satou MD, Heita Ozawa MD, Kazuhiko Hatate MD, Takatosi Nakamura MD, Wataru Onozato MD, Atushi Ihara MD, Masahiko Watanabe MD, Kitasato University East Hospital

Magnified views of the operative field are highly useful in cases involving laparoscopic surgery for rectal cancer, permitting detailed observation of dissected tissue and nerve alignment. Combined with appropriate knowledge of the intrapelvic anatomy, magnified views make it possible to dividing the rectum and preserving nerves without bleeding. The dissection and resection associated with low anterior resection require skill. Due to the difficulty of handling the tumor with the required delicacy, the risk of disseminating tumor cells is high. While the procedures are similar for upper rectal cancers and cancers of the sigmoid colon, laparoscopic low anterior resection can be performed even in cases of advanced cancer. But with lower rectal cancers, this procedure should be restricted to patients in the early stages, unless the surgeon has considerable experience. T2 is the limit even for highly skilled surgeons. The major technical issue associated with the present technique is safe cleaning and resection of the rectum while protecting the tissue from excessive strain. Magnified views of the operative field create favorable conditions for dissection up to the lower rectum, even better than open surgery. However, with the current laparoscopic intestinal forceps, it is difficult to properly hold the part of the intestinal tract that is between the tumor and the anus in the lower rectum. The development of removable intestinal forceps addressed this issue to some degree, but fell short of providing satisfactory results. A recently developed laparoscopic clamp forceps permits adjustment of the angle of the section holding the intestinal tract and provides more reliable gripping. This forceps allows relatively safe cleaning and resection. We anticipate further improvements in surgical forceps for better adaptability to ultralow low anterior resection. In DST anastomosis, it is difficult to sever the rectum perpendicular to the long axis in one motion using any of the currently available staplers. Thick rectal walls make stapling unreliable, and misfires can occur. If these device shortcomings can be resolved to ensure safe rectal resection, we can expect laparoscopic surgery and the magnified views it offers of the operative field to become essential in the treatment of rectal cancer.

## Colorectal/Intestinal Surgery - P185

### PLASMA TIMP-1 LEVELS ARE TRANSIENTLY INCREASED AFTER LAPAROSCOPIC-ASSISTED COLORECTAL RESECTION FOR BENIGN INDICATIONS.
Shantha Kumara MD, Hoffman A MD, Nasar A MD, Belizon A MD, Baxter R MD, Jain S MD, Feingold D MD, Arnell T MD, Moradi D MD, Whelan R L MD, Columbia University

**Introduction:** TIMP-1 (Tissue Inhibitor of Metalloproteinases-1) is an enzyme that degrades metalloproteinases yet also promotes proliferation of a broad range of cell types and also has anti-apoptotic effects as well. It has been demonstrated that early after both laparoscopic-assisted and open colorectal resection for malignancy that plasma TIMP-1 levels are significantly increased. It is not known if the postoperative TIMP-1 elevation is related to the surgery itself or the removal of the cancer. The purpose of the present study was to determine the impact of colorectal resection for benign disease on TIMP-1 levels.

**Methods:** A total of 51 patients undergoing minimally invasive colorectal resection for benign indications were studied. The operations performed were: sigmoid resection/ left colectomy (n= 31; 61%), right colectomy (n=18; 35%); and lap subtotal colectomy (n=2; 4%). Mean incision length was 5.33 (cm). Plasma samples were obtained from blood taken preoperatively, on postoperative day (POD) 1 and POD3. Plasma TIMP-1 levels were determined in duplicate via ELISA. Wilcoxon's signed ranks test was used to determine statistical differences and a p value of less than 0.05 was considered significant. Data is reported as the median (M), and 95% Confidence Intervals (CI).

**Results:** A total of 50 of the cases were successfully completed laparoscopically (98%). There were no mortalities. The median preoperative TIMP-1 level for the group was 158.0; CI (121.0-178.2). The POD1 median result was 216.0; CI (179.0-261.0, n= 35) whereas the POD 3 result was 191.0; CI (154.0-225.0, n=30). When compared to the Preop baseline

<figure><img src="image_102.png" /></figure>
<figure><img src="image_103.png" /></figure>

# SAGES POSTER ABSTRACTS

value, the POD1 was significantly greater (P= 0.0001) however no significance relationship was found with POD3 (p=0.057).

**Conclusions:** Similar to the situation for patients with colorectal cancer, minimally invasive colorectal resection for benign indications is associated with a significant elevation of plasma TIMP-1 level on POD1 and non-significantly on POD3. Although unproven, it is likely that this increase is related to the surgical trauma. A similar study of colorectal resection patients with benign disease undergoing a traditional open procedure would help determine the contribution of the abdominal wound(s) to the TIMP-1 increase found after major abdominal surgery.

## Colorectal/Intestinal Surgery - P186

**COLORECTAL RESECTION, OPEN MORE SO THAN MINIMALLY INVASIVE, IN PATIENTS WITH BENIGN INDICATIONS IS ASSOCIATED WITH PROANGIOGENIC CHANGES IN THE PLASMA LEVELS OF ANGIOPOIETIN 1 AND 2,**

Shantha Kumara MD, Hoffman A MD, Nasar A MD, Belizon A MD, Baxter R MD, Jain S MD, Feingold D MD, Arnell T MD, Moradi D MD, Whelan R L MD, Columbia University

**INTRODUCTION:** Angiopoietin 1 (Ang1) is a protein that stabilizes mature blood vessels and is thought to inhibit the angiogenic response to VEGF. Angiopoietin 2 (Ang 2), in contrast, blocks Ang-1 thereby enhancing VEGF response. The ratio of Ang 1/Ang2 reflects the net effect of these proteins on new blood vessel formation. The purpose of this study was to determine the impact of open and minimally invasive (MIS) colorectal resection on the plasma levels of these 2 proteins. To assess only surgery's affects on these factors, patients with malignancies were excluded from this study as tumors produce pro-angiogenic factors.

**METHODS:** 31 MIS and 19 open surgery patients undergoing colorectal resection were studied. Plasma samples were obtained preoperatively (PO) and on postoperative day(s) (POD) 1 and/or 3. Ang 1 and Ang 2 levels were measured in duplicate via ELISA. Wilcoxon's matched pairs test and the Mann Whitney U Test were used where appropriate to determine statistical differences. A p value of less than 0.05 was considered significant.

**RESULTS:** In the MIS group the Ang1/Ang2 ratio was significantly lower on POD1 (M=3.4, CI 2.2-4.4, n= 29, p=0.001) and POD 3 (M= 2.3, CI 1.3-3.2, n= 29, p=0.0001) compared to the Preop result (M=7.0, CI 4.3-8.5, n=31). Similarly, in the Open group the Ang1/Ang2 ratio was significantly lower on POD1 (M=1.7, CI 1.2-3.3, n= 17, p=0.001) and POD 3 (M=0.8, CI 0.5-1.8, n=11, p=0.003) when compared to the Preop result (M=4.9, CI 2.9-9.1, n=19). Of note, the MIS Ang1/Ang2 ratios on POD1 and POD3 were significantly higher than the Open groups? Ang1/Ang2 ratios on POD1 (p=0.044) and POD3 (p=0.015). Furthermore, in both the MIS and open groups on POD 1 and 3 the Ang 1 plasma levels were significantly lower than Preop values. The open group Ang 2 values on POD 1 and 3 were significantly greater than the corresponding MIS groups? (POD1, p=0.01; POD3, p=0.003).

**CONCLUSION:** Colorectal resection for benign indications, both open and MIS, results in decreases in plasma Ang 1 and increases in Ang 2 levels, the net effect of which is proangiogenic as reflected by the lower postoperative Ang1/Ang2 ratios seen in both groups. The Ang 2 alterations are significantly more profound in the Open group as are the changes in the Ang1/Ang2 ratio. These plasma protein changes are most likely secondary to surgical trauma. It remains to be seen if similar alterations will be found in the cancer setting.

## Colorectal/Intestinal Surgery - P187

**USE OF TRANSANAL ENDOSCOPIC MICROSURGERY FOR EXCISION OF RECTAL LESIONS,** Alex J Ky BA, Erin K Ly BA, Mount Sinai Hospital NY, NY

**Introduction:** Transanal endoscopic microsurgery (TEM) was developed by Buess in 1983 as a minimally invasive surgery for the removal of anorectal lesions that cannot be excised by conventional transanal instruments. We present our experience from a single surgeon from a institution using this

technique.

**Method:** A retrospective chart review was performed on all patients who underwent the TEM between November 2002 to July 2006. The indication for using this technique were any benign lesions located between 6-18cm from the anal verge. All patients were followed up flexible sigmoidoscopies at 1month, 6 months and 1 year postoperatively.

**Results:** Ninety five patients were felt to be appropriate for this TEMS technique between this time period. The diagnosis for these cases were 67 benign adenomas, 23 carcinoids, 4 were T1 rectal cancers. One cannot be completed due to inability to advance the TEMS instrument through a narrow and tortuous rectum. All patients underwent a preoperative enema before the procedure. The average operative time was 68 minutes. The average length of stay was less than 24 hours. 84 of these patient went home the same day. The longest length of stay was 2 days for a patient who had a long segment of carpet of adenomas at 16cm where the peritoneum was entered and subsequently closed.

Perioperative pain was managed with only oral narcotics. Average intraoperative blood loss was 50cc. Two patient had postoperative bleeding that stopped without intervention or transfusions.

## Colorectal/Intestinal Surgery - P188

**LAPAROSCOPIC RESECTION FOR STAGE IV COLORECTAL CANCER,** Wai Lun Law MD, Hok Kwok Choi MD, Yee Man Lee DO, Judy Ho MD, Department of Surgery, University of Hong Kong Medical Centre

**Background:** Up to 20% of patients with colorectal cancer presented with stage IV disease. Data on the outcome of patients with laparoscopic resection for disseminated colorectal cancer are limited. This study aimed to review the outcome of laparoscopic resection for stage IV colorectal cancer.

**Methods:** From the prospectively collected database for patients with colorectal cancer, those with stage IV disease who underwent elective resection of tumor during the period from Jan 2000 to Jun 2006 were included. The outcomes of those with laparoscopic resection were reviewed and comparison was made between patients with laparoscopic and open resection.

**Results:** Two hundred patients (127 men) with the median age of 69 years (range: 25-91 years) were included. Seventy-seven underwent laparoscopic resection. Conversion was required in 10 patients (13.0%) and all except one conversion were due to fixed or bulky tumors. There was no operative mortality (30-day mortality) in the laparoscopic group. The complication rate was 14% and the median postoperative hospital stay was 7 days. When patients with laparoscopic resection were compared with those with open operations, there was no difference in age, gender, comorbidity or tumor size between the two groups. However, the complication rate was significantly lower in those with laparoscopic resection (14% vs. 32.0%, p=0.007) and the median hospital stay was significantly shorter (7 days vs. 8 days, p=0.005). The operative mortalities and the survivals were similar in the two groups.

**Conclusions:** Palliative resection can be performed safely in patients with stage IV colorectal cancer. The operative outcomes in terms of complication rate and hospital compare favorably with patients with open resection.

## Colorectal/Intestinal Surgery - P189

**LAPAROSCOPIC SURGERY FOR SPLENIC FLEXURE COLON CANCER,** YS Lee MD, YJ Heo MD, IK Lee MD, HM Jo MD, WK Kang MD, JK Park MD, ST Oh MD, JG Kim MD, YH Kim MD, The Catholic University of Korea

**Purpose:** While carcinoma of the splenic flexure colon is uncommon, and is associated with high risk of obstruction, and has dual lymphatic drainage system, COST study excluded transverse colon cancer including splenic flexure colon cancer. This study reviews our experiences of splenic flexure colon cancer which were treated laparoscopically, and discusses the appropriate and safe laparoscopic surgical procedure.
SAGES POSTER ABSTRACTS

<figure><img src="image_104.png" /></figure>

**Methods:** Authors reviewed the medical records of patients who underwent laparoscopic surgery for splenic flexure colon cancer from January 1995, to June 2006, retrospectively. Splenic flexure colon was defined as 5cm from the splenic flexure proximally and distally by radiologic studies. Curative surgery for splenic flexure colon cancer was defined like this: primary cancer removal, safe resected margin, no metastasis, complete lymphadenectomy including high ligation of left colic and left branch of mid colic artery. Results: Total 407 patients underwent laparoscopic surgery for colon cancer, among them 17 patients underwent laparoscopic surgery for splenic flexure colon cancer. The mean age of the patients was 62.7 years, and ratio of male-to-female was 10:7. Laparoscopic left colectomy was done in 15 cases, laparoscopic left colectomy with distal pancreatectomy and splenectomy was in 1 case, laparoscopic total proctocolectomy with ileal pouch anal anastomosis was in 1 case. Mean operation time was 349 minutes and average hospital stay was 15.8 days. 1 case of chyle discharge and 2 cases of ileus were developed, but treated conservatively. There was no surgical mortality.

**Conclusions:** Laparoscopic surgery for splenic flexure colon cancer is technically feasible and safe procedure.

Colorectal/Intestinal Surgery – P190

NUCLEOTIDE-GUIDED MESORECTAL EXCISION IN LOCAL TREATMENT OF NON ADVANCED LOW RECTAL CANCER (NALRC) BY TEM, Giovanni Lezoche MD, Giancarlo

D'Ambrosio BA,Rita Massa MD,Luigi Solinas MD,Pietro Ursi MD,Stefania Rebonato MD,Adriana Rotundo MD,Emanuele Lezoche, Il Clinica Chirurgica & Service of Nuclear Medicine-Policlinico Umberto I - University of Rome "la sapienza"

**Introduction:** In despite of the recent progresses of open as well as of laparoscopic rectal surgery LAR or APR with TME still have significative morbidity (7-15%) and mortality (2-5%), that in high risk patients is 10%. Furthermore functional sequelae are more frequent (20-70%) and several authors use routine anomy to protect the anastomosis. Local excision of NALRC utilizing transanal technique led to an unacceptable high percentage of local recurrence. Transanal Endoscopic Microsurgery has multiple technical advantages when compared to transanal procedures and recently has been proposed, combined with neoadjuvant treatment, in order to reduce the risk of local recurrence. During TEM procedure in the last year we employed a modified sentinel node technique in order to improve both local exeresis of the tumoral lymphatic drainage and intraoperative hystological staging.

