<figure><img src="image_24.png" /></figure>

dard demographic data and previous VGE. "Gamers" had high VGE, defined as more than 3 hours per week of videogame playing. "Non-gamers" had little or no VGE. Both groups trained to proficiency on two tasks (AcquirePlace and Traversal) of the MIST-VR simulator, proficiency defined as meeting previously validated criteria on two consecutive trials. The number of trials required to achieve proficiency for each task was recorded.

**Results** The 26 participants included 11 M4s/15 PG-1s, 17 males (8 gamers/ 9 non-gamers) and 9 females (3 gamers/ 6 non-gamers), mean age 27.8 years. There were no differences in time to proficiency between the M4 and PG-1 residents, and there were no significant differences in the relative number of gamers per gender. All participants eventually met proficiency criteria. The 11 gamers reached proficiency more quickly than the 15 non-gamers (median 0 trials vs. 6 trials, p = 0.01). Women overall took longer to reach proficiency than did men (median 10 trials vs. 0 trials, p = 0.002). When stratified according to VGE, female non-gamers took longer to reach proficiency than male non-gamers (median 11 trials vs. 1 trial, p = 0.006) but among gamers, there was no difference between females and males (median 0 trials vs. 0.5 trials, p=NS).

**Conclusion** Previous VGE shortens time to achieve proficiency on two tasks on a validated surgical simulator. The possibility that VGE may ameliorate gender differences in length of time required to acquire surgical skills should be explored further.

## S074

**FLS SIMULATOR PERFORMANCE PREDICTS INTRAOPERATIVE LAPAROSCOPIC SKILL, A L McCluney MD, M C**
Vassiliou MD, P A Kaneva, D D Stanbridge RN, L S Feldman MD, G M Fried MD, Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, QC, Canada

**INTRODUCTION:** Simulators are increasingly used for teaching and testing laparoscopic skills. However, the relationship between performance in a simulator and operative skill has yet to be firmly established. This study defines the sensitivity and specificity of SAGES FLS simulator performance for the prediction of intraoperative laparoscopic skill.

**METHODS:** 40 subjects consisting of 19 novice (PGY 1-2), 13 intermediate (PGY 3-4), and 8 expert (PGY 5, fellows, and attending) laparoscopic surgeons underwent SAGES FLS manual skills testing. During laparoscopic cholecystectomy, each subject dissected the gallbladder from the liver bed and was objectively assessed with the previously validated Global Operative Assessment of Laparoscopic Skill (GOALS). ANOVA with posthoc analysis was used to compare mean FLS scores and mean GOALS scores across experience levels. The relationship between individual FLS scores and GOALS scores was analyzed with Pearson's correlation coefficient. Receiver Operator Curves were used to determine the optimal FLS score for predicting high intraoperative performance. Data are presented as mean±SD. Significance was defined as p<0.05.

**RESULTS:** As expected, mean FLS scores increased with experience level (p<0.01). Mean GOALS scores also increased with experience (p<0.01), and distinguished between novice (12±2), intermediate (17±4), and expert (22±1) laparoscopic surgeons. FLS and intraoperative GOALS scores correlated well (0.73, p<0.01). A passing FLS score (>357) yielded a sensitivity of 100% and a specificity of 90% in predicting and expert level GOALS score (>20).

**CONCLUSIONS:** In this study, scores obtained in the FLS simulator predict intraoperative laparoscopic skill as measured by objective GOALS metrics. All surgeons performing at an expert level in the OR passed FLS while 90% of surgeons with GOALS < 20 failed FLS. The FLS simulator score could thus be used as a benchmark for junior level trainees to verify their readiness to competently dissect the gallbladder from the liver bed during laparoscopic cholecystectomy.

## S075

### PRECISION TRUMPS SPEED IN LAPAROSCOPIC SKILL

**RETENTION, Prashant Sinha MD, Nancy J Hogle MS, Dennis L Fowler MD, College of Physicians and Surgeons, Columbia University, New York, NY**

**Intro:** Without ongoing practice, acquired motor skills may deteriorate over time. The purpose of this study is to document the level of retention of laparoscopic skills over time.

**Methods:** Thirty-three general surgery PGY 1, 2, or 3 residents trained to established criteria and passed an exam for each of seven technical skills on a virtual simulator (LapSim® Surgical Science Ltd., Göteborg, Sweden). Six months later, the residents again tried to complete the seven skills each of three times. During the six months, the simulators were available, but additional practice was not required. The retesting process consisted of three attempts, the first of which was acclimatization. The results of the subsequent 2 exams were compared with baseline data.

**Results:** At retest, the number of residents passing clip application (7, 21%) and cutting tasks (18, 55%) were significantly lower than for the other 5 tasks (p < 0.05). In failed tests, instrument wandering and tissue damage were more common than increases in task time. Upper level residents were significantly more likely to pass than first year residents. Time of day did not influence passing rates. Differences in Task Performance

<table><thead><tr><th></th><th>Time diff</th><th>p</th><th>Path length diff</th><th>p</th><th>Tiss damage diff</th><th>p</th></tr></thead><tbody><tr><td>Camera Nav</td><td>-6.36±7.1</td><td>p=0.001</td><td>-3.19±1.30</td><td>p=0.08</td><td>-0.19±0.81</td><td>p=0.019</td></tr><tr><td>Instrument Navigation</td><td>3.22±0.85 (L)<br>3.37±0.75 (R)</td><td>p=0.001<br>p=0.001</td><td>0.098±0.043 (L)<br>3.37±0.75 (R)</td><td>p=0.025<br>p=0.001</td><td>-2.02±0.20</td><td>p=0.001</td></tr><tr><td>Coordination</td><td>-5.55±2.98</td><td>p=0.066</td><td>-0.12±0.075 (smt)<br>-0.12±0.046 (casm)</td><td>p=0.103<br>p=0.008</td><td>-2.73±0.37</td><td>p=0.001</td></tr><tr><td>Grasp</td><td>-3.72±2.02 (L)<br>-3.24±1.46 (R)</td><td>p=0.07<br>p=0.03</td><td>-0.93±0.075 (L)<br>-0.215±0.076 (R)</td><td>p=0.52<br>p=0.006</td><td>-2.29±0.26</td><td>p=0.001</td></tr><tr><td>Lift & Grasp</td><td>7.23±7.74</td><td>p=0.055</td><td>-0.947±0.11 (L)<br>-0.070±0.10 (R)</td><td>p=0.66<br>p=0.51</td><td>-3.32±0.47</td><td>p=0.001</td></tr><tr><td>Cutting</td><td>-3.73±2.95</td><td>p=0.21</td><td>-0.15±0.041 (cut)<br>-0.11±0.037 (grasp)</td><td>p=0.001<br>p=0.004</td><td>-1.99±0.32</td><td>p<0.001</td></tr><tr><td>Chip Apply</td><td>-31.7±8.73</td><td>p=0.001</td><td>-0.70±0.17 (L)<br>-0.13±0.25 (R)</td><td>p=0.001<br>p=0.001</td><td>-42.9±4.8</td><td>p=0.001</td></tr></tbody></table>

**Conclusions:** We found that instrument and tissue handling variations were more consistently reduced relative to completion time in exams that were passed. Fine motor (more difficult) tasks demonstrated significant deterioration in performance over time compared with navigation and coordination (easier) tasks. Ongoing practice, either using the simulator or performing surgery, may be necessary to retain laparoscopic skills.

## S076

### EXPERTS CAN DO MORE THAN ONE THING AT A TIME: EFFECT OF DISTRACTION WHILE PERFORMING A SIMPLE LAPAROSCOPIC TASK IN EXPERT AND NOVICE

**SURGEONS, Katherine E Hsu MD, Robert A Gizicki BS, Fung Ying Man BS, Liane S Feldman MD, Gerald M Fried MD, Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada**

**INTRODUCTION:** While operating, surgeons are required to make cognitive decisions and are often interrupted to attend to questions from other members of the health-care team. Technical automatization may be achieved by experienced surgeons such that these distractions have little effect on performance of either the surgical or cognitive task. This study assessed the effect of adding a distracting cognitive task on performance of a basic laparoscopic skill in novice and expert surgeons.

**METHODS:** Nine novice (med stud, PGY 1-2) and 7 expert (PGY4-5/fellow/attending) laparoscopic surgeons practiced the FLS laparoscopic peg transfer task until their scores stabilized. This task was repeated 5 times and the mean score recorded. Subjects were also tested on the number of addition questions they could answer correctly in one minute. This was repeated 5 times with the mean number of questions attempted and accuracy (%correct) recorded. The tasks were performed concurrently 5 times. Data are presented as mean (SD). In each group, baseline vs distracted performance was compared with paired t-test.

**RESULTS:** There were no baseline differences between the expert and novice groups in peg score (97(6) vs 94(9),
p=0.5), number of questions attempted in one minute (9(2) vs 11(2), p=0.14), number of correct answers (8(3) vs 10(2), p=0.19) or %correct (91(7)% vs 93(4)%, p=0.33). When comparing baseline to dual-task performance, experts had no decline in peg transfer score (97(6) vs 95(3), p=0.34), number of questions attempted in one minute (9(2) vs 8(3), p=0.27), number of correct answers (8(3) vs 8(2), p=0.38) or %correct answers (91(7)% vs 94(5)%, p=0.49). In contrast, dual tasking in novices was associated with a decrease in the number of questions attempted (11(2) vs 8(2), p<0.01) and the number of correct answers (10(2) vs 7(1), p<0.01), with no change in peg transfer score (94(9) vs 93(7) p=0.34) or %correct answers (93(4)% vs 90(5)%, p=0.21) compared to baseline.

**CONCLUSION:** Distraction significantly decreased a novice's ability to process cognitively based math problems, while there was no effect on expert subjects. This suggests that experts have achieved a level of automatization of the peg transfer basic surgical skill, so that the cognitive distraction did not affect performance of either task. Experts were able to equally attend to both tasks while the novices attended to the surgical task at the expense of some aspects of performance of the cognitive task.

## S077

**COMPUTER-BASED LAPAROSCOPIC AND ROBOTIC SURGICAL SIMULATORS: PERFORMANCE CHARACTERISTICS AND PERCEPTIONS OF NEW USERS**, David W Lin MD, John R Romanelli MD, Renee E Thompson MD, Michael E Ganey MD, Ron W Bush BS, Neal E Seymour MD, Baystate Medical Center, Department of Surgery

The expanding inventory of advanced surgical training devices now includes simulators for laparoscopic and robotic surgery. In order to define perceptions of the need and value of such devices, we evaluated the initial experience of surgeons using both in the course of performance of an advanced laparoscopic skill.

**METHODS:** At the 2006 SAGES meeting, 62 Learning Center attendees evaluated a new virtual reality (VR) robotic surgery simulator (RS) [SimSurgery, Oslo, Norway] as well as either a computer-enhanced laparoscopic [ProMIS (PM), Haptica, Ltd, Dublin, Ireland] or a VR simulator [SurgicalSIM (SS), SimSurgery and METI, Inc, Sarasota, FL]. Demographic and training data were collected and all were assessed during one iteration of laparoscopic suturing and knot-tying on RS and either PM or SS. An 8-question survey was used to determine users' impressions of task realism, interface quality, and educational value (5-point Likert scale).

Performance data [time, path length, smoothness (PM), errors (SS/RS)] were collected and comparisons made between user-defined groups and different simulation platforms (Mann-Whitney Test, ANOVA).

**RESULTS:** Task completion rate was greater for experts than nonexperts on all platforms (PM 100% vs 75%; SS 100% vs 36%; RS 93% vs 36%). Experts performed better than nonexperts on all performance measures on PM (p<0.05: time 154±16 vs 205±12; path length 820±97 vs 1287±97; smoothness 952±111 vs 1582±127). There were no significant differences between experts and nonexperts for SS and RS performance measures. Perception of value of haptic features was less for subjects with prior robot experience (n=10; p<0.05). Otherwise realism, interface quality, and educational value scores did not differ on the basis of prior simulator or robot use. Nonexperts found that robotic simulation better reflected clinical skill than did experts. Overall, subjective quality was scored higher for PM than for SS or RS.

**CONCLUSIONS:** The ability of performance metrics of the computer-enhanced simulator to discern predicted performance differences between experts and nonexperts was better than for VR devices with a single task iteration. Initial use of VR devices was associated with a lower overall perception of realism and educational value as compared to use of physical objects in the non-VR simulator. This may reflect the need for familiarization with the computer-generated environment before the educational potential of VR can be realized.

## S078

**LAPAROSCOPIC VIRTUAL REALITY SIMULATOR TRAINING LEADS TO A SHORTENING OF THE LEARNING CURVE ON REAL CASES**, R Aggarwal MD, J Ward, I Balasundaram MD, A Darzi MD, Imperial College London

**Introduction:** It is now generally accepted for technical skills training to commence in the skills laboratory on simulated tissues. The aim is to reduce the length of the learning curve on real cases, which should lead to improved patient safety. Though simulator-based training has been shown to transfer to improved performance in the operating room, there have been no studies to date to analyze the persistence of this effect over time. The aim of this study was to assess the degree to which completion of a proficiency-based virtual reality (VR) training curriculum improves ongoing performance, when compared with traditional modes of training.

**Methods:** 20 novice laparoscopic surgeons were recruited to the study. All subjects underwent a baseline test of basic laparoscopic skill on a video-box trainer, followed by a half-day didactic session on laparoscopic techniques. Subjects were then equally and randomly divided into two groups: group A each completed five cadaveric porcine laparoscopic cholecystectomies (LCs) on a video-box trainer over a period of two weeks; group B completed a proficiency-based VR training curriculum on a laparoscopic simulator and then performed three cadaveric porcine LCs each. Assessment of laparoscopic technical skill on the LCs was by a validated motion analysis device which derives parameters of time taken, path length and number of movements, and video-based global rating scores (out of 35).

**Results:** There were no baseline differences in laparoscopic skill between the two groups. There were significant differences in performance on the first LC between groups A and B for time taken (median 4590 vs. 2165 secs, p=0.038), total path length (169.2 vs. 86.8 metres, p=0.001), total number of movements (2446 vs. 1029, p=0.009) and video rating scores (10 vs 22, p=0.009). The two groups achieved equivalence of performance at the fifth (group A) and third (group B) LCs for all parameters.

**Conclusions:** Training in skills laboratories has been shown to improve initial performance in the operating room, though the persistence of this effect has not been previously evaluated. In this study it is apparent that proficiency-based VR training can shorten the learning curve on a real procedure, leading to a more cost and time-effective mode of acquiring new skills.

## S079

**100% FLS TECHNICAL SKILLS CERTIFICATION PASS RATE FOLLOWING PROFICIENCY-BASED TRAINING**, Daniel J Scott MD, E. Matt Ritter MD, Seifu Tesfay RN, Elisabeth A Pimentel BS, Alykhan Nagji BS, Gerald M Fried MD, University of Texas Southwestern Medical Center, Dallas, Texas. Uniformed Services University, Bethesda, Maryland, McGill University Health Center, Montreal, Canada.

**Introduction:** The Fundamentals of Laparoscopic Surgery (FLS) Program has been extensively validated as a high-stakes examination for certification purposes but optimal methods for skills training are lacking. The purpose of this study was to develop a proficiency-based FLS skills training curriculum and evaluate its effectiveness in preparing trainees for certification.

**Methods:** Novice medical students (n=21) were enrolled in IRB-approved protocols at 2 institutions. Trainees underwent approximately 2 hours of open knot-tying practice, viewed the FLS video tutorials, and were pre-tested by performing 1 repetition of each of the 5 FLS tasks, scored using standard testing metrics. Trainees then practiced the tasks in a distributed fashion over a 2-month period until proficiency was achieved for all tasks on at least 2 consecutive repetitions (10 additional reps were required for tasks 1 & 5) or for a maximum of 80 repetitions per task. Proficiency levels were based on the mean performance of 5 repetitions of each task by 2 experts. For training purposes, testing metrics were modified to allow on-the-fly scoring; to achieve proficiency, trainees were required to perform each task in a
specified amount of time while committing "allowable" errors (no dropped pegs, all cuts within 2mm of the circle pattern line, up to 1mm accuracy errors, no knot security errors). Trainees were post-tested using the high-stakes exam format. Data reported are mean ± s.d.; analyses were by Mann-Whitney and Fisher Exact tests (p <0.05 considered significant).

**Results:** No trainee passed the certification exam at pre-testing. Trainees achieved proficiency for 96% of the 5 tasks during training, which required 9.7 ± 2.4 hours (range 6-14) and 119 ± 31 repetitions (range 66-161). Trainees rated the proficiency levels as "highly appropriate" (4.7 ± 0.1, 5-point scale). At post-testing, 100% of trainees passed the certification exam and demonstrated significant improvement compared to pre-testing for total score (468 ± 24 vs. 126 ± 75, p <0.001), self-rated laparoscopic comfort (89.4% vs. 4.8%, p <0.001) and skill level (3.6 ± 0.9 vs. 1.2 ± 0.5, p <0.001, 5-point scale).

**Conclusions:** This proficiency-based curriculum is feasible for training novices and uniformly allows sufficient laparoscopic technical skill acquisition for FLS certification. This curriculum has now been endorsed by the SAGES FLS Committee and is planned for widespread implementation as part of the FLS Program.

## S080

### THE IMPACT OF KNOWLEDGE OF RESULTS IN SURGICAL SKILLS TRAINING., A. O'Connor MD, C. Cao PhD, S.

Schwaitzberg MD, Department of Mechanical Engineering, Tufts University.

**Background:** Concerns about the adequacy of advanced laparoscopic training continue to be raised despite a proliferation of training systems exist. The manner in which the training modules are structured to maximize learning has not been examined. There are many aspects to the accumulation of laparoscopic skills during training, one of which is Knowledge of Results (KR), i.e. the information provided to individuals about the outcomes of their motor responses in their environment. We studied the effects of KR on the learning curve of laparoscopic suturing and knot tying.

**Aims:** We evaluated the learning curves of 9 medical students with no previous laparoscopic surgical experience under three different conditions, each with different levels of knowledge of results. Methods: Subjects were randomly assigned to one of three groups. Each subject attended a training session for 1 hour each day, 6 days a week for 4 weeks. Group 1 (No feedback) received no knowledge of results (KR) and no performance feedback. Group 2 (feedback only) received factual KR following each training session, but no coaching. Group 3 (feedback and coaching) received KR and coaching. Learning curves were plotted based on task time, smoothness of instruments and instrument's path length. The task used was an intracorporeal suture/knot tying in the ProMIS laparoscopic simulator. Perceived workload for each session was recorded using a standardized NASA TLX workload score.

**Results:** The variability across each session for each student was calculated for each of the three parameters. There was statistical significance between the groups for all parameters (p-values 0.0002, 0.0002 and 0.009). Significant differences were found between groups 2 and 3 and group 1 (p values 0.0314-0.0410) Groups 2 and 3 learned significantly faster than those in Group 1, reaching performance plateaus at earlier sessions. There were no significant differences between groups 2 and 3 (p-values 0.1211, 0.1758 and 0.1375). Providing individuals with knowledge of results lowered their perceived workload, adding instructional feedback lowered this even further. These results demonstrate that KR is essential for efficient surgical skill acquisition. Individual coaching, a labor intensive proposition, reduces workload but has NO added beneficial effect on the speed of learning. These results provide a useful basis for developing efficient and cost effective surgical skills training curriculum.

## S081

### EXPERT BENCHMARK FOR THE GI MENTOR II, Roy

Phitayakorn MD, Jeffrey M Marks MD, Harry R Reynolds MD, Conor P Delaney MD, Case Medical Center, Department of Surgery, Case Western Reserve University, Cleveland, OH.

**BACKGROUND** There is increasing interest in the use of virtual-reality simulators in general surgery residency training. Many simulators lack a benchmark against which trainees can measure competence and skill.

**METHODS** Surgeons who had performed over 1000 colonoscopies were evaluated on Module 1, Case 5 of the GI Mentor I or II? virtual reality endoscopy simulator (Simbionix, Cleveland). Participants were given five minutes to familiarize themselves with the simulator, and then performed the study case with standardized instructions.

Metrics were recorded by the previously calibrated simulator.

**RESULTS** Twenty-three surgeons (21 male, 2 female) participated. Mean height was 69.6 ± 2.6 inches, mean age 51 ± 9 years, median surgical glove size 7.5, and surgeons had 18.4 ± 10.2 years of practice, and did 8 ± 6 colonoscopies weekly. Ten participants had advanced training in endoscopy, laparoscopy, or colorectal surgery; eight had used the simulator before, of whom six had used it once. Mean time to complete the study case was 13.6 ± 5.3 minutes and time to reach the cecum was 6.5 ± 4.3 minutes. Participants examined 92.3 ± 3.6% of the simulated colonic mucosa with a clear view of the lumen 89.5 ± 4.2% of the time. Total time the colon was looped was 22 ± 35 seconds (range=0-133). The overall efficiency of screening was 70.33 ± 23.45% (range=20 to 94%). Participants tended to mistake normal simulated colonic structures as pathology.

**CONCLUSION** Performance on a virtual reality endoscopic simulator has a wide amount of variability even among a group of experienced endoscopists. Expert benchmark tests should be performed on simulators that will be used for resident assessment prior to any attempts at certification of competence.

## S082

### 3719 LAPAROSCOPIC TOTALLY EXTRAPERITONEAL HERNIA REPAIRS., Yuen Soon MD, Henry M Dowson MD, M E Bailey MS, Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK

**Introduction:** Laparoscopic totally extraperitoneal hernia (TEP) repairs have been shown to be safe method of repairing inguinal hernias. United Kingdom's National Institute of Clinical Evidence technology appraisal in September 2004, a systematic review comparing 5560 patients in 37 randomised controlled trials suggested that laparoscopic hernia repairs are associated with decreased wound infection and haematoma. Its complication rates are otherwise similar to open surgery, recommending that laparoscopic hernia repairs are suitable for primary hernia repairs. In this large personal series we demonstrate that Laparoscopic TEP hernia repair may be performed safely with low complication rates.

**Methods:** Over the last 12 years at the Royal Surrey County Hospital and the Nuffield Guildford Hospital 3719 hernia repairs have been performed in 2737 patients under the care of a single surgeon. Patients were followed up by either clinical examination, postal questionnaire or telephone enquiry.

**Results:** 3719 hernia repairs were performed in 2737 patients. There were no major peri-operative or post-operative complications. There were no conversions to any open procedures. 8 hernia repairs were converted from TEP to TAPP (transabdominal preperitoneal hernia). 6 were for significant peritoneal tears and 2 were for obliterated preperitoneal space. There were 29 recurrences (0.77% of hernia repairs; 1.06% of patients). Significant haematomas occurred in 15 patients (0.5%) but none of which required drainage. Mesh infection occurred in 4 patients (0.15%). Chronic groin pain occurred in 22 patients (0.8%).

