2005 SAGES Abstracts

ABSTRACTS Thursday, April 14, 2005 

S001 

TREATMENT RESULTS OF LAPAROSCOPY-ASSISTED GAS- 

TRECTOMY FOR GASTRIC CANCER, Shinichi Sakuramoto MD, 

Shiro Kikuchi MD,Shinichi Kuroyama MD,Nobue Futawatari 

MD,Natsuya Katada MD,Nobuyuki Kobayashi MD,Masahiko 

Watanabe MD, Department of Surgery, Kitasato University 

School of Medicine 

[Aim] The aim of this study was to present treatment results of 

laparoscopy-assisted gastrectomy for early stage gastric cancer. 

[Material and Methods] We have performed laparoscopyassisted 

gastrectomy on 106 patients with gastric cancer since 

1998 including laparoscopy-assisted distal gastrectomy (LADG) 

in 99 patients, laparoscopy-assisted total gastrectomy (LATG) 

in 6, and laparoscopy-assisted proximal gastrectomy (LAPG) in 

1. 

[Results] LADG and LAPG: In initial 9 patients, first tier nodes 

were laparoscopically dissected, then second tier nodes were 

directly dissected through the small open wound of 7 cm. In 

the following 45 patients, surgical technique of hand-assisted 

laparoscopic surgery (HALS) was used and lymph nodes were 

dissected in a similar way. Mean surgical time was 279.4±47.0 

min and 246.1±42.4 min, respectively. Further, in next 16 

patients, all lymph nodes were laparoscopically dissected, and 

surgical time was 228±34.5 min. The length of open abdominal 

wound was shortened to 4-5 cm. In 71st patient or after, surgical 

time was elongated to 294.9±53.0 min because the celiac 

branch of vagus nerve was preserved. Mean blood loss was 

151.2±110.6 g, the number of dissected lymph nodes was 

31.5±14.0, and mean postoperative hospital stay was 14.6±8.3 

days. LATG: Mean surgical time was 343.3±81.6 min, blood 

loss was 180.0±117.3 g, the number of dissected lymph nodes 

was 46.8±23.3, and postoperative hospital stay was 15.2±4.4 

days.Postoperative complications in all the 106 patients included 

wound infection in 2, anastomotic stricture in 2, cholecystitis 

in 1, postoperative bleeding in 1, and intra-abdominal 

abscess in 1, but all were conservatively alleviated. 

Pathological examination revealed depth of tumor invasion; T1 

in 102 and T2 in 4, lymph node metastasis; n0 in 102, n1 in 3, 

and n2 in 1. The n2 patient who had m cancer with long diameter 

2.4 cm and the number of metastatic lymph nodes 16/39 

died at 3 years and 9 months after surgery. All the patients 

excluding this patient are currently surviving without recurrence. 

[Conclusion] In lymph node dissection in laparoscopy-assisted 

gastrectomy for gastric cancer, the laparoscopy-assisted procedure 

provides better surgical field and shorter time operation 

when compared with the direct procedure. Laparoscopy-assisted 

surgery offers radical cure equivalent to that in open surgery, 

as well as excellent postoperative QOL. 

S003 

ANALYSIS OF THE SAGES OUTCOMES INITIATIVE CHOLE- 

CYSTECTOMY REGISTRY, Vic Velanovich MD, Marian 

McDonald MD,Rocco Orlando MD,L W Traverso MD, Henry 

Ford Hospital, Virginia Mason Medical Center 

Introduction: The SAGES Outcomes Initiative has been collecting 

data from SAGES members who performed cholecystectomies. 

The purpose of the initiative is to track outcomes and 

performance for the benefit of the membership to both document 

quality and assess outcomes. This is a report of cholecystectomies 

within the database. Methods: The SAGES 

Outcomes Initiative gallbladder registry is a voluntary database 

where SAGES members record perioperative and postoperative 

information on their patients who undergo cholecystectomy. 

Perioperative data include age, gender, work status, 

comorbidities, ASA class, primary/secondary diagnoses and 

procedures, preoperative symptoms and presence of gallstones, 

procedure performed, and intraoperative complications. 

Follow-up data include adverse postoperative events, 

complication severity, readmission related to gallbladder surgery, 

reoperation, symptomatic change, and work status. 

Results: There were 1721 entries with perioperative and postoperative 

data. The resident was the operating surgeon in 

54.6% of laparoscopic cholecystectomies (LC), 30.6% of LC 

with cholangiograms (LC-C), and 14.3% of LC with bile duct 

exploration (LC-CBDE) (p


SAGES 2005 

plications in this unique population with malignant disease. 

Methods: Risk factors for postoperative complications were 

analyzed from a prospective database of 848 consecutive 

laparoscopic colorectal operations for adenocarcinoma from 

November 1993 to May 2004 (354 females [41.8%], median 

age: 70 [29-94]) including: Demographic variables, co morbid 

conditions and cancer-specific variables. Logistic regression 

analysis univariate and multivariate was used to test predicting 

factors for complications. Results: A laparoscopic approach 

was done in 601 patients for colon disease (70.8%), and 247 

for rectal adenocarcinoma (29.1%). Postoperative complications 

were observed in 192 of 848 cases (22,6%). The most 

common complications were postoperative ileus (n=46, 5.4%) 

and anastomosic leakage (n=44, 5.2%). Highest rates of complications 

were observed in patients who required intraoperative 

transfusions (43/84, 51.2%) and chronic obstructive pulmonary 

disease (COPD) (33/76, 43.4%). Univariate analysis 

found significant predictors of complications: male gender 

(OR: 1,84 [1.31-2.60]), ASA score (OR: 1.29 [1.01-1.66]), previous 

co morbid conditions (OR: 1.88 [1.34-2.66]), coronary 

artery disease (OR: 1.81 [1.08-3.04], COPD (OR: 2.96 [1.82- 

4.81]), rectal surgery (OR: 2.35 [1.63-3.47]), low anterior resections 

(OR: 2.37 [1.63-3.47]), conversion to open surgery (OR: 

2.35 [1.53-3.60]), operative time (OR: 1.01 [1.002-1.008], the 

need of transfusions (OR: 4.33 [2.72-6.88] and preoperative 

radiotherapy (OR: 2.50 [1.68- 3.70]). Multivariate analysis found 

male gender (OR: 1,45 [1.01-2.08]), the need of transfusions 

(OR: 4.06 [2.49-6.61]), rectal surgery (OR: 2.37 [1.67-3.38]), 

COPD (OR: 2.96 [1.82-4.81] as independent predictors of complications. 

A separate multivariate model to predict anastomotic 

leakage confirmed transfusions (OR: 3.21 [1.46-7.08]), 

rectal surgery (OR: 4.47 [2.27-8.82]) and COPD (OR: 2.52 [1.07- 

5.92] as independent factors of this complication.Conclusion: 

This study shows the importance of COPD as a predictor of 

major complications. It also confirms male gender to be associated 

to higher morbidity. Laparoscopic rectal surgery and the 

need of intraoperative transfusions could help to identify 

groups at risk for a more aggressive approach in postoperative 

period. 

S007 

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING IN 

PATIENTS 60 YEARS OF AGE AND OLDER, D A Provost MD, N 

Dukkipati MD,S Kaza MD,M J Watson MD, The Clinical Center 

for the Surgical Management of Obesity, The University of 

Texas Southwestern Medical Center at Dallas 

Objective: To evaluate the results of laparoscopic adjustable 

gastric banding (LAGB) in patients 60 years of age and older, 

and to compare complications and weight loss to the younger 

cohort. 

Methods: The institutional bariatric surgery database was 

queried to identify all patients undergoing LAGB. Patients 60 

years of age and older were identified and compared to 

patients less than 60 years of age with regards to complications 

and weight loss. All were Lap-Bands® placed by the pars 

flaccida technique. 

Results: LAGB were placed in 56 patients aged 60 years and 

older (mean age 64.5, mean BMI 48.3), who were compared to 

277 patients under 60 years of age (mean age 42.5, mean BMI 

48.3). In the older patients there were 3 major perioperative 

complications: 1 patient with an abdominal abscess requiring 

celiotomy and band removal, 1 MRSA pneumonia and bacteremia, 

and one early prolapse (band removed). Late band 

related reoperations were required in 6 older patients: 4 band 

prolapse (2 replaced, 2 removed), one band removal for MRSA 

band infection (in the patient with the perioperative bacteremia), 

and 1 port removal for localized port infection. Late 

reoperations for band related complications were required in 

12.5% of the older patients compared to 9.7% of the younger 

group. Prolapse requiring reoperation occurred in 7.1% of the 

older patients compared to 3.6% in the younger cohort. Major 

infectious complications were higher in the older patients 

(7.1% vs. 0.4%), as was the incidence of band extirpation (7.1% 

vs. 1.8%). There were no perioperative mortalities. Weight loss 

(expressed as mean % excess BMI lost) was comparable 

between the older and younger patients: 33.8% vs. 31.7% at 6 

months, 40.1% vs. 44.0% at 12 months, and 46.7% vs. 54.3% at 

18 months, respectively. Excellent improvement or resolution 

of preoperative obesity related comorbidities was observed. 

Conclusions: Excellent weight loss can be achieved with the 

Lap-Band® adjustable gastric banding system in patients 60 

years of age or older with an acceptable perioperative complication 

rate. Perioperative major infectious complications and 

the incidence of band extirpation appear to occur more frequently 

in the older patient population. 

S008 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR BMI 

UNDER 35. A TAILORED APPROACH., Ricardo Cohen MD, Jose 

S Pinheiro MD, Jose Correa MD,Carlos A Schiavon MD, Center 

for the Surgical Treatment of Morbid Obesity, Hospital Sao 

Camilo, Sao Paulo, Brazil 

Introduction: There is a group of patients with BMI under 35 

that are obese (class 1: 30-34.9), have uncontrolled comorbidities, 

and that have tried to lose weight (lifestyle modification 

and pharmacotherapy) with no success. This group does not 

meet the ?traditional? criteria for obesity surgery and no other 

treatment is offered to them. 

Methods: Thirty-seven obese patients were under clinical treatment 

with no resolution or improvement of their life-threatening 

comorbidities. The mean BMI was 32.5, 30 women and 7 

men; and the ages ranged from 28 to 45 years old (young 

patients). All patients had diabetes type 2, hypertension, and 

lipid disorder. GERD was present in 7 patients and sleep apnea 

in 3. Patients underwent the same preoperative evaluation as 

other patients for gastric bypass. Patients were required to 

have approval by their primary care physician. Written 

informed consent was obtained from all patients. A laparoscopic 

Roux-en-Y gastric bypass (LRYGB) with a 50cm biliary 

limb and a 150cm alimentary limb was performed in these 

patients. After extensive explanation and documentation, 

Brazilian insurance companies approved the procedure in 3 

cases. International (non-American) insurance companies 

approved the procedure in 4 cases. 

Results: Follow-up ranges from 6 to 38 months. The mean 

excess weight loss is 77% (similar to regular LRYGB patients). 

Thirty-six patients had total remission of their comorbidities. 

One patient still has mild hypertension but with a reduction in 

the number of anti-hypertensive drugs (3 to 1). There were no 

surgery-related complications. Postoperative quality of life is 

considered good to excellent (Moorehead and Ardelt). 

Conclusions: Obese patients with BMI under 35 and with 

severe comorbidities benefit from laparoscopic Roux-en-Y gastric 

bypass. This treatment option should be offered to this 

group of patients. 

S009 

PREGNANCY FOLLOWING LAPAROSCOPIC ADJUSTABLE 

GASTRIC BANDING, Subhi Abu-Abeid MD, Joseph Klausner 

MD,Dan Bar-Zohar MD, Tel-Aviv Sourasky Medical Center, 

Department of Surgery B 

Most patients undergoing bariatric surgery are females, and 

the vast majority is in their reproductive age. Morbid obesity is 

usually associated with sterility, gestational hypertension, diabetes 

mellitus and delivery complications. 