**Methods:** Only patients with imaging stage of T1,T2-N0 were treated with TEM local excision, T2 N0 pts underwent to neoadjuvant treatment. 99mTc nanocoll (37-74 MBq), diluted in 1 ml of saline solution were injected submucosally around and inside the tumor 45 min before the dissection. Only in the first cases we combined nucleotide with blue-dye, because the blue-dye reduce the endoscopic vision and make more difficult the procedure. The excision of rectal wall was 5-10 mm external to injected area, then a wide ablation of perirectal fat was performed according to the technique previously described (Surg Endosc, 1996). Once the specimen was excised, TEM stranopoll was removed and all the residual cavity was searched for nuclear activity introducing the probe transanally. All the areas with high residual activity were marked with metallic clips and subsequently excised by TEM This procedure was repeated until no radioactivity spots were detected in the residual cavity.All the specimen were examined intraoperatively and no positive tissue for metastases was found. Those results were confirmed to the definitive histology.

Micrometastases were searched immunohistochemically by monoclonal antibodies specific for cytokeratine while blood and lymphatic vessels were assested using monoclonal antibodies specific for CD31 and Podoplanina.

**Conclusion:** The described modify sentinel node technique is feasible and represent a useful guide for ablation of all lymphatic areas surrounding the cancer at risk for local metastases.

Colorectal/Intestinal Surgery – P191

GI RECOVERY RESPONDER ANALYSIS: RESULTS OF PHASE III TRIALS OF ALVIMOPAN (ALV) 12 MG VERSUS PLACEBO (PLA) IN PTS UNDERGOING BR, K. Ludwig MD,E. Viscusi MD,B. Wolff MD,C. Delaney MD,W. Du PhD,L. Techner, Duke U Med Ctr, Jefferson Med Coll, Mayo Clinic, U Hospitals of Clev, Adolor Corp

**INTRO:** A responder analysis was performed to examine alv, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, in the management of postoperative ileus (POI). The proportion of patients who achieved GI recovery and hospital discharge after BR was analyzed in multicenter, randomized, double-blind NA trials.

**METHODS:** Adult pts undergoing laparotomy for BR scheduled for postoperative IV patient-controlled opioid analgesia received oral alv 12 mg or pla preoperatively and twice-daily postoperatively until hospital discharge or for 7 postoperative days (PODs). This pooled post hoc analysis examined the proportion of responders (pts who achieved the event without developing complications of POI) on POD5 and 7 for efficacy endpoints of GI-2 recovery (composite of time to first bowel movement [BM] and toleration of solid food) and time to hospital discharge order (DCO) written. Treatment effects on time to events were analyzed using the Cox proportional hazards model. P values were calculated using Fishers exact tests.

**RESULTS:** Alvimopan significantly accelerated GI-2 recovery and DCO written (hazard ratio=1.5 and 1.4, respectively; P<0.001). More pts in the alv group achieved GI recovery and DCO written. For ex, 80% of pts in the alv group achieved GI-2 recovery by POD5 compared with 66% of pts in the pla group.

**CONC:** In this responder analysis, a significantly greater proportion of pts who received alv 12 mg achieved GI-2 recovery and DCO written by POD7 compared with pts who received pla. This pooled analysis suggests that by accelerating GI recovery, alv also reduces the proportion of pts with a prolonged hospital stay.

<table><thead><tr><th></th><th>Pla n=695</th><th>Alv 12 mg n=714</th><th></th></tr></thead><tbody><tr><td>GI-2, PODs 5, 7</td><td>66.3%, 74.7%</td><td>80.1%, 84.5%</td><td>p&lt;0.001</td></tr><tr><td>DCO, PODs 5, 7</td><td>61.0%, 80.0%</td><td>77.0%, 90.2%</td><td>p&lt;0.001</td></tr></tbody></table>

Colorectal/Intestinal Surgery – P192

LAPAROSCOPIC TREATMENT OF INTRAABDOMINAL FISTULAS: SINGLE SURGEON EXPERIENCE, Nitin G Malhotra MD,Edward C Lee MD,Kelly Garrett MD, Department of Surgery, Albany Medical Center, Albany, NY

**Background:** Laparoscopic surgery (LS) has enabled us to reach new frontiers in abdominal surgery. This study is aimed at the feasibility and clinical outcomes of using laparoscopic surgery in repair of complicated intraabdominal fistulas.

**Methods:** Between February 1998 and August 2006, 24 patients underwent LS for complicated intraabdominal processes and were found to have associated fistulas. Clinical data was retrieved in a retrospective chart review of a single colorectal surgeon's cases at our institution.

**Results:** The average patient age in the study population was 45 years (range 18 to 82). Twenty-four patients underwent LS for complications of diverticular disease (42%) and Crohn's disease (58%). This encompassed colovesicular and colovaginal fistulas with diverticulitis and coloenteric, colocutaneous and enteroenteric fistulas for CD. Conversion to an open procedure was 25% and was required for six patients secondary to adhesions (33%), bleeding (17%) and phlegmons (50%). Four of the six had active CD leading to conversion ratios of 28% for CD and 20% for diverticulitis. The average estimated blood loss (EBL) with laparoscopic versus (vs) conversion to open cases was 136.7 vs. 325 ml (range of 30 to 400ml). Median length of procedure per OR records was 162.3 vs 141.5 minutes (range of 118 to 285 minutes). Return of bowel function occurred on average of 3.3 vs. 6 post-operative days (range 2 to 6 days). The length of stay post-operatively was 4.9 vs. 4.3 days (range 3 to 10
<figure><img src="image_105.png" /></figure>

# SAGES POSTER ABSTRACTS

days). Perioperative mortality and morbidity was 0% and 8% respectively. No further surgery was required in a 60-day follow-up period. During this time, one readmission occurred for a wound infection (4%). **Conclusions:** With new technology and operative techniques, LS has enabled us to attempt complicated abdominal surgery. This study shows that LS for complicated CD and diverticulitis is feasible with promising clinical outcomes and low morbidity. In addition, we propose that the decision to convert to an open procedure be made early as our data shows that these patients have a shorter length of procedure and post-operative stay. As surgeons become more experienced in complex laparoscopic cases, we anticipate that LS will become the standard of care for treatment of intraabdominal fistulas.

## Colorectal/Intestinal Surgery - P193

**CONVERSION RATES IN LAPAROSCOPIC COLORECTAL SURGERY SINCE THE COST TRIAL**, Nell Maloney MD, John J Park MD, Leela M Prasad MD, John H Stroger Jr Hospital of Cook County and Advocate Lutheran General Hospital Introduction: Since the publication of the COST trial, the role of laparoscopy in colorectal surgery has expanded. The present study was performed to assess differences between patients requiring conversion based on the diagnosis of benign versus malignant disease. Methods: Retrospective review was performed for all laparoscopic cases from 5/2004 through 6/2006. Cases that were converted to open procedures were identified. Data collected included patient factors such as age at time of surgery and body mass index (BMI), tumor factors such as location and size of tumor, reason for conversion and hospital length of stay. Data was analyzed using Student T Test. Results: Two hundred and seventy-four laparoscopic colon resections were performed during the study period. One hundred and thirty-nine cases were done for cancer diagnoses and 136 for benign disease. Twelve conversions were identified, five in the cancer cohort and seven in the benign cohort, indicating a 3.6% conversion rate in the cancer cases compared to 5.2% with benign disease (p=NS). The most common reason for conversion was obesity (three patients), other reasons included bleeding, disease process, inability to visualize important structures, adhesions, presence of a mesh and bradycardia.

<table><thead><tr><td></td><td>Benign</td><td>Malignant</td><td>P-Value</td></tr></thead><tbody><tr><td>Age</td><td>67 yrs</td><td>77 yrs</td><td>0.157</td></tr><tr><td>BMI</td><td>27.4</td><td>34.5</td><td>0.013</td></tr><tr><td>Operative Time</td><td>208 min</td><td>232 min</td><td>0.5</td></tr><tr><td>Hospital Stay</td><td>6.1 days</td><td>10.6</td><td>0.07</td></tr><tr><td>Blood Loss</td><td>242cc</td><td>490cc</td><td>0.02</td></tr></tbody></table>

Characteristics of patients requiring conversion

**Conclusions:** Rates and reasons for conversion are similar for patients with benign and malignant diagnoses of colon pathology. Patients with cancer diagnoses may have both an increased blood loss and a longer hospital stay, although this may be related to the greater BMI in the cancer group.

## Colorectal/Intestinal Surgery - P194

**LAPAROSCOPIC ADHESIOLYSIS FOR BOWEL OBSTRUCTION: PREOPERATIVE USEFULNESS OF CINE MAGNETIC RESONANCE IMAGING**, H Matsuoka PhD, T Mori PhD, T Masaki PhD, K Takei MD, M Sugiyama PhD, Y Atomi PhD, H Haradome PhD, Department of Surgery and Radiology, Kyorin University, Tokyo, Japan

**AIM:** Since there were higher morbidity rates reported in previous literatures, case selection for surgery by laparoscopic approach has been stressed. The aim of this study was to clarify the usefulness of cine magnetic resonance imaging (cine MRI) for case selection of laparoscopic adhesiolysis.

**Patients and Methods:** Among 45 patients with bowel obstruction who underwent preoperative cine MRI, laparoscopic adhesiolysis could be performed in 7 cases. Device we used for dynamic cine MRI was a Gyroscan Intera 1.5 Tesla (Phillips Inc.). Examination was obtained with one breath hold with a supine position. Laparoscopic adhesiolysis was applied under following criteria by cine MRI (location of obstruction was detected, relatively favorable bowel

decompression followed by long tube treatment).

**Results:** Laparoscopic adhesiolysis was performed successfully in all cases without morbidity. Although three of seven cases had bowel resection due to persistent adhesive scar on the small bowel, mean time of operation was 113 min. ?i89~146, resuming oral intake at 5?i3? 7?jPOD, and length of postoperative hospital stay was 12 days?i10? 19?j. Preoperative diagnostic accuracies by cine MRI are as follows. The adhesive site was located in all cases (100%: 7/7). Cause of obstruction was also clarified in 6 cases by cine MRI as to whether the cause was tumor or adhesion (80%: 6/7). All patients were also negative for any strangulation. **Conclusion:** Cine MRI was an useful tool for clarifying preoperative status of bowel obstruction in whom laparoscopic adhesiolysis is performed.

## Colorectal/Intestinal Surgery - P195

**LAPAROSCOPIC AND OPEN REVERSAL OF HARTMAN'S PROCEDURE - A COMPARATIVE RETROSPECTIVE ANALYSIS**, Haggi Mazeh MD, Alexander Greenstein MD, Kristin Swedish BA, Scott Nguyen MD, Aaron Lipskar MD, Kaare Weber MD, Edward Chin MD, Celia M Divino MD, Department of Surgery, The Mount Sinai Hospital, New York, NY

**Introduction:** Restoration of intestinal continuity in patients with colostomy after Hartman's procedure traditionally has required a laparotomy. The aim of this study is to present our institution's experience with laparoscopic reversal of Hartman's procedure and to compare short term outcomes with those of open reversal.

**Methods:** After institutional review board approval, we conducted a retrospective chart review of all laparoscopic and open Hartman's reversal procedures performed between January 1998 and June 2006. Specifically, we focused on those patients who had reversal of a left or sigmoid end colostomy, and excluded those with loop or transverse colostomies. These patients were then matched by age, BMI and indication for the initial Hartman's procedure to an equivalent number of open Hartman's reversals. In addition to demographic data, information was collected regarding operative course, perioperative complications, and indication for the initial Hartman's procedure.

**Results:** In total, 41 patients were identified who underwent laparoscopic reversal of Hartman's procedure and were matched to 41 patients with open reversal. The mean average time to closure was 190 days. The groups had similar average age and BMI, and the predominant indication in both groups was diverticular disease. Laparoscopic reversal of Hartman's procedure was attempted in 41 patients and was converted to open in 8 patients (19.5%) due to dense adhesions (6 patients) and difficulty with the anatomy or anastomosis. The most common short term complications were ileus and surgical site infection. There were no anastomotic leaks and no mortalities. The mean operative time in the laparoscopic and open groups was 193 and 209 minutes respectively, but this difference was not statistically significant. The laparoscopic group had a significantly lower (p<0.0005) estimated blood loss of 166ml versus 326ml, a shorter time to bowel function return - 4.1 versus 5.2 days (p<0.05), and a shorter hospital stay - 6.4 versus 8.0 days (p<0.05). The major complication rate was also significantly lower (p<0.05) in the laparoscopic group (4.8%) than in the open group (12.1%).

**Conclusions:** Laparoscopic reversal of Hartman's procedure is a safe and practical alternative to open reversal. It can be performed in a similar operative time with fewer complications and a faster recovery time.

## Colorectal/Intestinal Surgery - P196

**USE OF OXIMETRY-CAPABLE INSTRUMENTS TO ENHANCE IDENTIFICATION OF ISCHEMIC BOWEL DURING SURGERY**, Ozanan R Meireles MD, Lia R Assumpcao MD, Takintope Akinbiyi MS, Eric J Hanly MD, Marcin Balicki BS, Gregory S Fischer PhD, Sunipa Saha MS, Samuel Shih MD, Russell H Taylor MD, Mark A Talamini MD, Michael R Marohn DO, Department of Surgery - Johns Hopkins University School of Medicine, Baltimore, MD

**Introduction:** Ischemic bowel can be a life threatening con-
dition for which diagnostic accuracy and prompt treatment are paramount. After restoring reversible ischemia to the gut, the primary goal in surgical treatment of ischemic bowel is to preserve as much viable bowel as possible while avoiding leaving non-viable tissue in situ. We hypothesize that the use of an oximetry-capable sensing surgical grasper could distinguish between well-vascularized versus 'at-risk' bowel.