**Conclusion:** These results demonstrate that laparoscopic TEP hernia repairs may be performed safely with excellent results. It is the new gold standard in the treatment of inguinal hernia.
<figure><img src="image_25.png" /></figure>

## S083

**PROSPECTIVE RANDOMISED TRIAL OF MESH FIXATION IN 500 LAPAROSCOPIC TOTALLY EXTRA-PERITONEAL HERNIORRHAPHIES.**, craig j taylor MD,laurent j layani MD,stephen i white MD,michael Ghusn MD,liew victor MD, John Flynn Gold Coast Hospital, Queensland Australia, The Tweed Hospital, Tweed heads Australia

**Background** New and persistent groin pain is reported by a significant number of patients following laparoscopic totally extra-peritoneal hernia repair (TEP). Mesh fixation by staples has been implicated as a possible cause, but is widely believed necessary to stabilize the mesh prior to tissue incorporation, otherwise early hernia recurrence may result. This study investigates whether an association exists between stapled mesh fixation, chronic pain, and early recurrence.

**Methods** A prospective double-blinded randomised trial was conducted between Dec 2004 and Jan 2006 involving three institutions. Eligible patients with an inguinal or femoral hernia underwent a standardised TEP repair with unshaped polypropylene mesh. Intra-operative randomisation determined if mesh fixation was performed by spiral metal tacks or left entirely alone. Patients were recalled for physical examination and interview by a separate independent surgeon after a minimum of 6 months. The incidence of new groin pain and recurrence were compared.

**Results** 500 herniae in 360 patients were entered into the study. A new and persistent pain was reported at 6 post-operative months by 38% vs 23% (p 0.003), occurring at least once a week in 22% vs 15% (p 0.049), or several times per week in 16% vs 8% (p 0.009) for fixation vs no fixation respectively. Patients who had bilateral repairs were 5 times more likely to prefer the side without fixation (p 0.006). Hernia recurrence after 6 months was 0.4% vs 0% respectively (p 0.85). Fixation increased operative costs by approximately $375AUD.

**Conclusion** Mesh fixation in TEP is associated with increased operative cost and persistent pain but no difference in the risk of hernia recurrence at 6 months.

## S084

**LAPAROSCOPIC TRANSPERITONEAL REPAIR OF INCISIONAL FLANK HERNIAS: A RETROSPECTIVE REVIEW OF 27 PATIENTS**, Chris A Edwards MD,Bruce J Ramshaw MD,Archana Ramaswamy MD,Timothy Geiger MD,Kevin Bartow BS,Louis Jeannsonne, University of Missouri - Columbia

**Introduction:** Incisional hernias of the flank are uncommon defects with only small scattered case reports regarding the feasibility of laparoscopic treatment. These defects can be technically challenging due to difficulties in patient positioning and obtaining adequate mesh overlap and fixation. This difficulty is compounded by the rarity of the defect and difficulty with acquiring surgical experience in treating these difficult hernias. The purpose of this study is to present the largest known case series of laparoscopic repair of incisional hernia of the flank and to describe the surgical technique.

**Methods:** A retrospective chart review was performed from April 2002 to August 2006 at two university hospitals of three surgeons? experience. All patients who underwent a laparoscopic repair of a flank hernia were identified and reviewed with regards to short term outcomes.

**Results:** Twenty seven patients were identified with incisional flank hernia treated laparoscopically. The average defect size was 188 sq. cm. repaired with an average mesh size of 650 sq. cm. The mean OR time was 144 min. and mean LOS was 3.1 days. There were two re-operations within the cohort. One was for a new unrelated midline hernia 7 months after repair of the initial flank hernia and one re-operation for chronic pain with removal of a previously placed mesh. Neither patient had failure of the flank hernia repair. Two other patients were treated for chronic pain by an anesthesia pain service. There were no recurrences at a mean follow up of 3.6 months.

**Conclusion:** Laparoscopic repair of incisional hernias of the flank can be performed safely and effectively with good

short term outcomes. Important key technical details include adequate retroperitoneal dissection and wide mesh overlap. It is important to obtain inferior fixation to Cooper's ligament and the ileopubic tract for inferior hernias. It is also important to apply superior fixation to the costal margin with mesh overlap extending across the diaphragm for superior hernias near the costal margin.

## S085

**TRANSABDOMINAL PREPERITONEAL APPROACH FOR INCISIONAL / VENTRAL HERNIAS**, Pradeep Chowbey MS, Chairman - Minimal Access & Bariatric Surgery Centre,Sir Ganga Ram Hospital, New Delhi (India)

Abdominal wall hernias in the lower abdomen, flanks and in close proximity to bony structures are considered difficult hernias to repair. We performed laparoscopic transabdominal partially extraperitoneal repairs (LTER) for 102 such hernias located in an inverted horse shoe shaped area of the abdominal wall (flanks and suprapubic area). A peritoneal flap was raised from the lower margin of the hernial defect for at least 5 cms till bone / ligament / fascia was clearly identified and dissected for secure fixation of lower margin of the mesh.There were 84 females and 18 males with mean age of 52.5 ± 8.7 years. Location of the hernias included lower midline scar 62, pfannensteil scar 10, lower paramedian scar 18, Lumbar hernias 12 (primary and acquired). Thirty Six repairs were for recurrent hernias and 39 patients had irreducible or partially reducible hernias. The mean hernia diameter was 6.38 ± 4.96cm and the average size of mesh required was 442 ± 198 cm2. The mean operating time was 123.9 ± 25.7 min. The mean blood loss was 150 ± 80 cc. Postoperative hospital stay averaged 2.80 ± 1.39 days. Intraoperative and postoperative complications accounted for 18% and 12%. At a mean follow up of 34.2 ± 20 months, one patient had recurrence. LTER for selected abdominal wall hernias is feasible and safe. The main advantage appears to be an increased lower margin of mesh coverage for the hernial defect and more importantly secure fixation of the lower margin of the mesh to bone / ligament / fascia that adds to the strength of the repair.

## S086

**LAPAROSCOPIC VERSUS OPEN HERNIA REPAIR: 5 YEAR RECURRENCE RATES**, Naveen Ballem MD,Rikesh Parikh MD,Eren Berber MD,Allan E Siperstein MD, Cleveland Clinic

**Background:** Current studies with 2-3 year follow-up favor laparoscopic ventral hernia repair due to lower recurrence rates, fewer wound infections, and shorter hospital stays. There is scant data in the literature for this group of patients regarding longer follow-up. This study compares the actual 5 year recurrence rates of laparoscopic vs. open techniques and determines factors that may affect recurrence.

**Methods:** A retrospective analysis of ventral hernia repairs at a tertiary center between Jan. 1996 and Dec. 2001 was performed. In this era, the method of repair often depended on which surgeon evaluated the patient. All patients were followed for a minimum of 5 years (median of 7.5 yrs). Demographic and clinical parameters were analyzed using Kaplan Meier analysis and Multivariate Cox Proportional Hazard Model.

**Results:** Of 331 patients, 119 underwent laparoscopic ventral hernia repair (LAP), 106 open hernia repair with mesh (O-M), 86 open suture repair (O-S), and 20 laparoscopic converted to open (LCO). Statistical analyses showed equal parameters among groups except defect sizes (mean ± SEM): LAP (9.8cm ± 1.2), O-M (11.2cm ± 3.3), LCO (16.6 ± 5.4) vs. O-S (4.6cm ± 1.6), p<0.02. Actual recurrence rates at 1 and 5 years were: LAP (15% and 29%), O-M (11% and 28%), O-S (10% and 19%), and LCO (35% and 60%). Multivariate analysis identified larger defects to have higher recurrence rates, particularly in the O-S group (p<0.02). With the exception of the LCO group, surgical technique did not predict recurrence, nor did body mass index, diabetes, smoking, or use of tacks vs. sutures.

**Conclusion:** This is the first study to compare 5 year actual recurrence rates between laparoscopic and open ventral
hernia repairs. Contrary to prior reports, our longer term data indicates similar recurrence rates, except for higher rates in the laparoscopic converted to open group. Due to the continued recurrences over the period studied, longer term follow-up is necessary to appreciate the true rate of hernia recurrence.

## S087

**IS AGE A RISK FACTOR IN LAPAROSCOPIC INGUINAL HERNIA REPAIR?**, J. R Salameh MD, G. M Varkarakis, Departments of Surgery, University of Mississippi Medical Center and G.V. Sonny Montgomery VAMC, Jackson, Mississippi

**INTRODUCTION:** Laparoscopic totally extra-peritoneal (TEP) inguinal hernia repair is a safe and effective technique. We compared the outcome of laparoscopic TEP inguinal hernia repair between patients less and over 60 years of age.

**METHODS:** We retrospectively reviewed the records of all patients undergoing laparoscopic TEP inguinal hernia repair between October 2002 and February 2006 performed by one surgeon (JRS). 60 patients, all male, were identified and divided in two groups: Young, less than 60 years of age (30) and Elderly, 60 years of age and older (30). Mean age was 52 (range: 21 - 59) for the Young group and 71.7 (range: 60 - 89) for the Elderly group. Both groups were identical in terms of co-morbidities, bilateral hernias (33% vs. 40%), recurrent hernias (27% vs. 27%) and incidental femoral hernias (3.3% vs. 3.3%). Outcome variables were compared between the groups using Fisher's exact test.

**RESULTS:** All procedures were completed laparoscopically. Mean operative time was 85.2 minutes for the Young and 84.6 minutes for the Elderly and length of stay was 0.06 vs. 0.53 days respectively. Early outcomes were as follows:

<table><thead><tr><th>Group</th><th>Intra-op compl.</th><th>Urin.</th><th>Retention</th><th>Post-op compl.</th></tr></thead><tbody><tr><td>Young (n=30)</td><td>0/30 (0%)</td><td>0/30 (0%)</td><td></td><td>5/30 (16.6%)</td></tr><tr><td>Elderly (n=30)</td><td>2/30 (6.6%)*</td><td>3/30 (10%)</td><td></td><td>4/30 (13.3%)</td></tr><tr><td>p</td><td>0.246</td><td>0.119</td><td></td><td>0.500</td></tr></tbody></table>

*Both intraop compl. were transient bradycardia

In the Young, 10% patients had pain that lasted more than 2 weeks versus 3.3% in the Elderly (p = 0.306). There were no recurrence or chronic pain (>12 weeks) in either of the two groups at a mean follow-up of 24.3 months.

**CONCLUSIONS:** Laparoscopic TEP inguinal hernia repair seems to be as safe and effective in elderly patients as it is in younger patients without detectable difference in early or late outcomes.

## S088

**RESULTS OF LAPAROSCOPIC REPAIR OF ENLARGED HIATAL HERNIA WITH ACELLULAR DERMIS**, Alex Reznichenko MD, Philip L Leggett MD, Harvinderpal Singh MD, Michael Kia DO, Sherman Yu MD, Terry K Scarborough MD, Erik B Wilson MD, The University of Texas Health Science Center at Houston, Minimally Invasive Surgeons of Texas

**Background:** Hiatal hernias have traditionally been repaired with primary crural closure. However, significant recurrence rates have encouraged the use of mesh reinforcement for enlarged defects. Biosynthetic meshes such as acellular dermis are being more frequently used in repair due to the considered lower risk of infection and erosion. This study reports the outcomes of 36 patients receiving laparoscopic enlarged hiatal hernia repair with acellular dermis reinforcement.

**Methods:** From 2003 to 2006, 36 patients at two institutions with symptomatic enlarged hiatal hernias received laparoscopic surgical repair. The crural fascial edges were approximated with non-absorbable sutures, followed by buttressing the crural repair with acellular dermis. There were 8 patients with type I hernias, 17 with type II hernias, and 11 with type III hernias. Average age was 60 years with 23 females(64%). Data was registered in a database and retrospectively reviewed.

**Results:** Preoperative symptoms were noted as reflux in 22 patients(61%), dysphagia in 12 patients(33%) and postprandial pain in 19 patients(53%). Nine patients(25%) were diagnosed with Barrett's preoperatively. Fundoplications were performed in all patients with 29 Nissens (81%), 6 Dors(17%), and 1 Toupet(3%) completed. There were no complications attributable to the use of acellular dermis intraoperatively or postoperatively and no perioperative mortality. Follow up of all patients averaged 3.5 months. Symptoms resolved in all patients, except 3 patients(8%) developed postoperative dysphagia; one was managed with 2 endoscopic dilations and resolved. Two patients(6%) developed delayed dysphagia at 3 months postoperatively and were diagnosed with recurrent hiatal hernias by endoscopy. Both patients were reoperated upon laparoscopically and repaired with no recurrent symptoms at 9 and 18 months.

**Conclusion:** Laparoscopic repair of enlarged hiatal hernia with acellular dermis is a safe and effective modality but does completely prevent recurrence. Longer follow up may reveal further recurrences. Additional studies of biosynthetic versus synthetic mesh are necessary to compare risks of recurrence to risks of infection or erosion.

## S089

**PEDIATRIC ROBOTIC SURGERY: A SINGLE INSTITUTIONAL REVIEW OF OUR FIRST 100 CASES**, John J Meehan MD, Anthony Sandler MD, The Children's Hospital of Iowa, University of Iowa Hospitals and Clinics

**Purpose:** Robotic surgery is a new technology which may expand the variety of operations performed minimally invasively. We present a retrospective review of our first 100 consecutive robotic cases in children.

**Methods:** All procedures were performed using the 3 arm Da Vinci surgical robot. Additional non-robotic accessory ports were utilized dependant on the type of operation.

**Results:** Twenty-four different types of procedures were completed using the robot. Twenty (83%) of these procedures had never been attempted minimally invasively by the authors. Age ranged from 1 day to 23 years with an average age of 8.4 years. Weight ranged from 2.2 kg to 103 kg with a median weight of 27.9 kg. Twenty-two patients were less than 10.0 kg. Fifteen oncology patients underwent robotic resections. Solid tumors were successfully resected robotically in 6 of 6 thoracic cases and 5 of 9 abdominal cases. Open conversion rate was 13%. One case (1%) was converted to thoracoscopic. No conversions to open surgery or complications occurred as a result of injuries or failures of the robotic instruments. However, four cases were opened due to equipment failures or injuries from traditional laparoscopic equipment. Completed abdominal procedures included fundoplication (35), cholecystectomy (16), splenectomy (4), total proctocolectomy with pull-through (3), adrenalectomy (2), Ladd's procedure (2), neuroblastoma resection (2), small bowel resection (2), Heller myotomy (2), neonatal Bochdalek CDH repair (1), rectal prolapse (1), Kasai (1), duodenal atresia (1), ovarian teratoma (1), ovarian cystectomy (1), mesenteric lymphangioma (1), hemicolectomy (1), and pyloroplasty (1). Completed thoracic procedures included mediastinal mass resection (4), neurogenic tumor resection (2), CCAM resection (1), bronchogenic cyst (1), intralobar sequestration (1), and pulmonary segmentectomy. Procedures attempted but unsuccessful robotically included a large gastric duplication, thoracic approach to a neonatal Bochdalek CDH, an intraabdominal retroperitoneal tumor, and pancreatic tumor resection.

**Conclusions:** Robotic surgery is safe and effective in children. An enormous variety of procedures can be accomplished including complex neonatal operations. The technology is ideal for thoracic procedures, particularly solid chest tumors. Subjectively, we found robotics enabling: it allowed us to perform many different MIS procedures we would not have otherwise attempted using standard MIS instruments.
<figure><img src="image_26.png" /></figure>

## S090

VALIDATED ROBOTIC LAPAROSCOPIC SURGICAL TRAINING IN VIRTUAL REALITY ENVIRONMENT, Ka-Chun Siu

PhD,Bernadette Brown-Clerk BS,Dimitrios Katsavelis MS,Irene H Lee MS,Dmitry Oleynikov MD,Nick Stergiou PhD, HPER Biomechanics Lab, University of Nebraska at Omaha, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA. A virtual reality (VR) environment has been developed to improve training for laparoscopic surgery. Currently, only verbal training sessions and subjective skill assessments by expert surgeons are used to train and evaluate surgeons on the da Vinci Robotic Surgical System (Intuitive Surgical, Inc.). The simulated VR provides a subjective and quantitative approach to evaluate and improve surgical performance and efficacy. This study presents our preliminary data of the VR training environment for robotic laparoscopy. We compared the VR to the actual training environment using a bimanual carrying (BC) task to determine the validity of the VR simulation. Four volunteers simultaneously transferred two plastic pieces in opposite directions five times consecutively. This task requires significant bimanual coordination that mimics actual laparoscopic skills. Our VR is the first training simulation developed for robotic laparoscopic surgery. The VR was constructed using the simulation software Webots (Cybertonics Corp). The da Vinci instruments and training task platform were modeled as 3D objects using SolidWorks (Fig 2). This simulation was driven by the kinematic data from the robotic operating console through LabVIEW. The VR simulation mimics the motions of a simplified BC task. Data analysis included time to task completion, distance traveled, instrument tip speed as well as the range of motion (ROM) of the operator's wrist and elbow. Paired t-tests were used to compare the VR and real environment. As a result, there were no significant differences between the actual environment and the simulated VR with respect to robot performance, except the wrist ROM. Our preliminary data shows that the VR can be used for robotic laparoscopy training. A significant reduction in wrist performance may be attributed to an oversimplification of the BC task. Complexity of the VR should be improved to further investigate the effectiveness and reliability of the VR training environment.

## S091

A LIFELIKE PATIENT SIMULATOR FOR TEACHING ROBOTIC COLORECTAL SURGERY, Russell K Pearl MD, Slawomir J

Marecik MD,Raymond J Evenhouse MD,Leela M Prasad MD,Herand Abcarian MD, Cook County Colon and Rectal Surgery Residency Training Program, Chicago, Advocate Lutheran General Hospital, Park Ridge, IL

Patient simulators are playing an increasingly important role in training both surgical residents and practicing surgeons. We have created an innovative teaching model which allows the operator to practice robotic suturing techniques within the confines of the pelvis. The simulator consists of a plastic model of a human pelvic skeleton which has been mounted on a sturdy laminate covered base by an adjustable bracket designed to alter the pelvic angle over a wide range. A clear plastic replica of a patient with a distended abdomen (pneumoperitoneum) with its thighs abducted and elevated to simulate the lithotomy position was fashioned utilizing the vacuum molding technique and fixed to the adjustable pelvic skeleton so that the surface contours and pelvic bones move as a single unit. Several holes were drilled into the clear plastic "skin" to allow for the insertion of standard ports, and a larger aperture was created to accommodate a hand assist device. Lengths of 12 gauge solid copper wire fitted with metallic alligator clips were mounted to the base to hold small strips of pig intestine in proper alignment for suturing. A previously held suturing exercise utilizing surgical residents demonstrated the effectiveness of this tissue approximation method.

## S092

EFFICACY OF REMOTE ROUNDING AND PATIENT CARE UTILIZING THE ROVER ROBOT, Michael S Lofgren

MD,Stephen D Wohlgemuth MD, Eastern Virginia Medical School Department of Surgery

**Introduction:** This study was designed to assess the impact of remote, physician directed, robotic rounding on patient length of stay and satisfaction in the immediate postoperative period.

**Methods:** Patients undergoing laparoscopic gastric bypass (lap GBP) between December 2005 and June 2006 at a tertiary 569 bed hospital were enrolled in a prospective randomized trial. Patients were placed into one of two groups. The first treatment arm underwent a lap GBP on the day of admission. On post operative day (POD) 1, the patient underwent a radiographic swallow evaluation and was seen personally by an attending physician. Throughout the remainder of the day the patient would be re-evaluated by either a nurse practitioner or physician assistant. On POD 2 the patient would then again be seen by an attending physician and a determination would be made as to potential discharge or continued hospitalization. Any subsequent hospital days would repeat this same algorithm. The second treatment arm also underwent a lap GBP on the day of admission. On POD 1, the patient underwent the same radiographic swallow evaluation and was seen personally by an attending physician. Throughout the day the patient would have continued interaction with either a nurse practitioner or physician assistant. In the evening the patient would be re-evaluated by an attending physician through the use of the rounding robot. At the time of the robot rounding evaluation, a decision would be made as to potential discharge. If the patient remained hospitalized, each additional day would repeat the same algorithm. At the time of discharge, patients within the rounding robot arm of the study received a patient satisfaction questionnaire

**Results:** A total of 39 patients were enrolled in the study: 14 in the rounding robot arm and 25 in the control arm. 12 completed patient satisfaction surveys were returned. In the robot arm of the study the length of stay (LOS) was 3.42 days SD 2.03, 2.26-4.60 95% CI, in the non-robot arm the LOS was 3.16 days, SD 1.07 2.72-3.60 95% CI. When comparing the two groups, the two-tailed P value was 0.5894, -0.73 to 1.27 95% CI.

**Conclusions:** The use of supplemental robot based patient evaluation fails to demonstrate a significant difference in postoperative LOS. Although patient questionnaires indicate a high acceptance of the technology, further investigation is needed to assess the potential value of robotic postoperative patient assessment.

## S093

IS THE 4TH ARM AN USEFUL TOOL IN ROBOTIC GENERAL

SURGERY?, G. Pernazza MD, J. H Palep MD, G. Caravaglios MD,A. Coratti MD,F. Sbrana MD,F. M Bianco MD,P. C. Giulianotti MD, "Misericordia" Hospital - ASL 9 - Grosseto, Italy

Aim of the study was to evaluate the clinical impact of the fourth robotic arm of the daVinci Intuitive Surgical System.

**MATERIAL & METHODS:** 650 procedures have been performed since October 2000. The first 100 cases were excluded from the study as part of the learning curve. So we considered 276 procedures performed with the three-arms system (3As) till October 2004 and 274 procedures performed till date with the four arms system (4As).

Data concerning operative arms positioning, operative time, intraoperative complications and system failures were systematically collected and compared considering the most significant procedures performed with and without the fourth arm.

**RESULTS:** The 4As procedures were shorter than 3As ones, but the difference was statistically significant only in Nissen fundoplications (p<0.05), gastric resections (p<0.005) and minor hepatic resections (p=0.001).

No intraoperative complications were recorded in the 4As group.
In the 3As group we observed a liver injury due to an over-retraction by the assistant (Nissen fundoplication). The complication required a conversion to open surgery to be controlled.