Objectives: To evaluate pregnancy outcomes in patients following 

weight loss after laparoscopic adjustable gastric banding 

(LAGB). 

Methods and procedures: The procedure includes laparoscopic 

placement of silicon adjustable gastric band, 2 cm below the 

gastroesophageal junction. We retrospectively analyzed 81 

pregnancies in 74 women following LAGB, evaluating previous 

fertility status, gestational complications, weight changes and 

newborn status. 

Results: All 81 pregnancies were singleton. Sixty-eight women 

had a single pregnancy, 5 had 2 and 1 had 3 pregnancies. 

Before pregnancy, mean BMI values prior and after LAGB were 

43.3±5.8 and 30.2±2.9 kg/m2, respectively (p


pregnancies and impaired glucose tolerance in 13. Cesarean 

section was performed in 17 cases. Two women were operated 

during pregnancy (16.3 weeks) due to band slippage, and the 

band was removed laparoscopically. 

Conclusions: LAGB is safe and well tolerated during pregnancy. 

The option of band adjustment permits optimal maternal 

medical control. 

S010 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS IN THE ELDER- 

LY POPULATION., Carlos A Schiavon MD, Jose S Pinheiro MD, 

Jose Correa MD,Ricardo Cohen MD, Center for the Surgical 

Treatemnt of Morbid Obesity, Hospital Sao Camilo, Sao Paulo, 

Brazil 

Introduction: Obesity is a devastating disease and is associated 

with a series of life-threatening complications. If patients 

over 60 years of age are submitted to large and aggressive 

procedures, such as coronary bypass surgery and hip joint 

replacement surgery, why shouldn?t gastric bypass be performed 

for the treatment of morbid obesity in this group of 

patients? 

Methods: We reviewed the data of 108 patients who were over 

60 years of age and underwent laparoscopic Roux-en-Y gastric 

bypass in our Institution (9.8% of our patients). 

Results: Most were women (71 patients) and mean BMI was 44 

(38 to 55). Mean age was 66 (60 to 76). Preoperative comorbities 

were as follows: artropathy was present in 76 patients, 

hypertension in 73 patients, diabetes in 66, cardiopathy in 54, 

lipid disorders in 35, GERD in 19, and sleep apnea in 12.There 

were no intraoperative complications. Mean hospital stay was 

36 hours. One patient presented with postoperative pneumonia. 

There were no postoperative leaks in this group of 

patients. We had a 92.6% follow-up after 48 months in this 

group of patients, in contrast to a 68.8% follow-up in our 

younger patients. EWL was 71% at 12 months, 69% at 24 

months, and 67% at 48 months. Hypertension was cured in 46 

(63%) patients and 24 (32%) presented with easier controlled 

disease. 51 (77%) diabetic patients were cured and 6 (9%) 

decreased medication dosage. Lipid disorders were cured in 

33 (94%) patients. All patients with cardiopathy presented significant 

improvement in their disease. GERD and sleep apnea 

were cured in all patients. 87 (81%) patients practice physical 

activities regularly. 

Conclusions: Patients over 60 years old benefit from laparoscopic 

gastric bypass with high resolution of comorbidities 

and good long-term weight loss. Patients are extremely adherent 

to treatment. 

S011 

ETHNIC DIFFERENCES IN WEIGHT LOSS SUCCESS FOLLOW- 

ING ROUX-EN-Y GASTRIC BYPASS, Robert T Marema MD, 

Nadege Francois BS,Cynthia K Buffington PhD, U.S. Bariatric 

Introduction. The incidence of obesity among African 

American (AA) females is higher than for AA males or other 

ethnicities, and AA females are more resistant to diet-induced 

weight loss. In the present study, we examined the effects of 

Roux-en-Y gastric bypass (RYGBP) on the postoperative 

weight loss of AA vs. Caucasian females, along with possible 

predictors of weight loss differences, i.e. eating abnormalities, 

psychosocial status. 

Methods. The study population included 184 study participants 

with the following measurements obtained prior to and one 

year after RYGBP: 1) total body weight, 2) % excess weight 

loss (EWL), 3) fat and fat-free mass (bioelectric impedance), 5) 

psychosocial status, i.e. depression (Beck Depression 

Inventory-II), Quality of Life (Moorehead-Ardelt), and 5) aberrant 

eating behavior, i.e. carbohydrate craving, food addiction, 

eating control, binge eating, and emotional eating. 

Results. The data show one year postoperative that % EWL of 

the AA females was significantly (p0.05) differences 

between AA and Caucasian females with regard to any of the 

measures of eating behavior. Levels of depression and quality 

of life scores also did not significantly differ (p>0.05). 

Conclusion. There are ethnic differences in the efficacy of the 

RYGBP procedure among females one year postoperative. The 

reduced surgical weight loss of AA females is significantly 

associated with changes in fat mass but not eating behavior or 

psychosocial issues. 

S012 

PREDICTORS OF SUCCESS AFTER LAPAROSCOPIC GASTRIC 

BYPASS; A MULTIVARIANT ANALYSIS OF SOCIOECONOMIC 

FACTORS, Rami E Lutfi MD, Alfonso Torquati MD,NiKhilesh 

Sekhar MD,William O Richards MD, Vanderbilt University 

Laparoscopic roux-en-y gastric bypass (LGB) has proven efficacy 

in causing significant and durable weight loss, however 

there have been no studies looking at the value of patient 

demographics in terms of predicting postoperative weight 

loss. Aim: to identify independent predictors of successful 

weight loss after LGB. Methods: Socioeconomic demographics 

were prospectively collected on patients presenting for LGB. 

Primary end-point was % of excess weight loss (EWL) at 1-yr 

follow up. EWL was plotted in a normal histogram; insufficient 

weight loss was defined as EWL



POSTOP values were obtained from 15 to 537 days after surgery 

(median POD 175). PREOP and time groups of POSTOP 

values were compared using the Kruskal-Wallis One-Way 

ANOVA. 

Results: 38 women and 10 men were studied. Median age was 

42 years (22 ? 59 yrs), PREOP BMI 48 kg/m2 (35 ? 62 kg/m2), 

and weight 283 lbs. (178 ? 446 lbs). The median POSTOP 

weight at follow up was 191 lbs. (123 ? 360 lbs) and BMI 32.3 

kg/m2 (21 ? 53 kg/m2). A significant (p 1 year than at 1-3 

months. 

Conclusion: Glucose, insulin and HOMA IR levels rapidly 

dropped to normal levels within 1-3 months following LRYGB. 

Also, insulin and HOMA IR levels dropped significantly to even 

lower levels more than a year after surgery. The initial rapid IR 

improvement following LRYGP supports a short term role for 

incretin gut hormones in improving IR, while the subsequent 

additional long-term improvement suggests further modulation 

of IR by weight loss and by adipocytokines released from 

the shrinking fat mass. 

S014 

IMPLANTABLE GASTRIC STIMULATION TO ACHIEVE WEIGHT 

LOSS IN LOW BMI PATIENTS: EARLY CLINICAL TRIAL 

RESULTS, Ken Champion MD, Mike Williams MD, Emory- 

Dunwoody Medical Center, Atlanta Georgia, USA 

Implantable Gastric Stimulation (IGS) offers a novel approach 

for surgical weight loss which may allow it to be utilized in 

obese patients who don?t meet NIH criteria for traditional 

bariatric procedures. This paper reports our early outcomes 

with a FDA clinical trial of IGS for low BMI patients to achieve 

weight loss. 

With FDA and institutional IRB approval, 60 potential low BMI 

(30-34.9) candidates were screened by a selection psychological 

algorithm with 33 approved as potentially responsive to 

gastric stimulation, and 19 consenting to implantation. There 

were 18 females and 1 male, mean age 42 (range 32-60), mean 

BMI 33.1 (range 30.9-34.9) and mean weight 90.9 Kg (range 

79.5-116.4). There were a total of 22 co-morbidities (mean 1.2), 

38 previous abdominal surgeries, and 32% had undergone a 

?plastic surgery? procedure related to their weight. Post-op 

protocol mandated monthly dietary and exercise counseling 

and attendance at an IGS support group. 

All cases were completed laparoscopically as an outpatient 

procedure. Follow-up is 4-6 months. There were two intra-op 

mucosal perforations requiring lead repositioning. Three 

patients have undergone explantation due to non-compliance 

with protocol. Ten patients have lost a mean of 13% EWL 

(range 0.5-26%), and four (21%) have lost more than 25% EWL. 

Six patients have gained a mean of 6.4% excess weight and 

one patient is unchanged. 

Our outcomes suggest IGS may offer a novel approach for surgical 

weight loss in a subset of low BMI patients, with 53% 

(10/19) experiencing early modest weight reduction, but 

patient compliance is still an issue despite aggressive pre-op 

screening, and further follow-up is required.. 

S015 

CPAP AND BIPAP USE CAN BE SAFELY OMMITTED AFTER 

LAPAROSCOPIC GASTRIC BYPASS, John Yadegar MD, William 

Bertucci MD,Todd Drasin MD,Amir Mehran MD,Erik Dutson 

MD,Carlos Gracia MD, UCLA Medical Center 

Introduction: Obstructive sleep apnea (OSA) is prevalent in the 

morbidly obese population. The need for routine preoperative 

testing for OSA has been debated in the literature. Most 

authors advocate the use of continuous (CPAP) or bi-level positive 

airway pressure (BIPAP) in the postoperative setting. 

Others, however, have reported pouch perforations or other 

86 http://www.sages.org/ 

gastrointestinal complications as a result of their use. We 

reviewed our experience and present an algorithm for the safe 

management of patients with OSA without the use of CPAP or 

BIPAP. 

Methods: From 1/2003 to 8/2004, 250 laparoscopic gastric 

bypasses (LRYGB) were performed at UCLA. Preoperative testing 

for OSA was not required. The data pertaining to OSA, 

CPAP/BIPAP use, and postoperative pulmonary complications 

were collected into a prospective database. Patients with OSA 

were not placed back on CPAP/BiPAP after surgery. They were 

observed in a monitored bed overnight, ensuring continuous 

oxygen saturation of >92%. All patients were placed on patient 

controlled anesthesia (PCA), trained in the use of incentive 

spirometry, and ambulated within a few hours of surgery. 

Results OSA/CPAP OSA/No CPAP No OSA # Patients 31 33 

186 Avg Age 50 46 46 Avg BMI 48.2 46.8 46.4 Pneumonia 0 1 

0 Reintubation 0 0 0 

Conclusions: Postoperative CPAP/BiPAP may be safely omitted 

in LRYGB patients with OSA, provided they are observed in a 

monitored setting and their pulmonary status is optimized by 

aggressive incentive spirometry and early ambulation. In the 

majority of these patients, OSA resolves with weight loss, 

obviating the need for further CPAP/BiPAP therapy. 

S016 

ANALYSIS OF THE SAGES OUTCOMES INITIATIVE HERNIA 

REGISTRY, Vic Velanovich MD, Phillip P Shadduck MD,Leena 

Khaitan MD,L W Traverso MD, Henry Ford Hospital, Regional 

Surgical Associates, Emory Univeristy, Virginia Mason Hospital 

Introduction: Prospective registries serve the purposes of 

improving patient care, advancing medical science, and guideing 

healthcare decision making. The SAGES Outcomes 

Initiative is a voluntary, prospective, multiinstitutional registry, 

containing data on >12,000 surgical procedures. Methods: The 

SAGES Outcomes initiative hernia module contains on 656 

non-incarcerated inguinal hernias. Perioperative data collected 

include patient age, gender, work status, comorbidities, ASA 

class, primary/secondary diagnoses and procedures, surgeons 

& assistants, hernia type, repair technique, and intraoperative 

complications. Follow-up data include LOS, complications and 

severity, narcotic use, work/activities, and symptom change. 