**Methods:** A laparoscopic grasper was fitted with oximetry capability. A pilot study was performed in adult swine in which three 10 cm segments of well-vascularized small bowel were bowel clamped proximally and distally followed by segmental vascular-clamp interruption of the mesenteric blood supply for 90 seconds, followed by subsequent release and revascularization. During these procedures, serosal surface oxygenation was measured using the grasper's sensing blades before clamping, 60 seconds after clamping, and 60 seconds after unclamping. Using Infrared/Red light ratios, the smart tool software depicted oximetry readings in real time on the monitor.

**Results:** The readings showed differences in oxygenation when the bowel was clamped and unclamped, demonstrating low oxygen levels at 60 seconds of clamping, correlating with the acute decrease in blood supply. After 60 seconds of unclamping the oxygenation levels returned to baseline levels correlating with the restoration of blood flow.

**Conclusions:** Oximetry-capable sensing 'smart' instruments have the potential to distinguish ischemic from well-perfused small bowel in real time during surgical cases. This technology may enhance the accuracy with which non-viable bowel is identified, decreasing the need for immediate 'second look' re-operation, as well as reducing unnecessary resection of viable bowel based on misleading visual characteristics.

## Colorectal/Intestinal Surgery - P197

**JEJUNAL DIVERTICULA - A SOURCE OF MASSIVE GASTROINTESTINAL BLEEDING**, Subhasis Misra MD, Prasanta Raj MD, Shannon Tarr BS, Richard Treat MD, Fairview Hospital, Cleveland Clinic Health System

**INTRODUCTION:** Massive gastrointestinal bleeding of unknown etiology is one of the challenging cases encountered by the general surgeon. We present an interesting case study of a 75-year-old male admitted with symptoms of lower abdominal pain and rectal bleeding.

**METHODS:** A retrospective review of the patient's history revealed that the patient had two similar episodes of gastrointestinal bleeding five and seven years ago requiring transfusion of four and five units of packed red blood cells (PRBC) respectively. Past medical history was significant for diverticulosis of the sigmoid colon. Upon this admission, the patient was on plavix and aspirin therapy for coronary artery disease. Initial evaluation with upper endoscopy and lower endoscopy, showed the colon to have fresh as well as old blood. Tagged red cell scan and angiogram did not show a definite source of the bleeding. Bleeding parameters were normalized but the patient continued to have rectal bleeding requiring 12 units of PRBC transfusion.

**RESULTS:** Total colectomy with ileorectal anastomosis was performed, as no exact source of the bleeding was known. An incidental finding of multiple jejunal diverticula were noted during this operation. After surgery, the patient continued to bleed requiring six units of PRBC transfusions. On postoperative day four, the patient was taken back to the operating room where a moderate amount of intraluminal blood was found in the small bowel region containing the jejunal diverticula. The entire segment of jejunum containing diverticula was resected. The patient had no further episodes of gastrointestinal bleeding.

**CONCLUSION:** Jejunal diverticula are known to cause several complications including lower gastrointestinal bleeding. This case illustrates that jejunal diverticula can be a source of massive gastrointestinal bleed. We therefore recommend that in patients with jejunal diverticula, consideration should be given to resect the affected area, in cases of massive gastrointestinal bleed, where no definite source is identified.

## Colorectal/Intestinal Surgery - P198

**SPECTACULAR COLOSTOMY - A NEW TECHNIQUE**, Prasanta Raj MD, Subhasis Misra MD, Michael Cho MD, Shannon Tarr BS, Richard Treat MD, FAIRVIEW HOSPITAL, CLEVELAND CLINIC HEALTH SYSTEM

**OBJECTIVE:** Colostomies are necessary in multiple surgical conditions where diversion of colon contents is essential to the surgical management. Complete diversion usually involves two abdominal wall stomas or an end stoma with the distal closed end of the bowel placed inside the abdomen. Complete diversion with two lumens exposed outside, mandates two separate areas of bowel opening. We designed a new technique for complete fecal diversion by separating both ends of bowel, which are exposed outside of the abdomen, while the patient has only one fascial opening and uses only one normal colostomy appliance.

**METHODS:** Skin is marked for an incision, which is shaped like a pair of half-spectacle or reading glasses. A transverse incision is done and the straight upper rim of the spectacle is made. Fascia is incised directly underneath this incision in a transverse fashion. The transverse colon is then mobilized and brought outside the abdominal wall while preserving the blood supply. A rod is used to stabilize the loop of transverse colon outside the abdomen. Multiple absorbable sutures are then placed from the fascia to the bowel serosa. Similar approximation is done on either side of colon. The skin inferior to the transverse part of the spectacle is removed allowing better fascia visualization. Then the skin in between the divided ends is approximated with interrupted deep dermal vicryl sutures; this forms a "skin bridge" between either sides of the transverse colon. Transverse colon is divided and a few sutures are placed on the medial portion of the stoma to the fascia. Transverse colon is then matured. Patencies of the stomas are checked. A single large stoma appliance is applied over both the stomal openings.

**RESULTS:** In a few days the distal stoma opening gets very small and becomes a mucus fistula. Ten cases have been done so far over the last two years. In all the cases the colostomy functioned well, there were no issues with the mucous fistula and a normal sized appliance was attached easily and with good seal.

**CONCLUSION:** The "Spectacular Colostomy" technique offers many advantages and can be used in selected patients with added benefits. This technique is simple, makes one fascial opening, uses one stoma appliance, provides complete diversion, is easy to reverse as a mucus fistula is too close, needs less wound care and is good for use in patients with carcinomatosis and inoperable rectal and other pelvic tumors.

## Colorectal/Intestinal Surgery - P199

**THE ADOPTION OF LAPAROSCOPIC COLORECTAL SURGERY: A NATIONAL SURVEY OF GENERAL SURGEONS**, H Moloo MD, F Haggar BS, F Balaa MD, E Poulin MD, J Mamazza MD, E Sabri MSc, H Stern MD, I Graham PhD, J Grimshaw PhD, R Boushey MD, The Ottawa Hospital

**Introduction:** National cross-sectional study focusing on general surgeons' attitudes and opinions regarding the current practice of laparoscopic colorectal surgery. The aim is to determine the percentage of surgeons performing laparoscopic colorectal procedures, regional variations, limiting factors and identify strategies for adopting the laparoscopic approach (LR).

**Materials and Methods:** A 28-item questionnaire jointly designed by the Departments of Surgery and Epidemiology was sent to all members of the Royal College of Physicians and Surgeons of Canada (RCPSC). Surgeon and practice demographics, subspecialty training and information on their attitudes regarding laparoscopic colorectal surgery were assessed by the questionnaire. Responses from surveys were digitally scanned into a database and descriptive and correlative information was derived using chi-squared, Wilcoxon rank sum, Student's t-test, and multivariate logistic regression.
<figure><img src="image_106.png" /></figure>

SAGES POSTER ABSTRACTS

**Results:** The response rate was 54.8% (694/1266) with 66.6% [95% CI: 63.0%-70.2%] of respondents performing colorectal surgery. Of these, 53.6% [95% CI: 48.8%-58.4%] perform laparoscopic colorectal surgery (LC group) with 46.4% only offering open colorectal surgery (OC group). Members in LC group were significantly younger (45.7 vs 49.7 p<0.001), had fewer years of experience (14.1 vs 17.3 p=0.005) and more practiced in academic centers (59.9% vs 50.3% p=0.03) compared to OC group. In addition, members in the LC group were more likely to have MIS (p=0.010) or Colorectal (p=0.014) subspecialty training. The median number of laparoscopic colorectal cases per year in the LC group was 9.33 (IQR; 6-20); most LC surgeons performed right hemicolectomy (86.6%) and sigmoid colectomy (78.0%); few (24.1%) surgeons performed APR. 76% offer curative cancer resections increasing to 95% for benign diseases. Multivariate logistic regression analyses identified four significant factors related to performing LCS: fewer years of experience (p<0.0001), being male (p=0.0023), practicing in a populous region (p=0.0009), and having MIS fellowship training (p=0.004)

**Conclusion:** A large percentage of general surgeons are offering the LR. Recent graduation, male gender, practice location in a populous region and formal MIS training appear to be significant independent predictors for offering LR.

Colorectal/Intestinal Surgery - P200

ENTERIC FISTULAS FROM CROHN'S DISEASE CAN BE TREATED SAFELY AND EFFECTIVELY WITH LAPAROSCOPIC SURGERY, Alfred Trang MD, Murali Naidu MD, Daniel Herron MD, Barry Salky MD, The Mount Sinai Medical Center

**Introduction:** Laparoscopic surgery for Crohn's disease, while technically complex, has been demonstrated to be safe and beneficial for many patients. However, few data exist regarding the laparoscopic management of Crohn's disease complicated by fistula.

**Methods:** We performed a retrospective chart review of all patients who underwent laparoscopic treatment of Crohn's disease associated with fistulas. All patients were treated by a single surgeon at a high volume referral center during a 3 year period (2003-2006).

**Results:** We identified 35 patients who underwent laparoscopically assisted bowel resections for enteric fistulas due to Crohn's disease during the study period. Many different types of fistulas were identified, with the three most common being ileosigmoid, ileoileal and ileovesical. Sixteen patients presented with multiple fistulas. The average age of patients was 39 and the male to female ratio was 24:11. Ten patients had prior abdominal surgery. Only one patient had to be converted to an open procedure due to dense adhesions and the inflammatory process. Average length of stay was 5.7 days. There were no mortalities. Postoperative complications included two small bowel obstructions (6%), one abscess (3%), two bleeding complications (6%), and two anastomotic leaks (6%). Five patients (14%) required a second operation.

**Conclusions:** Laparoscopic treatment of Crohn's disease fistulas, while technically demanding, may be safe and effective in a high volume referral center. Our series demonstrated acceptable low morbidity rates and short lengths of stay. Minimally invasive surgery can be safely performed on patients with prior abdominal surgeries and those requiring multiple resections.

Colorectal/Intestinal Surgery - P201

MINIMALLY INVASIVE APPROACHES TO COMPLEX CROHN'S DISEASE: THE CURRENT ROLE OF HALS IN EXTENSIVE COLECTOMY, Kiyokazu Nakajima MD, Riichiro Nezu MD, Yasuyuki Kai MD, Keigo Yasumasa MD, Masaya Nomura MD, Toshinori Ito MD, Toshiro Nishida MD, Department of Surgery, Osaka University Graduate School of Medicine

**Background:** Hand-assisted laparoscopic surgery (HALS) has been considered as a practical alternative to laparoscopic-

assisted surgery (LAP) in the surgical treatment of complex colorectal diseases. However, its role in complex operation for Crohn's disease (CD), especially extensive colectomy, has yet to be established. The objectives of this study were, 1) to compare operative and early postoperative outcomes of conventional open (OPEN), LAP, and HALS extensive colectomy, and 2) to determine benefits of HALS in complex and multi-quadrant operations for CD.

**Methods:** We reviewed 38 consecutive patients that underwent extensive colectomy (resection of >3 segments of large intestine) as their initial abdominal surgery for CD between 1992 and 2006. The patients were divided into three groups: OPEN, LAP, and HALS, and their background/postoperative data were prospectively registered and retrospectively analyzed.

**Results:** Fourteen OPEN, 6 LAP and 18 HALS cases were reviewed. The groups were comparable in age at surgery, gender, body mass index, medical comorbidity, extent and type of CD, indications and procedures. Median operative time was significantly longer in LAP (330 min; range 154-540) compared to HALS (251; 165-340) and OPEN (200; 172-315) groups, respectively. Blood loss was significantly less in LAP (170 ml; 115-257) and HALS (225; 35-890) compared to OPEN (438; 280-780) group. HALS was effective to accomplish technically-demanding components in extensive colectomy e.g. retraction of friable bowel, division of thickened mesentery, and takedown of internal fistulas. No difference was seen in postoperative complications and length of hospital stay among these groups. There was no mortality in the series.

**Conclusions:** 1) HALS significantly reduces operative time compared to LAP, while retaining acceptable morbidity rate and recovery benefits of minimal access surgery e.g. less blood loss compared to OPEN. 2) HALS currently seems preferable for technically-demanding and multi-quadrant colorectal procedures such as extensive colectomy for CD.

Colorectal/Intestinal Surgery - P202

RETROGRADE APPROACH TO LAPAROSCOPIC SIGMOID COLECTOMY FOR DIVERTICULITIS: A 6 YEAR SINGLE INSTITUTION SINGLE SURGEON EXPERIENCE OF A NOVEL TECHNIQUE, Jennifer I Linn MD, Biswanath Gouda MD, Thomas J Nelson MD, Sunil Bhoyrul MD, Scripps Clinic, Torrey Pines, CA 92037

**Background:** Laparoscopic sigmoid colectomy is typically performed similar to traditional open techniques. We have been performing retrograde laparoscopic sigmoid colectomy for diverticulitis at our institution since October 2000. This involves beginning with the pelvic dissection and transection of the rectum at the outset of the operation. Next the mesocolon is divided and descending colon mobilized to the level of the proximal resection margin. After removal of the diseased colon and placement of the anvil an intracorporeal end to end stapled anastomosis is completed. We conducted a retrospective study to review our experience in the context of this surgery being performed using an innovative technique that runs counter to established norms.

**Methods:** From October 2000 to May 2006, 53 laparoscopic sigmoid colectomies were performed at the Scripps Clinic. All patients' charts were retrospectively reviewed for operative time, blood loss, conversion to open surgery and hospital stay.

**Results:** There were 5 conversions to open (9.4%) Median operative time was 129 minutes for laparoscopically completed cases and 152 minutes for converted cases. Median estimated blood loss was 87.5 ml and 159 ml respectively. The median length of hospital stay was 3 days for laparoscopic cases and 5 days for converted cases.