**CONCLUSION:** The 4As seems to offer many potential advantages in robotic surgery. Improving of operative time may be an interesting aspect but not the most important one.

A clear potential is the opportunity to perform a "solo-surgery" technique, without the need of an assistant surgeon, especially in low complexity procedures such as cholecystectomy and oesophagogastric junction procedures. Some difficult technical steps of major operations like hepatic or pancreatic resections are clearly improved and made safer by the dynamic but stable and under surgeon control retraction.

The 4th arm utility in thoracic and colonic surgery seems to be questionable because the 4As is more cumbersome and more difficult to setup in relation to the small size of the operative field (chest) and the need of multiple cooperation (colon).

In rectal surgery, when performing TME, the 4As seems to be advantageous in retracting the mesorectum.

## S094

**VISUAL CLUES ACT AS A SUBSTITUTE FOR HAPTIC FEED-BACK IN ROBOTIC SURGERY**, Monika E Hagen* MD, John J Meehan** MD, Isan Ihnan* MD, Philippe Morel* PhD, University Hospital Geneva*, University of Iowa**

**BACKGROUND:** The lack of haptic feedback (HF) in robotic surgery is one of the major concerns of novice surgeons to that field. The superior visual appearances acquired during robotic surgery may give clues that make HF less important. We tested the null hypothesis that visual clues are not effective substitutes for HF in robotic surgery and are not creating the perception of HF.

**AIM:** The aim of this study was to clarify if the lack of HF is compensated by superior visualization in robotic surgery and creation of a perception of HF.

**METHODS AND DESIGN:** We surveyed 40 individuals on their perceptions of the need for HF when performing robotic surgery. 3 groups were compared. The 1st group of 20 surgical inexperienced students and doctors (age 25 to 35) took part in a dexterity study using the da Vinci surgical system in a dry lap for the first time. The 2nd group included 8 moderately experienced laparoscopic surgeons (age 30 to 45) using the robot in their first to fifth operations (22 procedures, each procedure assessed). The 3rd group included 10 surgical experts (8 American, 2 European; 2 pediatric surgeons, 4 urologists, 4 abdominal surgeons) with substantial experience of robotic surgery (Range: 150 to above 600 cases). Visual analog assessment with a scale from 1 to 10 was made of the following questions: perception of HF, how much HF was missed and how much the absence of HF impaired their level of comfort with the procedure. Robotic experts were also asked if complications have occured due to the lack of HF.

**RESULTS:** 50% of the 1st group, 55% of the 2nd group and 100% of the 3rd group reported the experience of the perception of HF (Difference between group 1 and group 3: p<0.05). The 1st group missed HF for 6,5 (on a scale from 1 to 10), the 2nd group for 4,3 and the 3rd group for 4 now and 7,2 when they first started robotic surgery (Difference between group 1 and 3: p<0.05; group 3 first and now: p<0.05). The lack of HF caused discomfort for group 1 of 4; 4, 4 for group 2 and 2,6 for group 3. 1 complication (perforation of gallbladder) was reported by the robotic experts due to the lack of HF.

**CONCLUSION:** The data support the conclusion that even beginners quickly find that visual clues are effective substitutes for haptic feedback in robotic surgery by creating the perception of haptic feedback. With more experience, perception of haptic feedback and the level of comfort with robotic surgery increases significantly.

## S095

**COMPARISON OF PATIENT-CENTERED OUTCOMES AFTER LAPAROSCOPIC NISSEN FUNDOPLICATION PERFORMED FOR GASTROESOPHAGEAL REFLUX DISEASE OR PARAESOPHAGEAL HERNIA**, L Mark MD, A Okrainec MD, L E Ferri MD, L S Feldman MD, S Mayrand MD, G M Fried MD, McGill University

**INTRODUCTION:** Patients undergoing laparoscopic Nissen fundoplication (LNF) with paraesophageal hernias (PEH) are older and less healthy than those with gastroesophageal reflux disease (GERD). We evaluated whether outcomes relating to GERD symptoms and quality of life (QOL) were impacted by the presence of PEH.

**METHODS:** 150 patients (41 PEH) were evaluated before and one year after LNF. Outcomes evaluated were heartburn (0-5), dysphagia (0-5), disease-specific QOL (GERD-HRQL, 0-45), and general health-related QOL (SF-12 physical and mental component scores, PCS and MCS). Data (mean+/-SD) were compared using t-tests. (Table: \*=p<0.05 GERD vs. PEH; \*\*=p<0.05 Preop vs. 1-yr postop.)

**RESULTS:** Preoperative data for GERD-HRQL, heartburn, and dysphagia were available for 136 patients, with 96% one year follow-up. SF-12 data were collected for 99 patients with 100% follow-up. PEH patients were older at 68.5+/-10.3 years (p=0.000). Preoperative GERD-HRQL and heartburn were significantly worse in the GERD group (p=0.000 each). Preoperative PCS scores were higher in GERD patients (p=0.045). At one year, GERD patients showed significant improvement in GERD-HRQL (p=0.027). GERD and PEH patients showed improved dysphagia (p=0.046 and p=0.000, respectively) and MCS scores (p=0.000 each group.) There was no statistical difference in GERD-HRQL, heartburn, or dysphagia scores between GERD and PEH patients postoperatively. Postoperative PCS score showed improvement in GERD patients (p=0.000), and was significantly higher compared to PEH patients (p=0.002.)

**CONCLUSION(S):** LNF provides excellent control of GERD symptoms and QOL in patients with GERD or PEH.

## S096

**LAPAROSCOPY SHOULD BE THE APPROACH OF CHOICE FOR ACUTE APPENDICITIS IN MORBIDLY OBESE**, Esteban Varela MD, Ninh Nguyen MD, University of Texas Southwestern and University of California Irvine

**Objective:** The morbidity associated with open appendectomy in obese patients may be significant, particularly wound related complications. This study determines outcomes in obese patients undergoing laparoscopic (Lap) and open appendectomies for acute appendicitis using an administrative database of academic centers.

**Methods:** Using ICD-9 diagnosis and procedure codes we obtained data from the University HealthSystem Consortium database for 67,347 patients who underwent appendectomies between 2002 and 2006. A total of 1,671 morbidly obese patients had appendectomies (2.5%). Outcomes included patient's length of stay (LOS), costs, morbidity and mortality.

**Results:** Data for appendectomies in morbidly obese patients. Means ± SD; \*=p<0.05 by t-test; \*=p<0.05 by Z-test;

<table><thead><tr><th>Variables</th><th>Open (n=903)</th><th>Lap (n=768)</th></tr></thead><tbody><tr><td>Mean LOS (days)</td><td>4.4 ± 3.7</td><td>2.9 ± 2.9 ?</td></tr><tr><td>Mean costs (K$)</td><td>10.4 ± 11.9</td><td>8.6 ± 6.6 ?</td></tr><tr><td>Mortality</td><td>0</td><td>0</td></tr><tr><td>Morbidity</td><td>16.3</td><td>9.0 *</td></tr><tr><td>Infection (%)</td><td>2.7</td><td>1.1 *</td></tr></tbody></table>

**Conclusion:** Compared to open appendectomy, laparoscopic appendectomy performed in morbidly obese patients is associated with lower cost, shorter length of stay, lower morbidity, with a similar mortality. Laparoscopic appendectomy for the treatment of acute appendicitis in the obese population has distinct clinical advantages compared to open appendectomy and should be the approach of choice.
<figure><img src="image_27.png" /></figure>

## S097

### LAPAROSCOPIC ANTECOLIC ROUX-EN-Y GASTRIC BYPASS WITH CLOSURE OF INTERNAL DEFECTS LEADS TO FEWER INTERNAL HERNIAS THAN RETROCOLIC APPROACH,

Kimberely E Steele MD, Gregory P Prokopowicz MD, Thomas Magnuson MD, Anne Lidor MD, Michael Schweitzer MD, Johns Hopkins Hospital

**Introduction:** Laparoscopic Roux-en-Y gastric bypass has been reported to have a higher rate of postoperative internal hernias than open gastric bypass. Despite closure of the mesenteric defects, internal hernias are reported to occur in up to 5% of cases. To minimize this complication, an antecolic antegastric approach to the anastomosis of the Roux limb and gastric pouch has been used. In contrast to the retrocolic retrogastric technique, which creates three mesenteric defects, the antecolic approach produces only two defects: Peterson's and the jejunojejunostomy. It is expected that this approach will result in fewer internal hernias.

**Aims:** To compare the rate of internal hernias among patients undergoing laparoscopic Roux-en-Y gastric bypass using a retrocolic retrogastric versus an antecolic antegastric approach.

**Methods:** We reviewed the experience of a single surgeon, using the above two techniques for laparoscopic gastric bypass, from August 2001 to September 2005. Only Roux-en-Y procedures were included in this analysis. Patients were followed for a minimum of one year postoperatively, and were encouraged to report any symptoms, treatments, or hospitalizations. The retrocolic retrogastric approach was used on 274 patients and the antecolic antegastric approach on 205 patients. All defects were closed at the time of surgery. With the antecolic approach, Peterson's defect was closed from the root of the mesentery of the Roux limb and the transverse colon mesentery up to the transverse colon.

**Results:** Among the 274 patients who underwent retrocolic retrogastric technique, seven (2.6%) developed a symptomatic internal hernia. No internal hernias were reported amongst the 205 patients who underwent the antecolic antegastric method. Thirty-five of 479 patients (7%) required diagnostic laparoscopy for post-operative abdominal pain. No internal hernias were found in this group; however, 15 patients were found to have cholelithiasis and underwent laparoscopic cholecystectomy. Using chi-square analysis, use of an antecolic approach was associated with a decreased rate of internal hernias (p<0.025).

**Conclusion:** The antecolic antegastric approach to laparoscopic Roux-en-Y gastric bypass is associated with fewer postoperative hernias than the retrocolic retrogastric approach. The frequency of hernias using either technique is low if meticulous attention is paid to closure of all mesenteric defects.

## S098

### IMPROVED RESULTS FROM LOW VOLUME CENTER IN NEW YORK STATE - SHOULD VOLUME CRITERIA FOR CENTERS OF EXCELLENCE BE REVISITED?, Ashutosh Kaul

MD, Thomas Sullivan BS, Michael Parker MD, Edward Yatco MD, Thomas Cerabona MD, New York Medical College

Aim of this presentation is to highlight the improving results of bariatric surgery in low volume centers in New York State and to initiate a debate on evidence based criteria for centers of excellence. We analyzed 12-year data (1991-2003) from statewide planning and Research Cooperative Systems (SPARCS) database maintained by New York State. Bariatric surgery procedures identified by DRG were scrutinized by patient demographics and complications and institution based on volume (low volume (LV) 0-49, Medium volume (MV) 50-124 and High Volume (HV) over 125 cases per year.

24, 534 patients underwent bariatric surgery with volume jumping from 500 in 1991 to around 8000 in 2003, a 16-fold increase. There was dramatic improvement in results in all volume centers with mortality falling from a peak of 1.1% in 1994 to 0.1% in 2003. Non-significant predictors of mortality

included DM, prior MI, hepatic disease and hypertension. The average mortality rates from 2000 to 2003 were LV 0.67%, MV 0.2% and HV 0.26%. The results showed dramatic improvements in low volume centers from 1% in 2000 to 0.4% in 2003. Incidence of postoperative complications in LV also was improving though results were better in higher volume centers during that period. (LV 11.3%, MV 10.1%, HV 7.1%).

The incidence of reintubation in LV and MV was nearly the same (LV 1.63%, MV 1.6% and HV 0.76%). The incidence of blood transfusions over the 12-year period was LV 2.4%, MV 2.4% and HV 1.8%. Analysis showed significantly higher postoperative GI complications and pulmonary complications in lower volume centers.

It was seen that though Higher volume centers still had the best results, lower volume centers were rapidly closing the gap with their results in last two years came closer to levels obtained in higher volume centers. This could be due to better training, more fellowship trained surgeons and the learning curve. The dramatic improvements in results in New York State from lower volume centers are encouraging.

In light of these dramatic improvements in results from lower volume centers it is important to have further data and to possibly revisit the present volume levels for center of excellence. Increased GI and pulmonary complications in LV centers could be concentrated to improve results. Different preoperative patient selection criteria and special emphasis on factors leading to postoperative GI and pulmonary complications could be studied.

## S099

### THORACOSCOPIC ESOPHAGEAL MOBILIZATION DURING MINIMALLY INVASIVE ESOPHAGECTOMY: A HEAD-TO-HEAD COMPARISON OF PRONE VERSUS DECUBITUS POSITIONS, Thomas Fabian MD, Mario Katigbak MD, Jerry Martin MD, Alicia McKelvey MD, John Federico MD, Hospital of St. Raphael, Yale University School of Medicine Department of Thoracic Surgery

**Background:** The thoracoscopic portion during minimally invasive esophagectomy (MIE) is generally performed in the left lateral decubitus position. Recently there has been increasing interest in esophageal mobilization in the prone position; potential benefits of this technique include improved operative time, surgeon ergonomics and operative exposure. We sought to objectively compare thoracoscopic mobilization of the esophagus in the left lateral decubitus position versus the prone position and identify potential differences between the two techniques.

**Methods:** A retrospective review of a prospective MIE database identified 19 patients undergoing thoracoscopic esophageal mobilization with cervical anastomosis during a 12-month period (June 2005-June 2006). Of these, 8 cases were performed in the left lateral decubitus position and 11 cases performed in the prone position.

**Results:** The patients were comparable in age, stage of tumor and percent undergoing neoadjuvant therapy. There was no statistically significant difference between decubitus position and prone position with regard to lymph nodes dissected 14.3 vs. 14.9 (p=0.767), complications 6/8 vs. 7/11 (p=0.062), length of stay 13.4 vs. 12.1 days (p=0.738), or intraoperative blood loss 84cc vs. 73cc (p=0.556) respectively. One patient in the decubitus group died within 30-days as an outpatient not considered related to thoracoscopic mobilization technique. Operative times were significantly shorter in the prone versus the decubitus group (88 versus 133 minutes, p=0.0142).

**Conclusions:** Prone thoracoscopic esophageal mobilization appears equal to decubitus thoracoscopic esophageal mobilization with respect to blood loss, number of lymph nodes dissected, and complications, but offers a significant reduction in surgical time.
<figure><img src="image_28.png" /></figure>

## S100

**THE SYSTEM OR THE SURGEON? NSQIP-CONFIRMED OUTCOMES AVOIDING THE LEARNING CURVE AT A UNIVERSITI-Y-BASED TRAINING PROGRAM**, Bruce Schirmer MD,Sang K Lee MD,C. Joseph Northup MD,Michael S Miller BS,Virginia B Simpson RN,F. Beth Turrentine MSc,Jan Dix MS,Anna D Miller RN, University of Virginia

**OBJECTIVE:** We hypothesized that a comprehensive university-based training program, as exemplified by a program evolving to perform laparoscopic bariatric surgery, could demonstrate the importance of the system as being at least as important as the surgeon in achieving successful surgical outcomes.

**METHODS:** Outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures were reviewed for the period 1999-2004. Data were taken from an institutional database, whose input was by individuals not involved in the surgical operation. For the years 2003-2004, the institutional NSQIP program data were reviewed and compared to the institutional database. Outcomes of cases performed by attendings (AT) were compared to cases performed by fellows and residents (F/R).

**RESULTS:** AT performed 101 procedures for an 82.2% female population, age 40.5+1.0 years, weight = 304.0+4.9 lbs, BMI = 48.6+0.7, with 2.45+16 comorbidities. F/R performed 711 procedures for an 82.6% female population that was older (42.5+0.4, p=.042) with higher BMI (57.6+0.3, p<.001) and more comorbidities (2.78+0.6, p=.036). F/R procedures took less time (198.7+2.8 vs. 237.5+8.2 min, p<.001), while AT patients had shorter hospital stays (2.94+13 vs. 3.78+27 days, p=.004). Intraop complications, blood loss, % conversion to open, reoperation rate, postoperative complication rate, leak rate, 30 day and total mortality, and 1-5 year % excess weight loss were similar for both groups. NSQIP data (n=528) confirmed comparable values to the database for hospital stay (3.12+22 days), postop complication rates (14.6%), and 30 day mortality (0.38%) for the years analyzed.

**CONCLUSION:** The performance of LRYGB by fellows and residents in this setting produced excellent outcomes, comparable to that of attendings. These data demonstrate avoidance of the learning curve for new surgeons seen in other settings, and emphasize the importance of the system over the surgeon in contributing to safe surgical outcomes.

## S101

**DO ELDERLY PATIENTS BENEFIT FROM LAPAROSCOPIC COLORECTAL SURGERY?,** Benjamin Person MD,Susan Cera MD,Juan J Nogueras MD,Dana R Sands MD,Eric G Weiss MD,Anthony M Vernava III MD,Steven D Wexner MD, Cleveland Clinic Florida, Weston, FL

**Background:** The aim of study was to analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery performed in the elderly population compared to younger patients and to those who underwent laparotomy.

**Methods:** A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders was undertaken. Resections by both LAP and laparotomy were included; patients in whom a stoma was created were excluded. There were 2 groups: age younger than 65 years (Group A) and age 65 years or older (Group B). Parameters analyzed included demographics, body mass index (BMI), length of operation (LO), length of incision (LI), length of hospital stay (LOS), morbidity and mortality.

**Results:** From 7/1990 to 6/2006, 641 patients (M/F - 292/349) underwent these procedures; 407 patients in group A and 234 patients in group B. There were significantly more males in group A (207/407 - 51%) compared to 85/234 (36%) in group B (p=0.0004). There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) ? p=0.0003. The conversion rates in both groups were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p=0.78). The LO was similar in both groups: LAP - 179 (70-410)min in group A and 175 (45-300)min in group B (p=0.9); converted - 217 (100-415)min in

group A and 203 (120-390)min in group B (p=0.4); laparotomy - 143 (40-320)min in group A and 138 (45-420)min in group B (p=0.6). The LI in patients in group B who underwent LAP procedures was significantly shorter than in group A - 5.8 (3-12)cm vs. 6.4 (3-12)cm (p=0.04). The LOS was significantly shorter in patients in group A who underwent laparotomy: 7.1 (3-17) days vs. 8.7 (4-22) days in group B (p<0.0001), and LAP: 5.3 (2-19) days vs. 6.4 (2-34) days in group B (p=0.01). In patients in both groups LOS in the LAP group was significantly shorter than in the open group. There were no significant differences in morbidity or mortality.

**Conclusions:** The longer LOS and slightly higher incidence of complications may be related to the higher incidence of co-morbidities in the elderly population. However, elderly patients who undergo LAP procedures have a significantly shorter LOS and fewer complications compared to elderly patients who undergo laparotomy. Thus, laparoscopy should be considered in all elderly patients in whom either ileo-colic or sigmoid resection is planned.

## S102

**LAPAROSCOPIC VS OPEN PROCTECTOMY FOR RECTAL CANCER: WHAT IS THE REAL DIFFERENCE? A MATCHED CASE-CONTROL STUDY OF CLINICAL AND ONCOLOGIC OUTCOMES**, Marat Khaikin MD,Badma Bashankaev MD,Susan Cera MD,Dana R Sands MD,Eric G Weiss MD,Juan J Nogueras MD,Anthony M Vernava III MD,Steven D Wexner MD, Cleveland Clinic Florida, Weston, FL

**Introduction:** This study aimed to compare clinical and oncologic outcomes of laparoscopic (LP) and open proctectomy (OP) for rectal cancer.

**Methods:** Data were reviewed from 2004 to 2006. LP was case-matched to OP by stage, surgery, ASA.

**Results:** 32 patients with LP were compared to 50 with OP. OP had a significantly higher BMI than LP (29.1 vs 25.3;p=0.005). LP had stage II and III in 81.3% and OP in 76% (p>0.05). uT3 stage prior to surgery was in 78.1% of LP and in 74% of OP (p>0.05). LP was performed for lower rectal cancer in 56% and OP in 46% (p<0.05). LP patients underwent neoadjuvant chemoradiation in 56% compared to 62% of OP (p>0.05). Anastomosis was performed in 84% and 94%, respectively (p=0.1). Diverting ileostomy was done in 74% and 78.7%, respectively (p=0.2). The procedure was successfully completed by laparoscopy in 28 patients (87.5%) whereas in 4 patients (12.5%) the procedure was converted to laparotomy. The median operative time was 240 minutes in LP and 185 minutes in OP (p=0.01). There was no significant difference in blood loss. The morbidity rates were 25% and 38%, respectively (p=0.1). Neoadjuvant chemoradiation resulted in 44.9% of complete tumor response, correlating with complete pathologic response in 90.9%.

<table><thead><tr><td></td><td>Laparoscopy</td><td>Laparotomy</td></tr></thead><tbody><tr><td>LOS (d)</td><td>6</td><td>7</td></tr><tr><td>1st BM (d)*</td><td>3</td><td>4</td></tr><tr><td>Lymph nodes (n)</td><td>18.7 (3-52)</td><td>19.7 (3-96)</td></tr><tr><td>Rad margin(cm)</td><td>1.4 (0.1-4)</td><td>1.8 (0.4-5)</td></tr><tr><td>Dist margin(cm)</td><td>2.4 (0.1-7)</td><td>2.6 (0.1-6.5)</td></tr></tbody></table>

*p<0.05; BM-bowel movement; LOS length of stay

**Conclusions:** LP for rectal cancer is feasible in 87.5% and despite a longer operative time than OP, is safe with the advantage of faster bowel function recovery. LP does not compromise oncologically adequate resection or significantly differ from OP in short-term outcomes.

## S103

**LAPAROSCOPIC RECTAL RESECTION FOR RECTAL CARCINOMA WITH AND WITHOUT NEO-ADJUVANT LONG COURSE RADIOTHERAPY**, C K Byrnes MD,F Keane MD,P Neary MD, Adelaide & Meath Hospital, Dept Surgery, Dublin, Ireland

**Introduction:** To assess the impact of neo-adjuvant radiotherapy on the feasibility and short-term outcome of laparo-
<figure><img src="image_29.png" /></figure>

scopic rectal resection.

**Methods** Details of patients with a rectal tumour whom underwent a rectal resection were retrieved from a prospectively entered database. Those who underwent a local transanal resection were excluded unless they subsequently had a colonic resection. Data were analysed for demographics, tumour type/stage, operative details, stoma formation, pathological details, length of stay, and complication rates.