These data are analyzed and reported here for the first time. 

Results: The patient demographic data are typical. The complication 

rates for the most frequent hernia types and repair techniques 

are summarized in the table. Although voluntary databases 

have the inherent potential for methodologic concerns, 

it is noteworthy and reassuring that the complication rates in 

the SAGES registry are consistent with those reported from 

clinical trials and mandatory registries. Conclusion: The first 

analysis of the SAGES Outcomes Initiative hernia database is 

encouraging. Efforts are ongoing to simplify data entry, refine 

data parameters, audit data, increase surgeon participation, 

and begin to ask clinically important questions. 

S017 

LAPAROSCOPIC MANAGEMENT FOR HYDROCELE OF THE 

CORD OR SCROTUM IN CHILDREN, Hiroo TAKEHARA MD, 

Hiroki ISHIBASHI MD,Masaki OHSHITA MD,Mitsuo SHIMADA* 

MD, Dept. of Pediatric Surgery and Pediatric Endosurgery, 

Tokushima University Hospital , *Dept. of Digestive Surgery, 

University of Tokushima, School of Medicine, Tokushima, 

Hydrocele of the cord or scrotum is a common condition in 

infancy that usually presents at birth. In most children with 

hydrocele, the processus vaginalis closes and the hydrocele 

resolves during the first 12D18 months of life. The recommended 

management of hydrocele is therefore to observe the 

patient without surgery for the first 2 years of life. We have 

performed 475 laparoscopic percutaneous extraperitoneal closure 

(LPEC) procedures in 355 children with inguinal hernia, 

including 43 with hydrocele. Of these 43 patients, 17 (2D5


years of age) had communicating hydrocele, 15 (1D5 years of 

age) had noncommunicating hydrocele associated with a contralateral 

inguinal hernia, and the remaining 11 (2D6 years of 

age) had noncommunicating hydrocele of the scrotum. 

The laparoscopic correction of hydrocele involves high-circuit 

suturing of the processus vaginalis, as in LPEC for inguinal 

hernia. The distal part of the noncommunicating hydrocele is 

left open via the internal inguinal ring or a small incision in the 

scrotum. No occurrence or recurrence of hydrocele was 

observed in the 358 LPEC procedures in our series. The advantages 

of this procedure are not only cosmetic and minimally 

invasive closure, but also a lower risk of injury to the spermatic 

duct or vessels and complete closure of the communication 

between the peritoneal cavity and the hydrocele to a greater or 

lesser degree. 

S018 

MESH-RELATED COMPLICATIONS FOLLOWING HERNIA 

REPAIR, Jason H Clarke MD, Mark D Walsh MD,Thomas N 

Robinson MD, University of Colorado Health Sciences Center 

Introduction: Specific complications following hernia repair 

with mesh are related to the mesh material used. 

Methods: All medical device reports associated with the use of 

surgical mesh for hernia repair were retrieved from the FDA?s 

Manufacturer User Facility Device Experience Database from 

1/96 to 9/04. Statistics were performed using chi squared 

analyses and significance was determined using Fischer?s 

exact test. 

Results: There were 252 complication reports regarding the 

use of surgical mesh for hernia repair. The most common 

complications reported were infection (42%), mechanical failure 

(18%), chronic pain (9%), allergic reaction (8%), and intestinal 

complications including obstruction, perforation and fistula 

(7%). Less frequent complications included adhesions, seromas, 

and erosion/migration. Complications involved the following 

specific types of mesh: polypropylene, composite 

PTFE/polypropylene (COMP), composite sepra/polypropylene 

(SEPRA), PTFE alone, and biomaterial. The most common 

complication for each mesh type was: polypropelene ? infection 

(43%), COMP ? infection (42%), SEPRA ? mechanical failure 

(80%), PTFE alone ? infection (75%), and biomaterial ? 

allergic reaction (57%). The use of COMP mesh resulted in 

more intestinal complications compared to all other mesh 

types (14% vs. 5%, p



of tacks placed approximately 2-3cm inside the edge of the 

mesh from above. Steep dependent patient positioning is used 

to ensure no bowel is caught behind the mesh. After the first 

row, another row of tacks and sutures are placed closer to the 

edge of the mesh. 

Results: All patients had failed prior attempts at VHR with an 

average of 12 prior repairs (range 1? 30). Mean defect size was 

626cm2 (range 15x14 cm2 to 38x25cm2). All required between 

two to four pieces of Gore-Tex Dualmesh® sutured together 

for tension free repair. Average operative times were 285 mins. 

Two patients had their procedure aborted after lysis of adhesions, 

to avoid mesh placement, in the setting of a potential 

missed bowel injury. Both were returned to the operating 

room within a week for delayed mesh placement, only one of 

which was successful. The second patient had extensive bowel 

edema and was repaired at a later date. We had two conversions 

(one Reeves-Stoppa and one Component Separation), 

one enterotomy and one bladder injury. There were no mortalities 

however two of the ten patients had a prolonged hospital 

course and ICU stay. One developed extensive IVC thrombosis 

while another developed an abdominal compartment syndrome. 

In follow-up there were two recurrences due to infected 

mesh removal. 

Conclusion: Patients with large ventral hernia defects and loss 

of domain, can still be approached laparoscopically for both 

lysis of adhesion and hernia repair. The technique is complex 

and is modified to allow for mesh fixation from above. 

Potential for missed bowel injuries, bowel edema and abdominal 

compartment syndrome may be reasons to abort the procedure 

and delay the mesh placement for a later date. 

S023 

LAPAROSCOPIC VS. OPEN INCISIONAL HERNIA REPAIR: A 

SINGLE INSTITUTION ANALYSIS OF HOSPITAL RESOURCE 

UTILIZATION FOR 884 CONSECUTIVE CASES, David Earle MD, 

Neal Seymour MD,Erica Fellinger MD,Alexander Perez MD, 

Baystate Medical Center, Tufts University School of Medicine 

Objective: To analyze and compare the utilization of hospital 

resources associated with laparoscopic and open incisional 

hernia repair. 

Methods: Prospectively collected administrative data were 

examined for 1493 cases of ventral hernia repair performed 

between November 1999 and June 2004. 605 non-incisional 

hernias (556 umbilical, 36 epigastric, 13 parastomal, and 4 

spigelian) were excluded and 884 incisional hernia repairs 

were examined for OR time, OR supply and total hospital cost 

($US), length of stay (LOS), and 30 day postoperative ER visits. 

Data are expressed as mean±SEM and statistical comparisons 

were by chi squared analysis and Student?s t-test. LOS, ER 

visit, and financial data were only available from 2001 on. 

Results: 469 incisional hernias were repaired by laparoscopic 

(53%) and 415 by open technique (47%). Laparoscopic repair 

was associated shorter LOS (1±0.2days vs. 2±0.6days), longer 

operative time (149±4min vs. 89±4min), higher supply costs 

(2,237±71 vs. 664±113), lower total hospital cost (6,396±477 vs. 

7,197±1,819) and a greater number of postoperative (30 day) 

ER visits (37% vs. 24%). A statistically significant annual 

increase in the utilization of the laparoscopic approach was 

observed (14% in 1999, 37% in 2000, 47% in 2001, 49% in 2002, 

62% in 2003, 68% in 2004). 36 cases (4%) were recurrences of 

earlier cases in the series; 9 (25%) occurred after laparoscopic 

and 27 (75%) after open repairs. 

Conclusions: This review confirms previously reported clinical 

benefits of laparoscopic ventral hernia repair. Higher supply 

cost, and longer OR time are anticipated contributors to total 

cost of the procedure, but are offset by significantly shorter 

hospitalization. A more detailed analysis of clinical outcomes, 

as well as patient and surgeon satisfaction is necessary to 

delineate the reason for the clear evolution toward laparoscopic 

treatment of incisional hernia. 

S025 

SAGES BARIATRIC SURGERY OUTCOME INITIATIVE, Ninh T 

Nguyen MD, Bruce Schirmer MD,Bruce M Wolfe MD,William 

Traverso MD, University of California, Irvine Medical Center, 

Orange, CA 


The recent initiative of Centers of Excellence in bariatric surgery 

calls for documentation of surgeon?s outcome. The 

SAGES Outcome Initiative is a national database introduced in 

1999 as a method for surgeons to accumulate and compare 

their data to summary national data. A bariatric-specific 

dataset was later established in 2001. The aim of this study 

was to review the SAGES bariatric surgery outcome data 

accrued from 2001-2004 and compared to data derived from a 

national administrative database. 

The SAGES Bariatric Outcome Initiative is a prospective online 

database available to all SAGES members. The University 

HealthSystem Consortium (UHC) is an administrative database 

of academic centers and affiliate teaching hospitals. Using ICD- 

9 procedural and diagnosis codes, we identified all hospitalizations 

during which a bariatric procedure was performed in 

2003. 

The SAGES Bariatric-specific Outcome Initiative provides valuable 

data that are not currently available in an administrative 

database and can be utilized for benchmarking purposes. 

However, the use of this database is currently underutilized. 

S026 

MODERATE WEIGHT LOSS PRODUCES SIGNIFICANT 

IMPROVEMENT IN COMORBID CONDITIONS AFTER LAPARO- 

SCOPIC ADJUSTABLE GASTRIC BANDING, Sergey Lyass MD, 

Scott A Cunneen MD,Masanobu Hagiike MD,Monali Misra 

MD,Miguel Burch MD,Theodore M Khalili MD,Gary Furman 

MD,Edward H Phillips MD, Cedars-Sinai Medical Center, Los 

Angeles, California 

Laparoscopic adjustable gastric banding (LAGB) has gained a 

wide popularity outside the US due to the low postoperative 

morbidity and considerable weight loss. Studies in the US 

have failed to reproduce these outcomes. Studies showed conflicting 

results regarding the reduction of comorbidities and 

weight loss. 

Objective. To assess weight loss and changes in comorbid 

conditions one year after LAGB. 

Patients and Methods. Of the 255 patients (pts) who underwent 

LAGB 126 were followed for at least 12 months. Weight 

loss, changes in co-morbidities and BAROS scores were concurrently 

collected and retrospectively analyzed using multiple 

linear regression. 

Results. There were 32 males and 94 females with a mean age 

of 45±12 (19-70). Preop weight was 300±58 lbs, (199-487), with 

BMI of 48±7, (34-68). 112 pts (89%) had at least one comorbid 

condition (mean 2.6±1.7, 1-6). Excess body weight loss year 

after operation was 37±17% (range 0-102). Of the 326 comorbid 

conditions 236 (72.4%) resolved completely or significantly 

improved one year after operation and 90 (27.6%) remained 

unchanged. (Table) 

BAROS score was more than 4 (good/excellent outcome) in 66 

pts (52%), 1 to 3 (fair outcome) in 43 pts (34%), and less than 1


(failure) in 17 pts (14%). Weight loss was more substantial in 

the pts with lower preop BMI and was not related to age (b=(- 

)0.8, p=0.0003, 95%CI ()1.15 to ()0.35; b=(-)0.2, 

p=0.2, 95%CI ()0.4 to ()0.08 respectively). BAROS 

scores were found to be not related to both preop BMI and 

age (b= 0.01, p=0.7; b= (-)0.01, p=0.2, respectively).Conclusion: 

Moderate weight loss associated with LAGB at one year of follow 

up produced improvement in QOL and substantial reduction 

of comorbidities in the majority of pts. Diabetes, hypertension, 

GERD and coronary artery disease completely resolved 

or significantly improved in more than 75% of the pts. 