**Conclusion:** This retrospective series demonstrates favorable results for the retrograde approach to sigmoid colectomy. We suggest that this technique makes the operation more facile, and provides superior exposure of the sigmoid mesentery
<figure><img src="image_107.png" /></figure>

## Colorectal/Intestinal Surgery - P203

NEW PORTS DESIGN IN LAPAROSCOPIC CENTRAL LYMPH NODES DISSECTION WITH LEFT COLIC ARTERY PRESERVATION FOR COLON CANCER, Masanori Nishioka MD, Hidenori Miyamoto MD, Nobuhiro Kurita MD, Kouzou Yoshikawa MD, Mitsuo Shimada MD, Department of Surgery, The University of Tokushima, Japan

**[Background]** Lymph nodes dissection is necessary for advanced colorectal cancer. Overall survival and disease-free survival after laparoscopic colectomy for invasive colon cancer with lymph nodes metastasis is no worse than the previously reported rates for the same procedure done by an open technique (Surg Endosc. 2005). However, lymph nodes dissection around inferior mesenteric artery with left colic artery preservation using basic five ports design is difficult for anatomical feature inferior mesenteric artery. We report about the new ports design that a port is inserted from a suprapubic region.

**[Purpose]** Purpose of this study was to evaluate the new ports design in laparoscopic central lymph nodes dissection with left colic artery preservation for colon cancer.

**[Methods]** This study included 10 consecutive patients who performed laparoscopic central lymph nodes dissection with left colic artery preservation for sigmoid colon cancer. The new ports design (n=5) was compared with basic ports design (n=5). Tumor stages, average number of lymph nodes harvested, operation time, intraoperative blood loss were examined.

**[Results]** Tumor size of new ports design group was 4.6cm (basic ports design: 5.1cm). Stage II, III was 1, 4 patients, respectively (3, 2). Average number of lymph nodes harvested was 15.8 (11.4). The mean of operation time was 281 minutes (313 minutes). The mean of intraoperative blood loss was 58ml (58ml).

**[Conclusions]** The new ports design that a port is inserted from a suprapubic region reduces operation time and is effective in laparoscopic central lymph nodes dissection with left colic artery preservation for sigmoid colon cancer.

## Colorectal/Intestinal Surgery - P204

HAND-ASSISTED LAPAROSCOPIC COLECTOMY: IS THERE AN ADVANTAGE OVER OPEN RESECTIONS?, Yuri W Novitsky MD, H. James Norton PhD, Kent W Kerher MD, B. Todd Heniford MD, Carolinas Medical Center

**Introduction:** Hand-assisted laparoscopic colectomy has been introduced as an alternative to the standard laparoscopic technique. However, it has not yet been established whether intrabdominal placement of a hand abrogates the benefits of minimally invasive techniques. We hypothesized that the hand-assisted approach confers the advantages of minimal access surgery over traditional open colectomy.

**Methods:** We performed a retrospective review of consecutive patients undergoing elective open (O) and hand-assisted (HA) colon resections at a tertiary care hospital. Open colectomies performed by the laparoscopic surgeons were excluded. Outcome measures included demographics, operative time, perioperative complications, operative and total hospital charges, and length of stay. Statistical analysis was performed using Wilcoxon Rank Sum, Fisher's Exact, and Student's t-test with p<0.05 considered significant.

**Results:** Three hundred-three O and 56 HA consecutive elective colectomies were identified and reviewed. Of these, 161 (53.1%) O and 30 (53.8%) HA were left-sided. The two groups were similar in age (60.3 vs 59.3 years), sex (62.6% vs 67.1% females), and body mass index (28.9 vs 29.1 kg/m2). The mean operative time was longer in the HA group (165 vs 199 minutes, p = 0.002). There were no major intraoperative complications in either group and no conversions form HA to O colectomy. Postoperatively, no patient in the HA group and 13 (4.3%) patients in the O group required blood transfusion. Anastomotic leak was discovered in 6 (2%) patients in the O and none in the HA groups. There was no difference in wound infection rates [5 (1.3%) in the O and 2 (3.6%) in the HA groups, p=0.1]. All 7 (2.3%) mortalities occurred in the O group. The length of stay was significantly shorter in the HA group (5.4 vs 11.6 days, p<0.001).

Both operative and total charges were significantly lower in the HA group ($3,310 vs $4,174, p<0.002; $25,032 vs $32,301, p<0.001)

**Conclusion:** Hand-assisted laparoscopic colectomy is a safe alternative to open resections. It may be associated with a decreased postoperative morbidity and mortality. Despite longer operative times, the use of hand-assisted techniques resulted in a significant reduction of the duration of hospitalization and decreased operative and total charges. Overall, in the elective setting, hand-assisted laparoscopic colectomies appear to maintain the advantages of minimally invasive techniques over open colonic resections

## Colorectal/Intestinal Surgery - P205

IMPACT OF AN EXPERIENCED LAPAROSCOPIC COLORECTAL SURGEON TO AN EXISTING TRADITIONAL COLORECTAL PRACTICE IN AN ACADEMIC MEDICAL CENTER., Vincent J Obias MD, Farhad Zeinali MD, Harry L Reynolds MD, Brad Champagne MD, Conor P Delaney MD, University Hospitals of Cleveland, Case Medical Center

**Introduction:** Laparoscopic colectomy (LAC) is steadily gaining acceptance. The potential benefits of LAC have been reported by high volume institutions with established laparoscopic programs, however, introduction of LAC has often been associated with prolonged operative times, increased costs and no reduction in hospital stay over that seen with open surgery. There are no published data looking at the impact of introducing an experienced laparoscopic colorectal surgeon using fast-track post-operative care pathways on an established and experienced colorectal practice.

**Method:** A consecutive group of 73 patients who underwent LAC performed during the first 11 months of a new practice were compared to a case-matched group of patients who underwent open colectomy (OC). Patients were identified from a prospective database and matched for age, gender, DRG and operation. Open complication data were obtained from electronic medical record review. Patients were compared for outcome and direct costs. Hospital information was collated using integrated hospital cost management system and decision software (Transition Systems Inc. Boston, MA; TSI). Statistics were performed with Paired t test and Fishers exact test.

**Results:** Median age was 66.5 for the LAC group and 63.0 for the OC group (p=0.1935). Surgical procedures were: right colectomy (n=63), left/sigmoid colectomy (n=26), subtotal colectomy (n=18), total proctocolectomy (n=8), anterior resection (n=27), and abdominoperineal resection (n=4). Laparoscopic operative times were a median of 142 minutes. Overall morbidity for LAC was 19.2% and for OC was 16.4% (p=0.829). There was no mortality. Median length of stay was: LAC=3.0 days; OC= 7.0 (p=0.0001). Median direct cost per LAC was $4396 versus $6500 for OC (p=0.0013). Bundled anesthesia and surgical costs were $2438 for LAC and $2612 for OC, while bundled post-operative care expenses (ICU, nursing, pharmacy, laboratory, radiology, and rehabilitation) were $1315 for LAC and $3010 for OC.

**Conclusion:** The results demonstrate the benefit of an experienced laparoscopic colorectal surgeon to an already established colorectal practice. LAC significantly reduced direct costs and resource utilization, with similar morbidity to OC. Hospital stay was also significantly reduced. Although surgical costs were similar, post-operative care costs were reduced yielding a significant overall net financial benefit to the institution.

## Colorectal/Intestinal Surgery - P206

A CASE OF COLONIC INTUSSUSCEPTION RESULTING FROM LIPOMATOUS TUMOR TREATED BY LAPAROSCOPIC-ASSISTED SURGERY, Junya Oguma MD, Hikaru Tamura MD, Masahiko Aoki MD, Kei Hosoda MD, Hiromu Kido MD, Kingen Natsu MD, Tetsu Amemiya MD, Department of Surgery, Ohtawara Red Cross Hospital, JAPAN

**INTRODUCTION:** There is no report until now about a case of colonic intussusception resulting from lipomatous tumor treated by laparoscopic-assisted surgery.

**CASE REPORT:** A 46-year-old woman was admitted to our
<figure><img src="image_108.png" /></figure>

SAGES POSTER ABSTRACTS

hospital complaining of prolapse of a tumor from the anus after evacuation and left lower abdominal pain. The tumor about 5 cm from the anus was reduced with my hand, and an abdominal computed tomography revealed intussusception in the sigmoid colon. A reduction of the intussusception was performed using a barium enema. After careful examination, we diagnosed this case as colonic intussusception resulting from a lipoma. We performed a segmental sigmoid colectomy assisted by laparoscopy. Pathological examination revealed an atypical lipomatous tumor growing from submucosal layer. The postoperative course was uneventful.
**CONCLUSION:** Laparoscopic-assisted surgery is a preferable treatment for repeated colonic intussusception, such as this case.

## Colorectal/Intestinal Surgery - P207

**HAND-ASSISTED LAPAROSCOPIC RIGHT HEMICOLECTOMY OFFERS ADVANTAGES OVER OPEN RIGHT HEMICOLECTOMY AND STANDARD LAPAROSCOPIC HEMICOLECTOMY IN PATIENTS WITH COLONIC NEOPLASIA**, Jason A Petrofski MD, Zachary Hollis BA, Christopher R Mantyh MD, Sandyha Lagoo MD, Kirk A Ludwig MD, Duke University Medical Center

**Introduction:** Randomized trials demonstrate that laparoscopic assisted colectomy for neoplasia offers short-term advantages over open colectomy while providing equivalent oncologic outcomes. However, operative times are significantly longer and adoption of laparoscopic techniques for colectomy have been hampered by a long learning curve. Hand-assisted laparoscopic colectomy is an alternative approach that may address these issues. This study compares the outcomes of patients with right sided colonic neoplasia undergoing hand-assisted laparoscopic right hemicolectomy (HAL) to those undergoing standard laparoscopic right hemicolectomy (LRC) and standard open right hemicolectomy (ORC).

**Methods:** A retrospective analysis was performed of 120 consecutive patients undergoing HAL (n=40), LRC (n=40), and ORC (n=40) for right-sided colonic neoplasia utilizing electronic chart review and a prospectively-maintained anesthesia database. Groups were compared by analysis of variance (ANOVA) and chi-square tests, where appropriate.

**Results:** The groups were well matched for age, BMI, previous laparotomies, and co-morbidities. Specimen review showed no between group differences in oncologic parameters (margin status and number of lymph nodes harvested). However, operative times were significantly lower in the HAL and ORC groups (108.4 ± 31.7 and 97.2 ± 37.8) compared to the LRC group (143.6 ± 41.8; p<0.05). In addition, there were no conversions to laparotomy in the HAL group (n=0) compared to four in the LRC group. There were fewer post-operative complications in the HAL and LRC groups (11% & 13%) compared to the ORC group (40%; p<0.05), and length of stay (LOS) in days was less in the HAL and LRC groups (4.7 ± 1.9; 5.1 ± 2.3) when compared to the ORC group (8.2; p<0.05).

**Conclusion:** Both LRC and HAL for neoplasia were associated with a lower complication rate and shorter length of stay than open right colectomy, while maintaining equivalent oncologic clearance as measured by margin length and lymph node harvest. The hand-assisted technique had advantages over the standard laparoscopic technique, however, with a lower conversion rate and shorter operative time and than standard laparoscopic resection, but with a similar LOS.

## Colorectal/Intestinal Surgery - P208

**PREVENTION OF STOMAL COMPLICATIONS**, Madhav V Phadke MD, Lewis H Stocks MD, Yeshwant G Phadke MD, WakeMed, Raleigh. Affiliated with UNC Chapel Hill, NC
**Abstract**

**INTRODUCTION** Objectives: 1. Block the source (open lumen) of infection by leaving the ileostomy/colostomy stoma obstructed with staples. 2. Prevent infection responsible for complications. 3. Use well established principle of delayed-primary wound healing. 4. Observe the Nature. Does not like putting serosa against serosa when bowel is

everted. 5. Abolish effect of peristalsis on lumen of stoma to keep it concentric. 6. Reward of helping the Nature is an automatic "self-maturation" of stoma. This secret to keep stoma obstructed was discovered during an ileostomy in 1986 by serendipity.

**METHODS & PROCEDURES** Following its discovery during a Brooke Ileostomy, the procedure was used for both, Ileostomy and Colostomy. Staple obstructed stoma was brought out in a conical fashion to abolish effect of peristalsis on lumen. Stoma was fixed to a round opening in rectus sheath. Paracolic gutter was closed using cut edge of mesentery instead of bowel serosa to prevent mucosal prolapse. Stoma was covered using an appliance with a transparent pouch for daily inspection. During postoperative ileus, there is angiogenesis on surface of a single layer of serosa, making the stoma wound refractory to infection. After 72-96 hours post-op, stoma begins to bulge with peristalsis. Stoma was opened at its apex near the anti-mesenteric corner with electrocautery as a bedside procedure. Mucosal tube separates from serosal tube and only the mucosal cuff protrudes, everts, advances with peristalsis, and "autografts" on angiogenesis on surface of a single layer of serosa. Advancing margin of the mucosal cuff fuses with circumference of opening in dermis. The maturation of the stoma is natural and automatic. Absence of sutures reduce tissue trauma and eliminate foreign body reaction resulting in a better wound healing. This scientific procedure was named ?DELAYED-PRIMARY SELF-MATURATION? (DPSM).

**RESULTS** 37 colostomies and 9 ileostomies were performed using DPSM. Infection in the stoma and/or main wound and subsequent complications were prevented in all.

**CONCLUSIONS**

DPSM is technically easier, faster and more scientific than a conventional Ileostomy or Colostomy. It prevents infection which in turn prevents complications. It is recommended for all types of intestinal stomata when indicated.

## Colorectal/Intestinal Surgery - P209

**NECROSIS INTESTINAL IN A 14-MONTH-OLD INFANT WITH AN INTESTINAL OBSTRUCCION BY ASCARIS**, Alexander Ramirez Valderrama MD, Hospital Francisco Valderrama, Turbo (Ant) - Colombia

The ascaridiasis is a very frequent intestinal parasitism, it is considered that affects around 1000 million people all over the world, being the children the most vulnerable, especially in the Third World Countries. Within the abdominal complications of the ascaridiasis we found the biliar obstruction, partial intestinal obstructions, being the main one the intestinal obstruction, which is accompanied by an important morbidity and mortality.