**Results** 43 patients under went a rectal resection for a malignant rectal tumour over a one year period. Based on the initial multi-disciplinary assessment; including clinical assessment, pathological type, pelvic CT and MRI and endo rectal USS, 22 had long course neo-adjuvant radiotherapy followed by surgery and 21 underwent surgery without radiotherapy. Age and sex distribution of the two groups were similar. Pathological T stage averaged 2.4 in the neo-adjuvant group and 2.7 in the non neo-adjuvant group. There were 2 complete pathological responses in the neo-adjuvant group.

Laparoscopic to open conversion rates in both groups were similar; two of 16 in the neo-adjuvant group, and one of 16 in the non-neo adjuvant group. The average nodal yield was lower in the neo-adjuvant group compared to the non neo-adjuvant group (7.8 vs.11.3; p=0.018), but was similar between the open and laparoscopic approaches (8.0 vs. 9.7; p=0.33). Optimal mesorectal excision was reported in all low rectal resections. Major complications included one marginal artery thrombosis in the laparoscopically performed non neo-adjuvant group, requiring further surgery. Other complications included haemorrhage, cardiac failure, chest and wound infections were similar in both groups. The postoperative hospital stay was a median of 10 days in the non neo-adjuvant group and 13 in the neo-adjuvant group (p=0.79). The median length of stay was significantly shorter for those undergoing a laparoscopic procedure than an open approach (10 days versus 18 days; p<0.05).

**Conclusion** Laparoscopic anterior and abdomino-perineal resection following neo-adjuvant radiotherapy can be carried out with an acceptably low conversion and complication rate and is similar to that without neo-adjuvant therapy and/or open surgery. Overall length of stay was significantly reduced by laparoscopic surgery.

## S104

### CLINICAL OUTCOME OF THE LAPAROSCOPIC SURGERY FOR ADVANCED COLORECTAL CANCER, Takeshi Naitoh
MD,Takashi Tsuchiya MD,Hiroshi Honda MD,Masaya Oikawa
MD,Yasuhiro Hasegawa MD, Sendai City Medical Center, Department of General Surgery

**[Backgrounds]** Laparoscopic colorectal cancer surgery has been widely accepted because of less pain, faster recovery and good cosmetic results. Although several authors presented results of prospective studies which support advantages of laparoscopic colorectal cancer surgery, an oncological validity of this surgery is not well analyzed yet, specially for advanced cancer. The aim of this study is to assess the clinical outcome of the laparoscopic surgery for advanced colorectal cancer in our hospital.

**[Patients and Methods]** During June 1999 and Aug. 2006, we operated more than 1200 cases of colorectal cancer patients. Of those 321 patients underwent laparoscopic colorectal surgery. Among these cases, we assessed a pathological staging, an operative time, estimated blood loss, and clinical outcome, retrospectively.

**[Results]** Male female ratio was 188:133, and mean age of these patients was 64.3 year-old. Among these cases, 107 tumors were located in the cecum or ascending colon, 28 in the transverse colon, 9 in the descending colon, 92 in the sigmoid colon, and 85 in the rectum. Among 52 cases of rectal cancer, 27 cases were localized in Rs, which is rectosigmoid region, 48 in Ra, which is rectum above the peritoneal reflection, and 10 in Rb, which is rectum below the peritoneal reflection according to the Japanese classification of colorectal cancer. Mean operative time was 181 min., and mean estimated blood loss was 61 ml. No operative mortality was recognized. Of those cases, 121 cases were recognized as pathological Dukes B2 and C cases; 44 as

Dukes B2, 77 as Dukes C. They all underwent curative R0 operation. With the mean follow up period of 34 months, 14 cases (11.6%) had recurrence of the disease; 3 in Dukes B2 (6.8%), 11 in Dukes C (14.3%). Site of the recurrence were as follows; 9 in the liver, 4 in the lung, 2 in the peritoneum, 1 in the lymph node. Four cases were died of cancer recurrence, so far (3.3%).

**[Conclusion]** Although further evaluation is mandatory, laparoscopic surgery for advanced colorectal cancer is safe and would be oncologically adequate procedure.

## S105

### ARE THERE ANY DIFFERENCES OF LAPAROSCOPIC RESECTION ACCORDING TO COLORECTAL CANCER LOCATION?, Shigeki Yamaguchi MD,Shuji Saito MD,Masayuki Ishii
MD,Hirofumi Morita MD,Koji Morimoto MD,Hiroyuki Tomioka MD,Yusuke Kinugasa MD,Atsuyuki Maeda MD,
Division of Colon & Rectal Surgery, Shizuoka Cancer Center

**Purpose:** Purpose of this study was to examine short term results according to colorectal cancer location.

**Patients:** Since September 2002 of hospital opening to August 2006, 981 colorectal cancers were removed. Laparoscopic procedure was indicated in stage I & II of colon cancer and stage I of rectal cancer by our hospital guideline. Consecutive 348 patients with laparoscopic resection were enrolled in this study.

**Results:** Mean age was 64.3, and they were 211 men and 137 women. Location was; 1) cecum and ascending colon (CA); 82 (C: 24, A: 58), 2) transverse and descending colon(TD); 58(T: 40, D: 18), 3) sigmoid colon (S); 124, 4) rectum (R); 84 (recto-sigmoid: 52, upper rectum: 18, lower rectum: 14). Preoperative stage was diagnosed by CT scan as I: 186, II: 148, III: 14. Mean operating time and blood loss count of each procedures were as follows; CA: 185min. 46g, TL: 212min. 50g, S: 201min. 37g, R: 271min, 75g. Overall conversion rate was 4.6% (16/348) caused by adhesion (5 cases), cancer invasion (4 cases), poor view (3 cases), marginal artery injury (2 cases), Stapler trouble (2 case). Each conversion rate was; CA: 3.7%, TL: 5.2%, S: 3.2%, R: 7.1%. Median and mean length of postoperative stay was 8 / 9.0 days, and each stay was; CA: 7 / 8.5, TL: 7 / 7.6, S: 8 / 8.6, R: 8 / 10.9. There was no death and 12.4% (43/348) of the patients had postoperative complications, 5.5% of them major. Major complications were anastomotic leak; 8, ileus; 8, cholecystitis; 1, colon perforation; 1, hypoxia; 1. Those occurred in; CA: 2.4%, TD: 3.4%, S: 4.0%, R: 11.9%. Anastomotic leak was seen in 7.1% of proctectomy.

**Conclusions:** Based on oncologic principle, any location of colorectal cancer was feasible to do laparoscopic procedure. However proctectomy took more time and occurred more complications than colectomy.

## S106

### HAND-ASSISTED AND LAPAROSCOPIC-ASSISTED SURGERY: A COMPARISON OF PATIENT CHARACTERISTICS AND OUTCOMES IN A MINIMALLY INVASIVE COLORECTAL PRACTICE., Y N You MD,I Hassan MD,R R Cima
MD,D W Larson MD,E J Dozois MD,J H Pemberton MD,S A Barnes PhD, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.

**INTRODUCTION:** Laparoscopic surgery (LAP) has significant patient benefits but is technically challenging. Hand-assisted laparoscopic surgery (HALS) allows tactile feedback and has a shorter learning curve. We investigated the characteristics and short term clinical outcomes of HALS and LAP patients (pts) since the introduction of HALS to our minimally invasive colorectal practice.

**METHODS:** Prospectively collected data on 258 pts undergoing HALS (n=109) or LAP (n=149) during a calendar year (2004) were analyzed for patient and disease characteristics, operative parameters, and perioperative outcomes.

**RESULTS:** HALS and LAP pts were similar in age (51 vs. 54 yrs), gender (56 vs. 52% male), body mass index (26 vs. 26 kg/m2), co-morbidities (84 vs. 85% with one or more) and diagnosis (83 vs. 80% benign), but differed in incidence of previous surgery (49 vs. 30%; P=0.008). A significantly
greater proportion of HALS pts underwent complex procedures and extensive resections (P<0.001; Table). Rates of conversion (15 vs. 11%, P=0.44), intra-operative complications (4 vs. 1%, P=0.17), 30-day morbidity (18 vs. 11%, P=0.12) and surgical re-intervention (2 vs. 1%, P=0.58) did not differ. Recovery measured by days to flatus was not different [mean (std) 3(2) vs. 3(2) days, P=0.26], although HALS pts had longer operative times [276(96) vs. 211(107) min, P<0.0001] and a day longer stay in hospital [6(3) vs. 5 (3) days, P=0.0009].

**CONCLUSIONS:** Patients undergoing HALS had more complex procedures but enjoyed similar short-term outcomes as LAP pts. HALS therefore may permit the expansion of a minimally invasive practice to include more challenging procedures while maintaining patient benefits.

<table><thead><tr><th>Procedure</th><th>HALS (n=109)</th><th>LAP (n=149)</th><th>P-value</th></tr></thead><tbody><tr><td>PC/AC</td><td>55 (50%)</td><td>27 (18%)</td><td rowspan="4">&lt;0.001</td></tr><tr><td>Left-sided</td><td>34 (31%)</td><td>36 (24%)</td></tr><tr><td>Right-sided</td><td>15 (14%)</td><td>58 (39%)</td></tr><tr><td>Other</td><td>5 (5%)</td><td>28 (19%)</td></tr></tbody></table>

PC= Proctocolectomy, AC= Abdominal colectomy

## S107

**TRANS-ANAL EXTRACTION VS. LAPAROSCOPIC-ASSISTED REMOVAL: WHICH IS BETTER FOR SPECIMEN REMOVAL DURING LAPAROSCOPIC LEFT COLON RESECTIONS?, MORRIS E FRANKLIN JR MD, MATTHEW E SHEPHERD MD, GUILLERMO PORTILLO MD, JORGE M TREVINO MD, DANIEL ABREGO MD, JEFFREY L GLASS MD, JOHN J GONZALEZ MD, Texas endosurgery Institute**

**BACKGROUND:** Specimen removal for laparoscopic colon resections can be accomplished in several ways. We report our experience for trans-anal specimen extraction versus laparoscopic-assisted specimen removal for laparoscopic resections of the left colon or rectum.

**METHODS:** 1063 laparoscopic colon resections involving left colon or rectum were performed from 1996 to 2006. Trans-anal extraction was performed for specimens less than 5cm in diameter. All other specimens were removed through an incision on the abdominal wall.

**RESULTS:** 664 of our 1063 laparoscopic left-colon resections were able to be completed with trans-anal specimen extraction (62%). For both techniques, 47% of cases were for benign disease and 53% of cases were for colorectal malignancy. EBL was 94cc for trans-anal extraction, but was 204cc for the incision group. Anastomotic leak occurred once in the trans-anal extraction group and 7 times in the incision group (p=0.01). Abdominal abscess requiring intervention occurred once in the trans-anal extraction group and 4 times in the incision group (p=0.05). Incisional hernia was noted once in the trans-anal extraction group and 6 times in the incision group (p=0.01). Post-operative wound infections occurred once in the trans-anal extraction group and six times in the incision group (p=0.01). Transient incontinence was noted in 14 of the 664 patients in the trans-anal extraction group (2%) but did not occur in the incision group (p=0.01). 12 of these patients had complete resolution of their incontinence and 2 patients (0.2%) had bowel movement frequency at one year follow-up. Both of these patients had received neoadjuvant chemoradiation therapy and neither required additional intervention for incontinence.

**CONCLUSIONS:** Trans-anal specimen extraction can be performed effectively in 62% of laparoscopic colon resections involving the left colon or rectum. Compared to laparoscopic-assisted specimen removal via an incision on the abdominal wall, trans-anal extraction results in less blood loss. There is a higher incidence in post-operative anastomotic leaks, incisional hernias, abdominal abscesses, and wound infections in patients undergoing laparoscopic-assisted specimen removal compared to trans-anal extraction. Transient incontinence occurs in 2% of the patients completed with trans-anal extraction.

## S108

**DOES EXTRACTION SITE LOCATION IN LAPAROSCOPIC COLORECTAL SURGERY IMPACT ON INCISIONAL HERNIA RATE?, Alex Omiccioli, Ravinder Singh MD, Susan G Hegge MD, Craig A McKinley MD, The Centre for Minimal Access Surgery (CMAS-McMaster University and CMASNorth-North Bay District Hospital)**

**Introduction:** Incisional hernias are a common post-operative complication in abdominal surgery. Major risk factors for their development include wound infection, obesity, and age. The objective of this study was to evaluate the impact extraction site location has on incisional hernia rates in Laparoscopic Colo-rectal Surgery (LCS).

**Methods:** A prospective study of 208 consecutive patients who underwent laparoscopic colorectal surgery between March 2002 and July 2006 was performed. In order to be included in the study, patients were required to have had an extraction site on the abdominal wall. Patients were excluded if they were lost to follow-up or converted to open. In the remaining 175 patients, mean follow-up was 20 months. Extraction site incisions were classified into two groups: midline or off-midline. Midline wounds involved sharp division of the linea alba and were closed with a single layer of #1 Vicryl (Ethicon Inc). Off-midline incisions involved sharp division of the anterior and posterior sheaths with blunt spreading of the muscular layers and were closed in two layers with #1 Vicryl (Ethicon Inc.). Risk factors including wound infection, body mass index (BMI), age, diabetes, and mean follow-up were evaluated in both the midline and off-midline groups.

**Results:** The incisional hernia rate for the entire series was 5.7%. Incisional hernia rates for the midline (77 patients) and off-midline (98 patients) groups were 13.3% and 0%, respectively (statistically significant, p=0.001). There was no clinically significant difference in age, follow-up time, BMI, and wound infection rate between the two groups.

**Conclusion:** In our series, the midline extraction site resulted in a significantly higher incisional hernia rate than the off-midline extraction sites. We therefore recommend using an off-midline blunt muscle splitting extraction site when performing LCS.

## S109

**CHOICE OF APPROACH FOR APPENDICECTOMY: A META-ANALYSIS OF OPEN VERSUS LAPAROSCOPIC APPENDICECTOMY, John M Bennett BA, Alex P Boddy BA, Michael Rhodes MD, Norfolk and Norwich University Hospital NHS Trust**

**Introduction:** Although laparoscopic appendicectomy has been performed since 1983, the optimal approach for appendicectomy is still under debate. Unlike laparoscopic cholecystectomy the benefits of laparoscopy for appendicectomy have not been as apparent.

**Method:** A systematic review and meta-analysis of all randomised controlled trials between 1995 and 2006. Studies were analysed in two subgroups (pre-2000, post-2000) to examine for changes in outcomes with the expansion in laparoscopic training. Analysis was performed using weighted mean differences and Peto odds ratios (ORs), using a random effects model.

**Results:** Thirty six studies met the criteria for analysis. Operation time was 20 minutes longer in the laparoscopic arm pre-2000, decreasing to 5 minutes longer post-2000. Hospital stay was shorter by 0.41 days pre-2000 and 0.89 days post-2000. Laparoscopy showed a constantly lower risk of post-operative wound infection (Peto OR 0.48 and 0.59) and a change in favour of laparoscopy for post-operative ileus risk (Peto OR 1.65 and 0.41). The OR of developing an intra-abdominal abscess remains high for laparoscopy (Peto OR 2.19 and 2.33).

**Conclusion:** The meta-analysis shows improvement in the outcomes of laparoscopic appendicectomy with the data for operation time, hospital stay, return to normal activity, wound infection and ileus demonstrate the superiority of the laparoscopic approach.
<figure><img src="image_30.png" /></figure>

## S110

**LONG-TERM RESPONSE OF RADIO-FREQUENCY ENERGY DELIVERY (SECCA PROCEDURE) FOR THE TREATMENT OF FECAL INCONTINENCE**, Sander R Binderow MD, Atlanta Colon and Rectal Surgery, PA

**Purpose:** To evaluate the safety and long-term response of radio-frequency energy delivery (Secca Procedure) for the treatment of fecal incontinence.

**Methods:** Community based study in which patients who suffered from unmanageable fecal incontinence and previously failed conservative management underwent the Secca procedure to the anal canal muscle. Patient response to treatment including satisfaction, frequency of fecal incontinence (FI) episodes, procedure recommendation were evaluated at baseline and 12 to 24 months following the procedure and results were analyzed using the Students paired t test.

**Results:** Forty nine patients (aged 61.8 (range 28-84) years) that have reached more than one year follow-up (12 to 24 months) were studied, including 38 females (77.5%). The mean follow-up in this group was 18 months. At follow-up, the frequency of fecal incontinence episodes per week improved significantly from a median of 7.0 to 1.0. (p<0.0015). Sixty three percent of patients exhibited at least a 50% reduction in weekly FI episodes and 69% greater than 30%. In this ?responder group, the observed mean improvement is 83.25% (p=0.00148). Sixty seven percent of patients reported satisfaction with the procedure outcomes. Six patients (12%) were completely dissatisfied and went on to receive further surgical intervention (SNS, Colostomy) which resulted in some improvement in symptoms. There were no long-term complications following the Secca procedure.

**Conclusions:** At a mean of 18 month follow-up there was sustained significant clinical improvement in both the frequency of FI episodes and patient satisfaction following the Secca procedure. The Secca is a safe and durable procedure that is an option for failed conservative management. We may also consider this as a potential treatment in combination with conservative therapies in the earlier phases of management of fecal incontinence.

## S111

**MEDICALLY-SUPERVISED DIETS ARE NOT SUPERIOR TO OTHER DIETARY INTERVENTIONS PRIOR TO WEIGHT LOSS SURGERY**, Dan Eisenberg MD, Alain Ramirez BS, Andrew J Duffy MD, Joshua I Hrabosky PhD, Kurt E Roberts MD, Robert L Bell MD, Yale University School of Medicine

**Objectives:** The insurance industry is placing increasing demands on patients considering weight loss surgery (WLS). A recent, arbitrary directive of many health insurers is a 6-month, medically-supervised, diet prior to a person being considered a candidate for WLS. However, there are no data in the medical literature to support this practice. The aim of this study is to determine the efficacy of non-surgical weight-loss programs in patients being considered for laparoscopic Roux-Y gastric bypass (LRYGB), and specifically to determine the impact of a 6-month medically-supervised diet.

**Methods and Procedures:** Demographics of all patients undergoing LRYGB were entered into a longitudinal, prospective database. Prior to surgery, all patients had undergone numerous dietary interventions. The most successful preoperative dietary intervention and the amount of weight lost during that intervention, was recorded for each patient. Six prominent subgroups were examined, which comprised the 6-month medically-supervised diet, diet pills, dietician counseling, low calorie diets, group diet programs (e.g. Weight Watchers) and meal replacement programs (e.g. Optifast). Between-subjects ANOVA and Dunnett's C post-hoc analysis were performed comparing the relative efficacies of the preoperative dietary interventions on 293 patients, who conformed to one of the six aforementioned subgroups.

**Results:** The most successful preoperative dietary intervention was group diet programs (41%), followed by meal

replacement (18%), diet pills (13%), 6-month medically-supervised diet (11%), low calorie diets (9%), and dietician counseling (7%). Patients who received medically-supervised diets did not report greater percent weight loss preoperatively (M = 15.5, SD = 8.8) than patients who received any other type of dietary program (M = 14.7, SD = 8.6), F(1, 352) = .27, n.s. A post-hoc Dunnett's C analysis further revealed that those who received medically-supervised diets did not differ from any of the other groups in percent weight change prior to LRYGB.

**Conclusions:** Although most diets fail in morbidly obese patients, the practice of dieting is important prior to any patient undergoing weight loss surgery. In this study, the 6-month medically-supervised diet was not more efficacious than other strategies designed to induce weight loss in the morbidly obese patient. It should not be mandatory prior to weight loss surgery.

## S112

**DO HOSPITAL COSTS DIFFER FOR ELECTIVE BARIATRIC SURGICAL PROCEDURES PERFORMED IN PATIENTS OVER 60 YEARS OLD?**, S J Belsley MD, J Afthinos MD, D J Stephens MD, J K Saunders MD, H Schmidt MD, A Trivedi MD, D Ewing MD, R Capella MD, V Iannace MD, D Davis MD, A Wasielewski RN, S Moran RN, G H Ballantyne MD, Hackensack University Medical Center and St. Luke's - Roosevelt Hospital Center

**INTRODUCTION:** Medicare's recent endorsement of Roux-en-Y gastric bypass recognizes bariatric surgery as a treatment for the health problems associated with morbid obesity in the elderly population. The potential benefits and costs need to be further elucidated.

**AIMS:** To compare the initial hospital costs for elective bariatric procedures in patients below the age of sixty and above.

**METHODS:** Retrospective review of prospectively maintained hospital records were evaluated for elective laparoscopic and open bariatric surgical procedures performed at Hackensack University Medical Center between June 1998 and July 2006. Data analysis was performed with SPSS 13.0.

**RESULTS:** A total of 5365 patients underwent elective bariatric surgery. 268 patients (5.0%) were aged sixty or over (75.6% female and 24.4% male). Although older patients had a greater number of medical comorbidities (2.46 vs. 1.38 p <.01), cost nor total mortality at 0.13% was related to patient age.

<table><thead><tr><th></th><th>Age &lt; 60 yrs</th><th>Age &gt;= 60 yrs</th><th>P Value</th></tr></thead><tbody><tr><td>Cost (US$)</td><td>10,042.90</td><td>10,203.07</td><td>0.625</td></tr><tr><td>OR Time (min)</td><td>92.4</td><td>89.7</td><td>0.403</td></tr><tr><td>LOS (days)</td><td>2.92</td><td>2.72</td><td>0.177</td></tr><tr><td>APR Score</td><td>1.06</td><td>1.15</td><td>&lt;.01</td></tr><tr><td>ASA Score</td><td>2.49</td><td>2.59</td><td>0.042</td></tr></tbody></table>

**CONCLUSION:** Initial hospital costs for elective bariatric surgical patients do not differ between younger patients and those aged sixty and above. Further studies evaluating the long term cost-effectiveness of bariatric surgery are needed.

## S113

**USE OF LOCAL ANESTHETIC INFUSION PUMP IN LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS: A PROSPECTIVE DOUBLE-BLINDED RANDOMIZED PLACEBO CONTROLLED TRIAL**, T LaMasters MD, J Lau MD, H Lemmens MD, J Morton MD, Stanford Departments of Surgery and Anesthesia

**Background:** Continuous infusion of local anesthetic into surgical wounds has been shown to decrease pain medication usage and narcotic related complications like apnea. Patients undergoing laparoscopic roux-en-Y gastric bypass (LRYGB) with a transabdominal EEA staple technique may complain of incisional pain at the enlarged left lower port site. We hypothesized that the use of the ON Q pain pump in the left lower port site of the LRYGB would decrease post op pain and medication use.

**Methods:** A prospective randomized double blind study was
conducted. The patients were randomized to receive either a 72 hour infusion of 0.5% Bupivacaine or 0.9% saline using the On-Q pain pump infiltrated into the left lower port site wound. Standardized pain scores and medication utilization were recorded at four time periods during the hospital stay. There were no complications. Continuous variables were analyzed by matched Students' T test.