Reduction of co-morbidities and improvement of QOL can be 

anticipated in pts with any preop weight and age. 

S027 

LAPAROSCOPIC ADJUSTABLE GASTRIC BAND IN SUPER 

MORBIDLY OBESE PATIENTS (BMI >50): A PROSPECTIVE, 

COMPARATIVE ANALYSIS, Wilbur B Bowne MD, Kell Julliard 

MS,Armando E Castro MD,Palak Shah MD,Craig B Morgenthal 

MD,Emad Kandil MD,Abel Gonzalez MD,Anthony J Acinapura 

MD,George S Ferzli MD, Department of Surgery, SUNY-Health 

Science Center of Brooklyn and Lutheran Medical Center, 

Brooklyn, NY 

INTRODUCTION: The advantages of laparoscopic adjustable 

gastric banding (LAGB) are well known. We review our experience 

with emphasis on outcome compared to the standard 

laparoscopic Roux-en-Y gastric bypass (RYGBP).METHODS: A 

prospective database identified patients who underwent operative 

management for severe obesity between February 2001 

and June 2004. The study group included super morbidly 

obese patients (BMI > 50) following LAGB and RYGBP. 

RESULTS: 315 patients underwent operative management for 

severe obesity. Among 108 patients with super morbid obesity, 

55 (51%) and 53 (49%) underwent LAGB and RYGBP, respectively. 

Overall median follow-up was 14 months (range, 1- 43 

months). Preoperative factors of patient age, gender, BMI, and 

medical comorbidity were similar between the 2 groups. 

Compared to RYGBP, LAGB patients had a greater incidence of 

late complications, reoperations, less weight loss, and 

decreased overall satisfaction. 

CONCLUSIONS: In super morbidly obese patients LAGB is significantly 

associated with more late complications, reoperations, 

less weight loss, and patient dissatisfaction compared to 

RYGBP. Further evaluation of LAGB in this patient population 

appears warranted. 

S028 

US EXPERIENCE WITH 760 LAPAROSCOPIC ADJUSTABLE 

GASTRIC BANDS: INTERMEDIATE OUTCOMES, Manish S 

Parikh MD, George A Fielding MD,Christine J Ren MD, New 

York University School of Medicine, Department of Surgery 

Laparoscopic adjustable gastric band (LAGB) has been consistently 

shown to be a safe and effective treatment for morbid 

obesity, especially in Europe and Australia. Data from the US 

regarding the LAGB has been insufficient. This study reveals 

our experience with 760 primary LAGB over a 3-year period. 

All data was prospectively collected and entered into an electronic 

registry. Characteristics evaluated for this study include 

pre-operative age, BMI, gender, race, conversion rate, operative 

time, hospital stay, percent excess weight loss (%EWL) 

and post-operative complications. Annual esophagrams were 

performed. 

From July 2001 through September 2004, 760 patients (540 

females, 220 males) underwent LAGB for the treatment of 

morbid obesity, including 640 Caucasians, 61 African- 

Americans, and 48 Latin Americans. Mean age was 42 years 

+/- 11 (range 13,72) and mean BMI was 45.9 +/- 7 (range 30, 

91.5). There was one conversion to open (0.01%). Median 

operative time and hospital stay were 55 minutes and 24 

hours, respectively. The mean %EWL at 1 year, 2 years, and 3 

years was 44.6 +/- 17.6. 52.3 +/- 19.1, and 51.6 +/- 18.4, respectively. 

There were no mortalities. Post-operative complications 

occurred in 13% of patients: 2.6% gastric prolapse (?slip?), 

2.1% concentric pouch dilatation (without slip), 1.4% acute 

post-operative band obstruction, 1.4% port/tubing problems, 

1.1% overall band removal, 0.79% wound infection, 0.79% 

aspiration pneumonia, 0.66% port infection/abscess and 0.03% 

severe esophageal dilatation (reversible). 

These American results substantiate the data from abroad that 

LAGB is a safe and effective treatment for morbid obesity. 

S029 

BANDED ROUX-EN-Y GASTRIC BYPASS AS A REVISIONAL 

PROCEDURE AFTER FAILED LAPAROSCOPIC ADJUSTABLE 

SILICONE GASTRIC BANDING, Akuezunkpa O Ude MD, Amna 

Daud MD,Daniel Davis DO,Marc Bessler, Center for Obesity 

Surgery, New York Presbyterian Hospital and Columbia 

University, New York, NY. 

Background: Laparoscopic Adjustable Silicone Gastric Banding 

(LASGB) has become an increasingly popular surgical technique 

for treatment of morbid obesity in the United States. 

Failure to achieve and maintain adequate weight loss may 

require revision to gastric bypass. We conducted a retrospective 

review of seven patients who failed to achieve adequate 

weight loss after LASGB, and were revised to a roux-en-y gastric 

bypass (RYGB) distal to a deflated, gastric band. 

Methods: We report on seven patients who presented with 

either inadequate weight loss or significant weight regain after 

LASGB. The revision consisted of deflating the existing band, 

transecting the stomach distal to the band and creating a 75 x 

150cm retrogastric, retrocolic RYGB. We have examined percent 

excess weight loss (%EWL) and complications at their 

most recent follow up visit 

Results: Between April 2000 and May 2004, 148 patients underwent 

LASGB and 14% (n=21) patients failed to achieve 25% 

EWL by 12 months. Seven female patients underwent revision 

of LASGB to RYGB. At the time of their primary procedure, the 

patients had an average Body Mass Index (BMI) of 52.6 (36.4 ? 

74.5) kg/m2. Patients lost an average of 10.8 %EWL from their 

primary procedure, resulting in a BMI at the time of revision of 

48.8 (36-66) kg/m2. After revision, patients lost an additional 

31-49% (mean=42.2) of their excess weight, resulting in a total 

%EWL of 27-60 (mean %EWL=46) from the combined surgeries. 

All patients have seen improvement or resolution of their 

co-morbidities. Two patients have undergone band adjustments 

and are continuing to lose weight. No patients were lost 

to follow up, which ranged from 3 to 46 months (mean=15). 

Conclusions: These results indicate that leaving the deflated 

band in situ and performing a RYGB distal to the band is a 

safe and effective revisional strategy. Advantages of this procedure 

include: 1) the ability to calibrate the size of the gastrojejunostomy 

over time to produce even greater weight loss; 

and 2) operating on unscarred gastric tissue which may 

decrease the high leak rates associated with reoperative 

bariatric procedures. 

S030 

ENDOSCOPIC EVALUATION OF THE GASTROJEJUNOSTOMY 

IN LAPAROSCOPIC GASTRIC BYPASS: A SERIES OF 340 

PATIENTS WITHOUT POST-OPERATIVE LEAK., Nikhilesh R 

Sekhar MD, Alfonso Torquati MD,Rami E Lutfi MD,William O 

Richards MD, Vanderbilt University, Department of Surgery 

BACKGROUND: A significant and potentially deadly complication 

of the Roux-en-Y Gastric Bypass is leakage from the gastrojejunostomy 

(GJ). The aim of our study was to evaluate the 

efficacy of intraoperative endoscopy in preventing postoperative 

anastomotic leakage. 

METHODS: The study enrolled 340 consecutive patients undergoing 

laparoscopic gastric bypass procedures performed from 

1/2001 to 7/2004. In all cases, an endoscopist performed video 

gastroscopy to evaluate the integrity of the GJ using air insufflation 

of the pouch after distal clamping of the Roux limb. 

Intraoperative leaks were repaired and the anastomosis was 

retested. Demographic, operative, and endoscopic data were 

http://www.sages.org/ 


89



collected and analyzed. Logistic regression was used in both 

univariate and multivariate modeling to identify independent 

preoperative variables associated with the presence of intraoperative 

leak Model parameters were estimated by the maximum-likelihood 

method. From these estimates, odds ratios 

(OR) with 95 % confidence intervals (CI) were computed. 

RESULTS: There were no postoperative anastomotic leaks or 

mortalities in our series. Overall, endoscopic evaluation of the 

GJ resulted in the detection of 56 intraoperative leaks (16.4%). 

There was a significant difference in the incidence of intraoperative 

leakage for patients older than 40 (21%) vs. those 

younger than 40 (10.5%; P=0.01). In the initial 91 cases, the GJ 

was performed by the EEA technique; the subsequent 249 

were performed with a combination of GIA and handsewn 

technique. There was a trend toward more leakage in the GIA 

group (18%) vs EEA (12%), however the difference was not significant 

(P=0.188). Age remained an independent risk factor for 

leak detected intra-operatively in the multivariate logistic 

regression model after adjusting for covariates. An age greater 

than 40 increased the risk of intraoperative leakage by 2.3 

times (OR 2.3; 95% CI: 1.2-4.6; P=0.01). The rate of postoperative 

anastomotic stricture was the same among patients 

detected with an intra-operative leak (5.4%) and those without 

(5.6%; P=0.934). 

CONCLUSION: Endoscopic evaluation of the GJ is a sensitive 

and reliable technique for demonstrating anastomotic integrity 

and preventing postoperative morbidity after gastric bypass. 

Age greater than 40 was identified as an independent risk factor 

for intra-operative leak in this series. 

S031 

GASTROJEJUNOSTOMY STENOSIS FOLLOWING LAPARO- 

SCOPIC ROUX-EN-Y GASTRIC BYPASS: 21 VS. 25-MM CIRCU- 

LAR STAPLER, Jon C Gould MD, Michael J Garren MD,James 

R Starling MD, Department of Surgery, University of 

Wisconsin, Madison 

Introduction: Stenosis of the gastrojejunostomy after laparoscopic 

Roux-en-Y gastric bypass is a common occurrence. The 

incidence varies widely among case series reported in the literature. 

Using a circular stapler with a larger internal diameter 

to create the gastrojejunostomy should result in a lower incidence 

of stenosis when compared to a stapler with a smaller 

diameter. 

Methods: Our initial technique for constructing the gastrojejunostomy 

in laparoscopic gastric bypass involved the use of a 

21-mm circular stapler (Group 1). The anvil was placed in the 

stomach through a gastrotomy prior to creation of the pouch. 

After a large initial experience, we switched to a 25-mm circular 

stapler (Group 2). The rest of our surgical technique did not 

change. Stenosis was confirmed by endoscopy in patients 

complaining of the inability to eat or excessive vomiting. 

Stenosis was defined as an internal gastrojejunostomy diameter 

less than that of a therapeutic endoscope (11-mm). All data 

was entered prospectively in a computerized database. 

Results: Group 1 consists of our first 145 consecutive patients. 

Stenosis occurred in 23 patients (15.9%) at a mean interval of 

7.5 weeks (range 5-12 weeks). A mean of 1.7 dilations (range 

1-3) were required to correct the stenosis. Group 2 consists of 

53 consecutive patients with a 25-mm circular stapled gastrojejunostomy 

and at least 12 weeks follow-up. There were 2 

patients who developed stenosis (3.8%, p=0.04). Each of these 

patients underwent endoscopic dilation at 6 weeks and 

responded to a single dilation. Patient groups were equal in 

BMI (Group 1: 49.8+/-7.0 kg/m2 vs. Group 2: 50.8+/-6.1, p=0.26), 

gender distribution (83% female vs. 87%, p=0.57), and age 

(44.0+/-10.6 years vs. 44.2+/-10.7, p=0.85). 

Conclusions: The use of a 25-mm circular stapler in laparoscopic 

gastric bypass results in a significant decrease in the 

incidence of stenosis when compared to gastric bypass with a 

21-mm stapler. Extended follow-up will be required to determine 

if weight loss is similar with each technique. 