We presented the case of 14 - month - old girl infant with an intestinal obstruction by ascaris that required surgical treatment, it was found massive infestation of ascaris, with more than one hundred worms, ischemia at level of ileum distal and generalized intestinal peritonitis, handled with wide intestinal resection and peritoneal washing, presenting a good clinical evolution.

<figure><img src="image_109.png" /></figure>

## Colorectal/Intestinal Surgery - P210

**BIOABSORBABLE GLYCOLIDE COPOLYMER STAPLE LINE REINFORCEMENT FOR LAPAROSCOPIC APPENDECTOMY**, Alan A Saber MD, Michael Boros MD, Arun Rao MD, Michigan State University, Kalamazoo Center for Medical Studies
SAGES POSTER ABSTRACTS

**Introduction:** Laparoscopic appendectomy is gaining acceptance as the preferred method for treatment of acute appendicitis. The aim of this study was to evaluate the efficacy and safety of the use of bioabsorbable glycolide copolymer (Bioabsorbable SeamGuard; W. L. Gore & Associates, Inc, Flagstaff, Ariz) for reinforcement of endoscopic linear stapler in laparoscopic appendectomy.

**Material and Methods:** Fourty six patients with a clinical diagnosis of acute appendicitis underwent laparoscopic appendectomies using bioabsorbable glycolide copolymer sleeves applied onto 3.5 mm endoscopic linear stapler for simultaneous transection of appendicular base and mesoappendix. Demographic data, BMI, operative time, estimated blood loss, complications including staple line disruption, leak or bleeding, number of staple line reinforcements used and length of hospital stay were recorded.

**Results:** Thirty two females and 14 males were included in the study. The mean operative time was 47 minutes (range, 22-110 minutes). No conversion to open appendectomy was needed. Apart of 3 patients that had intraoperative oozing from mesoappendix staple line, there was no staple line bleeding, disruption, or leak. Thirty two patients (69.6 %) required single application of endoscopic linear staple with bioabsorbable reinforcements to transect both the appendix and the mesoappendix at the same time. Two applications were necessary in twelve patients while two patients required 3 applications. Thirty six patients (78.3%) were discharged 24 hours postoperatively.

**Conclusion:** Laparoscopic appendectomy using endoscopic linear stapler with bioabsorbable glycolide copolymer reinforcement is a safe and efficient procedure for acute appendicitis. This technique may simplify the operative procedure and reduce the operative time. In the majority of cases a single application of endoscopic linear staple with Seam Guard reinforcements is required to transect the appendix and the mesoappendix simultaneously.

Colorectal/Intestinal Surgery - P211

LAPAROSCOPIC COLON SURGERY: AN EIGHT YEAR EXPERIENCE, Arthur Rawlings MD, Danuta I Dynda MD, Melanie Sloffer MS, Jay Woodland MD, David L Crawford MD, University of Illinois College of Medicine at Peoria, Methodist Medical Center of Illinois

**INTRODUCTION:** Laparoscopic colon surgery (LCS) has grown in popularity since its first description in 1991. This study assesses the eight-year experience of one surgeon.

**METHOD:** A review on prospectively collected data on 113 consecutive patients that underwent LCS between January 1999 and August 2006. All procedures were performed by the same minimally-invasive surgical specialist at three hospitals (university and private). Demographic data, such as age, gender, and body mass index (BMI) was collected along with pre- and post-operative diagnosis, operative time, complications, conversions, and length of hospital stay. Relationships between collected variables and procedure were assessed.

**RESULTS:** The population consisted of 58 females and 55 males with mean age of 64 years (range: 24-94) and mean BMI of 27.9 (range: 17-45). The distribution of diagnosis was fairly even: 24% benign neoplasm, 35% malignant neoplasm, 26% diverticular disease, and 16% other pathologies. In the first 4 years, 44 LCS were performed. The second half had 69 cases with double the amount of patients with greater than 30 BMI and more attempts at complex cases like restorative proctacolectomy. Overall, 32 complications occurred including 6 wound infections, 6 anastomotic leaks, 5 abscesses, 4 respiratory difficulties, and 3 ileus. The conversion rate was 12% (13/113); 54% of these conversions were due to severe adhesions. Post-operative mortality was 2.7%.

**CONCLUSION:** During this eight-year period, case volume, complexity, and patient BMI have all increased. Complication and mortality rates are comparable to those reported in literature.

<table><thead><tr><th>LCS Type</th><th>R colon (42%)</th><th>L colon (39%)</th><th>Other</th></tr></thead><tbody><tr><td>OR time (mean)</td><td>135 minutes</td><td>199 minutes</td><td>226 minutes</td></tr><tr><td>LOS (mean)</td><td>5.3 days</td><td>6.0 days</td><td>6.8 days</td></tr><tr><td>Complication*</td><td>13/48 (27%)</td><td>12/46 (26%)</td><td>7/19 (37%)</td></tr><tr><td>Conversion</td><td>5/48 (10%)</td><td>7/46 (15%)</td><td>1/19 (5%)</td></tr></tbody></table>

Colorectal/Intestinal Surgery - P212

?PEEK PORT?: A NOVEL APPROACH TO AVOID CONVERSION UTILIZING HAND-ASSIST TECHNOLOGY, Javier Salgado MD, Thomas E Read MD, David Ferraro MD, Richard Fortunato DO, Lea O'Keeffe BS, James T McCormick DO, Robert P Akbari MD, Philip F Caushaj MD, Division of Colon and Rectal Surgery, Western Pennsylvania Hospital, Clinical Campus of Temple University School of Medicine. Pittsburgh, PA, USA.

**Purpose:** To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients deemed high risk for conversion had an 8cm midline incision (?peak port?) made with the laparoscopic equipment unopened. If intraperitoneal conditions were favorable, a hand-assist device was placed through this incision and the procedure performed laparoscopically; if unfavorable, the midline incision was extended. Patients deemed low risk for conversion were approached laparoscopically from the outset.

**Methods:** Data from a single surgeon's consecutive series of 189 patients brought to the operating room with the intention of proceeding with laparoscopic colectomy were retrieved from a prospective database, supplemented by chart review.

**Results:** Study population: 103 men and 86 women, mean age 62 years (17-94), mean BMI 28 (18-53). Operative procedures were right colectomy(n=85), left colectomy/restorative proctectomy(n=73), APR(n=6), subtotal/total colectomy/procotocolectomy(n=25). Of the 19 patients who underwent initial "peak port", 7(37%) underwent immediate extension to formal laparotomy. 12/19(63%) underwent hand-assisted laparoscopic colectomy, with one subsequent conversion to formal laparotomy secondary to severe diverticulitis with enterocolic fistula. Of the 170 patients initially approached laparoscopically, 87(51%) were attempted with standard laparoscopic techniques and 83(49%) with a hand-assisted technique. 4/170(2%) required conversion to laparotomy because of dense adhesions(n=1), enterocolic fistula(1), ureteral injury(1), morbid obesity(1). Overall, 5/182 patients (3%) in whom laparoscopic access was established by either method underwent conversion to laparotomy using this paradigm. In addition, we were able to preoperatively identify those patients at high risk for conversion to laparotomy (7/19 in the "peak port" group vs. 4/170 in those approached laparoscopically from the outset, p<0.0001, Chi square).

**Conclusions:** This approach to the patient with a potentially hostile abdomen allows for rapid assessment of intraperitoneal conditions that would preclude successful laparoscopic colectomy, and is associated with a low rate of conversion from laparoscopy to laparotomy. Adoption of this technique should reduce cost by avoiding the utilization of laparoscopic equipment in patients who will ultimately require formal laparotomy.

Colorectal/Intestinal Surgery - P213

ALVIMOPAN, A PERIPHERALLY ACTING MU-OPIOID RECEPTOR (PAM-OR) ANTAGONIST, SIGNIFICANTLY ACCELERATED GASTROINTESTINAL RECOVERY AND HOSPITAL DISCHARGE IN PATIENTS RECEIVING INTRAVENOUS PATIENT-CONTROLLED OPIOIDS AFTER SMALL BOWEL RESECTION (SBR), B. Wolff BA, H. Reynolds, Jr. BA, I. Lavery BA, W. Du PhD, L. Techner, Mayo Clinic, Case U, Clev Clinic Found, Adolor Corp

**INTRO:** Time to GI recovery and hospital discharge order (DCO) written were examined after SBR in trials of alv for the management of postoperative ileus.

**METHODS:** This was a pooled subset analysis of adult pts scheduled for postop IV opioid-based pt-controlled analgesia who underwent SBR in phase III trials. Pts received alv 12 mg or placebo (pla) preop then twice-daily postop until hos-

<figure><img src="image_110.png" /></figure>
<figure><img src="image_111.png" /></figure>

# SAGES POSTER ABSTRACTS

pital discharge or for 7 PODs. Treatment effects were analyzed using the Cox proportional hazards model (HR) and Kaplan-Meier means (hours). Efficacy endpoints included GI-2 recovery (time to first BM & toleration of solid food), and DCO written. Nausea and vomiting (N/V) were reported as adverse-events.

**RESULTS:** Efficacy and safety results are presented in the table. CONC: Alv 12 mg significantly accelerated GI recovery and hospital discharge compared with pla in this subset analysis of phase III trials. Alv was well tolerated with a lower incidence of nausea and vomiting compared with pla. Moreover, this analysis is consistent with results from the larger population of all BRs in alv phase III trials.

<table><thead><tr><th></th><th>Pla n=50</th><th>Alv n=65</th><th></th></tr></thead><tbody><tr><td>GI-2, HR</td><td>—</td><td>2.5</td><td>p&lt;0.001</td></tr><tr><td>GI-2, mean hrs</td><td>115.6</td><td>78.0</td><td>-37.6 (33%)</td></tr><tr><td>DCO, HR</td><td>—</td><td>2.0</td><td>p&lt;0.001</td></tr><tr><td>DCO, mean hrs</td><td>131.7</td><td>98.0</td><td>-33.7 (26%)</td></tr><tr><td>N/V</td><td>57%/25%</td><td>44%/20%</td><td>—</td></tr></tbody></table>

## Colorectal/Intestinal Surgery - P214

**LAPAROSCOPIC PROCTOCOLECTOMY USING COMPLETE INTRACORPOREAL DISSECTION**, Nicolas Rotholtz MD, Laura Aued MD, Sandra Lencinas MD, Gerardo Zanoni MD, Mariano Laporte MD, Norberto Mezzadri MD, Colorectal Surgery Section. General Surgery Department. Hospital Alemán de Buenos Aires. Argentina.

**Introduction:** Although many studies have demonstrated good results with laparoscopic proctocolectomy in patients with ulcerative colitis (UC), most surgical procedure require at least one additional incision bigger than 5 cm to complete the surgery. The aim of this study was to evaluate the use of laparoscopic proctocolectomy with ileoanal J pouch with complete intracorporeal dissection using 4 cm right lower quadrant (RLQ) incision.

**Methods and Procedures:** Data were prospectively collected on all patients with UC who required proctocolectomy with ileoanal J pouch between August 2003 and July 2006. The dissection was completely performed by laparoscopy using the medial to lateral approach for the colon and total mesorectal excision for the rectum. Once the rectum was resected laparoscopically, a 4 cm incision in the RLQ was performed to resect the specimen; either an end or loop ileostomy was then implanted at the RQL wound. The surgery was performed in two (proctocolectomy with ileoanal J pouch and loop ileostomy) or three steps (subtotal colectomy, end ileostomy with sigmoid fistula; proctectomy with ileoanal J pouch and loop ileostomy).

**Results:** 40 surgical procedures were performed in 28 patients. 57.2% were male and 42.8% female, with a mean age of 35.4±16.6 years. Mean body mass index was 21±4. 14 patients (50%) had surgery in two steps and the other 14 in three. In 4 (10%) cases, surgery was converted due to mega-colon in one case, narrow pelvis in 1, and difficult rectal dis-section in 2. The overall morbidity rate was 15%. Two patients required reoperation and there was no mortality. The mean operative time was 250±65.5 minutes; procto-colectomy: 298.2±63.5 minutes; subtotal colectomy: 205±45.7 minutes and proctectomy 249±49.5 minutes. The mean hospital stay was 4.9±1.9 days.

**Conclusion:** A complete laparoscopic proctocolectomy dis-section is feasible and safe for surgical treatment of UC.

## Colorectal/Intestinal Surgery - P215

**IS HAND ASSISTED SURGERY FOR DIVERTICULITIS BETTER THAN OPEN OR STANDARD LAPAROSCOPIC SURGERY?**, Dan Ruiz MD, Marat Khaikin MD, Guilherme Kapaz MD, Dana R Sands MD, Steven D Wexner MD, Juan J Nogueras MD, Eric G Weiss MD, Cleveland Clinic Florida, Weston, FL

**Introduction:** Surgery for diverticulitis can be challenging even with an open procedure. In this study we compared hand assisted laparoscopic surgery (HALS) to laparoscopic (LS) and open surgery (OS) for recurrent diverticulitis.

**Methods:** Between July 2003 and January 2006, 20 cases of elective HALS for recurrent diverticulitis were matched by age, gender, ASA, BMI, type of surgery, and diagnosis to 20 patients who underwent LS and 20 who underwent OS. Data were evaluated and compared for age, diagnosis, procedure, operative time, estimated blood loss (EBL), resumption of liquid diet, postoperative hospital stay, and morbidity. Conversion was defined as any unplanned extension of the specimen extraction site or creation of a separate or longer incision for the purpose of tissue dissection.

**Results:** There were no statistical differences among the 3 groups regarding age, gender, BMI, and ASA. Compared with LS, HALS resulted in a significantly reduced operative time and blood loss. Compared with OS, shorter operative time, fewer complications and better clinical outcome were reached.