**Results:** Fifty patients were recruited and all surgeries were completed laparoscopically with no complications. Both cohorts had statistically similar demographics (Saline/Marcaine): age (42/47), % female (85/64), and BMI (51/50). There was no significant difference in POD# 3 pain scores (Saline, 1.4/Marcaine, 1.1, p=.64). There was a trend toward decreased cumulative narcotic utilization between the study patients and placebo respectively, 8.4 mg vs. 4 mg, p=.06.

**Conclusions:** This study demonstrated infusion of local anesthetic into a single port site using the On-Q pain pump does not decrease postoperative pain scores but demonstrated a trend towards decreased cumulative pain medication usage following LRYGB. Further study may further substantiate this trend and demonstrate the utility of local anesthetic infusion pumps in decreasing pain medication utilization and related complications.

## S114

**HIATAL HERNIA REPAIR AT THE INITIAL LAPAROSCOPIC ADJUSTABLE GASTRIC BAND OPERATION REDUCES THE NEED FOR REOPERATION**, Iosif Gulkarov MD, Meredith Wetterau MD, Christine J Ren MD, George A Fielding MD, New York University School of Medicine

**Background:** Intractable reflux, either due to gastric prolapse or concentric pouch dilatation has been the most common indication for reoperation or band removal after laparoscopic adjustable gastric banding (LAGB). We have previously found that a simple hiatal hernia repair (HHR) leads to remission of these symptoms minimizing the need for band removal. We have subsequently added crural repair/HHR at the initial operation, where indicated. In this study we have compared the rate of reoperation in patients who underwent LAGB alone, or with concurrent HHR.

**Study design:** A retrospective review of a prospective database of all patients undergoing LAGB was performed, to determine the incidence of reoperation in the two groups.

**Results:** Between July 2001 and August of 2006, 1,298 patients underwent LAGB and 520 patients underwent LAGB with concurrent HHR (LAGB/HHR). The mean initial weight and BMI were 128 kg (range 71.1-245.7) and 45.4kg/m2 (range 28-80). Average follow up for the LAGB and LAGB/HHR groups was 24.8 and 20.5 months respectively. Rate of reoperation for HHR alone, or with band slip or concentric pouch dilatation, for LAGB and LAGB/HHR groups was 5.55% and 1.73% respectively (p< 0.001). Total reoperation rate for slip, HHR and pouch dilatation was 7.86% and 3.46% respectively (p<0.001). There was no significant difference in rate of slip repair alone between groups, 2.31% and 1.73% (p<0.44).

**Conclusions:** Adding HHR to LAGB where indicated significantly reduces reoperation rate. Every effort should be made to detect and repair HHR during placement of the band, as it will decrease future need for reoperation.

## S115

**POUCH ENLARGEMENT (PE) AND BAND SLIPPAGE (BS): IS IT NECESSARY TO REMOVE THE BAND?**, Maria V Gorodner MD, Carlos A Galvani MD, Alberto Gallo MD, Racquel Bueno MD, Federico Moser MD, Santiago Horgan MD, University of Illinois at Chicago

**Background:** the laparoscopic adjustable gastric banding (LAGB) is a safe and effective alternative for the treatment of morbid obesity. However, it is reported to have a high incidence of long-term band-associated complications (i.e. PE-pouch enlargement/BS-band slippage) that presumably lead an insufficient weight loss. Therefore, band removal (BRE) and additional bariatric surgery are proposed.

**Objectives:** a) to demonstrate that surgical treatment of these complications can be safely performed; and b) weight loss after band repositioning (BR) is satisfactory.

**Methods:** retrospective analysis of prospective collected data. Between 3/2001 and 7/2006, 795 patients underwent LAGB at our institution. Barium swallow was performed pre, postoperatively and during the adjustments.

**Results:** PE or BS occurred in 156 patients; 86% were female. The mean age was 39±10 years. PE occurred in 139 (17%) patients; 13 (9%) of them were reoperated (BR: 9 (69%) and BRE: 4 (31%) patients). BS occurred in 17 (2%) patients; all of them required surgical treatment (BR: 13 (76%) and BRE: 4 (24%). Mortality was 0%.

<table><thead><tr><th></th><th></th><th></th><th></th><th></th></tr></thead><tbody><tr><td>Initial BMI</td><td>45±7</td><td></td><td></td><td></td></tr><tr><td>Time to Reop</td><td>16±9 months</td><td></td><td></td><td></td></tr><tr><td>F/u after Reop</td><td>17±4 months</td><td>Before Reop.</td><td>After Reop.</td><td>p</td></tr><tr><td>BMI(kg/m?)</td><td>34±7</td><td></td><td>35±7</td><td>NS</td></tr><tr><td>% EWL (*)</td><td>51±26</td><td></td><td>46±25</td><td>NS</td></tr></tbody></table>

(*)%EWL: % excess weight loss

**Conclusion:** This data suggest that; a) surgical treatment of PE and BS is safe. B) BR is feasible and offers the possibility of maintaining the weight loss, without adding the risk implied in the conversion from LAGB to a more hazardous procedure.

## S116

**EFFECT OF ESOPHAGEAL DILATATION ON WEIGHT LOSS AT 1 YEAR AFTER LAPAROSCOPIC GASTRIC BANDING**, LUCA MILONE MD, AMNA DAUD MD, EVREN DURAK MD, LORRAINE OLIVERO RIVERA, BETH A SCHROPE MD, WILLIAM B INABNET MD, MARC BESSLER MD, Department of Surgery, Minimal Access Surgery Center, Columbia University College of Physician and Surgeons

**BACKGROUND:** Esophageal dilatation is a complication that can occur after Laparoscopic Adjustable Gastric Banding (LAGB). There are few studies in the literature which describe the clinical and weight loss effects. The aim of this study is to assess whether a correlation exists between esophageal dilatation and weight loss at 1 year after LAGB.

**METHODS:** We performed a retrospective charts review of all LAGB performed at Columbia University from March 2001 to August 2005. The one year follow-up was considered when between 10 and 14 months after surgery. Esophagus of 35 mm or greater was considered dilated. Parameters considered before surgery and at 1 year were: weight, excess weight, BMI, % Excess Weight Loss (%EWL) and esophageal dilatation as captured in the radiology reports.

**RESULTS:** Of 254 patients, 125 had follow-up and esophagogram performed at one year. Of these, 17 were found to have esophageal dilatation with an average of 38 mm (35-49 mm). Dilated patients presented with higher pre operative BMI and weight. There were no significant differences between 1 year weight loss and % EWL, how ever dilated patients experience significantly higher reflux symptoms.

**CONCLUSION:** In our practice the incidence of dilation is 14%. Presence of dilatation did not impact %EWL at 1 year. At this time point GERD symptoms started to appear. Further follow-up studies are warranted to assess the impact of dilatation of future weight loss in these patients.

## S117

**LAPAROSCOPIC REVISIONAL BARIATRIC SURGERY**, Harvinderpal Singh MD, Benjamin Clapp MD, Michael Kia DO, Steven Glorsky MD, Hardar Spivak MD, Terry Scarborough MD, Sherman Yu MD, Eric Wilson MD, The University of Texas Health Science Center at Houston

**Background:** With laparoscopic Bariatric surgery becoming standard of care, need for laparoscopic revisional surgery is increasingly being encountered because of inadequate weight loss or complications. Revisional bariatric surgery is generally considered to be more difficult. This study com-
<figure><img src="image_31.png" /></figure>

pares the outcomes of converting various initial bariatric surgeries to a laparoscopic Roux-en-Y gastric bypass (RYGB).

**Methods:** A retrospective review was performed of patients undergoing conversion from previous bypass surgery to laparoscopic RYGBP. Ninety six laparoscopic revisional RYGBPs were performed by 4 surgeons over 4 years. Initial bariatric surgeries included vertical banded gastroplasty(VBG, n=40), nonadjustable gastric band(n=19), Lap Band(n=33) and open RYGBP (4). The operative time, blood loss, change in BMI at six month, length of stay and the rate of conversion to an open procedure were examined between the different types of procedures.

**Results:** Operative time for Lap Band revision was 105 minutes compared to 384, 283 and 370 minutes for nonadjustable band, VBG, and open RYGBP revisions respectively. The Lap Band also had less blood loss, less than 30 cc, compared to 199 cc, 170 cc, and 83 cc respectively. The Lap Band also had the least length of stay at 2.8 days vs. 5.6, 4.4 and 4.75. The six month post procedure change in BMI was similar, 8.5. Finally, the conversion to open procedure was also the least amongst the Lap Band group (1 of 33) vs. nonadjustable band (2 of 19), VBG (4 of 40), or open RYGBP (1 of 4). Overall, there was no mortality and one leak.

**Conclusion:** Laparoscopic conversion to RYGBP is safe and effective, with low mortality and modest blood loss. Revision of the Lap Band had the least operative time, length of stay, and blood loss. However, revisional surgery is technically challenging requiring additional operative time and has higher conversion rates to open procedures.

## S118

### LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS VERSUS REBANDING AFTER FAILED LAPAROSCOPIC GASTRIC BANDING: A THREE YEAR FOLLOW-UP, Markus K Müller
MD,Nicolas Attigah MD,Stefan Wildi MD,Dieter Hahnloser MD,Pierre-Alain Clavien MD,Markus Weber MD, Department for Visceral and Transplant Surgery, University Hospital Zurich, Switzerland

**Background:** More than 130,000 Laparoscopic Adjustable Gastric Banding (LAGB) have been used for the treatment of morbid obesity during the last decade. Complications and failures are increasingly reported in the long-term follow-up. The aim of the current study was the assessment of two different salvage operations, laparoscopic Roux-en-Y bypass (LRYGB) and laparoscopic gastric rebanding after failed LAGB with a 3-years follow-up.

**Patients and Methods:** 74 consecutive patients with a failed LAGB underwent either laparoscopic gastric rebanding or LRYGB at our department. There were 16 male and 60 female patients with a mean age of 43, 1 years. The indication for reoperation was an increasing BMI and band related problems like pouch dilatation, band slippage and penetration after LAGB. The mean preoperative BMI was 46,1 kg/m2 (±7,7). Successful salvage operations were assessed by postoperative changes of the BMI, impact on comorbidities and the need for further reoperations (secondary failure).

**Findings:** Patients after LRYGB had a significantly better weight loss than patient with a rebanding (-6.1 kg/m2 ± 4,5 kg/m2 vs. +1.5 kg/m2 ± 6.6 kg/m2; p<0.001). 45% of the patients (n = 20) in the rebanding group underwent further operative revision because of device related problems, e.g. slippage and band penetration, or unsatisfactory weight loss. Only 6 patients (20%) with LRYGB were reoperated. Thus, the secondary failure rate in the rebanding group was significantly higher compared to the bypass group (p=0,028). Furthermore the LRYGB group showed also a significant better control of serum cholesterol in the analysis.

**Conclusion:** This study confirms previous findings that LRYGB is superior in terms of weight loss and complications compared to rebanding as salvage procedure. We therefore strongly propose that LRYGB should be performed as salvage procedure in the setting of a failed LAGB.

## S119

### GASTRIC BANDING AS A SALVAGE PROCEDURE FOR PATIENTS WITH WEIGHT LOSS FAILURE AFTER ROUX-EN-Y GASTRIC BYPASS, Ryan M Gobble MD, Christine J Ren MD, Manish S Parikh MD, Matthew R Greives BA, George A Fielding MD, Department of Surgery, New York University School of Medicine

This study reviews the outcomes after laparoscopic-adjustable gastric band (LAGB) placement in patients with weight loss failure after Roux-en-Y gastric bypass (RYGB).

All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included pre-op age and body mass index (BMI), gender, conversion rate, operative (OR) time, length of stay (LOS), percent excess weight loss (EWL), and post-operative complications.

9 patients (7 females, 2 males) were referred to our program for weight loss failure after RYGB (4 open, 5 laparoscopic). Mean age and BMI pre-RYGB were 40 years [24 - 48 years] and 52.9 kg/m2 [41.2 - 71 kg/m2], respectively. Mean EWL after the RYGB was 40% [28 - 49%]. All patients were referred to us for persistent morbid obesity due to weight loss failure or weight regain.

Average time between RYGB and LAGB was 3.8 years [1.8 - 5.5 years]. Mean age and BMI pre-LAGB were 45 years [29 - 61 years] and 41.2 kg/m2 [36 - 51 kg/m2], respectively. Vanguard bands were placed laparoscopically in most patients. There was one conversion to open. Mean OR time and LOS were 79 minutes and 29 hours, respectively. The 30-day complication rate was 0% and mortality was 0%. There were no band slips or erosion, however, 1 patient required reoperation for a flipped port. The average follow-up after LAGB was 10-months (1-18 months) with a mean BMI of 35.6 [25.4 - 42.6 kg/m2] and an overall mean EWL of 59% [32 - 74%]. Patients undergoing LAGB after failed RYGB lost an additional 19.2% EWL [9-46%].

Our experience shows that LAGB is a safe and effective solution to failed RYGB.

## S120

### ENDOLUMINAL THERAPY FOR THE TREATMENT OF OBESITY (INTRAGASTRIC BALLOON), José A Sallet MD, João B Marchesini MD, Pablo Miguel MD, José A. Sallet, João B. Marchesini, Pablo Miguel, Carlos E. Pizani, Maurélio L. B. Ribeiro, Álvaro M. Ferraz, .. Fabio L. Bonaldi, Paulo C. Sallet. Dyker S Paiva, Roberto Tussi

Brazilian Intragastric Balloon Group, Interdisciplinary Obesity Treatment Group, Sallet Institute, São Paulo, Brazil.

**Background:** Intragastric balloon has been used in obese patients as a restrictive gastric procedure inducing early satiety and weight loss. This prospective study assesses both the safety and effectiveness of the intragastric balloon (BIBá) in the treatment of obese patients.

**Method:** From November 2000 to April 2006, after the Brazilian Ministry of Health's approval of BIB protocol 1126 overweight and obese patients were treated with the intragastric balloon. 938 of them completed a 6-month follow-up: 310 male (BMI= 42.8±10.7 Kg/m?) and 628 female patients (BMI= 35.5±7.8 Kg/m?) (mean BMI= 38.5±9.8 Kg/m?). All patients were encouraged to take part in a multidisciplinary program involving clinical, psychiatric, physical training, and dietary approaches.

**Results:** After a 6-month follow-up subjects showed significant reductions in percent excess weight loss (%EWL= 44.8±30.5%) and percent of total weight loss (%TWL= 12.5±6.7%). The main side effects were nausea/vomiting (472 cases, 42%), and epigastric pain (236 cases, 21%), requiring prosthesis removal in 25 patients (28%). Minor
complications were reflux esophagitis (123 cases, 11%) and symptomatic gastric stasis (91 cases, 8%) which were clinically controlled. Balloon impaction occurred in 2 cases (0.12%) and in one patient (0.14%) there was spontaneous deflation of the balloon leading to a small-bowel subocclusion which was solved by laparoscopy.

**Conclusion:** The intragastric balloon (BIB®) is effective to temporarily control obesity, inducing a %EWL of approximately 45%. It is not associated with mortality and shows minimal risk of major complications. Results regarding subsequent follow-up (after BIB removal) are necessary to a better assessment of its effectiveness.

## S121

### LAPAROSCOPIC SLEEVE GASTRECTOMY WITH ILEAL TRANSPOSITION (S.G.I.T): A NEW SURGICAL PROCEDURE AS EFFECTIVE AS GASTRIC BYPASS FOR WEIGHT CONTROL IN A PORCINE MODEL.

Camilo Boza MD, Michel Gagner MD, Nicolás Devaud MD, Alex Escalona MD, Rodrigo Muñoz MD, Mónica Gandarillas MD, Weill Medical College of Cornell University. New York Presbyterian Hospital. Pontificia Universidad Católica de Chile, Santiago Chile.

**Introduction:** Bariatric surgery has evolved in multiple forms in the last decades combining food restriction and malabsorption. The aim of this study was to develop a new technique based on food restriction and early stimulation on the distal gut maintaining the alimentary tract continuity.

**Methods:** Thirty three Yorkshire pigs, weight 22.2 + 5.4 kg (X+DS) were randomly assigned into 4 laparoscopic procedures: Ileal Transposition (T1) (IT, n=8); Sleeve Gastrectomy with Ileal Transposition (T2)(SGIT, n=9); Roux-en-Y gastric Bypass (T3) (RYGP, n=8); Sham operation (T4)(SHAM=8). Firing 45mm linear staplers over a 60 F boogie resecting the greater curvature and fundus performed sleeve gastrectomy. Ileal transposition was performed by isolating a 100 cm ileal segment proximal to the ileocecal valve and reanastomosed by dividing the proximal jejunum 15 cm distal to the ligament of treitz. Creating a proximal gastric pouch and a 300cm alimentary limb performed gastric Bypass. Sham operation was performed by bowel transections and reanastomosis in the ileum and proximal jejunum together with gastrotomy and closure. Animals were followed evaluating weekly weight increase and food intake. We used ANOVA and Bonferroni (Dunn) tests to detect differences between groups.

**Results:** We observed significant differences in mean weight after 18 weeks between SGIT (30.9 + 13.4 kg) and SHAM (72.5 + 10.7 kg) (p=0.0002), RYGB (28.6+2.5 kg) and SHAM (p= 0.0001), IT (56.1+ 13.4 kg) and SHAM (p= 0.0081). No differences were observed between RYGB and SGIT. We also

observed significant differences in food intake (grams per day) in the third month between SGIT (1668 + 677 g) versus SHAM (3252 + 476 g) (p=0.0006), and RYGB (2011+ 565 g) versus SHAM (p=0.039). No differences were observed in food intake between SGIT and RYGB.

**Conclusion:** SGIT proved to be as effective in the short term as RYGB on weight progression with no bypass of the proximal gut.

## S122

### LAPAROSCOPIC TREATMENT OF THE METABOLIC SYNDROME FOR NON-MORBID OBESE TYPE 2 DIABETES MELITUS PATIENTS, Aureo L De Paula PhD, Antonio L Macedo MD, Nelson Rassi MD, Sergio Vencio MD, Alfredo Halpern PhD, Cesar A Machado MD, Vladimir Schraibman MD, Hospital de Especialidades, Goiania, Brazil

**Introduction:** The objective of this study is to evaluate the results of the laparoscopic transposition of a segment of ileum to the jejunum in order to treat the metabolic syndrome in patients with Type 2 Diabetes Mellitus (T2DM) and BMI below 35kg/m2. The criteria of the NECP was used.

**Method:** The laparoscopic procedures were done to 60 patients. 24 were female and 36 male. Mean age was 51.7 years (27-66). Mean BMI was 30.1 (23.6?34.4). All patients had the diagnosis of T2DM for at least 3 years and evidence of stable treatment with oral hypoglycemic agents and or insulin for at least 12 months. Mean duration of T2DM was 9.6 years (3-22). Arterial hypertension was diagnosed in 70% of patients (mean number of drugs - 1.6) and hypertriglyceridemia in 70%. HDL was altered in 51.7% of patients and the abdominal circumference in 68.3%. Two techniques were performed, consisting of an ileal interposition (II) in the proximal jejunum and a sleeve gastrectomy (II-SG) and an II associated to a diverted sleeve gastrectomy (II-DSG).

**Results:** The II-SG was performed in 32 patients and the II-DSG in 28. Mean post-operative follow-up was 7.4 months. Mean BMI was 23.8.kg/m2. 52 (86.7%) patients achieved adequate glycemic control. Hypertriglyceridemia was normalized in 71.4% of the patients. HDL above 40 for men and above 50 for women was achieved by 90.3% of the patients. Abdominal circumference below 102cm for men was reached by 86.1% of the patients and below 88cm for 41.7% of the women. Arterial hypertension was controlled in 90.5%. The patients that did not normalize their glucose were using oral hypoglycemic agents.

**Conclusions:** The laparoscopic II-SG and the II-DSG seem to be promising procedures to be used for the control of T2DM and the metabolic syndrome. A longer follow-up period is needed.
<figure><img src="image_32.png" /></figure>

## V01

**LAPAROSCOPIC COMPONENT SEPARATION**, Michael J Rosen MD, Case Medical Center

A single staged approach for resection of infected mesh, component separation, and definitive abdominal wall reconstruction has been successfully reported by our group. The extensive subcutaneous dissection and division of perforator vessels can result in skin flap necrosis and complex postoperative infections. This video details the technique of minimally invasive component separation at the time of resection of infected prosthetic material. This patient underwent resection of exposed Composix mesh and laparoscopic component separation.

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

## V02

**STRATEGIES IN THE MANAGEMENT OF LESIONS AMENABLE TO PARTIAL NEPHRECTOMY**, Marc Zerey

MD,Jacob M McClean MS,B Todd Heniford MD,Pierce B Irby MD,Kent W Kercher MD,Chris M Teigland MD, Carolinas Medical Center, Departments of General Surgery and Urology

Hand-assisted laparoscopic partial nephrectomy provides a minimally invasive surgical option for patients presenting with low-stage renal tumors.

We illustrate our surgical technique including port placement, mobilization of adjacent viscera, dissection and control of the renal artery, identification and excision of the tumor, and measures taken to ensure hemostasis. In addition we demonstrate our approach to more challenging endophytic lesions requiring repair of the collecting system and lesions adjacent to the hilum, requiring segmental revascular control. Furthermore, an approach to the performance of a heminephrectomy is demonstrated.

We conclude our video with a summary of baseline demographics, tumor characteristics, and short-term outcomes for all hand-assisted laparoscopic partial nephrectomies performed to date at our institution.

## V03

**TRANSGASTRIC LEFT ADrenalectomy in a sUrViveD tranSCAtrIC ChOleCyStEC-**

tOMY, Stefano Sereno MD,Antonello Forgione PhD,Michele Simone MD,Silvana Perretta MD,Ali Alzahrani MD,Bernard Dallemagne MD,Jacques Marescaux MD, IRCAD-EITS, University Louis Pasteur, Strasbourg, France

**INTRODUCTION** The aim of this study was to evaluate the feasibility and technical limitations of multiple transgastric surgeries in a survival animal model.

**METHODS** A 30 kg female pig was prepared with 48 fasting and oral antibiotics. Under general anaesthesia, we performed a transgastric cholecystectomy with a two working channels 16 mm diameter video-gastroscope (PV-TG-2 KARL STORZ, Tuttlingen, Germany). The gastrotomy was closed with endoscopic clips (EZ-clip OLYMPUS, Tokyo, Japan) and the pig was kept alive.