S032 

CRITICAL ANALYSIS OF PERIOPERATIVELY-PLACED VENA 

CAVA FILTERS FOR GASTRIC BYPASS SURGERY, Alfredo M 

Carbonell DO, Eric J DeMaria MD,John M Kellum MD,James 

W Maher MD,Luke G Wolfe MS,Harvey J Sugerman MD, 

Minimally Invasive Surgery Center at the Virginia 

Commonwealth University Medical Center, Richmond, VA 

Optimal prophylaxis for thromboembolism prevention following 

obesity surgery remains poorly defined. We analyzed our 

experience with obese patients undergoing gastric bypass 

(GB) who had perioperatively placed vena cava filters to determine 

the impact of this preventive strategy on pulmonary 

embolus (PE) and define optimal patient selection for this procedure. 

The bariatric database was queried for patients who 

had undergone an open or laparoscopic GB or revision and a 

perioperatively placed vena cava filter. Data was analyzed 

using standard statistical methods and multivariate analysis 

(Odds Ratio=OR). Since 1984, 3,742 GB procedures were performed; 

161 patients received cava filters prior to surgery 

(n=21, 13%), intraoperatively (n=120, 75%), or postoperatively 

(n=20, 12%). Among patients with previous filters, 33% had a 

previous PE history. No patient had a PE after GB in this 

group. In the group undergoing filter placement after GB, 45% 

were placed after a PE (two, ultimately fatal), and 55% were 

placed for other reasons. Intraoperative filters were placed at 

the time of GB due to a prior history of PE in 8%. Multivariate 

analysis of independent variables predicting selection of 

patients for filter placement coincident with GB confirmed criteria 

used by many bariatric surgeons to select high risk 

patients. These include patients with venous stasis ulcers (OR 

4.85,p


tive day #1. There were two post-operative complications. One 

patient required stimulator repositioning due to discomfort 

and another required stimulator explantation for overlying skin 

erosion after abdominal wall trauma. Patients experienced a 

significant decrease in nausea and vomiting as measured by 

the GI symptomatology questionnaire. Half of all patients no 

longer require prokinetic medications, and there was a subjective 

reduction of GERD symptoms, early satiety and epigastric 

pain. A significant increase in quality of life as measured by 

the Rand 36 Health Survey was seen, and six of eight patients 

no longer demonstrated gastroparesis on GES. 

CONCLUSION: Laparoscopic implantation of an electrical stimulation 

device is a safe and effective treatment for the management 

of medically refractory gastroparesis. 

S035 

ENDOSCOPIC RETROGRADE CHOLAGIOPANCREATOGRAPHY 

AND GASTRODUODENOSCOPY AFTER ROUX-EN-Y GASTRIC 

BYPASS, Larissa Guerrero BS, Jose Martinez MD,Patricia 

Byers MD,Peter Lopez MD,Brian J Dunkin MD, University of 

Miami Department of Surgery 

Background: One concern in performing Roux-en-Y gastric 

bypass (RYGB) for morbid obesity is that subsequent endoscopic 

evaluation of the gastric remnant and duodenum is difficult. 

By gaining percutaneous access to the gastric remnant, 

however, gastroduodenoscopy as well as endoscopic retrograde 

cholangiopancreatography (ERCP) can be easily performed. 

This report describes the results of a novel technique 

for performing ?trans-gastrostomy? gastroduodenoscopy and 

ERCP. 

Methods: Four patients with a RYGB for morbid obesity underwent 

trans-gastric remnant endoscopic evaluations. The 

patients had gastrostomy tubes placed into their gastric remnants 

by interventional radiology. The tube tracts were then 

sequentially dilated over time to 24F. At the time of endoscopy, 

the gastrostomy tube was removed, skin anesthetized, and 

either a pediatric duodenoscope (outer diameter 7.5 mm) or a 

transnasal gastroscope (outer diameter 5.9 mm) was inserted 

through the gastrostomy tube tract. 

Results: All patients were successfully evaluated. The first 

patient had a dilated common bile duct after RYGB; ERCP and 

sphincterotomy was done for papillary stenosis. The second 

patient presented with a dilated gastric remnant on CT scan; 

endoscopic evaluation of the gastric remnant and duodenum 

ruled out recurrence of a duodenal tumor which had been previously 

resected. The third patient had a nuclear medicine 

scan with a localized bleed to the gastric remnant; a healing 

pre-pyloric ulcer was seen and biopsied during endoscopy. 

The fourth patient necessitated endoscopy to evaluate a prepyloric 

ulcer with history of bleeding; endoscopy was successful 

and the ulcer was biopsied. 

Conclusion: The trans-gastrostomy endoscopic route assures 

access to the excluded stomach and proximal small bowel 

post RYGB. Studies of transoral endoscopic access to the duodenum 

after gastric bypass have reported 60-80% success 

rates when using a retrograde approach; the success rate is 

even less as the alimentary and biliopancreatic limbs become 

longer. Another disadvantage of the retrograde approach is 

the use of an enteroscope or pediatric colonoscope without an 

elevator for performing ERCP. These longer scopes also render 

a number of ERCP tools useless. By contrast, the trans-gastrostomy 

endoscopic route is safe and effective and the use of 

standard duodenoscopes should improve the cannulation success 

rate during ERCP in these patients. 

S036 

DEVELOPMENT OF A TOTAL COLONOSCOPY MODEL IN RATS 

FOR THE STUDY OF COLORECTAL CANCER, Chris Haughn 

MD, Miro Uchal MD,Sam Rossi MD,Yannis Raftopoulos 

MD,Yunus Yavuz MD,Ronald Mårvik PhD,Roberto Bergamaschi 

PhD, Minimally Invasive Surgery Center, Allegheny General 

Hospital, Pittsburgh, PA 

Experimental models of solid colorectal tumor either require 

laparotomy for induction and/or an anastomosis following 

resection. The long murine cecum avoids the need for an 

anastomosis making cecum the preferred site for induction. 

This study aims to evaluate total colonoscopy with sub mucosal 

injection of cecal wall (TC) in rats in terms of failure rates 

(FR), complication rates (CR) and reproducibility (R). 

This protocol was approved by IACUC. A gastric bolus of 

bowel prep was given. Anesthesia was injected s.c.. A video 

fiberscope (5.9-mm outer diameter, 180°/90° up/down bending, 

100°/100° right/left bending, 103-cm working length, 120° view 

field, 2.0-mm channel) (GIF-XP160, Olympus) allowed for irrigation, 

and suction. 1-ml saline was injected in cecal wall thru 

a 2-mm 23-G needle placed on a 2-mm wire (NM 23L, 

Olympus) resulting in a visible blister. FR was defined as failure 

to reach and inject the cecum. Rats were allowed to recover. 

CR was measured at necropsy. R was assessed by comparing 

TC time, FR and CR for 3 operators. The sample size of 120 

(type I error = 0.05 , power=80%) was based on the outcome of 

a pilot study of TC in 152 rats. Data were presented as median 

(range). Chi square, Fisher?s exact, or Student?s t-tests were 

used for analysis. 

2 of122 rats (1.6%) died after prep or anesthesia. Bowel prep 

resulted in a 99.3% evacuation of solid feces. 120 male 

Sprague-Dawley retired breeders weighing 592 (349-780) gr 

underwent TC. Scope depth was 28 (20-36) cm. Irrigating fluid 

was 290 (100-600) ml. TC time was 7 (4-28) min. FR was 4%. In 

3 failed cases the scope reached the ascending colon. TC was 

re-attempted with success in these 3 failed cases 1 week after 

failed TC. CR was 2%. There were 2 perforations in the ascending 

colon. In these 2 rats bowel perforation accounted for FR. 

All 3 operators had similar TC time (p = 0.673), FR (p > 0.1) and 

CR (p > 0.1). 98.3% of rats survived to planned sacrifice. No 

other complications were found at necropsy. 

A reproducibile in vivo rat model has been achieved. This total 

colonoscopy model with sub mucosal injection of cecal wall 

should provide a valuable tool in the future for studies of solid 

colorectal tumors. 

S037 

LAPAROSCOPIC-ASSISTED TRANSGASTRIC ERCP AFTER 

ROUX-EN-Y GASTRIC BYPASS: TECHNIQUE AND RESULTS, 

Brian Lane MD, Samer Mattar MD,Faisal Qureshi MD,Joy 

Collins MD,Paul Thodiyil MD,Tomasz Rogula MD,Pandu 

Yenumula MD,Laura Velcu MD,Guilherme Costa MD,George 

Eid MD,Ramesh Ramanathan MD,Adam Slivka MD,Philip 

Schauer MD, Department of MIS Surgery, University of 

Pittsburgh Medical Center 

INTRODUCTION: An emerging dilemma is the difficulty in 

obtaining endoscopic access to the biliary tract after Roux-en-y 

gastric bypass. Patients who undergo LRNYGB and resultant 

weight loss are at risk for gallstone formation and gallbladder/biliary 

disease, with a reported combined incidence of 

30%. The anatomic changes of current LRNYGB techniques 

preclude standard ERCP. There have been isolated case reports 

of transgastric and transjejunal intraoperative ERCP in 

LRNYGB patients. The purpose of this study is to review our 

results and technique in a series of lap-assisted ERCP. 

METHODS: All consecutive post LRNYGB patients having a 

lap-assisted ERCP from 9/2001 to 7/2004 were included. The 

clinical indications for ERCP, success of biliary tree cannulation, 

therapeutic interventions employed, operative technique 

details, and complications were reviewed. 

RESULTS: 7 patients were identified (6 female, 1 male), ranging 

in age from 45 to 58. The time interval from LRNYGB was 

9 months to 4 years. Indications were: obstructive jaundice (5 

patients), gallstone pancreatitis (2 patients), and bile leak (1 

patient). Preoperative workup included MRCP in each case. All 

patients underwent successful lap-assisted transgastric ERCP. 

Technical details will be presented and therapeutic maneuvers 

included: 4 sphincterotomies, 3 stone retrievals and one stent 

placement for a post-op bile leak. Complications included a 

peri-gastrostomy wound infection and a GI bleed that resolved 

with expectant treatment. 

CONCLUSIONS: Although technically complex, Laparoscopicassisted 

transgastric ERCP is feasible and safe after LRNYGB. 

These procedures will have a growing need as the national 

population of LRNYGB patients increases. 



91



S038 

DEPTH OF ENDOSCOPICALLY PLACED SUTURES ?AN EXPERI- 

MENTAL STUDY IN A HUMAN CADAVER MODEL, Markus H 

Kleemann MD, Cord Langner MD,Albrecht Müldner 

MD,Christel Weiss PhD,Bernd C Manegold MD, 1 University 

Hospital Schleswig-Holstein, Campus Lübeck, Department of 

Surgery, Lübeck, Germany; 2 Medical University Graz, Institute 

of Pathology, Graz, Austria; 3 University Hospital Mannheim, 

Surgical Endoscopy Unit, Mannheim, Germany 

Background: Endoscopic suturing devices offer interesting 

access to interventional procedures at the gastrointestinal 

tract. For the time being main indication is the endoluminal 

suturing at the gastroesophageal junction to treat gastroesophageal 

reflux disease. There is some evidence that endoluminal 

endoscopic suturing offers an alternative to the closure 

of esophageal fistulas, to the fixation of feeding tubes and 

stents in the near future. A review of the literature missed 

anatomical data, which wall layers are stitched by sutures. The 

aim of this study was to determine the depth of endoscopically 

placed sutures at the esophagus of a human cadaver model. 

Methods: Overall 62 sutures were placed in the esophagus of 

10 cadavers (complete exenterative cadaver model) at three 

different suction levels, 0,4-0,6-0,8 bar using the suturing 

machine EndoCinch® (BARD). After preparation of the esophagus 

from its mediastinal bed, all sutures were fixed in formalin 

and stained with HE for histological examination. 