<table><thead><tr><th></th><th>HALS (n=20)</th><th>LS (n=20)</th><th>OS (n=20)</th></tr></thead><tbody><tr><td>Op Time(min)</td><td>145.5(30-220)</td><td>189.1(148-270)</td><td>126.2(30-210)</td></tr><tr><td>Blood loss(ml)</td><td>75 (50-300)</td><td>125 (50-300)</td><td>225 (50-600)</td></tr><tr><td>LOS (d)</td><td>5.4 (2-13)</td><td>5.5 (3-15)</td><td>6.5 (2-12)</td></tr><tr><td>Liquid diet (d)</td><td>1.5 (1-9)</td><td>1.1 (1-3)</td><td>3.4 (2-8)</td></tr><tr><td>Morbidity (n)</td><td>2</td><td>6</td><td>10</td></tr></tbody></table>

P <= 0.05 for all parameters; LOS = length of stay

**Conclusions:** HALS is an applicable technique in all laparoscopic cases and leads to a lower operative time with no detriment to the advantages of the standard laparoscopic surgery.

## Colorectal/Intestinal Surgery - P216

**A COMPARISON OF ABDOMINAL CAVITY BACTERIAL CONTAMINATION IN LAPAROSCOPY AND LAPAROTOMY FOR COLORECTAL CANCER**, Y Saida MD, Y Nakamura MD, J Nagao MD, T Enomoto MD, R Kanai MD, M Katagiri MD, S Kusachi MD, M Watanabe MD, Y Sumiyama MD, Third Department of Surgery, Toho University School of Medicine, Tokyo, Japan

**Purpose:** We compare intra-abdominal bacteria after lavage between laparotomy and laparoscopic surgery for the treatment of colorectal cancer.

**Methods:** Seventy-two patients with non-obstructive colorectal cancer, except those undergoing low anterior resection, abdomino-perineal resection, Hartmann?fs operation and total colectomy, were divided into two groups, laparotomy group (47 cases) and laparoscopic surgery group (25 cases). Cefotiam or Cefmetazole were administered to the patients just prior to surgery. At the beginning of the operation, just after laparotomy was made or trocars were inserted, 10ml saline was irrigated into the cul-de-sac and collected through a 10 F catheter. Just before closing the wound, 10ml saline was collected in the same way as initial lavage in both groups. The collected saline was used to determine the number of the surviving bacteria.

**Results:** At the beginning of both operations, no bacterial growth was observed. Bacteria were detected in the lavage fluid collected just before closing the wound in 23 of 47 cases (49%) in laparotomy group, and 7 of 25 cases (28%) in laparoscopic surgery group. The mean bacteria cell count after lavage was 4.6x106 CFU/ml aerobic bacteria and 1.9x103 CFU/ml anaerobic bacteria in the laparotomy group, and 1.8x104 CFU/ml aerobic bacteria and 1.6x102 CFU/ml anaerobic bacteria in laparoscopic surgery group.

**Conclusion:** Laparoscopic colorectal surgery demonstrated a lower incidence of bacterial intra-abdominal contamination than laparotomy, indicating that laparoscopy is less invasive than laparotomy from a microbiological perspective.

## Colorectal/Intestinal Surgery - P217

**CHEMOPREVENTION AFTER SURGERY FOR CROHN'S DISEASE:** **IS IT NEEDED?**, Molly Sebastian MD, David Chang MPH, Howard Kaufman MD, Susan Gearhart MD, Johns Hopkins University, University of Southern California

**Introduction:** The benefits of postoperative chemoprevention in Crohn's disease (CD) remain controversial. Therefore, we sought to determine the risk of early recurrence in two
# SAGES POSTER ABSTRACTS

populations from differing time periods treated surgically for CD.

**Methods:** Records of patients undergoing surgery for CD between 1995-1997 and 2001?2003 were reviewed. Questionnaires were sent to obtain complete information. Data between groups were compared using Stata.

**Results:** 185 patients were identified; 109 from 1995-1997 and 76 from 2001-2003. Complete follow-up was obtained on 71%. Overall, mean age was 37 +/-14 yrs with a mean duration of disease of 11.5 +/-9 yrs, 58% were female, 23% had a history of smoking, and 13% had a family history of CD. 35% of patients were on preoperative medical therapy for CD and 44% were placed on therapy within one month of surgery. The most common CD type was stenotic (54%) and most common surgery was ileocecal (46%) and laparoscopic (29%) resection. The 2-year recurrence rate was 27% (n=35); 96% (n=33) was radiographically or endoscopically proven requiring a change in medical therapy and 4% (n=2) required surgery. On bivariate analysis, there was no difference between the groups with regards to recurrence rate, age, sex, smoking or family history, surgery type (site), disease type, or medication compliance. However, significantly more patients were on perioperative medication for CD in the latter time period (table). On multivariate analysis independent of age, sex, smoking or family history, surgery type, disease type, postoperative medication use was associated with an increased risk for early recurrence (OR 3.63, p= 0.013) while preoperative use trended towards a decreased risk for early recurrence (OR=0.39, p=0.081).

**Conclusion:** Postoperative chemoprevention did not decrease the likelihood of early recurrence. Evaluation into the effect of postoperative chemoprevention on long term recurrence is needed.

<table><caption>Perioperative Medical Therapy for CD</caption><thead><tr><th></th><th>N of patients<br>1995-1997(%)</th><th>N of patients<br>2001-2003(%)</th><th>p value</th></tr></thead><tbody><tr><td colspan="4"><strong>Preoperative Medications</strong></td></tr><tr><td>Azathioprine/6-MP</td><td>20 (18)</td><td>25 (33)</td><td>0.023</td></tr><tr><td>Remicade</td><td>0</td><td>8 (10.5)</td><td>0.001</td></tr><tr><td>Overall</td><td>29 (26.6)</td><td>35 (46)</td><td>0.006</td></tr><tr><td colspan="4"><strong>Postoperative Medications</strong></td></tr><tr><td>Azathioprine/6-MP</td><td>26 (24)</td><td>31 (40.8)</td><td>0.014</td></tr><tr><td>Remicade</td><td>12 (11)</td><td>12 (15.8)</td><td>0.341</td></tr><tr><td>Overall</td><td>39 (35.8)</td><td>43 (56.6)</td><td>0.005</td></tr></tbody></table>

## Colorectal/Intestinal Surgery - P218

**LAPAROSCOPIC RIGHT COLON RESECTION IN THE LEARNING CURVE**, C Sheridan MD, R J Metz, Jr, D Selzer MD, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.

**Introduction:** Lap-assisted right hemicolectomy (LARH) is considered an appropriate procedure for surgeons within the learning curve. Evidence supports a minimum number of resections for benign disease before embarking on oncologic procedures. Although endoscopically unresectable polyps are a common indication for LARH, recent literature cautions against approaching these as "learning" cases due to significant risk of occult malignancy. We propose that for the surgeon in the learning curve, LARH for neoplastic disease can be done as safely as for benign disease provided a standard oncologic approach is used.

**Methods:** The first 58 laparoscopic colectomies performed by a single surgeon at an academic center were retrospectively reviewed. Demographic data, operative details, pathology, hospital stay, and complications were collected. 34 were right sided resections (28 LARH, 2 extended LARH, 4 lap ileocecectomy). 23 LARH were performed for neoplastic disease (e.g. polyps or cancer), all as oncologic resections. Outcomes of resections for benign disease (e.g. inflammatory bowel disease) were compared to resections for neoplastic disease. In addition, outcomes of resections for cancer were compared to resections for preoperatively presumed benign polyps.

**Results:** The 23 LARHs performed for neoplasms included 15 adenomatous polyps and 8 adenocarcinomas. 11 right colon resections were for benign disease. Statistical analysis with independent sample t-test showed no difference between resections for benign vs. neoplastic disease based

on operative time (OT) (229 vs. 245 min, p=.494) or EBL (108 vs. 71 ml, p=.181). However, there were fewer complications in the neoplastic vs. benign group (2 vs. 5, p=.012).

Similarly, there was no statistically significant difference between LARH for polyps vs. adenocarcinoma based on OT (250 vs. 236, p=.643), EBL (77 vs. 61 ml, p=.597), complications (1 each, p=.654), lymph nodes (14.5 vs. 17.6, p=.481), or margins (6.6 vs. 7.6 cm, p=.339). Finally, 4 of 15 (27%) polyps proved to have adenocarcinoma on final pathology.

**Conclusion:** Due to our observed high rate of malignancy, oncologic principles should always be followed in resection of neoplastic disease. Given this approach, LARH can be performed for polyp disease as safely as for benign disease and can still be considered a safe "learning" case for surgeons.

## Colorectal/Intestinal Surgery - P219

**LAPAROSCOPIC-ASSISTED ENDOSCOPIC REMOVAL OF A COLONIC MASS**, Andrea Silver MD, Ranjan Sudan, Karl M Francis, Creighton University Medical Center

**Introduction:** Endoscopic removal of large polyps or broad-based colonic masses can be technically challenging and carry a risk of perforation. Simultaneous laparoscopy may allow endoscopic resection avoiding laparotomy.

**Methods:** During screening colonoscopy a benign-appearing lesion was identified in the sigmoid colon 30 cm from the anal verge. It was broad-based leading to concern about perforation with endoscopic resection. Laparoscopic mobilization of the sigmoid colon was performed to aid in snaring the lesion, the proximal colon was occluded, and the lesion was resected piecemeal with a hot snare. The peritoneal surface of the colon was directly inspected with the laparoscope and tested for leaks.

**Results:** The lesion was successfully resected in a piecemeal fashion. The serosal surface of the colon appeared healthy with no evidence for air extravasation when immersed in water and insufflated.

**Conclusions:** Laparoscopy can assist in endoscopic removal of large colonic lesions. The bowel can be mobilized to aid in snare positioning, atraumatic occlusion of proximal bowel minimizes cecal distention, and the colonic wall can be directly visualized and tested for leakage of air. This provides a safe, effective alternative to laparotomy and colotomy. With the advent of better instrumentation for natural orifice transluminal endoscopic surgery (NOTES) this type of resection may be able to be completed safely endoscopically.

## Colorectal/Intestinal Surgery - P220

**CAN COMMUNITY SURGEONS PERFORM LAPAROSCOPIC COLO-RECTAL SURGERY WITH OUTCOMES EQUIVALENT TO TERTIARY CARE CENTERS?**, Ravinder Singh MD, Alex Omiccioli, Susan G Hegge MD, Craig A McKinley MD, The Centre for Minimal Access Surgery (CMAS-McMaster University and CMASNorth-North Bay District Hospital)

**Introduction:** Laparoscopic Colo-rectal Surgery (LCS) performed in tertiary care centers has been well studied in the literature. It has been shown to provide improved short term outcomes and comparable long term outcomes to the conventional open approach. However, LCS performed in a community hospital setting has not been well studied. In a previous paper, we presented the short term outcomes of 100 LCS performed by two community surgeons. In this follow-up study, we present both short and longer term outcomes for 239 patients who underwent LCS by the same two community surgeons.

**Methods:** This is a prospective study of 239 patients who underwent a LCS at the North Bay District Hospital (a 200 bed community hospital located 350 km away from the nearest tertiary care center). All cases were performed by two community surgeons with no formal training in LCS who transitioned themselves from an open to a laparoscopic approach.

**Results:** Between October 2000 and May 2006, 239 consecutive patients (126 women and 113 men, mean age of 64.3 + 13.8 years) underwent LCS for benign (N=123) and malignant (N=116) disease. Median operating time was 215.0 min-

<figure><img src="image_112.png" /></figure>
<figure><img src="image_113.png" /></figure>

# SAGES POSTER ABSTRACTS

utes (15.0 to 475.0) and the conversion rate was 7.5%. The intra-operative complication rate was 2.1%. There were 18 (7.5%) major post-operative complications and 35 (14.6%) minor post-operative complications. There was no intra-operative mortality, and six 30-day mortalities occurred secondary to ischemic bowel, stroke, 3 myocardial infarctions, and pneumonia. The median length of stay was 4.0 days (2.0 to 55.0). Twenty-nine patients underwent LCS for stage I Colorectal Cancer (CRC) with a mean follow-up of 20.9 months, and all (100%) patients remained disease free. Thirty-nine patients underwent LCS for stage II CRC with a mean follow-up of 17.2 months, and 37 (94.9%) patients remained disease free. Twenty-three patients underwent LCS for stage III CRC with a mean follow-up of 16.2 months, and 14 (60.9%) patients remained disease free. Finally, mean survival for the 13 patients who underwent LCS for stage IV CRC was 16.8 months. The mean number of resected lymph nodes was 11.2 + 8.3.

**Conclusion:** We note that both our short and longer term outcomes are similar to tertiary care centers. We therefore conclude that LCS can be performed in a community hospital setting with both short and longer term outcomes equivalent to tertiary care centers.

## Colorectal/Intestinal Surgery - P221

**LAPAROSCOPIC COLORECTAL SURGERY FOR STAGE IV ENDOMETRIOSIS**, Angela J Skull MD, Henry M Dowson MD, Timothy A Rockall MS, Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK

**Introduction and Objective:** Endometriosis is a debilitating condition of young women, causing pain and infertility. When severe it may involve the recto-vaginal pouch with nodular infiltration of the rectum and obliteration of tissue planes. Laparoscopic surgery offers an acceptable treatment and is increasingly being undertaken for those with severe disease. The aim of this study is to examine the short-term surgical results of laparoscopic excision of deep pelvic endometriosis with rectal involvement.

**Methods:** A prospective database (SPSS) was established for all patients undergoing laparoscopic excision of recto-vaginal endometriosis. Outcomes analysed include operation performed, operating time, conversion and complication rates, and length of hospital stay.

**Results:** There were 50 patients with a median age of 34 years (IQR 32-41). 50% of patients had a rectal wall shave, 18% had a disc excision of the rectal wall with primary closure, and 32% had an anterior resection. The median duration of surgery was 150 (140-210) minutes, and there was a conversion rate of 6%. 12% had a complication including 2 ureteric injuries that were recognised at the time of surgery and repaired primarily, and 1 pelvic abscess treated radiologically. There were no anastomotic leaks, and the median post-operative stay was 3 days (2.5-6).