One week later the success of the gastrotomy closure was assessed by laparoscopy and endoscopy and a transgastric adrenalectomy was performed.

**RESULTS 1.** Assessment of the gastric closure and peritoneal cavity: The laparoscopic exploration showed several adhesions which involved the cholecystectomy site, the liver, the diaphragm and the spleen, but no signs of bleeding, infections or perforation. The endoscopy confirmed the tight closure of the gastrotomy.

2. Re-operation with transgastric approach: After mechanical cleaning of the stomach a new gastrotomy on the posterior gastric wall was performed. We then entered the peritoneal cavity and easily identified the anatomical landmarks to the left adrenal gland. The dissection started along the upper pole of the left kidney opening the retroperitoneal space.

The transgastric left adrenalectomy was completed under endoscopic view. The left adrenal gland was extracted through the mouth of the pig and the new gastrotomy was closed with endoscopic clips. The animal was immediately sacrificed.

**CONCLUSIONS** Multiple transgastric operations such as cholecystectomy and adrenalectomy are feasible in the animal model. Successfully closure of gastrotomies with endoscopic clips is possible but challenging and difficult to reproduce.

## V04

**LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR SUPERIOR MESENTERIC ARTERY SYNDROME**, E M Pauli MD,R Nain

MD,T R Shope MD, Penn State Milton S. Hershey Medical Center

Superior Mesenteric Artery (SMA) Syndrome is a rare cause of proximal intestinal obstruction in adults. This video abstract presents the case of a 53 year-old woman with radiographic and endoscopic documentation of extrinsic duodenal compression by her SMA. We review her pre-operative evaluation, discuss imaging modalities for diagnosis and demonstrate our technique for performing a laparoscopic side-to-side stapled duodenojejunostomy.

## V05

**3D VIRTUAL REALITY AND SELECTIVE VASCULAR CONTROL FOR LAPAROSCOPIC LEFT HEPATIC LOBECTOMY**, D.

Mutter MD,B. Dallemagne MD,C. Bailey MD,L. Soler PhD,J. Marescaux MD, IRCAD-EITS / University Louis Pasteur, Strasbourg, France

**Background:** Careful control of haemostasis is particularly important in laparoscopic hepatic surgery, since a bloodless operative field allows to perform safer and smoother procedures. We present the case of selective vascular control for a left lateral segmentectomy facilitated by the use of 3D virtual reality.

**Materias and Method:** A 67 year old male patient presenting a 3.5 cm hepato-cellular carcinoma (HCC) located between segment II and III of the liver was referred for hepatic resection. Preoperative 3D reconstruction was used for planification of the procedure and virtual resection. Transplant was contra-indicated due to previous head and neck cancer surgery.

**Methods:** Five ports were used. The first step was a primary control of the hepatic pedicle. 3D reconstruction demonstrated the position of the division of the left hepatic artery. This was identified and divided at its division between the segment IV and the left lobe. The portal vein was divided at its same division. This resulted in a typical colour change of the left lateral segment as well as a small decrease in size. The bi-segmentectomy was completed using harmonic dissectors (Autosonix®, Tyco Healthcare), bipolar cautery, clips and application of Endo GIA vascular staples (Tyco Healthcare) on the portal pedicles. The left hepatic vein was finally isolated and controlled. After section, the specimen was placed in a bag and extracted after enlargement of the camera port. Follow-up was uneventful and there was no elevation of hepatic enzymes or postoperative ascites. The patient left the hospital on the 5th postoperative day.

**Conclusion:** 3D reconstruction allowed perfect simulation of the procedure. This facilitated the comprehension of vascular anatomy and control of the left lateral segment arteries and veins, thus preventing intra-operative bleeding. The use of this approach should be recommended where possible.

## V06

**ROBOTIC MICRODISSECTION OF THE HEPATIC HILUM FOR HEPATECTOMIES**, P. C Giulianotti MD,F. M Bianco MD,F.

Sbrana MD,G. Pernazza MD,J. H Palep MD, Ospedale della Misericordia - Grosseto - Italy

Robotic assisted surgery overcomes the limitations of standard laparoscopy techniques by giving us 3D stable vision, accuracy of dissection and a fixed operating field which transforms the procedure in to a bench-like microsurgery. The main advantages being the improved quality of dissected
tion of the portal pedicle avoiding a Pringles manouver and the possibility to recognise accurately the anatomical variants which help avoid bile duct and vascular injuries. In this video we have shown three examples of difficult hilum dissections dealt with robotic surgery.

## V07

**LAPAROSCOPIC SEGMENT III LIVER RESECTION FOR ISOLATED COLORECTAL METASTASIS**, Janos Taller MD, Gordon Wisbach MD, Brett Langenberg DO, Jay Grove MD, Naval Medical Center, San Diego

Laparoscopic liver resection for malignancies remains controversial despite an increasing acceptance of the treatment for benign tumors. In selected group of patients, when the technique is appropriately performed by a surgical team, expert in liver and laparoscopic surgery, the technique appears to be safe and consistent with oncologic principles. Our patient is 64 year-old female with Stage IV adenocarcinoma of the colon. 3 months prior to presentation, she underwent an open right colon resection for a cecal mass and biopsy of a solitary liver lesion. Her case was presented to the combined medical tumor board which recommended segmental liver resection followed by adjuvant chemotherapy for best long-term survival. Anatomically, pre-operative CT scan and PET imaging confirmed a single focus of metastatic disease in segment III of the liver and she was scheduled for a laparoscopic segment III liver resection. Our video abstract summarizes the various techniques we used to safely excise segment III of the liver utilizing laparoscopic technique. A combination of cautery, ultrasonic dissector, blunt dissection and endoscopic stapling were all used at various phases of the operation to resect the specimen and maintain vascular control of hepatic vessels. A small portion of the anterior wall of the stomach was also excised with the specimen because of apparent invasion by the liver metastasis after the previous open biopsy.

Operative time was 280 minutes, EBL was 250 mls. She was observed overnight in the ICU and transferred to the ward on POD#1. Because of her gastrotomy repair, her diet advance was delayed until POD#3. She was discharged home on POD#5 tolerating a regular diet, without complications. She resumed her normal activity after 2 weeks. Final pathology revealed complete excision of her metastatic disease with negative margins.

For laparoscopic liver resection to be effective, specific training and access to adequate technology are required. In addition, the rules for oncological surgery must be followed for minimally invasive operations, just as in open surgery. At present, good candidates for laparoscopic liver resection are patients with peripheral lesions requiring limited hepatectomy (minor resections involving 2 or fewer segments).

Further prospective evaluation is required to assess the results of laparoscopic liver surgery and its place in major liver resections.

## V08

**LAPAROSCOPIC UNROOFING OF LARGE SPLENIC CYSTS**, Aaron M Lipskar MD, Brian P Jacob MD, Brian Katz MD, Anthony Vine MD, Mark Reiner MD, Mount Sinai Medical Center

Splenic cysts are a rare entity. Percutaneous aspirations and ethanol injections have high recurrence rates. Traditional surgical management has been splenectomy. Due to the morbidity of splenectomy, spleen-sparing procedures are more favorable. From July of 1999 to July of 2006 we have performed seven laparoscopic unroofing procedures for symptomatic splenic cysts. In this video we describe our laparoscopic technique for cyst unroofing. The video is based on a 43 year old female with a history of blunt trauma and persistent left upper quadrant pain who was found to have a 10x9 centimeter simple splenic cyst.

## V09

**ROLE OF PANCREATIC DUCT STENT PLACEMENT AND INTRAOPERATIVE ULTRASOUND FOR LAPAROSCOPIC ENUCLEATION OF PANCREATIC HEAD INSULINOMA**, Leaque Ahmed MD, Peter D Stevens MD, Joseph Grossman BA, John A Chabot MD, William B Inabnet MD, Columbia University Medical Center

A 20 year old Female with Hypoglycaemic Symptoms was found to have elevated Insulin and Proinsulin levels. CT scan showed a mass in the head of Pancreas. Since the mass was close to the Pancreatic duct the patient underwent preoperative Pancreatic duct stent placement to help in locating the duct during surgery.

The patient underwent Laparoscopic enucleation of the Insulinoma guided by Laparoscopic Ultrasound and Intraoperative Insulin assay successfully. The patient did very well and was discharged home on POD 3. Insulin level after surgery was 4 micromoles/ML.

## V010

**LAPARASCOPIC SUBTOTAL PANCREATECTOMY**, Dan I Giurgiu MD, Scripps Mercy Hospital

Mininally invasive approaches to malignant pancreatic tumors remains controversial. However, many begin pan-creatic solid tumors can be resected safely via a laparoscopic approach. This case represents a large cystadenoma which replaced the body and tail of the pancreas. High quality preoperative imaging is crucial for determining resectability. Complete subtotal pancreatic resection with splenectomy is performed using advanced laparoscopic techniques.

## V011

**MINIMALLY INVASIVE ESOPHAGEAL LEIomyOMA ENUCLEATION - THORACOSCOPIC AND LAPAROSCOPIC APPROACHES**, Kathy Hsu MD, Liane S Feldman MD, Gerald M Fried MD, Lorenzo E Ferri MD, McGill University

Leiomyomas represent the most common tumor amongst the relatively rare benign neoplasia of the esophagus.

Although there is increasing interest in endoscopic therapies, surgical enucleation remains the standard of treatment for these tumors. Traditionally this has necessitated a thoracotomy, however with the advent of improved minimally invasive techniques and instrumentation, many of these tumours are amenable to thoracoscopic or laparoscopic enucleation. This video will employ three cases to highlight important features and helpful hints in the minimally invasive management of these benign tumours of the esophagus.

## V012

**LAPAROSCOPIC TRANSHIATAL ESOPHAGO-GASTRECTOMY AFTER INGESTION OF CAUSTIC AGENT**, Giovanni Dapri MD, Jacques Himpens MD, Elie Capelluto MD, Guy Bernard Cadiere PhD, Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium

Esophago-gastric perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. We discuss a laparoscopic transhiatal esophago-gastrectomy performed in a 43-years-old man, presenting at the Emergency Unit, after ingestion of a corrosive fluid. Abdominal CT-scan showed a pneumoperitoneum with subdiaphragmatic fluid. A gastroscopy showed a necrosis of the middle and lower esophagus with a perforation of the gastric fundus. Laparoscopic exploration confirmed the presence of free peritoneal fluid and the necrosis of the upper part of the stomach. The procedure started with the dissection of the stomach along the greater curvature, respecting the gastro-epiploic vessels. The stomach
<figure><img src="image_33.png" /></figure>

was separated from the first duodenum by a firing of blue linear stapler. Dissection continued along the lesser gastric curvature. Lower esophagus was completely freed and hiatus opened by medial vertical section of the crus. Esophagus was proximally freed along the descending aorta up to the left inferior pulmonary vein. A partially opening of the esophagus allowed the introduction of the scope inside and the necrosis of the lower and middle part of viscera was confirmed. Hence a subtotal esophagectomy was decided; the stomach was divided from the lower esophagus by a firing of blue linear stapler and retrieved from the abdomen in a plastic bag. A left cervicotomy was performed and the upper esophagus was freed and stripped. After esophageal resection, an esophagostomy was realized in the left part of the neck. A laparoscopic jejunostomy was performed and the procedure ended with the placement of 3 drains, in the hiatus, near the spleen and near the duodenal section. Patient developed a postoperative pancreatitis, resolved by medical therapy without a necrosis of the upper esophagus and pharynx. After 6 months a digestive reconstruction with coloplasty was realized.

## V013

**LAPAROSCOPIC REPAIR OF A COMBINED PARAESOPHAGEAL AND MORGAGNI HERNIA**, Jonathan P Pearl MD, Michael J Rosen MD, Jeffrey M Marks MD, Jeffrey L Ponsky MD, Raymond P Onders, University Hospitals of Cleveland, Case Western University School of Medicine Combined paraesophageal and Morgagni hernias are rare, with only 5 reported in the literature. In our case, a 62 year old woman presented with abdominal pain. A CT scan revealed findings consistent with a combined paraesophageal and Morgagni hernia. At operation, the right subcostal hernia contained transverse colon, which was easily reduced. The Type III paraesophageal hernia was repaired in a standard fashion. The Morgagni hernia was repaired using transfascial permanent sutures, as the defect was in close proximity to the pericardial sac. The patient recovered uneventfully and was free from symptoms at 6 month follow-up. This case contributes to the existing literature and demonstrates the versatility of laparoscopic diaphragm hernia repairs.

## V014

**BAND EROSION: LAPAROSCOPIC REMOVAL OF LAP-BAND**, A Gallo, R Bueno MD, C Galvani MD, S Horgan MD, V Gorodner MD, S Ayloo MD, University of Illinois @ Chicago Bariatric surgical procedures can be categorized into three groups, malabsorptive, malabsorptive/restrictive and purely restrictive. Laparoscopic gastric banding falls in the purely restrictive gastric procedure. It offers the advantage of minimally invasive surgery, adjustability and reversibility. The incidence of band erosion with penetration into stomach is documented in literature ranging from less than one percent to three percent. In this video we submit a case of band erosion. Patient presented for lap band adjustment with non-specific symptoms of nausea and vomiting of couple of months duration. Her esophagogram showed double lumen of contrast. As a consequence, an upper endoscopy was performed which revealed erosion of lap-band into the stomach.

As patient was clinically stable, she was scheduled for a laparoscopic removal of lap-band with intraoperative upper endoscopy. This video demonstrates the upper endoscopy and simultaneous laparoscopic removal of lap-band through the same incisions used for its placement. The stomach was repaired with laparoscopic suture placement and an omental patch placed on top of the repair along with fibrin glue and a JP drain. An upper GI study demonstrated no extravasation of contrast and the patient was discharged postoperative day one.

## V015

**LAPAROSCOPIC REVISION OF NISSEN FUNDOPLICATION TO ROUX-EN-Y GASTRIC BYPASS IN A MORBIDLY OBESE PATIENT**, Kambiz Zainabadi MD, Anita Courcoulas MD, Omar Awais DO, Ioannis Raftopoulos MD, Division of Minimally Invasive, Bariatric and General Surgery, University of Pittsburgh, PA.

This is a 50 year-old female who underwent a successful laparoscopic Nissen fundoplication 5 years ago but had significant weight gain postoperatively. An Upper GI series and an upper endoscopy showed an intact wrap without a hiatal hernia or GERD. At the time of revision the patient's weight was 256.5 lbs with a BMI of 42.2 Kg/m2. Operative time (OT) was 287 min and length of stay (LOS) was 5 days. The patient's recovery was uneventful with the exception of a small pulmonary embolism. At 3 month follow-up she lost 46 lbs and her BMI decreased to 35.1 Kg/m2. Our experience includes 9 (8 females, 1 male) patients with a mean age of 49.6 years and mean preoperative BMI of 38 Kg/m2 who underwent successful laparoscopic revision of Nissen fundoplication to Roux-en-Y fastric bypass (RYGB) with a mean OT of 331 min and LOS of 5.2 days. Minor or major complications occurred in 7/9 (77.8%) patients without mortality. At a mean follow-up of 20.5 (3-44) months the mean BMI decreased to 27.8 Kg/m2. In conclusion, laparoscopic revision of Nissen fundoplication to RYGB is technically feasible and should be considered in patients who 1) gained significant weight after a successful antireflux procedure and meet the NIH guidelines for bariatric surgery, 2) meet the NIH guidelines for bariatric surgery, presenting with recurrent GERD symptoms after one or more failed fundoplications in the past, or 3) had a Nissen-Collis gastroplasty in the past and recurrent GERD symptoms and are with ischemia of the gastric fundus at re-exploration. Keys for a successful outcome include: 1) lysis of all adhesions between the liver and the stomach facilitating the placement of the liver retractor and exposure and identification of vital structures during dissection. 2) Complete dissection and take-down of the wrap which prevents stapling over the fundoplication and creating an obstructed and septated pouch. 3) Dissection of the angle of His and the esophageal hiatus to allow exposure of crura as well as recognition, complete reduction and repair of a hiatal hernia if present. 4) Dissection of the fat pad near the gastroesophageal junction off the gastric wall to allow assessment of the pouch size.

## V016

**LAPAROSCOPIC REPAIR OF A PERFORATED MARGINAL ULGER TWO YEARS AFTER GASTRIC BYPASS**, Edward H Chin MD, Herron M Daniel MD, Umut Sarpel, Hazzan David MD, Mount Sinai School of Medicine

We present the case of a 43-year-old female who underwent a laparoscopic gastric bypass in 2003 for morbid obesity. Two years later, she had maintained significant weight loss, but developed acute abdominal pain, followed by nausea and emesis. In the emergency room, she had diffuse tenderness, tachycardia, and leukocytosis. After initial resuscitation, a CT was performed, which showed free air above the liver and thickened small bowel loops. She was brought emergently to the operating room for laparoscopy. At surgery, turbid fluid and inflamed small bowel loops were seen. A perforated marginal ulcer was discovered in the Roux limb. The perforation was oversewn primarily, and patched with omentum. The repair was tested by intraoperative endoscopy. A gastrostomy tube was also placed within the gastric remnant as enteral access. The patient did extremely well postoperatively, with an uneventful postoperative course. She was discharged on the fourth postoperative day. The gastrostomy tube was removed at one month, and she remains well since surgery. Marginal ulcer has been reported from 0.6-16% after laparoscopic gastric bypass. Etiologies include gastro-gastric fistula, excessively large gastric pouch containing antral mucosa, h. pylori infection, and smoking.
## V017

**LAPAROSCOPIC SLEEVE GASTRECTOMY**, Vadim Sherman MD, Philip R Schauer MD, Cleveland Clinic, Department of General Surgery

Patients with a high BMI (> 60) and/or associated high risk medical conditions have the greatest to gain from procedures such as Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD-DS), but the increased risk of postoperative complications often renders them poor surgical candidates. To this end, investigators have attempted various bridging procedures designed to impart an effective weight loss and reduce the risk of complications in the subsequent, definitive weight loss procedure. This includes laparoscopic sleeve gastrectomy (LSG). The second stage would involve completion to RYGB or BPD-DS. Technique: in general, 75-80% of the greater curvature is excised, leaving a tubularized stomach. Port placement is the same as for a standard RYGB. The lesser sac is entered by opening the gastro-colic ligament. A point on the greater curve, on the antrum, is chosen as the starting point, about 10 cm from the pylorus. A laparoscopic stapler, with a blue load (3.5 mm staple height), is introduced and fired on the antrum, towards the angle of His. A 42French bougie is then passed transorally into the pylorus, placed against the lesser curvature. The stapler is fired consecutively along the length of the bougie until the angle of His is reached. The short gastric vessels and the greater curvature ligaments (gastro-splenic and gastro-colic) are divided with ultrasonic dissection to complete the resection. Patients undergoing this procedure have dramatic weight loss and reduction of comorbidities, allowing progression to second stage weight loss surgery and decreased risk of complications.
Presentation of this technique is timely as there is a growing amount of data promoting LSG as a potential sole weight loss surgery for patients with low BMIs.

## V018

**PERCUTANEOUS ENDOSCOPIC ASSISTED SURGERY: AN INNOVATIVE MODIFIED VERTICAL GASTROPLASTY FOR WEIGHT LOSS**, Royd Fukumoto MD, Julio Teixeira MD, St Luke's Roosevelt Hospital Center, Columbia University

**Objective:** This is a description of a novel approach of endoluminal surgery for weight loss. The procedure was designed as a minimally invasive method of treating morbid obesity. The predicted population eligible for this approach includes patients who are medically unstable for traditional laparoscopic or open weight loss procedures.

**Methods:** Visualization for the procedure is provided mainly via a gastroscope. Access to the gastric cavity is provided by one trans-abdominal port placed percutaneously under endoscopic visualization. Using this port, 5mm or 10mm laparoscopic instruments are introduced into the gastric cavity. A tunnel of gastric mucosa is then created along the posterior stomach from the gastro-esophageal junction towards the pylorus. This tunnel is created by over-sewing gastric mucosa around the retroflexed gastroscope. After the tunnel is created, inspection of the entire gastric cavity can be performed using both the gastroscope and a laparoscope placed via the one working port. A foley catheter is then inserted into the stomach via the trans-abdominal port and left as a temporary gastrostomy tube. This tube can be used for enteral feeding or gastric decompression in the immediate post-operative period. The foley catheter is then removed 10-14 days later or once a fistula tract has formed.
**Conclusions:** This is envisioned as a bridge procedure that will allow patients to lose an initial amount of weight, eventually enabling them to tolerate standard weight-loss operations.

## V019

**PERCUTANEOUS MANAGEMENT OF COMMON BILE DUCT PATHOLOGY AFTER ROUX-EN-Y GASTRIC BYAPSS**, Syed Husain MD, Ahmed R Ahmed MD, Nael Saad MD, Nikhil C Patel MD, David L Waldman MD, William O'Malley MD, University of Rochester

Biliary pathology is common in morbidly obese population. As the number of patients undergoing bariatric surgery increases, surgeons are likely to encounter an increasing frequency of biliary disease post Roux en Y gastric bypass. This represents a unique therapeutic challenge as the bypassed stomach limits endoscopic access to the Ampulla of Vater. This precludes endoscopic therapies like endoscopic retrograde cholangio pancreaticography (ERCP), endoscopic common bile duct (CBD) stone retrieval and sphincterotomy. In this presentation, we discuss two representative cases of CBD stones and sphincter of Oddi dysfunction which were managed percutaneously. Therapeutic options include percutaneous choledochoscopy, percutaneous stone retrieval and percutaneous sphincteroplasty. Both of the presented cases had excellent symptom resolution and we were able to avoid surgical intervention in both cases. We surmise that percutaneous access to the biliary tree is a viable minimally invasive alternative in patients who have undergone Roux en Y gastric bypass.

## V020

**ENDOSCOPIC DELIVERY AND RETRIEVAL OF A NOVEL DUODENAL-JEJUNAL SLEEVE IN A PORCINE MODEL**, Michael E Tarnoff MD, Ketih S Gersin MD, Anthony Lembo MD, Tufts-New England Medical Center, Boston, MA; Beth Isreal Deacones Medical Center, Boston, MA; Carolinas Medical Center, Charlotte, NC

This video introduces the learner to a novel endoscopic duodenal-jejunal bypass sleeve. Through a combination of animation and video, the program highlights an overview of the device as well as the key steps in complete endoscopic delivery and retrieval in a porcine model.