Results: None of the sutures was placed in the mucosa alone, 

1.6% were found in the submucosa, 4.8% in the circular M. 

propria, 56.5% in the longitudinal M. propria and 37.0% were 

placed transmurally. At a suction level of 0.4 bar (0.6, 0.8 bar) 

0% (0%, 1.6%) were placed in the submucosa, 3.2 % (0%, 1.6%) 

in the circular M. propria, 11.0% (25.8%, 12.9%) in the longitudinal 

M. propria and 12.9% (6.5%, 17.7%) were placed transmurally. 

Conclusions: We report for the first time a systematic examination 

of the depth of endoscopically placed sutures in the 

esophagus. Most of the sutures were found in the muscular 

wall of the esophagus at a suction level of 0.6 bar. Also transmural 

placements were seen. Reduction of suction pressure 

may lead to reduction of transmural sutures. 

S040 

OBJECTIVE IMPROVEMENTS FOLLOWING FULL-THICKNESS 

GASTRIC CARDIA PLICATION FOR COMPLICATED GERD, 

Edward Lin DO, Shahriar Sedghi MD,Leena Khaitan MD,C. 

Daniel Smith MD, Emory University School of Medicine and 

Mercer University School of Medicine 

INTRODUCTION: Single full-thickness (transmural) plication of 

the proximal gastric cardia performed endoscopically has been 

proposed as a method of creating an intraluminal barrier 

against gastric reflux into the esophagus. We report 10 

patients with complicated GERD (3 with BMI > 50 and high 

dose medication requirements; 2 with hiatal hernia >2cm; 3 

failed prior antireflux surgery; 2 failed endoscopic mucosal 

suturing) who have undergone treatment with the Plicator 

device (NDO Surgical, Mansfield, Mass). METHODS: Prior to 

the procedure, all patients had objective testing (pH, 

endoscopy, contrast esophagrams, motility studies). Clinical 

outcomes were monitored for antisecretory medication use 

and symptom scores. Eight patients had objective post-procedure 

evaluations in the first 2 months after the procedure. 

Video documentation ensured consistent procedure application. 

RESULTS: Symptom scores improved for chest pain, 

heartburn, regurgitation, voice symptoms and cough in all 

patients. Complete symptom resolution in at least one category 

was observed in 70%. The reduction in medication use was 

reported in 80%, with 50% of the patients discontinuing medications 

completely. Amelioration of reflux was demonstrated 

in 6 of 8 contrast esophagrams, and 4 of 5 pH studies (3 completely 

normalized). All procedures were performed in the outpatient 

setting. There were no complications. CONCLUSIONS: 

Endoscopic full-thickness plication of the gastric cardia may 

offer surgeons another alternative for treating selected 

patients with complicated GERD. This is also the first report of 

employing endoscopic plication in patients who failed antireflux 

surgery with favorable early objective outcomes. 


S041 

THIN-LAYER ABLATION OF HUMAN ESOPHAGEAL EPITHELI- 

UM USING A BIPOLAR RADIOFREQUENCY BALLOON DEVICE 

(BARRX SYSTEM), Brian J Dunkin MD, Jose Martinez 

MD,Pablo Bejerano MD,C. Daniel Smith MD,Kenneth Chang 

MD,W. Scott Melvin MD, University of Miami, Emory 

University, University of California Irvine, Ohio State 

University 

Background: To determine the optimal treatment parameters 

for the ablation of human esophageal epithelium using a balloon-based 

bipolar radiofrequency (RF) energy electrode. 

Methods: Immediately prior to esophagectomy, subjects 

underwent EGD and ablation of 2 separate 3-cm long, circumferential 

segments of non-tumor bearing esophageal epithelium 

using a balloon-based bipolar RF energy electrode (BARRx, 

Sunnyvale, CA). Subjects were randomized to 1 of 3 energy 

density groups: 8, 10 or 12 J/cm2. RF was applied 1x proximally 

and 2x distally. Following resection, sections from each 

ablation zone were evaluated using H&E and diaphorase. 

Histological endpoints included: 1) complete epithelial ablation 

(yes/no), 2) maximum ablation depth, 3) residual ablation 

thickness after tissue slough. Outcomes were compared 

according to energy density group and 1x vs. 2x treatment. 

Results: Thirteen male subjects (age 49-85 years) with 

esophageal adenocarcinoma underwent the ablation procedure 

followed by total esophagectomy (transhiatal or Ivor- 

Lewis). Complete epithelial removal occurred in the following 

zones: 10 J/cm2 (2x) and 12 J/cm2 (1x and 2x). The maximum 

depth of injury was the muscularis mucosae; 10 and 12 J/cm2 

(both 2x). A second treatment (2x) did not significantly 

increase the depth of injury. Maximum thickness of residual 

ablation after tissue slough was only 35 mm. 

Conclusions: Complete removal of the esophageal epithelium 

without injury to the submucosa or muscularis propria is possible 

using this balloon-based RF electrode at 10 J/cm2 (2x) or 

12 J/cm2 (1x or 2x). A second application (2x) does not significantly 

increase ablation depth. This data has been used to 

select the appropriate settings for treating intestinal metaplasia 

in trials currently underway. 

S042 

PREDICTIVE FACTORS OF COEXISTING CANCER IN BAR- 

RETT’S HIGH-GRADE DYSPLASIA, Chadin Tharavej MD, Cedric 

G Bremner MD,Jeffrey H Peters MD,Steve R DeMeester 

MD,Jeffrey A Hagen MD,Guiseppe Portale MD,Tom R 

DeMeester MD, Department of Surgery, University of Southern 

California 

Background: Identification of high-grade dysplasia (HGD) in 

Barrett?s esophagus has been considered to be an indication 

for esophagectomy because of the high risk of coexisting cancer. 

However, rigorous endoscopic surveillance programs have 

recently been recommended, reserving esophagectomy for 

patients in whom cancer is identified on biopsy. This approach 

risks continued surveillance in patients who already have cancer, 

unless reliable markers for the presence of occult cancer 

are identified. The aim of this study was to determine the 

endoscopic, histologic and demographic features associated 

with the presence of occult cancer in HGD patients. 

Methods: Endoscopic, histologic and demographic findings in 

29 patients who underwent esophagectomy for HGD were 

reviewed. The presence of an ulcer, nodule, stricture or raised 

area on preoperative endoscopy was noted. Results of endoscopic 

biopsies taken before resection every 2 cm along the 

Barrett’s segment were reviewed. HGD was defined as unilevel 

if the dysplasia was limited to a single biopsy and as multilevel 

if more than one level was involved. The percent length 

of columnar epithelium containing HGD was calculated by 

dividing the number of biopsies with HGD by total number of 

levels biopsied. Patients were divided into two groups according 

to the presence or absence of cancer in the resected specimens, 

and these variables were compared. 

Results: Of 29 resected specimens, cancer was identified in 

13(44.8%) and non-cancer in 16. The presence of visible 

lesions was more significantly identified in cancer than in noncancer 

group (6/13 vs 0/16, p=0.01) and the number of patients 

with multi-level HGD was higher in cancer than in non-cancer


group (8/13 vs 3/16, p=0.02). In addition, mean number of 

biopsy levels containing HGD was more identified in cancer 

than in non-cancer group (2.2+/-0.32 vs 1.26+/-0.22, p=0.02) 

and the percent length of columnar epithelium containing HGD 

was also higher in cancer than in non-cancer group (50.7+/- 

7.5% vs 27+/-4.5%, p=0.01). Median age was 72 years (IQR, 

61.5-76) for cancer group and 62 years (IQR, 61.5-76) for noncancer 

group (p=0.05). The gender and length of Barrett?s 

mucosa was not different between 2 groups. 

Conclusions: In patients with HGD, the presence of a visible 

lesion on endoscopy and the presence of HGD in multiple 

biopsy levels are associated with an increased risk of the 

occult cancer. These patients should be considered for early 

esophagectomy. 

S043 

PER-ORAL TRANSGASTRIC ENDOSCOPIC SPLENECTOMY 

√ IS IT POSSIBLE?, Sergey V Kantsevoy MD, Bing Hu 

MD,Sanjay B Jagannath MD,Cheryl A Vaughn RN,Mark A 

Talamini MD,Anthony N Kalloo MD, Johns Hopkins University 

School of Medicine 

BACKGROUND: We have previously reported the feasibility of 

diagnostic and therapeutic peritoneoscopy including liver 

biopsy, gastrojejunostomy and tubal ligation by a per-oral 

transgastric approach. We now present results of per-oral 

transgastric splenectomy in a porcine model. AIM: To determine 

the technical feasibility of per-oral transgastric splenectomy 

using a flexible endoscope. METHODS: We performed 

acute experiments on 50-kg pigs. All animals were fed liquids 

for 3 days prior to procedure. The procedures were performed 

under general anesthesia with endotracheal intubation. The 

flexible endoscope was passed per-orally into the stomach and 

puncture of the gastric wall was performed with a needle-type 

sphincterotome. The puncture was extended to create a 1.5-cm 

incision using a pull-type sphincterotome and a double-channel 

endoscope was advanced into the peritoneal cavity. The 

peritoneal cavity was insufflated with air through the endoscope. 

The spleen was visualized. The splenic vessels were ligated 

with endoscopic loops and then mesentery was dissected 

using blunt electrocautery. RESULTS: Endoscopic splenectomy 

was performed on 3 pigs. There were no complications during 

gastric incision and entrance into the peritoneal cavity. The 

visualization of the spleen and other intraperitoneal organs 

was very good. Ligation of the splenic vessels and mobilization 

of the spleen was easily achieved using already commercially 

available devices and endoscopic accessories. The 

spleen was then removed in toto without significant bleeding. 

All animals remained hemodynamically stable during splenic 

removal. 

CONCLUSION: Transgastric endoscopic splenectomy in a 

porcine model appears technically feasible. Further long-term 

survival experiments are planned. 

S044 

THE ROLE OF TELEMENTORING AND TELROBOTIC ASSIS- 

TANCE IN THE PROVISION OF LAPAROSCOPIC COLORECTAL 

SURGERY IN RURAL AREAS, Herawaty Sebajang MD, Patrick 

Trudeau MD,Allan Dougall MD,Susan Hegge MD,Craig 

McKinley MD,Mehran Anvari PhD, Centre for Minimal Access 

Surgery, McMaster University, Hamilton Ontario Canada; 

Centre Hospitalier de la Sagami, Chicoutimi Quebec Canada; 

North Bay District Hospital, North Bay Ontario Canada 

PURPOSE: The aim of this study was to assess whether telementoring 

and telerobotic assistance would improve the range 

and quality of laparoscopic colorectal surgery being performed 

by community surgeons. 

METHODS: We present a series of 18 patients who underwent 

telementored or telerobotically assisted laparoscopic colorectal 

surgery in two community hospitals between December 

2002 and December 2003. Four community surgeons with no 

formal advanced laparoscopic fellowship were assisted by an 

expert surgeon from a tertiary care center. Telementoring was 

achieved with real time two way audio-video communications 

over various bandwidths and it included 1 redo ileocolic resection, 

2 right hemicolectomies, 2 sigmoid resections, 3 low 

anterior resections, 1 subtotal colectomy, 1 reversal of 

Hartmann and 1 abdomino-perineal resection. A Zeus TS 

microjoint system (Computer Motion Inc, Santa Barbara CA) 

was used to provide telepresence for the telerobotically assisted 

laparoscopic procedures: 3 right hemicolectomies, 3 sigmoid 

resections and 1 low anterior resection. 

RESULTS: There were no major intraoperative complications. 