**Conclusion:** Laparoscopic excision of severe pelvic endometriosis with rectal involvement is challenging, but feasible with low morbidity and short hospital stay. Ureteric involvement is common and pre-operative stenting is often helpful.

## Colorectal/Intestinal Surgery - P222

**LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER - 150 CONSECUTIVE CASES**, Henry M Dowson MD, Angela J Skull MD, Andrew Huang MD, Timothy A Rockall MS, Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, Surrey, UK

**Introduction:** In the United Kingdom, the National Institute of Clinical Excellence (NICE) guidance, has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer; however it is still performed in less than 5% of cases. We present the short term outcomes of a consecutive cohort of patients who have been treated laparoscopically.

**Methods:** All patients who electively present to our unit and are suitable for surgery are entered into a prospective database. Data collected includes patient demographics, type and length of operation, complications, postoperative stay, and pathological details including nodal harvest.

**Results:** 150 patients are included, 51% female, median age 72 years. Operations performed include Anterior resection 36%, right hemicolectomy 40%, left sided resection 9%, APR 5%. 93% of patients had a laparoscopic procedure, 7% required conversion, and 7% were excluded from laparoscopy due to morbid obesity or tumour size. The complication rate was 8.6%, including 2 leaks (2% of 126 anastomoses), and 3 wound infections. 9 patients were readmitted. 21% of tumours were Dukes A, 31% Dukes B and 40% Dukes C. There were no positive resection margins and the median number of nodes harvested was 22 (IQR 16-30). The median post operative stay was 4 days.

**Conclusion:** This consecutive series of 150 patients demonstrates that colorectal cancer can be treated successfully laparoscopically. Clear histological margins and adequate lymph node yield confirm an oncologically sound resection can be performed, with low morbidity and mortality.

## Colorectal/Intestinal Surgery - P223

**QUALITY OF LIFE FOLLOWING LAPAROSCOPIC AND OPEN COLORECTAL SURGERY**, Henry M Dowson MD, Angela J Skull MD, Karen Ballard PhD, Timothy A Rockall MS, Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK

**Introduction:** Laparoscopic surgery is increasingly being used for colorectal procedures. However, studies comparing laparoscopic and open colorectal surgery, have thus far failed to show significant differences between the 2 techniques with regards to the quality of life (QoL) of patients during their recovery.

**Methods:** 200 patients are being prospectively recruited into a trial comparing the outcomes between laparoscopic and open colorectal surgery. QoL is being assessed using the validated EQ5D (on alternate days) and SF36-acute (weekly) questionnaires, during the first 6 post-operative weeks. We present interim results on QoL differences between the 2 groups.

**Results:** 50 patients (58% female, median age 68) have thus far completed the trial, of whom 55% had cancer. EQ5D scores are higher (representing better health) in the laparoscopic group at all times, although these results have not yet reached statistical significance (day 14 p=0.097, day 28 p=0.074). SF36 shows an advantage for laparoscopic surgery at 1 week and 4 weeks post-operatively, mainly as a result of differences in physical functioning (physical dimension difference at day 28, p=0.056). However at 2 weeks post-operatively, QoL as measured by SF36, was similar in both the groups.

**Conclusion:** With a limited sample size at this stage, preliminary results from this large study demonstrate a strong trend in favour of laparoscopy, with regards to quality of life following laparoscopic and open colorectal surgery.

## Colorectal/Intestinal Surgery - P224

**OUTCOMES ANALYSIS OF LAPAROSCOPIC RESECTION FOR ISOLATED PATHOLOGY OF THE SMALL INTESTINE**, Jennifer A Spitler, Richard A Pierce MD, Valerie J Halpin, Christopher Eagon MD, William J Hawkins, Michael Brunt MD, Margaret M Frisella, Brent D Matthews, Department of Surgery, Washington University, St. Louis, Missouri

**Introduction:** The purpose of this study is to evaluate peri-operative clinical outcomes and pathology in patients undergoing laparoscopic resection for tumors and pathology isolated to the small intestine.

**Methods:** The medical records of all patients >18 years undergoing laparoscopic segmental small intestine resection from 5/97-8/06 were reviewed. Patients with inflammatory bowel disease or those undergoing laparoscopic ileo-colectomy were excluded. Data are given as mean ± SD. Statistical significance (p<0.05) was determined using two-tailed t-test and Fisher's exact test.

**Results:** Laparoscopic segmental small intestine resection was performed in 39 patients (M:F; 23:16) with a mean age of 49 years ± 15.5. The most common presentation was a SBO (n=14), an UGI bleed/anemia (n=10) and/or abdominal pain (n=7). There were no conversions to open. An intracor-
poreal anastomosis was performed in 22 patients and extra-
corporeal anastomosis in 17 patients. Mean operative time
was 104 ± 39 minutes and mean EBL was 46 ml ± 40 ml.
There were no intraoperative complications. Final pathology
was a Meckel's diverticulum (n=6), GIST(n=5), carcinoid
tumor (n=4), diverticulum (n=4), post-transplant lymphopro-
liferative disorder (PTLD)/lymphoma (n=4), misc benign
tumors (n=4), adenocarcinoma/polyp (n=3), ulcer/stricture
(n=3), no abnormality (n=2), leiomyosarcoma (n=1), metasta-
tic lung cancer (n=1), metastatic melanoma (n=1), and
enteritis (n=1). Nine patients experienced postoperative
complications (Grade I, n=4; Grade IIa, n=2, Grade IIb, n=2,
Grade IV, n=1) including an anastomotic leak (n=1) requiring
exploratory laparotomy, GI bleed (n=1) requiring 3 unit
PRBC transfusion and SBO (n=1) requiring re-exploration
and adhesiolysis. There was one death due to respiratory
failure. The mean postoperative LOS was 5.0 days ± 2.8. In
long-term follow-up, one patient (PTLD) developed an anas-
tomotic recurrence necessitating open small intestine resec-
tion. In comparing laparoscopic intracorporeal and extracor-
poreal anastomosis, there was no significant difference
(p>0.05) in mean EBL, OR time, perioperative complication
rate or LOS.

**Conclusions:** Laparoscopic segmental small bowel resection utilizing either intracorporeal or extracorporeal anastomotic techniques is an effective strategy for a variety of tumors and pathology isolated to the small intestine. Further studies are needed to compare outcomes to patients undergoing open resection for similar pathology.

Colorectal/Intestinal Surgery – P225

MANAGEMENT OF OBSTRUCTIVE COLORECTAL CANCER WITH ENDOSCOPIC STENTING FOLLOWED BY SINGLE STAGE SURGERY: OPEN OR LAPAROSCOPIC RESECTION?,
Francesco Stipa PhD, Andrea Cimitan MD, Giuseppe Villotti
MD,Alessio Pigazzi PhD, Antonio Burza MD, Mario A Vitale
MD, Departments of Surgery and Gastroenterology, San
Giovanni Hospital, Rome, Italy

Background. About a third of patients with colorectal carci-
noma have acute colonic obstruction requiring emergency
surgery. Current surgical options are: intraoperative lavage
and resection of the colonic segment involved with primary
anastomosis; resection of the colonic segment involved with
end colostomy (Hartmann's procedure), subtotal colectomy
with primary anastomosis; colostomy followed by resection.
All these procedures present risks and a poor quality of life.
Endoscopic stenting of malignant colonic obstructions pro-
vides instant relief of symptoms and allows optimal bowel
preparation, tumor staging and elective resection. This
study was designed to compare open and laparoscopic
resections following emergency colorectal stenting.

**Methods.** During a 3 years period, 31 patients with obstructing colorectal cancer underwent endoscopic colonic decompression with self expanding metallic stents (Precision, Boston Scientific, USA). Fifteen patients were treated with open resection, and 6 underwent a laparoscopic resection. The remaining 9 were managed with endoscopic palliation and adjuvant therapy.

**Results.** Hospital mortality was 3% (1 patient in the palliation group who died of respiratory complications). Mean time interval between stenting and surgery was 11 days (range 1-21). All lesions were located in the left colon. Mean hospital stay was 13 days in the open surgery group, and 7 days in the laparoscopic group (P=0.003). Follow up was completed in 96% of patients. Median follow up was 14 months. Seventeen patients were treated with postoperative chemotherapy. All patients in the palliative group died of disease with a median survival of 3 months. Of the 22 surgically treated patients 82% are alive. The remaining 4 patients died with diffuse metastases.

**Conclusion.** Following successful endoscopic stenting of malignant colorectal obstruction, elective surgical resection can be performed safely. The presence of the endoluminal stent does not prevent a laparoscopic approach. The combined endoscopic and laparoscopic procedures are a less invasive alternative to the multi-stage open operations and offer a faster recovery.

Colorectal/Intestinal Surgery – P226

IS LADG TRULY MINIMALLY INVASIVE?-SINGLE BLIND
RANDAMIZED TRIAL, S. Takiguch MD,Y Doki MPA,Y
Fujiwara,K Okada MD,M Yamazaki MD,H Miyata MD,K
Nakajima MD,T Nishida MD,M Sekimoto MD,M Monden,
Osaka University Graduate School of Medicine Dept. of
Surgery

LADG has been generally considered to be superior to open distal gastrectomy about post operative QOL. On the contrary there may be small difference about post operative pain between them because of pain control technique included epidural anesthesia. There was small number of evidence about this point. In this paper we report the results of our randomized single blind study in LADG vs. open DG.

**Method:** 40 patients of gastric cancer (Stage IA and IB) were registered in this randomized study. To investigate the difference of post operative recovery, post operative QOL was objectively evaluated by Active Tracer that was 24 hour action (the rate of acceleration) recorder. Questionnaire and VAS scale related to post operative pain was also investigated. For strict evaluation, patients in this study were not noticed method of operation in either way until post operative 7 days. Result: As to the post operative recovery, LADG was significantly superior to open surgery for 4 days. However, there was no difference after then. Conclusion: LADG offer a good early postoperative recovery.

Colorectal/Intestinal Surgery – P227

TOTALLY LAPAROSCOPIC RIGHT COLECTOMY: DESCRIP-
TION OF TECHNIQUE AND REVIEW OF OUR FIRST FIVE
PATIENTS., Janos Taller MD, Gordon Wisbach MD, Jay Grove
MD, Department of Surgery, Naval Medical Center, San Diego
Most case series on laparoscopic right colectomy reported
describe a "lap-assisted" technique requiring exteriorization
of the colon for resection or anastomosis, usually through a
small midline or RUQ incision. To confer the maximum ben-
efit, we believe that all facets of this operation should be
done intracorporeally. Specimen removal is accomplished
through a modified Pfannenstiel incision increasing recov-
ery and cosmetic benefits. We present our technique of
totally laparoscopic right colectomy (TLRC) and review our
first five patients.

All patients referred to our MIS service were considered for laparoscopic surgery. No exclusions were given for age, disease process or previous abdominal surgery. Patients were positioned supine with arms extended. Peritoneal access was gained with Hasson technique via an infraumbilical incision. Three 10mm & two 5mm ports were used. Dissection was undertaken using a medial to lateral approach. After division of the distal ileum, the right colon mesentery was bluntly freed from the retroperitoneum. The mesentery was divided, including the ileocolic artery, up though the right branch of the middle colic artery using an Enseal? device. The omentum was freed off of the right transverse colon medially to the mesenteric division and the colon divided with an endoscopic stapler. The lateral peritoneal attachments were divided by cautery. An ileocolic anastomosis was completed by endoscopic stapling of the distal ileum and transverse colon opposed in bayonet fashion. The mesenteric defect was sewn closed. The specimen was removed in a large endobag via the suprapubic trocar site enlarged as a Pfannenstiel incision.

From Dec 2005 to May 2006, 5 patients underwent TLRC. Indications were varied: symptomatic Crohn's Dz (1), large adenomatous polyps (2), and adenocarcinoma (2). Pertinent perioperative averages were: age 59.8 years, OR time 181 minutes, EBL 75 mls, liquid diet at POD#1, regular diet at POD#3, LOS - 3 days. There were no complications. At the 2 week post-op visit, all patients resumed normal activity. The maximum benefit of laparoscopic surgery is realized when there is minimal disturbance to the peritoneal surface and abdominal contents. Our technique demonstrates that true TLRC can be performed safely across a wide age spectrum & variety of disease processes. Further prospective studies are needed to confirm these results in a larger series of patients and compare them against the established literature.

<figure><img src="image_114.png" /></figure>
<figure><img src="image_115.png" /></figure>

# SAGES POSTER ABSTRACTS

## Colorectal/Intestinal Surgery - P228

CLINICAL, ANATOMIC AND PATHOLOGIC PREDICTIVE FACTORS FOR INIMEDIATE SURGICAL OUTCOME AFTER LAPAROSCOPIC APPROACH TO THE RECTUM, EM

Targarona MD, C Balague MD, JC Pernas MD, C Martinez MD, L Pallares MD, MP Hernandez MD, R Berindoague MD, V Aviles MD, I Gich MD, M Trias MD, Service of Surgery, Radiology* & Epidemiology**. Hospital Sant Pau, Autonomous University of Barcelona. Barcelona, Spain.