## V021

**GASTRO-GASTRIC FISTULA CLOSURE: A NEW MINIMALLY INVASIVE APPROACH**, Gonzalo M Torres-Villalobos MD, Todd A Kellogg MD, Rafael S Andrade MD, Daniel B Leslie MD, Robert P Gallegos MD, David W Hunter MD, Michael A Maddaus, Sayeed Ikramuddin, Departments of Surgery and Interventional Radiology, University of Minnesota, Minneapolis, MN, USA

We present the video of a novel technique for gastro-gastric fistula (GGF) repair. A 44-year-old woman was found to have a fistula between her gastric pouch and remnant 18 years after Roux-en-Y gastric bypass for morbid obesity. She previously underwent attempted repair, which was complicated by abdominal sepsis post-operatively. Upper gastrointestinal series, abdominal CT scan and upper endoscopy confirmed the diagnosis of GGF. Under endoscopic and fluoroscopic guidance, two ports were inserted percutaneously into the stomach. The fistula was closed with a percutaneous, transgastric, totally extraperitoneal approach. She remains well four months after this intervention. This procedure appears to be a safe and effective minimally invasive approach for closure of GGF after gastric bypass. This is the first description of an intragastric, percutaneous closure of a GGF after gastric bypass in the medical literature. Further experience with this technique is needed to define the selection criteria, limitations, advantages, and disadvantages.

## V022

**LAPAROSCOPIC REMNANT GASTRECTOMY: A NOVEL APPROACH FOR THE TREATMENT OF GASTRO-GASTRIC FISTULA FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYAPSS SURGERY**, Jayaraj Salimath DO, Ian S Soriano MD, David Pinto MD, Samuel Szomstein MD, Raul Rosenthal MD, The Bariatric Institute, Cleveland Clinic Florida

**BACKGROUND:** Gastro-gastric fistula is a rare but serious complication following laparoscopic roux-en-y gastric
<figure><img src="image_34.png" /></figure>

bypass surgery. Various treatment options have been proposed. Safe resection of the gastro-gastric fistula is the mainstay of treatment. We present a video showing a laparoscopic remnant gastrectomy as a novel approach in the treatment of gastro-gastric fistula.

**METHODS AND RESULTS:** We present a 30-year-old female who presented one year after a laparoscopic ante-colic, ante-gastric divided roux-en-y gastric bypass with recurrent episodes of epigastric pain, nausea, vomiting and recent weight regain. A gastrografии swallow demonstrated multiple fistulas between the gastric pouch and the gastric remnant. She underwent diagnostic laparoscopy, division of the gastro-gastric fistula medial to the fistula tract and remnant gastrectomy. The fistula was extracted en-bloc with the gastric remnant.

**CONCLUSIONS:** In experienced hands, laparoscopic remnant gastrectomy with en-bloc fistula resection can be performed safely with complete resolution of the gastro-gastric fistula and associated symptoms.

## V023

**NOTES: TECHNICAL PROBLEMS AND SOLUTIONS, Yoav Mintz MD, John Cullen MD, David Stuart MD, Eric Falor, Mark A Talamini MD, Department of General Surgery, University of California San Diego.**

Natural Orifice Trans Endoscopic Surgery (NOTES) is now practiced world wide. In the past few years multiple groups confronted this challenge. Some groups study the basic concepts such as infection control and immune response and others develop the technique for performing surgical procedures in this fashion. Many technical problems are encompassed in this technique with the current available instruments and should be recognized. Close collaboration with industry is mandatory in order to allow for the development of the necessary tools. The unique technical problems in NOTES include: blindly performed primary incisions; uncontrolled pneumoperitoneal pressure; no support for the endoscope in the abdominal cavity; inadequate vision; insufficient illumination; limited retraction and exposure; and the complexity of suturing and performing a safe anastomosis. The hybrid technique serves as a temporary approach to solve these problems and allows the continuing development of this technique until industry provides the necessary tools to overcome these problems. In this technique pneumoperitoneum is achieved and controlled using a Veres needle and the standard laparoscopic insuflator. The most significant advantage of this technique however is having an independent vision using the standard laparoscope. This interim phase of development enabled our group to gain expertise and perform various procedures such as bilateral tubal ligation, oophrectomy, liver biopsy, cholecystectomy, splenectomy and small bowel resection and anastomosis. The most difficult technical problem and fundamental requirement to justify the NOTES approach is to have a safe method for portal closure with near zero leak rate and related complications. Several methods are currently studied using prototype instruments designed by industry with collaborating physicians. Our group decided to use laparoscopic instruments through an additional natural orifice in order to achieve these goals. Dual Natural Orifice surgery enables the insertion of long and inflexible instruments to the peritoneal cavity and hence the ability to safely resect bowel, perform anastomosis and securely sealing the stomach incision. The above mentioned problems and possible solutions are discussed and presented in various NOTES procedures.

## V024

**COMPLETE ENDOSCOPIC CLOSURE OF GASTROTOMY FOLLOWING NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY (NOTES) UTILIZING THE NDO PLICATOR, Jeffrey Marks MD, Michael McGee MD, Raymond Onders MD, Amitabh Chak MD, Christina Williams MD, Judy Jin MD, Steve Schomisch, Jeffrey Ponsky MD, Case Western Reserve University**

Creating a method for secure closure of the gastrotomy following Natural Orifice Translumenal Endoscopic Surgery

(NOTES) is vital to the advancement of this emerging technology. This video displays the use of the NDO Plicator, a device developed for endoscopic treatment of gastroesophageal reflux disease (GERD), to facilitate closure of the defect following NOTES in a porcine model.

The device was fired three times, leaving three pledged suture bundles to close the gastric defect. Following closure, the animal was explored and the integrity of closure was assessed by in vivo contrast fluoroscopy and ex vivo burst pressure. The physiologic relevance of gastric bursting pressure is not known; therefore corollary studies with longer term evaluation in animals are necessary prior to proceeding to clinical trials.

## V025

**NEW AUTOMATED TECHNOLOGY FOR NOTES TRANSMURAL ACCESS, Marvin Ryou MD, Derek G Fong MD, Reina Pai MD, David W Rattner MD, Jude S Sauer MD, Christopher C Thompson MD, Brigham & Women's Hospital; Massachusetts General Hospital; Boston, MA, USA**

The goal of this on-going research is to develop and test a new family of devices to enable the safe, effective and rapid production of closeable transmural access sites for NOTES interventions. This video presents the current design and functional considerations of these automated devices. Each device incorporates an elongated rigid or flexible shaft to guide a multifunctional distal tip, which provides a specialized tissue holding vacuum manifold and two needles for remote purse string suture placement, an integrated precise transmural tissue cutting blade and a channel to assist, if desired, in guide wire passage through the new access site. An ex vivo porcine small intestine model is shown to illustrate the concurrent outside perspective and gastroscopic view of this technology and approach. New video is presented of an initial remote gastrotomy closures study comparing four different techniques for closing access site wounds. Four pigs survived well after having intraperitoneal NOTES procedures performed through anterior rectal transmural access sites made and closed with these automated devices. Successful findings from necropsy with colonoscopy at two weeks are highlighted. These encouraging early results support the potential of this technology and approach for safe and reliable NOTES transmural access site control. Further research and development are planned.

## V026

**A NOVEL PERCUTANEOUS ENDOSCOPIC SLEEVE GASTROPLASTY (PESG) USING THE ENDOSCOPIC FULL THICKNESS PLICATOR, James Ellsmere MD, Rabi Kundu MD, Daniel B Jones MD, Douglas Pleskow MD, Ram Chuttani MD, Gastroenterology and Minimally Invasive Surgery, Beth Israel Deaconess Medical Center**

**Background:** Endoscopic procedures are attractive because they can be performed with minimal morbidity under conscious sedation in an outpatient setting. A percutaneous endoscopic sleeve gastroplasty (PESG) may have a role in treating gastroesophageal reflux or as a restrictive weight loss procedure. We hypothesize that it is feasible to perform percutaneous endoscopic sleeve gastroplasty using the full thickness endoluminal plicator.

**Methods:** We developed the procedure using six ex-vivo porcine stomachs mounted in a model of the abdomen. We then performed non-survival surgery on three 30kg swine under an approved protocol. The animals were kept NPO for 24h prior to surgery. Following general anesthesia, two 24F PEGs were placed using a standard pull technique through the abdominal wall, in the midline and the left mid-clavicular line. The Plicator (NDO Surgical, Mansfield, MA) was then used to place a full thickness endoluminal plication 10mm lateral to the GE junction. Subsequently, the anterior and posterior stomach wall just lateral to the Plicator instrument were plicated at 10mm intervals creating a full thickness, tunnel-like gastroplasty along the lesser curve. The stomach wall was retracted into the arms of the Plicator prior to each firing using 5mm diameter tissue graspers placed through the PEGs. Five plications were performed in total. The shaft of the 15mm diameter Plicator effectively
acted as a sizing dilator. Following the procedure the animals were euthanized and a necropsy was performed. The gastroplasty was assessed endoscopically and fluoroscopically.

**Results:** The length of the gastric tube was 50mm. The diameter was 18mm. The suture line was full thickness and intact. There were no injuries to adjacent organs or extraluminal leaks. With the outlet occluded, the gastroplasty could be distended with 20cc of saline.

**Conclusion:** Percutaneous endoscopic sleeve gastroplasty is technically feasible and may prove durable. It may also prove to be simpler and less morbid than open and laparoscopic approaches.

## V027

**TRANSGASTRIC SALPINGECTOMY IN A PORCINE ANIMAL.**
A N.O.T.E.S. PROCEDURE, Manoel Galvao Neto MD, Almino Ramos MD, Joseberg Campos MD, Paulo Amaral MD, Eduardo Moura MD, Manoela Galvao MD, Andrey Carlo MD, Marcelo Falcao MD, Gastro Obeso Center - Sao Paulo - Brazil

**BACKGROUND:** The Natural Orifice Transluminal Surgery (N.O.T.E.S.) is an evolving field of interest in surgery. Its development still requires research and development of models in order to train and develop this approach. The authors developed a porcine model of transgastric salpingectomy using regular therapeutic endoscopic instruments with purposes of training and development future human techniques and will be presented it in a video.

**METHOD:** After Animal ethics and research committee clearance, an acute trial was done to develop the model and a survival trial it's up to begin. On the acute model, the animal is under general anesthesia, intubated and monitored; A double channel colonoscope is orally introduced; transgastric approach is obtained by identifying the anterior gastric wall with palpation of the abdomen; a site over the liver shadow is choose; the gastric wall is then perforated with a strait papilotome using monopolar, followed by a guide-wire over whom an (up to 15mm) dilatation balloon will be slide and positioned at the middle of its length on the gastric perforation; a direct vision hydrostatic dilatation is performed and the colonoscope is gentle push in to abdominal cavity aiming its way throughout the balloon; once in the abdomen, a pneumo peritoneum is obtained by means of a tube is connected proximally at one of the colonoscope channels and distally to a lap insufflator, set to 12mmHg of pressured; after abdominal cavity recognition, the endoscope is positioned on the way that aloud a direct vision of the operation field on the inferior abdomen; A Verres needle is passed under endoscopic view and the insufflation tube is connected to it in order to clear the colonoscope channel to be used in surgical field; by bi-manual instrumentation with forceps the fallopian tube is identified; the meso is clipped proximal and distally and divided with endoscopic scissors; An endoloop is applied at tube bases and then proximally sectioned with monopolar energy; The fallopian tube is collected and placed in to the stomach to be withdrawn orally; on the acute study the gastrotomy were not closed and the animal submitted to euthanasia; on the future chronic (survival) study the gastrotomy will be closed with different types of instruments. All attempts achieved success with a mean of 95min (60-135min) in 5 animals

**CONCLUSION:** Transgastric Salpingectomy in a porcine model is reliable and achievable and could help develop N.O.T.E.S. procedures

## V028

**COMBINED TRANSRECTAL AND TRANSGASTRIC NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY (NOTES) IN THE PORCINE MODEL,** Michael F McGee MD, Jeffrey M Marks MD, Amitabh Chak MD, Raymond P Onders MD, Steve J Schomisch BS, Jaime M Andrews BS, Conor P Delaney MD, Case Medical Center, Case Western Reserve University, Department of Surgery, Department of Gastroenterology, Cleveland, Ohio, USA

Most NOTES procedures utilize a transgastric approach. It has been hypothesized that using other access points may

improve access, visualization, and possibly ease closure techniques. Transgastric access requires endoscopic retroflexion to visualize and perform surgeries on the upper abdominal quadrants. A transrectal approach would eliminate the need for retroflexion and the resultant video image inversion and transposed movements of the endoscope. Multiple methods can gain NOTES access from a transrectal access point and are demonstrated. Combined transgastric and transrectal NOTES results in coordinated movements which provide better triangulation and retraction than single scope methods. Using a two scope method, a cholecystectomy is performed akin to a laparoscopic procedure in a porcine model.

## V029

**TRANSVAGINAL LAPAROSCOPIC CHOLECYSTECTOMY:**
LAPAROSCOPICALLY ASSISTED, Marc Bessler MD, Peter D Stevens MD, Luca Milone MD, Nancy J Hogle MS, Evren Durak MD, Dennis Fowler MD, Department of Surgery, Minimal Access Surgery Center, Columbia University College of Physician and Surgeons

Natural Orifice Transluminal Endoscopic Surgery (N.O.T.E.S.) is currently being explored as the next frame shift in minimally invasive surgery. Transgastric human appendectomy as well as peritoneoscopy, splenectomy and cholecystectomy in animal models have been reported in the literature. The aim of our experiment was to determine the feasibility and technical aspects of transvaginal flexible endoscopic cholecystectomy.

After approval from Columbia's IACUC, a Transvaginal Laparoscopically assisted Endoscopic Cholecystectomy was performed on four 30 kg Yorkshire pigs. Only one trocar was used for laparoscopic grasper to retract the fundus of the gallbladder. A 12 mm dual channel therapeutic gastroscope was inserted into the vagina either with or without a flexible shape lock device to provide rigidity and additional degrees of freedom. After the abdomen was entered from the vaginal posterior wall, the gallbladder was visualized with the endoscope, grasped with endoscopic forceps and handed to the laparoscopic grasper. The cystic structures were visualized and dissection was started. After the peritoneum over the duct and artery was opened with an endoscopic hook cautery device a blunt endoscopic grasper was used to dissect the tissues around the duct until the cystic duct was isolated. Controlling the cystic duct with clips as in laparoscopic cholecystectomy presents difficulty using the currently available endoscopic clips because they meet and occlude tissues only at the very distal tips. Given failure of the clips to occlude the duct we proceeded to use an endoscopic loop ligature. The artery was isolated and divided using the hook to dissect tissues behind it. Several techniques are used to accomplish this dissection. These include linear and rotational deflection of the tip of the scope, while tissue is grasped through the second channel, advancing and withdrawing the cautery hook along grasped tissue and the hook and pull technique, where tissue is grasped and drawn back towards the scope. Once the gallbladder is completely freed from the liver it is grasped and retracted either into the over tube or directly brought out through the vagina to be removed from the abdomen.

Aside from leakage of bile from the gallbladder there were no intraoperative complications. Operative time ranged between 110 and 155 minutes. Based on our experience in the porcine model, we believe that a Transvaginal Endoscopic Cholecystectomy is feasible in humans.

## V030

**LAPAROSCOPIC REPAIR OF A TRAUMATIC LUMBAR HERNIA,** David A Iannitti MD, John L Polhill MD, Walter L Biffl MD, William W Hope MD, William L Newcomb MD, Carolinas Medical Center, Charlotte, North Carolina

This video demonstrates a laparoscopic repair of a traumatic lumbar hernia. Salient points include patient positioning, port placement, hernia reduction, and mesh placement. Patient background and clinical follow-up are included.
<figure><img src="image_35.png" /></figure>

V031

LAPAROSCOPIC RETROPERITONEAL REPAIR OF A RIGHT SIDED BOCHDALEK HERNIA,

Michael J Rosen MD, Lee E Ponsky MD, Case Medical Center

Bochdalek hernias are rare congenital diaphragmatic defects. We report a case of a 50 year old male with chronic shortness of breath who was diagnosed with a right sided Bochdalek hernia. This hernia was repaired using a laparoscopic retroperitoneal approach.

V032

LAPAROSCOPIC LOW ANTERIOR RESECTION (TME) FOR CARCINOMA OF THE RECTO-SIGMOID COLON,

Barry Salky MD, Scott Nguyen MD, Mount Sinai Medical Center

This is a 48-year-old female with a rectal adenocarcinoma. TME with low anastomosis is demonstrated.

V033

LAPAROSCOPIC NO-TOUCH RESECTION OF A T4 COLON CANCER,

Minia Hellan MD, John Wang MD, Alessio Pigazzi MD, City of Hope

**Introduction:** Laparoscopic colectomy for cancer is widely accepted. However, resection of a colonic tumor infiltrating other organs is controversial. In our video we describe a medial-to-lateral en-bloc resection of a T4 cecal tumor infiltrating the abdominal wall.

**Procedure:** Two 12 mm and two 5 mm ports are inserted. The ileocolic pedicle is identified, isolated and divided with an endovascular stapler. The right mesocolon is held upward and bluntly dissected off the retroperitoneum towards the abdominal wall and rostrally above the duodenum and the head of the pancreas. The middle colic vein and right branch of the middle colic artery are now divided using the ligasure device. The gastrocolic ligament, hepatic flexure and the remaining peritoneal attachment along the white line of Toldt are taken down until the whole right colon and hepatic flexure are free except at the area of tumor attachment to the anterior abdominal wall. During this whole process no manipulation of the tumor whatsoever occurred. The mid-transverse colon and terminal ileum are divided intracorporeally. Now the clearly visible tumor mass is dissected off the abdominal wall including a wide margin of muscle and fascia. Attention is paid not to grasp the tumor itself but only surrounding normal tissue. The specimen is finally removed using an endocatch bag. An intracorporeal side-to-side anastomosis is now performed between the ileum and transverse colon. The patient tolerated the procedure well and was discharged home on POD 2. Final pathology revealed a T4N0 (0/15) tumor with a diameter of 5.2 cm. All margins were free of tumor with a minimum circumferential margin of 1.1 cm.

**Conclusion:** This video aims to demonstrate that selected cases of locally advanced colon cancer can be removed laparoscopically according to established oncologic principles.
## V034

**LAPAROSCOPIC TOTAL PROCTOCOLECTOMY**, Poh-Koon Koh MD, Bonnie Ritson, Feza H Remzi MD, Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio

This video presentation showcases the technique of laparoscopic total proctocolectomy employed by the authors in the surgical treatment of patients with Crohn's colitis refractory to medical therapy. The technical manoeuvres for dissection are highlighted and the positioning of both the patient and the surgical team necessary for the conduct of this advanced laparoscopic procedure are also depicted. This technique allowed the entire colon and rectum to be removed without a need for any abdominal incision and avoids a perineal wound. It is both aesthetically pleasing and reduces the post-operative pain for the patient.

## V035

**AN UNUSUAL APPLICATION OF ENDOLUMINAL SURGERY: TRANSANAL ENDOSCOPIC MICROSURGERY FOR TREATMENT OF RECTAL PSEUDOCANCER (CONGENITAL RECTAL WEB)**, Lauren Kosinski MD, John Marks MD, Hsiao-Ling Shen MPH, Gerald Marks MD, Lankenau Hospital and Institute for Medical Research

This video illustrates a novel application of the transanal endoscopic microsurgery (TEM) technique to the management of a congenital rectal web initially thought to be a rectal malignancy for which abdominoperineal resection had been recommended. TEM enhances access to and visualization of the lesion. A 270-degree, full-thickness excision with primary suture repair at the 5-cm level of the true rectum is demonstrated.

## V036

**LAPAROSCOPIC RESECTION RECTOPEXY FOR RECTAL PROLAPSE**, Daniel A Lawes MD, Jonathon E Efron MD, Tonia M Young-Fadok MD, Mayo Clinic, Scottsdale, Arizona.

We present a video of a laparoscopic resection rectopexy performed in a 31 year old female. This lady had one prior pregnancy with normal vaginal delivery 8 years previously. She presented to the gynecologists for stress incontinence and to the colorectal surgeons with a 2 cm rectal prolapse. On examination she was also found to have a grade 3 recto-coele, a grade 3 cystocele and a grade 4 uterine prolapse. It was decided to perform laparoscopic resection rectopexy and subsequent vaginal hysterectomy and colposuspension. The video demonstrates the characteristic highly redundant sigmoid colon and very mobile uterus. The steps in mobilizing the sigmoid colon are shown as is the ability for a laparoscopic approach to facilitate bloodless, nerve sparing dissection of the rectum under direct vision all the way to the pelvic floor. In addition the video demonstrates the close approximation of the posterior vaginal wall and anterior rectal wall in patients with a rectocele and the care required to dissect in the rectovaginal septum. Extra-corporeal resection of the sigmoid colon is performed using a laparoscopic tacking device, the pararectal tissues are fixed to the sacral promontory.

The patient made an uneventful post-operative recovery and was discharged home on day 4.

## V037

**LAPAROSCOPIC TRANSCYSTIC COMMON BILE DUCT STONE EXTRACTION FOLLOWING PREVIOUS LAPAROSCOPIC CHOLECYSTECTOMY**, Subramaniam Sadhasivam MD, Matthew T Baker MD, Shanu N Kothari MD, Gundersen Lutheran Medical center, La Crosse, Wisconsin.

The laparoscopic transcystic duct approach to clearance of common bile duct stones is well described. Laparoscopic transcystic duct exploration of the common bile duct, in a patient with a previous laparoscopic cholecystectomy, to our knowledge, has not been reported.

We present a case of a 64 year old female who had undergone an uneventful laparoscopic cholecystectomy in 2001 at a referring institution. She presented with abdominal pain and elevated liver function tests in 2005 to our institution.

Ultrasound confirmed the presence of a stone in the common bile duct. Endoscopic retrograde cholangiopancreatogram was unsuccessful due to presence of a duodenal diverticulum and pecutaneous transhepatic cholangiogram failed due to lack of dilated biliary radicals.

The video describes the intra-operative anatomy, laparoscopic ultrasound technique used to identify the cystic duct and common bile duct, intra-op cholangiogram demonstrating CBD stone and technical aspects of removing the stone. In conclusion, laparoscopic transcystic removal of a common bile duct stone in a patient with a previous laparoscopic cholecystectomy is a feasible and safe procedure.