There were two minor intraoperative complications involving 

serosal tears of the colon from the robotic graspers. In the 

telementored cases, there were two postoperative complications 

requiring reoperation (intraabdominal bleeding and small 

bowel obstruction). Two telementored procedures were converted 

because of the mentee?s inability to find the appropriate 

planes of dissection. One telerobotically assisted procedure 

was completed laparoscopically with telementoring from 

the expert surgeon. The median length of stay was 4 days. The 

surgeons considered telementoring useful in all cases (median 

score 4 out 5). The use of remote telerobotic assistance was 

also an enabling tool. 

CONCLUSION: Telementoring and remote telerobotic assistance 

is an excellent tool for supporting community surgeons 

and providing better access to advanced surgical care. In the 

future, Telesurgery may cut health care costs by proving a way 

to export medical expertise. 

S045 

MOBILE IN VIVO ROBOTS CAN ASSIST IN ABDOMINAL 

EXPLORATION, Mark E Rentschler MS,Jason Dumpert 

MS,Stephen R Platt PhD,Shane M Farritor PhD, Dmitry 

Oleynikov MD, University of Nebraska - Lincoln, University of 

Nebraska Medical Center 

In vivo robot-assisted laparoscopy offers distinct benefits compared 

to conventional robot-assisted laparoscopic approaches. 

These remotely controlled miniature robots provide the surgeon 

with an enhanced field of view from multiple angles and 

in the near future they will provide dexterous manipulators not 

constrained by small incisions in the abdominal wall. We created 

remotely controlled mobile robots that can traverse the 

abdominal organs, while providing video and sensor feedback 

of the abdominal cavity from multiple, unobstructed angles. 

The miniature mobile robots were equipped with a camera 

and environment sensors that provided real-time measurements 

of temperature, humidity, and pressure. These robots 

were inserted through a small incision into the insufflated 

abdominal cavity of an anesthetized pig. Then, the mobile 

camera robot was used to visualize trocar insertion and other 

laparoscopic tool placements. Next, the mobile robots traversed 

the abdominal organs as the surgeon explored the 

abdominal environment. Finally, during the cholecystectomy, 

the robot provided the surgeon with several different views of 

the gallbladder. 

These robots have shown that in vivo robots can overcome 

some of the limitations of current rigid, single view cameras. 

The robots were not confined by the entry point, and were free 

to move around the abdominal cavity to attain optimal camera 

angles and sensor readings. This approach limited the procedure 

to two incisions, allowed ease of exploration before the 

cholecystectomy and helped improve orientation and define 

depth during the cholecystectomy. Future work will provide a 

mobile manipulator that will provide task assistance which will 

enhance the capabilities of the surgeon. The outcome will be 

that patient trauma during laparoscopic abdominal surgery 

will be reduced to a single entry port where the robots are 

inserted into the abdominal environment. 

S046 

VIRALLY-DIRECTED FLUORESCENT IMAGING (VFI) CAN 

FACILITATE ENDOSCOPIC STAGING AND MINIMALLY INVA- 

SIVE CANCER SURGERY, Prasad S Adusumilli MD, David P 

Eisenberg MD,Brendon M Stiles MD,Stephen F Stanziale 

MD,Mei-Ki Chan BS,Michael Hezel BS,Rumana Huq BS,Valerie 



93


W Rusch MD,Yuman Fong MD, Department of Surgery and 

Molecular Cytology, Memorial Sloan-Kettering Cancer Center, 

New York, NY. 

Introduction: The replication-competent, tumor specific, genetically 

engineered herpes simplex virus NV1066 carries the 

transgene for green fluorescent protein (GFP). NV1066 infected 

cancer cells express GFP that can be detected by fluorescence 

endoscopy. We sought to determine the feasibility of GFPguided 

imaging technology in the intraoperative detection of 

small tumor nodules in the gastrointestinal lumen, solid 

organs, pleural and peritoneal cavities. 

Methods: Sixty-four human cancer cell lines originating from 

12 primary organs were infected with NV1066 at a multiplicity 

of infection (MOI, number of viral particles per tumor cell) of 

0.01, 0.1 and 1. Cancer cell specific infectivity, vector spread 

and GFP signal intensity were measured by flow cytometry 

and time-lapse digital imaging (in vitro); and by use of a stereomicroscope 

and laparoscope equipped with a fluorescent filter 

(in vivo). Selective infection of tumor nodules by NV1066 

was confirmed by RT-PCR for the viral marker gene ICP0 and 

GFP expression by fluorimetry. 

Results: In vitro, in all cell lines, NV1066 infected and 

expressed GFP at all MOIs. GFP signal was detected as early 

as 4-6 hours following infection. By 96 hours, 87±11% of the 

infected cells were positive for GFP. GFP signal intensity of 

infected cells was significantly higher than the autofluorescence 

of normal cells (230 - 670 logs) and uninfected tumor 

cells (43 ? 69 logs). In vivo, one single dose of intrapleural or 

intraperitoneal NV1066 spread within and across these cavities 

and selectively infected tumor nodules within 72 hours. 

Macroscopically undetectable tumor nodules (< 1 mm) by conventional 

laparoscopy were identified by GFP fluorescence as 

early as twelve hours after treatment. NV1066 selectively 

infected tumor nodules sparing normal tissue, as confirmed by 

RT-PCR for ICP0 and by fluorimetry for GFP protein. 

Conclusion: We have demonstrated that virally-directed fluorescent 

imaging (VFI) can be used for real-time visualization of 

macroscopically undetectable tumor nodules. This novel 

molecular imaging technology has the potential to enhance 

the intraoperative detection of endoluminal or endocavitary 

tumor nodules. Furthermore, by incorporating an automated 

detection device that chases GFP fluorescence, future endoscopic, 

minimally invasive and robotic laser / ablation technology 

can target microscopic cancer. 

S048 

A NEW TECHNIQUE OF LAPAROSCOPIC SENTINEL NODE 

NAVIGATION SURGERY FOR EARLY GASTRIC CANCER, 

Minoru Matsuda MD, Kazuya Kato MD,Manabu Yamamoto 

MD,Motoo Yamagata MD, 2nd. Department of Surgery, 

Asahikawa Medical College, Asahikawa Japan. Pippu Clinic, 

Pippu Japan. Adachi Kyosai Hospital, Tokyo Japan, 

Department of Surgery, Nihon University School of Medicine, 

Tokyo Japan 

Recently, a sentinel node navigation surgery (SNNS) is widely 

used for the intraoperative detection of metastatic lymph 

nodes. We employ the radioisotope SNNS (RI method) from 

November 2001 to optimize the surgical treatment for early 

gastric cancer. We also started to use an infrared scope 

(Infrared Ray Electronic Laparoscope System: Olympus, Japan) 

assisted SNNS (IR method) and RI method at the same time to 

improve the navigation ability. Aim of this study is to evaluate 

the usefulness of these 2 methods in laparoscopic surgery for 

early gastric cancer. 

Patients and methods 

From November 2001 to April 2004, there were 22 early gastric 

cancer patients who underwent the laparoscopic gastrectomy 

with a help of sentinel node navigation. 

RI method: Tc-99m-phytate solution colloid was used as 

radioactive tracer. RI was injected under endoscopic control on 

1 day before the surgery. Each injection was 0.5ml (74Mbq) 

and 4 submucosal injections were made around the lesion. A 

lymph nodes scintigram was done on the same day and the 

intraoperative scan was performed by ?Á-probe (Navigator 

GPS: Tyco, USA). 

IR method: A 2ml of ICG (5mg/ml) was injected into subserosal 

layer of the lesion under laparoscopic control. The injection 



site was found by?Á-probe since RI was injected around the 

lesion as described above. Infrared laparoscopic observation 

was started 20 minutes after the injection. 

Results 

By RI method, sentinel nodes were detected in all patients and 

the average number of nodes was 5.4. The sensitivity, specificity 

and accuracy were as high as 100%. On the other hand, 

only 75% of patients were detected by IR method and the average 

number of nodes was 3.2. Its sensitivity was 50%, specificity 

was 100% and accuracy was 83%. 

Conclusions 

RI method was reliable measure to detect the sentinel node, 

however, it is difficult to find the individual node by laparoscopic 

observation. 

IR method allowed us to detect the individual node but its sensitivity 

and accuracy need to be improved. Further evaluation 

and improvement are required, however, we consider that the 

combination of these 2 methods could be realize the better 

surgical treatment for laparoscopic cancer surgery. 

S049 

EFFICAY AND SAFETY OF THE USE OF POLIDOCANOL 3 % 

MICRO-FOAM FOR THE ERRADICATION OF ESOPHAGEAL 

VARICES IN COMPARISON TO VARICEAL BAND LIGATION, 

FIRST WORLD EXPERIENCE., ROBLES D. JOSE ISRAEL MD, 

YAHUACA M. JORGE MD,GUASCO G. EDUARDO MD,DE LA 

MORA GUILLERMO, HOSPITAL ANGELES DE QUERETARO. 

MATERIAL AND METHODS: WE INCLUEDE PATIENTS WITH 

ESOPHAGIC VARICEAL BLEEDING, PATIENTS WERE HEMODI- 

NAMICALY STABLE AND THE ENDOSCOPIC PROCEDURE 

WAS PERFORMED AS AN OUT PATIENT. PATIENTS WERE 

DIVIDED IN TWO GROPUS: GROUP A FOR VARICEAL BAND 

LIGATION AND GROUP B FOR POLIDOCANOL MICRO-FOAM. 

PATIENTS WERE RANDOMIZED IN A BALANCED FASHION. 

THE ETHIOLOGY Y OF HEPATIC DISEASE WAS DIVIDED INTO 

ALCOHOLIC LIVER DISEASE, VIRAL HEPATITIS AND OTHER 

CAUSES. CHILD ?PUGH CLASIFICATION WAS USED TO 

STAGE THE HEPATIC FUNCTION. THE NUMBER OF SESIONS 

REQUIRED FOR ERRADICATION OF VARICES WAS DETER- 

MINED FOR EACH GROUP. WE REPORT A ONE YEAR FOLLOW 

PU, CONTROL EVERY EACH 3 MONTHS AND OBSERVED 

COMPLICATIONS. 

RESULTS: WE INCLUEDE A TOTAL OF 39 PATIENTS; 7 

PATIENTS WERW EXCLUEDE BECAUSE THAT DROPPED-OUT. 

FO THE REMAINING 17 WERE RANDOMIZED TO GROUP A 

AND 15 TO GROUP B. SEVENTY-FIVE PER CENT OF THE 

PATIENTS WERE MALE. AS FOR ETHIOLOGY OF HEPATIC DIS- 

EASE 81.3 % OF ALCOHOLIC LIVER DISEASE, 15.6 % HEPATIC 

VIRAL AND 3.1 % AND OTHER CAUSES. A 71.9 % OF THE 

PATIENTS WERE IN CHILD-PUGH STAGE A. THE AVERAGE 

NUMBER O SESIONS WAS 4.3 FOR GROUP A AND 4.1 FOR 

GROUP B. ( STADISTIC DIFFERENCE OF 0.9143) THE COMPLI- 

CATION RATE WAS 17.6 % IN GROUP A AND 7.1 % FOR 

GROUP B (WITH A P = 0.049). 

ANALYSIS: WE COMPARE BOTH PROCEDURES (VARICEAL 

BAND-LIGATION AN POLIDOCANOL MICRO-FOAM) THERE IS 

NOT SIFNIFICAT DIFFERENCE BETWEEN THE NUMBER OF 

SESIONS REQUIRED TO OBTAIN ESOPHAGIC VARICES 

ERRADICATION. NEVERTHELDS, WHEN WE ANALZE THE 

COMPLICATIONS IN GROUP A WE OBSERVERD DISPHAGIA, 

ESOPHAGIC ULCER WITHOUT STENOSIS DEVELOPMENT 

AND REBLEEDINGS WHITHIN A 7 DAYS PERIOD. IN GROUP B 

WE ONLY OBSERVED ORTHOSTATIC HYPOTENSION IN ONE 

PATIENT (SIGNIFCANT DIFFERENCE IN FAVOR OF GROUP B). 