Laparoscopic approach has been widely accepted for colon resection, but some controversies exists about it definitive role in case of rectal tumors in spite of optimistic reports. Factors that may impact immediate outcome are of anatomic and pathological nature due to the size and volume of the tumor and prostate, as well the dimensions of the pelvis that may impair deep pelvic dissection. The aim of this study has been to evaluate the predictive value of pathological anatomic factors on immediate outcome after laparoscopic rectal resection. Material and methods. We included in the study a prospective series of 54 patients submitted to laparoscopic rectal resection for rectal tumors, in which a preoperative CT was performed. 3D reconstruction of the pelvis was performed, and tumor and prostate volume and diameters were calculated, as well main pelvic diameters (Ant Post (promontorium and sacrum), Lat-lat) (3D Doctor software package). Age, sex, BMI, type of procedure (anterior resection (AR), low anterior resection (LAR), abdominoperineal, (APR)) were also recorded. Dependent variables were operative time, conversion, postop complications and stay. Univariate and multivariate analysis were performed (SPSS package). Results. This series included 33 m and 20 f, of 70y (38-87). Surgical procedures: 9 AR, 28 LAR and 16 APR, Conversion 8/53 (15%), op time: 172'(90-360), Morbidity: 31%, Stay: 9 (6-43). Multivariate analysis showed that factors predictive for conversion were the craneo-caudal tumor length as well the promontorium-pubic axis. Predictors of postop morbidity were: BMI and sacro pubic axis; For operative time were sex, sacro-pubic axis and LAR. Conclusion: Local anatomy directly affect surgical outcome in laparoscopic approach to the rectum. Sex, BMI, ant-post pelvic diameters and tumoral length are independent predictors on conversion and op. time. This data should be taken in account when planning this kind of procedures

## Colorectal/Intestinal Surgery - P229

LAPAROSCOPIC EXTRA-PERITONEAL REPAIR OF INGUINAL HERNIA COMBINED WITH ELECTIVE RESECTION OF SIGMOID COLON, Michael B Tempel MD, Vafa Shayani

MD, Sharfi Sarker MD, Loyola University Medical Center

Previous studies have demonstrated the safety of utilizing synthetic mesh for repair of abdominal wall hernias during clean-contaminated procedures involving the intestinal tract. Hereafter, we report an unusual complication encountered during a combined laparoscopic inguinal hernia repair via the totally extra-peritoneal approach (TEP) and elective resection of sigmoid colon for treatment of chronic diverticulitis. The patient is a 39 year-old male with multiple episodes of diverticulitis over a 12-month period. On physical examination, he was noted to have a left inguinal hernia. The patient underwent a combined operative procedure which started with laparoscopic TEP repair of his left inguinal hernia using polypropylene mesh. Upon completion of the hernia repair, additional trocars were inserted through the full thickness of the abdominal wall for the purpose of the sigmoid colectomy. The posterior dissection of the peritoneum resulted in a difficult insertion of the suprapubic trocar, ultimately leading to a through and through bladder injury which was recognized and repaired at the conclusion of the procedure. Repair of the bladder injury did result in exposure of the polypropylene mesh to outside elements; however, the patient did not suffer any infectious complications involving the mesh. Based on this experience, we believe that while combining a synthetic mesh repair of a hernia with intestinal surgery is acceptable, the initial extra-peritoneal approach to an inguinal hernia may result in anatomic alterations that would lead to subsequent morbidity, including possible mesh complications.

## Colorectal/Intestinal Surgery - P230

FUNCTIONAL OUTCOME OF LAPAROSCOPIC MESH SACROCOLPORECTOPEXY FOR COMBINED RECTAL AND VAGINAL PROLAPSE, Dinesh K Thekkinkattil MD, Mike Lim MD, Simon Gonsalves MD, C Landon MD, Peter M Sagar MD, Leeds General Infirmary, Leeds United Kingdom

**Aim:** To evaluate the functional outcome and feasibility of laparoscopic mesh sacrocolporectopexy for patients with combined vaginal and rectal prolapse.

**Methods:** Suitable patients from October 2004 to June 2006 with combined vaginal and rectal prolapse underwent a novel procedure, with repair of both conditions using a single piece of mesh laparoscopically. Patient demographics, operative time and in-patient stay in the laparoscopic group was compared with a previously reported group of 29 patients who had excellent functional outcome from open mesh sacrocolporectopexy surgery. The Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory (PFDI) questionnaire with Urinary Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (PODI) and Colorectal-anal Distress Inventory (CRADI) sub-scales was completed by patients pre-operatively and at 3 months post-operatively. The PFDI is a validated questionnaire that assesses both global and individual pelvic floor function, according to compartments. Higher score signifies greater symptoms and distress.

**Results:** There were 6 patients. Median period of follow up was 8 (IQR 5-15) months. Patients in the laparoscopic group were significantly younger (47 (IQR 42-52) vs. 66 (IQR 59-73) years). Duration of operation was similar in the laparoscopic group compared with the open group (95 (IQR 89 - 116.2) vs. 82 (74 - 105) minutes, p-value 0.432). However, in-patient stay was significantly shorter in the laparoscopic group compared with the open group (3 (4-5) vs. 5 (4-7) days, p-value 0.018)

Global and subscale PFDI scores were significantly lower post-operatively compared with pre-operatively in laparoscopic patients.

PFDI & subscales, Prpeop score(range), Post op score(range), p-value

PFDI,(global,0-300), 128.1 (99.1 - 163.3), 32.8 (10.9 - 44.5), 0.028*

UDI (anterior, 0 - 100), 39.6 (29.1 - 46.9), 2.1 (0.0 - 13.5), 0.028*

POPDI(middle, 0 - 100), 27.1 (14.5 - 55.2), 4.2 (0.0 - 12.8), 0.042*

CRADI(posterior,0 - 100), 60.9 (48.4 - 78.9), 18.3 (10.9 - 24.2), 0.028*

* Wilcoxon's test; p-value of < 0.05 is considered significant.

**Conclusion:** Selected patients with concurrent vaginal and rectal prolapse have significant improvement of symptoms after laparoscopic mesh sacrocolporectopexy. Duration of operation between 2 groups is comparable whilst the inpatient stay is significantly shorter in laparoscopic group.

## Colorectal/Intestinal Surgery - P231

LAPAROSCOPIC SURGERY IN CROHN'S DISEASE: MANAGEMENT OF BOWEL FISTULAS., Mari Tsubamoto

MD, Hitoshi Inagaki MD, Tadashi Yokoyama MD, Tsuyoshi Kurokawa MD, Yasuhisa Yokoyama MD, Toshiaki Nonami MD, Department of Surgery, Aichi Medical University, Aichi, Japan.

Laparoscopic surgery has been applied to the management of Crohn's disease, with shorter recovery periods than reported for open surgery. We performed laparoscopic surgery for six patients with Crohn's disease from Jan. 2005 to July 2006. Three of these patients had fistulas. A 37-year-old man and 35-year-old man had ileo-rectal fistula and stenosis of the ileum. We performed a fistulectomy and partial ileectomy. A 20-year-old man had ileo-vesical fistula and stenosis of the ascending colon. We performed a fistulectomy and right hemicolectomy. The mean operative time was 141 min, and the mean blood loss was 122 g. None required conversion. There were no operative complications. Postoperative complications were two surgical site infections.

**Conclusions:** Laparoscopic management of enteric fistulas is
safe and effective. Laparoscopic surgery is feasible for
selected patients with Crohn's disease even with fistula.

Colorectal/Intestinal Surgery – P232

LYMPH NODE DISSECTION USING THE ELECTROTHERMAL
BIPOLAR SEALER (LIGASURE V&#63722;) IN THE LAPARO-
SCOPIC SURGERY FOR COLON CANCER, Fumihiro
Uchikoshi MD,Shigeyuki Ueshima MD,Shin Mizutani
MD,Katsuhide Yoshidome MD,Tsukasa Oyama MD,Masayuki
Tori MD,Yuko Yamagami MD,Kazuya Hiraoka MD,Hidekazu
Takahashi MD,Yu Yamada MD,Ryou Tunashima MD,Chie
Irikawa MD,Masaaki Nakahara MD, Department of Surgery,
Osaka Police Hospital

[Background] D3 lymph node dissection at the root of inferi-
or mesenteric artery, division of superior rectal artery, total
mesenteric excision (TME) procedure and division of distal
mesorectum determine the quality of operation in the
laparoscopic surgery for left side colon cancer. These proce-
dures directly influence long-term result as well as postop-
erative motility. We previously used harmonic scalpel in
these procedures. In this study, we applied the electrother-
mal bipolar sealer (LigaSure V, Valleylab, Boulder, CO), and
evaluated the efficacy of this device.

[Operative procedure] We always operate using 4 ports
including camera port under the view of flexible laparo-
scope. All procedures, namely D3 lymph node dissection,
division of vessels, TME procedure and division of distal
mesorectum were performed by LigaSure V.

[Results] In consecutive 50 cases from January 2006, no case encountered intra operative complication and convert- ed to open surgery. Operative time was shortened because there was no disturbance by the mist. However, it was diffi- cult a little to dissect mesorectum at the bottom of the pelvis because the tip of LigaSure V had no angle.

[Conclusion] This device is useful and feasible in the laparoscopic surgery for colon cancer.

Colorectal/Intestinal Surgery – P233

TRANSANAL ENDOSCOPIC MICROSURGERY FOR RECTAL
TUMORS. THE ST MARY'S EXPERIENCE., Emmanouil
Zacharakis,Paul Ziprin MD,Simon Freilich,Paraskeva
Paraskeva PhD,Ara Darzi PhD, Academic Surgical Unit, St
Mary's Hospital, London, UK.

Introduction: Local excision of rectal tumors is indicated in patients with benign lesions and those with carcinomas who are unfit for radical surgery. However, the traditional transanal approach is often cumbersome allowing access to distal tumors only and associated with higher incomplete excision and local recurrence rates. Transanal endoscopic microsurgery (TEM) has emerged as it permits more precise surgery, allowing access to mid and upper rectal tumors with lower local recurrence rates. The aim of this study is to describe a single Institution's experience in the use of TEM in both benign and malignant disease.

**Methods:** Between 1996 and 2005, TEM was performed in 76 patients for rectal tumors. The mean age of the patients was 66.3 (37-91) years. All patients underwent preoperative endoscopic biopsy and radiological staging by MRI and/or endoscopic ultrasound. The histological diagnosis was benign adenoma in 48 and adenocarcinoma in the remaining 28 patients. The mean distance (± SD) of the tumor from the anal verge was 10.9 ± 3cm and the mean size of the tumor was 3.4 ± 1.5cm. The mean follow-up was 37 (9-96) months.

**Results:** The mean operating time was 80.6 (38-180) min. In 2 cases (2.6%) the procedure was converted to low anterior resection. Clear resection margins were achieved in 71 out of 74 patients (95.9%), while the mean resection margin was 4.6 ± 3mm. The histological grading of malignant tumors was T1 in 14, T2 in 11 and T3 in 3 patients. The mortality among the patients of our study was 0%. The overall morbidity was 18.4% as 14 patients developed minor or major complications. Intraperitoneal perforation of the rectum occurred in 4 patients and was treated by conversion to anterior resection in two of them and loop stoma formation in the remaining two. Complications also consisted of urinary retention in 6,

bleeding in 5, transient incontinence in 2 and pyrexia in 2
patients. The mean hospital stay was 3.2 (1-51) days. During
the follow up, benign tumor recurrence was detected in 3
patients (6.2%). The recurrence rates among patients with T1
and T2 malignant tumors were 0% and 45.5% respectively.

**Conclusions:** TEM is a safe and feasible technique with low incomplete excision rates and should be the preferred method in patients with benign tumors of mid and upper rectum. Its role in the management of malignant rectal tumors should be limited to T1 tumors as it is accompanied by high recurrence rates when used for more invasive lesions.

Colorectal/Intestinal Surgery – P234

LAPAROSCOPIC HARTMANN'S PROCEDURE: A VIABLE
OPTION IN TREATING ACUTELY PERFORATED DIVERTIC-
ULTIS., Raza M Zaidi MD,Eugene Rubach MD,George
DeNoto MD, North Shore University Hospital, North Shore-
LIJ Health System

**Introduction:** A laparoscopic technique for acutely perforated diverticulitis (i.e. Laparoscopic Hartmann's procedure) has not been described. We present our technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy.

**Methods:** A retrospective review of patients with Hinchey
III/IV diverticulitis who underwent a laparoscopic
Hartmannï's procedure were included in this study.
Laparoscopic takedown of sigmoid colostomy was performed
2-3 months later. Data from these procedures including esti-
mated blood loss (EBL), length of operative procedure,
patient outcomes, and demographics are evaluated.

**Results:** Three patients underwent laparoscopic sigmoid colectomy with end colostomy. Mean age was 49.7. None of the patients had prior history of diverticulitis. Mean EBL was 150 mL, with a mean operative time of 2 hrs and 43 min. None of the procedures required conversion to use of a hand port, or conversion to open. Average return to bowel function was 4.7 days, with one patient developing a post-operative ileus. Mean postoperative stay was 7.3 days. There were no complications.

Laparoscopic Hartmann's takedown was performed in all patients approximately 2-3 months later. Mean EBL was 95 mL, with an average operative time of 3 hrs 31 min. One patient did have an intraoperative anastomotic leak successfully repaired and retested. Again, none of the procedures required use of a hand port, nor laparotomy. Return to bowel function averaged 2.3 days. Average length of stay was 5.3 days, with one patient developing a wound infection.

**Conclusions:** Laparoscopic Hartmann's procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.

Colorectal/Intestinal Surgery – P235

LAPAROSCOPIC SIGMOID COLECTOMY AFTER DIVERTIC-
ULTIS: THE THREE TROCAR TECHNIQUE., Marty
Zdichavsky MD,Michael Kramer MD,Alfred Königsrainer
MD,Frank Granderath MD, University Hospital Tübingen,
Dept. Surgery, Tübingen, Germany

**BACKGROUND:** Laparoscopic sigmoid colectomy has become a feasible and effective surgical treatment of diverticulitis. We approach a three trocar technique to preserve the advantages of a minimal surgical procedure with reduced wound incisions.

**METHODS:** A minimum of three trocars was used in 21 consecutive patients (8 male, 13 female; mean age 48.6 and 59.8 years, respectively) who underwent a laparoscopic sigmoid colectomy after diverticulitis. The trocar of the right-lower quadrant of the abdomen was extended for exteriorization of the sigmoid colon. This technique was performed as a single center and single surgeon procedure on patients who had diagnosed diverticular disease as repeated attacks of symptoms.

**RESULTS:** None of the 21 patients had conversion to laparotomy. Wound infection was observed in 2/21 and urinary tract infection in 1/21 patients. Average operating time was

<figure><img src="image_116.png" /></figure>