## V038

**AN INNOVATIVE TECHNIQUE FOR LAPAROSCOPIC CHOLECYSTECTOMY IN SITUS INVERSUS TOTALIS**, S. P. Dembla MS, D. D. Poddar MS, Shubha Garg, Gaurav Mittal, Anubhav Goel, Jaipur Golden Hospital, Delhi, India

Situs Inversus Totalis is an uncommon condition. After the inception of Laparoscopic Cholecystectomy; minimal access surgery is the gold standard for treatment of gall stone disease. Diagnosis as well as surgery is challenging in case of Situs Inversus Totalis. Here we report a case of Gall Stone disease (Acute cholecystitis and cholelithiasis) in a patient with Situs Inversus Totalis. We modified our approach by placing a mirror on right shoulder of the patient and monitor at left shoulder level, in a manner that reflection of monitor image could be seen in mirror. This innovation proved to be very helpful in orientating the anatomy during surgery. The Surgery was done in French technique, Surgeon standing between legs of the patient.

<figure><img src="image_36.png" /></figure>

Here we present the video of the surgery in monitor and mirror recorded at the same time.

## V039

**LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR BENIGN DUODENAL OBSTRUCTION**, Aaron Eckhauser MD, William Richards MD, Vanderbilt University Medical Center

This video is of RF, a 59 year old male who presents with benign duodenal obstruction. The patient underwent a radical right nephrectomy in 1974 for renal cell carcinoma with postoperative radiotherapy. He developed significant scarring in the 3rd portion of his duodenum causing satiety, nausea and vomiting.

His preoperative upper GI series shows a massively dilated stomach with a normal pylorus and a very narrowed 3rd portion of the duodenum.

We chose to do a duodenojejunostomy rather than a gastrojejunostomy for several reasons. First, we wanted to preserve the pylorus. Also, we wanted to prevent marginal ulceration, bile reflux gastritis and improve nutrition.

The patient underwent nasogastric tube decompression and rapid sequence intubation prior to surgery.

The video shows an extensive dissection in the right upper quadrant. The pylorus and the 2nd portion of the duodenum are sutured to a loop of jejunum approximately 30cm from the ligament of Trietz. A stapled anastamosis was created using a 45-mm endo-GIA stapler. The enterotomy is closed in 2 layers using a running 2-0 vicryl suture. The distal jejunum is clamped after the anastamosis and assessed for any leaks.
<figure><img src="image_37.png" /></figure>

The patient initially required TPN and NGT decompression postoperatively because of his massively dilated and atonic stomach. He was advanced to a regular diet and weaned off of TPN as tolerated. He is currently without nausea, vomiting or satiety and has gained 5 lbs since surgery.

## V040

**PEDIATRIC ROBOTIC EXCISION OF A CHOLEDOCHAL CYST,**
John J Meehan MD, Children's Hospital of Iowa, University of Iowa Hospitals and Clinics

One potential indication for robotic surgery in children is for complex hepatobiliary procedures. The articulating instrumentation coupled with the 3-dimensional imaging may allow surgeons to perform this minimally invasive procedure more effectively in small children. We present a video demonstration of a resection of a large choledochal cyst with Roux-en-Y choledochal jejunostomy done entirely intracorporeally using a surgical robot. We used a 12 mm 3-dimensional camera and two 5 mm robotic instrument ports. We also used one 5 mm accessory port for liver retraction and one additional 10 mm port for accessory instruments. The procedure lasted 5 and 1/2 hours, and she had no complications. She was discharged on post-operative day #2.

## V041

**LAPAROSCOPIC MORGAGNI HERNIA REPAIR: REPORT OF TWO CASES; ONE CONCOMITANTLY WITH SLEEVE GASTRECTOMY,**
Suthep Udomsawaengsup MD,Stacy Brethauer MD,Carolina Goncalves MD,Adrian Dan MD,Jeffrey Landers MD,Sam Rossi MD,Vijaya Nirujogi MD,Bipan Chand MD,Philip Schauer MD, The Cleveland Clinic Foundation, Cleveland

**Background:** Morgagni hernia is a relatively rare hernia that can result in symptoms of respiratory compromise, gastroesophageal reflux, and abdominal pain. Laparoscopic repair of Morgagni hernias can be challenging due to the adjacent thoracic structures and anatomic limitations for mesh fixation.

We present two cases of laparoscopic Morgagni hernia repair. Both involve incarcerated transverse colon and omentum within the hernia sac resulting in severe symptoms. The specific techniques for mesh fixation around the defects are demonstrated.

One patient is morbidly obese and underwent concomitant laparoscopic sleeve gastrectomy.

## V042

**LAPAROSCOPIC ESOPHAGEAL DIVERTICECTOMY AND LONG MYOTOMY FOR DIFFUSE ESOPHAGEAL SPASM,**
Barry Salky MD,Alfred Trang MD, Mount Sinai Medical Center

Symptomatic epiphrenic diverticuli should be resected in conjunction with esophageal myotomy. The primary disturbance is the motility disorder. Diffuse esophageal spasm is an unusual cause of epiphrenic diverticulum. This video will demonstrate the approach to the lower mediastinum, diverticulectomy, myotomy and partial fundoplication in the treatment of diffuse esophageal spasm.

## V043

**THE HILL-NISSEN HYBRID PROCEDURE: A NEW ANTIREFLUX OPERATION,**
Jeraldine S Orлина MD,Ralph Aye MD,Brian Louie MD,Subashini Daniel MD, Swedish Medical Center

The laparoscopic approach has become the gold standard in the treatment of medically resistant GERD and paraesophageal hernias. Patients suffering from severe reflux and Barrett's esophagus, however, have been shown to have failure rates as high as 60% at ten years. Likewise, cases of giant paraesophageal hernia repairs have shown recurrence rates as high as 40%.

We have specifically examined two both well established therapies for GERD, the laparoscopic Nissen fundoplication and the laparoscopic Hill repair, in an effort to glean the positive aspects of each method and thus design a more superior, durable, and effective procedure.

We propose a hybrid procedure that combines the critical aspects of both techniques to create a superior surgical result. This procedure would include the collar-sling sutures of the Hill repair as well as the "floppy" wrap of the modified Nissen fundoplication. This would provide fixation of the GE junction below the diaphragm and recreate the normal anatomy of the gastroesophageal valve. Furthermore, the added security of a wrap as a means to augment the lower esophageal sphincter would be present. Finally, the "tightness" of the repair can be evaluated by intra-operative manometry and modified accordingly.

By combining complementary components of the Nissen fundoplication and the Hill repair, we hope to provide a more durable and effective solution to the problem of increased rates of recurrence in patients with Barrett's esophagus and giant paraesophageal hernias.

## V044

**LAPAROSCOPIC DUODENAL DIVERTICUCTOMY,**
Heather L Evans MD,John C Bennett MD,Bruce D Schirmer MD, Christopher J Northup MD, University of Virginia Health System

Internal duodenal diverticulum (IDD) is a rare congenital anomaly characterized by incomplete luminal formation of the duodenum. We present a case of a 25 year old woman with progressive severe abdominal pain and nausea. An upper gastrointestinal series (UGI) demonstrated the "windsock" sign, a barium filled sac lying entirely within the duodenum surrounded by a narrow radiolucent line (figure 1, "A"). Upon laparoscopic exploration, the cystic duct was cannulated and a common bile duct stent advanced through the ampulla under intraoperative endoscopic guidance. After a Kocher maneuver was performed, the IDD was everted through a lateral duodenotomy. The lumen within the IDD was identified lateral to the ampulla and a circumferential excision of the IDD was undertaken with successive fires of an endostapler. After the duodenotomy was closed in two layers, the CBD stent was removed and a cholecystectomy performed. A post-operative UGI failed to demonstrate leak or obstruction at the staple line (figure 1, "B"). Six months later, the patient is asymptomatic. While there are several published cases of laparoscopic excision of external duodenal diverticuli, as well as those of endoscopic excision of IDD, we believe this is the first report of a giant IDD removed via laparoscopy.

## V045

**LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS IN A PATIENT WITH SITUS INVERSUS,**
Eraj M Basseri MD,Neel R Joshi MD,Mark D Gaon MD,Gregg K Nishi MD,Theodore m Khalili MD, Cedars-Sinai Medical Center

Kartagener syndrome (KS) was first recognized in 1933 as the clinical triad of situs inversus, chronic sinusitis, and bronchiectasis. In the US the frequency of KS is 1 case per 20,000 live births. Situs inversus occurs randomly in half these patients, therefore present in 0.01% of the population. Typically patients will have a normal life expectancy, despite the complete mirror image reversal of thoracic and abdominal organs. Clinical manifestations include chronic upper and lower respiratory tract disease resulting from ineffective mucociliary clearance. Males demonstrate infertility secondary to immotile spermatozoa. A 3-5% incidence of congenital heart disease is observed in these patients, usually with transposition of the great vessels.

We present the case of a 36 year-old morbidly obese male with known situs inversus who underwent laparoscopic Roux-en-Y gastric bypass surgery for the purpose of weight loss. There is only one account of this advanced laparoscopic procedure being performed in the literature.

The patient is a 36 year-old male with a past medical history including Kartagener syndrome, hypertension, sleep apnea, and morbid obesity. He has been overweight for the majority of his adult life and has failed multiple medical weight loss programs. His current BMI is 53.6. Using criteria established by the National Institute of Health, he was clearly a candidate for bariatric surgery. We performed routine preoperative evaluation including a thorough cardiopulmonary
<figure><img src="image_38.png" /></figure>

costal area. Ultrasonic shears of 5 mm were used for adrenal dissection from the retroperitoneum. Ligation of the vein was achieved with free silk ties. A thin plastic bag was inserted through the trocar tract, and after insertion of the adrenal tumor, the opening was tied with a silk free tie. A 10 mm gastroscope distended the gastric fundus for an anti-or gastrotomy. The opening of the bag was snared and pulled through the gastrotomy, with laparoscopic counter traction, permitting a transoral transgastric extraction. Gastrotomy closure was done with a running suture laparoscopically. The patient was discharged without incident on the 3rd postoperative day, after careful observation. This technique is feasible and permits extraction of larger adrenal tumors without the need for a larger abdominal incision (> 5 mm), with possibly lesser risk of herniation and postoperative pain.

## V052

**LAPAROSCOPIC HARVESTED OMENTAL FLAP FOR STERNAL WOUND DEHISCENCE**, Ashutosh Kaul MD, Thomas Sullivan BS, Alex Rakhlin MD, Edward Yatco MD, Thomas Cerabona, New York Medical College

This video highlights the technical steps in creation of an omental flap for management of sternal dehiscence using minimally invasive surgical techniques.

Sternal dehiscence is associated with a high mortality rate. The greater omentum seems to be the ideal tissue due to its vascularity, high lymphatic content, its long pedicle and malleability. It also provides a large size and bulk to fill up spaces.

There are four key components in flap creation. First is colo-epiploic detachment of the omentum along an avascular plane, followed by division of anastomotic branches between Barkow's and gastro-epiploic arcade. The flap is then mobilized from its gastric attachments pedicled on rt. gastro-epiploic artery. It is then transposed into the mediastinum.

This case was of a morbidly obese male who developed sternal wound infection after five-vessel bypass using both internal mammary vessels. He had undergone two unsuccessful sternal debridements and had developed mediastinitis with necrotic sternal bone edges.

We created an omental flap using minimally invasive surgical techniques. This flap was then transposed into the mediastinum where it was placed over the heart and skin closed over it.

The patient did well and on follow up the overlying skin has completely healed.

This video highlights that laparoscopic omental flap creation can be safely done even in morbidly obese patients with multiple co-morbidities. This approach may provide advantages over an open approach and possibly widen indications for use of omental flaps.

## V053

**DIPHRAGMATIC HERNIA OF UNKNOWN ETIOLOGY**, Vered Avidan MD, Umut Sarpel MD, L B Katz MD, Mount Sinai School of Medicine

Diaphragmatic hernias are generally classified as congenital (e.g. Bochdalek, Morgagni) or traumatic. The later are sometimes diagnosed years after the inciting event.

We present a case of acute diaphragmatic hernia of unknown etiology.

The patient recalled no recent or remote blunt or sharp thoracoabdominal injury other than a CABG surgery, after which he had a normal chest x ray.

The patient presented to a primary care facility with acute gastric volvulus that lead to the diagnosis of a diaphragmatic hernia, and was transferred to our hospital for further care. The diaphragmatic defect was big enough to allow herniation of the stomach, spleen and splenic flexure of the colon.

The video takes the viewer through the stages of reduction and repair of the defect, all done laparoscopically. We demonstrate the absence of hernia sac, typical of diaphragmatic hernia (as oppose to hiatal hernia), and the absence of adhesion, hinting that not only the patient's symptoms were

acute, but possibly also the defect itself. We discuss the difficulty of reducing the hernia content, especially the spleen, and the means we used for its reduction.

Finally, we present the postoperative course including the immediate development of re-expansion pulmonary edema.

## V054

**MINIMALLY INVASIVE REPAIR OF TRAUMATIC HYPOPHARYNGEAL INJURY**, Mark D Gaon MD, Eraj M Basseri MD, Ryan Osborne MD, Gregg K Nishi MD, Theodore M Khalili MD, Cedars-Sinai Medical Center

The treatment of traumatic pharyngeal injuries typically involves and extensive open neck dissection. We present a video of blunt traumatic injury to the posterior hypopharynx which was repaired in a minimally invasive fashion using traditional laparoscopic instruments.

The patient is a 22 year old female who reportedly fell forward and hit the anterior midline of her neck against the edge of a table. She presented to the emergency department with complaints of dysphagia and a hoarse voice. Examination of the oral cavity was normal. A gastrograffin swallow demonstrated significant subcutaneous air tracking down to the mediastinum, an abnormality of the posterior hypopharynx, but no free extravasation of contrast. A CT scan of the neck with oral contrast confirmed the findings of the swallow study.

The patient was taken to the operating room where an exam under anesthesia was performed with rigid laryngoscopy and esophagoscopy. Small mucosal tears of the right false cords and aryepiglottic fold were noted, as well as a full thickness perforation of the posterior hypopharynx. Through this defect, the prevertebral fascia was visible. Conventional repair of this injury would require an open neck dissection. However, we attempted and successfully repaired the defect through the rigid esophagoscope using a 5mm laparoscope, laparoscopic needle driver, and extracorporeal knot pusher. The repair was completed primarily with a series of four interrupted absorbable sutures. The patient tolerated the procedure well and was discharged home on the second postoperative day but was kept NPO and on tube feeds for 5 days. On the fifth postoperative day, rigid laryngoscopy was repeated which showed an intact repair. The nasogastric tube was removed and the patient was started on a diet which she tolerated well. The patient is currently doing well 5 months postoperatively and has no complaints or residual effects from her injury.

## V055

**SURGICAL TEAM TRAINING ON A BENCH MODEL**, MH Whitfore MD, D V Martinec, B Zheng PhD, L L Swamstrom MD, The Oregon Clinic

Video provides a brief introduction of the apparatus and tasks employed in the Legacy Inanimate System for Endoscopic Team Training (LISETT) program. The construct validity of using LISETT for team training is presented.

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

The team performance differences between a dedicated team and an undedicated team on the LISETT tasks are highlighted in the video. The experienced surgeon provided specific instructions for camera driving. Manipulated by the experienced doctor, the laparoscope was moved smoothly and always kept the surgical site in center. In contrast, the surgical site was frequently moved out of the scene by the novice in the undedicated team. The experienced surgeon performed more supportive movements for his/her teammate, but the inexperienced surgeon in the undedicated team failed to do so.

A total of 22 teams assembled by surgeons with different surgical experiences were included in the study of construct
validity for LISETT. Scatter plot is displayed to show correlation between LISETT score and surgical experiences score. LISETT scores correlated positively with surgeon's experience (r = 0.776, p < 0.001). Teams constructed by experienced surgeons (staff surgeons and fellow, n = 5) performed significantly better (89.1 +/- 4.3) than intermediate (fellow and senior residents 77.3 +/- 9.3, n = 8) and inexperienced group (junior residents and medical students 40.2 +/- 17.8, n = 9). Teams being rated with above-average exhibited higher LISETT scores (81.3 +/- 10.8; n = 6) than the intermediate (62.2 +/- 26.3; n = 12) and the below-average teams (58.6 +/- 19.9).

The video ends by discussing the significance of using a bench model on training of team skills outside the OR.

## V056

### LAPAROSCOPIC SLEEVE GASTRECTOMY FOR WEIGHT LOSS IN MORBID OBESITY, Q Tucker MD, D Pinto MD, T Escalante-Tattersfield MD, S Szomstein MD, R Rosenthal MD, The Bariatric Institute, Cleveland Clinic Florida, Florida, USA
Surgery is the most effective treatment for weight loss and improvement in some comorbid conditions in patients with morbid obesity. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed bariatric procedures in the United States. Laparoscopic Sleeve Gastrectomy (LSG) has only recently been accepted as a primary restrictive bariatric procedure. We offer LRYG, LSG, and LAGB to all patients who fulfill the NIH Consensus Conference guidelines for weight loss surgery. As our experience with LSG is expanding we are attempting to identify definitive indications for LSG in our patient population. In this video, we present our technique of LSG and describe our current indications. We use a 7 trocar technique for LSG with identical port placement to our LRYGB procedure. Following induction of anesthesia and endotracheal intubation, the abdominal cavity is accessed through a 1-cm supraumbilical incision with a direct visual approach using a bladeless trocar. The abdominal cavity is insufflated with carbon dioxide to a pressure of 15 mmHg. The operating ports are inserted under direct vision. The left liver is retracted cranially, and the angle of His identified with exposure of the left crus of the diaphragm. A point on the greater curvature approximately 5 cm proximal to the pylorus is identified as the distal extent of the resection. An ultrasonic coagulator is used to divide the vessels along the greater curve up to the angle of His. A 52 Fr bougie is inserted transorally to the level of the distal stomach. Linear cutting stipers are used to vertically transect the stomach creating a narrow gastric tube with an estimated capacity of 150 mls. The staple line is oversewn with a running 2/0 silk suture. The resected stomach is placed in a specimen bag and extracted. A single 19-guage French Blake drain (Johnson & Johnson, New Brunswick, NJ) is placed adjacent to the stomach. All patients have a routine gastrografin swallow study on postoperative day 1 and are commenced on oral fluids if normal.

## V057

### LAPAROSCOPIC LIGATION OF LUMBAR ARTERIES: MANAGEMENT OF PERSISTENT TYPE II AORTIC ENDOLEAKS, G. Brent Sorensen MD, William D Jordan MD, Ronald H Clements MD, University of Alabama, Birmingham
Abdominal aortic aneurysms are a significant source of morbidity and mortality in the United States. Over 60,000 are repaired each year. A new technology called Endovascular Aneurysm Repair, or EVAR, has emerged as a therapeutic option for repair of these aneurysms. This approach is currently being used in approximately one in three aortic aneurysm repairs. With this new technology has come a new set of complications - endoleaks. Type II endoleaks occur from retrograde flow into the aneurysm sac from aortic branches. This backflow can lead to increased aneurysm size, and potentially rupture. These endoleaks are usually managed with endovascular or percutaneous techniques. Failure of these techniques classically has been

treated with open ligation of the arteries. We describe a technique of laparoscopic ligation of the lumbar arteries to control a type II endoleak. Real-time fluoroscopy and CT angiography are used to localize the correct location of the endoleak. This technique provides a safe, durable, low-morbidity option in the management of persistent type II endoleaks.

## V058

### LAPAROSCOPIC ASSISTED RESTORATIVE PROCTOCOLECTOMY FOR FAMILIAL ADENOMATOUS POLYPOSIS, Jill Genua MD, David Vivas MD, Steven D Wexner MD, Cleveland Clinic Florida, Weston, Florida

This video displays a laparoscopic assisted restorative proctocolectomy with loop ileostomy for familial adenomatous polyposis (FAP). The patient is a 17-year-old female who presented with a 2-year history of rectal bleeding. Upper and lower GI endoscopy revealed adenomatous polyps and, accordingly, the patient was scheduled for restorative proctocolectomy. Results: After mechanical and antibiotic bowel preparation and preoperative antibiotic prophylaxis, the patient was placed in the supine modified lithotomy position. Bilateral ureteric catheters were placed; the abdomen, pelvis and perineum were prepped in a standard method. Using 5, 10-12 mm ports (infraumbilical camera port, left iliac fossa, left upper quadrant, right iliac fossa and right upper quadrant), the entire left and right colon were mobilized. The gastrocolic omentum was divided. The right colic, left and right branches of middle colic, and the inferior mesenteric vessels were individually divided with a 35-mm endoscopic linear cutter. The upper two-thirds of the rectum were mobilized laparoscopically. Total mesorectal excision was performed under direct vision through a Pfannenstiel incision with manual and visual guidance from both abdominal and perineal fields. A 30-mm stapling device was placed 2 cm cephalad to the dentate line. A 45-mm stapler was used to divide the terminal ileum. A 20 x 20 cm J-pouch was fashioned using 4 sequential firings of the 55-mm stapler and a 33-mm anvil was placed within the lumen using a pursestring. A 33-mm circular stapler was introduced through the anus to create the pouch anal anastomosis. A drain was left in the pelvis and a loop ileostomy was created 60 cm cephalad to the pouch. The patient had an uneventful postoperative course and was discharged home on postoperative day four. Pathology revealed more than 100 tubular and tubulovillous adenomas without dysplasia or invasive carcinoma.

## V059

### THORACOSOPIC LYMPHADENECTOMY FOR ESOPHAGEAL CANCER, Masayuki Higashino MSc, Masashi Takemura MSc, Shinya Tanimura MSc, Yosuke Fukunaga MSc, Department of Gastroenterological Surgery, Osaka City General Hospital

Three hundred and two esophageal cancer patients underwent thoracoscopic esophagectomy since July 1995. This operation facilitates magnification of the mediastinal region resulting safe and thorough lymphadenectomy of upper and left side mediastinum. Indication: Ninety-five percent of all of thoracic esophageal cancer including cases of post chemo radiation were indicated in this operation. Exclusive criteria are severe pleural adhesion and cases of not performing hemi-ventilation anesthesia. Device: We originated a tracheal retractor that is constructed of two frames inserted from a 11.5 mm size port and united in the thorax resulting omission of small thoracotomy. Thoracoscope is 45 degrees rigid type, which allows better view of upper and left side mediastinum than conventional open surgery. Procedure: When the upper mediastinal lymphadenectomy along the right recurrent laryngeal nerve is performed, taping and retracting the right subclavian artery allows good view and avoids injury of the nerve. At the middle mediastinum, taping and retracting the esophagus allows good view of left side of mediastinum. We frequently use ultrasonic coagulating system for keeping the right plain and performing thorough lymphadenectomy. When left side pleura, Aorta, pericardium are made up for