CONCLUTIONS: POLIDOCANOL MICRO FOAM COULD BE ON 

USEFUL METHOD FOR ERRADICATION O ESOPHAGIC 

VARICES DEVOID OF COMPLICATIONS WHICH WERE ASSOCI- 

ATED TO POLIDOCANOL USE IN THE PAST WHICH CAUSED 

THIS PRODUCT TO BE BANNED BY FDA. 

S050 

ENDOSCOPIC TECHNIQUES TO USE THE STOMACH AND 

PERITONEAL CAVITY AS AN “ARTIFICIAL LUNG”, Joshua P 

Cantor MD,Shamus R Carr MD, Atul S Rao MD, Thiru V. 

Lakshman, Joshua E Collins BS,Tracy Sims,Vanessa Paris 

BA,Joseph S Friedberg MD, University of Pennsylvania; 

Thomas Jefferson University


INTRODUCTION: Pulmonary failure results in many deaths 

worldwide. Diseases such as ARDS, SARS, and pneumonia, 

are reversible if the victim can be kept alive and adequately 

oxygenated during the most severe stage while the underlying 

problem is treated. Current ventilatory techniques are often 

not adequate to accomplish this. Perfluorocarbons (PFC) are 

inert liquids with an extraordinary capacity to dissolve gasses 

and may be a key to patient survival under these circumstances. 

The purpose of this study was to determine if perfusing 

the peritoneal cavity or stomach with oxygenated PFC 

could augment systemic oxygen (O2) levels. If successful, this 

technique could be implemented at the bedside with endoscopic 

techniques. 

METHODS: 15 pigs weighing 45 to 55 kg were intubated and 

rendered hypoxic by ventilating them with a subatmospheric 

blend of O2 and nitrogen. Inflow and outflow catheters were 

placed in the peritoneal cavity and connected to a perfusion 

circuit including a pump, heater and oxygenator. 8 animals 

underwent peritoneal perfusion with oxygenated PFC and 7 

controls with oxygenated saline. 7 more animals were perfused 

with catheters inside the excluded stomach. ABG?s were 

collected at baseline and every 30 minutes for the duration of 

perfusion. A student?s t-test was used to compare the PaO2 at 

baseline to the PaO2 achieved during perfusion with oxygenated 

saline and oxygenated PFC. 

RESULTS: In the peritoneal perfusion group, an FiO2 of 14% 

resulted in a baseline PaO2 of 39.4±5.0, increasing to 55.3±7.6 

mmHg with oxygenated PFC perfusion (p



technique included a laparoscopic Kocher maneuver and 

stomach/hiatus mobilization, thoracoscopic esophageal mobilization 

with lymphadenectomy and cervical specimen removal 

and esophagogastric anastamosis. 

Results: One patient required conversion to open esophagectomy 

due to adhesions from a heart transplant. There were no 

deaths. Mean operative time was 5.8 hours (range: 5 ? 8 

hours). Average blood loss was 200 cc. Patients remained ventilated 

for a median of 0.5 days and the median ICU utilization 

was 1 day. Mean hospital length of stay was 9 days (range: 5 ? 

22 days). Anastamotic leaks occurred in 2 patients (treated 

with closed suction drainage), and a pyloric leak was seen in 

one patient. Minor pulmonary complications occurred in 32% 

(n = 7). Late anastamotic strictures requiring dilation were 

observed in 27% (n = 6). There was one microscopically positive 

margin in one cancer patient. 

Conclusions: Minimally invasive esophagectomy is a technically 

challenging procedure that can be safely performed in a 

community hospital setting with comparable short-term outcomes 

as a traditional open approach. Success depends on a 

multidisciplinary esophageal cancer care team that appropriately 

selects patients, performs the surgery and manages postoperative 

care. 

S064 

ROBOTIC-ASSISTED TRANSHIATAL ESOPHAGECTOMY 

(RATE), Maria V Gorodner MD, Santiago Horgan MD,C. 

Galvani MD,F. Moser MD,M. Baptista MD,A. Arnold MD,J. 

Espat MD,G. Jacobsen DO, University of Illinois at Chicago. 

Background: Esophagectomy is a technically demanding operation; 

for open procedures a mortality rate between 5% to 19% 

has been reported. The techniques for minimally invasive 

esophagectomy (MIE) were first described in 1993. 

Subsequently laparoscopic and thoracoscopic techniques have 

been limited by instrumentation. Robotic (telesurgery) instrumentation 

has the potential to advance MIE. The goal of this 

study is to report our early experience using robotic-assisted 

technology to perform RATE. 

Methods: Between September 2001 and May 2004, 18 patients 

underwent RATE at our institution. Review of prospectively 

maintained database was performed. 

Gender, age, postoperative diagnosis, operative time, conversion 

rate, blood loss, hospital stay, follow up length and complications 

were assessed. 

Results: 18 patients underwent RATE; 16 men (89%), mean age 

of 54 (41-73 years). Postoperatively, 9 patients had Barrett?s 

esophagus, 8 of them with high grade dysplasia; 3 patients 

had adenocarcinoma in situ; 5 had T1 N0 MX lesions; 1 presented 

a T2 N0 M0 lesion and 1 patient had a T3 N1 M0 lesion. 

Conclusion: this early cohort experience demonstrated RATE 

to decrease mortality rate, blood loss and hospital stay compared 

to open esophagectomy. RATE has the potential of 

becoming standard of care for the treatment of esophageal 

cancer. 

S065 

BRAVO CAPSULE INDUCES ESOPHAGEAL HYPERCONTRAC- 

TILITY AND CHEST PAIN, Chadin Tharavej MD, Chih-cheng 

Hsieh MD,Tasha A Gandamihardja MD,John Lipham 

MD,Jeffrey H Peters MD,Jeffrey A Hagen MD,Steve R 

DeMeester MD,Cedric G Bremner MD,Tom R DeMeester MD, 

Department of Surgery, University of Southern California 

Background: The Bravo catheter-free pH monitoring system 

uses a capsule attached to the esophageal mucosa to detect 

acid exposure to the esophagus. Our experience using this 

system showed that fifty percent of normal volunteers reported 

intermittent chest pain during the monitoring period. 

Therefore, we hypothesize that the Bravo capsule may induce 

hypertensive esophageal contractions which may lead to chest 

pain. 

Methods: The study group consisted of 40 consecutive 

patients with reflux symptoms who had stationary esophageal 

manometry within one hour of the Bravo capsule placement. 

The control consisted of 40 patients with reflux symptom from 

a population of 477 patients who were computer matched to 

the study group for age, sex, lower esophageal sphincter (LES) 

pressure, LES length, and 24 hour pH composite score. The 

symptom of chest pain was assessed by a standardized questionnaire. 

Distal esophageal contraction amplitudes (DEA) of 

10 wet swallows were averaged. The number of patients with 

new onset of chest pain, the number of patients whose DEA 

exceeded the 95th percentile of normal (>180 mmHg) and the 

mean amplitude of the groups were compared 

Results: The mean contraction amplitude was higher in a 

Bravo group (144.7 vs 105.5 mmHg, P=0.002).The number of 

patients with a mean contraction amplitude exceeded 95th 

percentile of normal was also significantly higher in the Bravo 

group (13/40 vs 5/40, p=0.03). Ten patients in the study group 

developed new onset of chest pain during their study. Six of 

these patients had hypertensive distal esophageal contractions. 

Conclusions: The intraesophageal Bravo capsule can cause 

hypertensive esophageal contractions which may lead to chest 

pain. 

S066 

LONG-TERM OUTCOME OF LAPAROSCOPIC REDO FUNDOPLI- 

CATIONS FOR THE TREATMENT OF GERD, Dave R Lal MD, 

Erik Jensen BS,Mark Cahill BS,Carlos A Pellegrini MD,Elina 

Quiroga MD,Brant K Oelschlager MD, Department of Surgery, 

University of Washington. 

Laparoscopic antireflux surgery is an effective treatment for 

gastroesophageal reflux disease (GERD). In a small subset of 

patients, the initial operation fails, typically resulting in recurrent 

reflux or severe dysphagia. Although redo fundoplications 

can be performed laparoscopically, few studies have examined 

their long-term efficacy. Methods: We identified from a 

prospective database all patients undergoing redo laparoscopic 

fundoplications at the University of Washington between 

1996 and 2001, and for the purpose of this study, contacted 

them for long-term follow-up. Seventy-seven patients were 

identified, 41 (53%) were contacted. Symptom questionnaires 

addressing the frequency and severity of 11 common symptoms 

and overall patient satisfaction were administered. This 

data was then compared to results obtained prior to the redo 

fundoplication. The median length of follow-up was 50 months 

(range 20-95). Results: After redo fundoplication, there was a 

significant reduction in frequency of presenting complaints, 

with the majority of patients having substantial improvement 

or complete resolution of symptoms (Table 1). The most common 

side effect was diarrhea (26 patients), in only six patients 

(23%) this was a new symptom after surgery. Overall, 68% 

rated the success of the procedure as either ?excellent? or 

?good,? and when asked whether they were happy they chose 

to have the redo procedure, 78% said ?yes.? Table 1. Symptom 

questionnaire results 

Conclusion: Although not nearly as successful as primary fundoplications, 

the majority of patients with reflux or dysphagia 

following antireflux surgery can expect a durable improvement 

in symptoms with a laparoscopic redo fundoplication. 

96 http://www.sages.org/


S067 

FIRST DECADES EXPERIENCE WITH LAPAROSCOPIC REDO 

NISSEN FUNDOPLICATION IN INFANTS AND CHILDREN, 

Steven S Rothenberg MD, Presbyterian St Lukes 

Introduction: Antireflux procedures are one of the most common 

operations performed in infants and children, but are 

associted with a relativey high failure rate often requiring revision. 

This paper evalutes the safety and efficacy of a laparoscopic 

approach fr redo fundoplication in children. 

Methods: From June1993 to September 2004 115 patients with 

recurrent GERD following fundoplication underwent a laparoscopic 

redo Nissen procedure. Ages ranged from 6 months to 

19 years and weight 6.4 to 88 kg. 65 had previous open (54 

Nissen, 10 thal, 1 Toupet) and 50 previous laparoscopic. 18 

patients had more then one previous redo. 

Results: All procedures were completed successfully laparoscopically. 

The average operative time was 100 minutes. The 

inta-operative complication rate was 1.1%. The time to full 

feeds was .8 days an average hospital stay was 2.2 days. The 

post-operative complication rate was 3.2% and the wrap failure 

rate is 6%. Six have undergone laparscopc re-revision and 

one open. All are currently intact. 

Conclusion: Laparoscopic redo Nissen fundoplication is a safe 

and effective procedure. It is associated with the same benefits 

as a primary repair with low morbidity and a shorter hospital 

stay. Early follow-up suggests the long term outcome is better 

then that associated with redo-open fundoplications. 

S068 

FOR WHICH ESOPHAGEAL DISORDERS IS COMBINED 

MANOMETRY AND IMPEDANCE MOST HELPFUL?, Leena 

Khaitan MD, Sandy Everett RN,C D Smith MD, Emory 

University School of Medicine 

Background: Multichannel intraluminal impedance (MII), a new 

technology for evaluating bolus transit through the esophagus, 

is combined with manometry to more accurately evaluate 

esophageal function (esophageal function testing or EFT). The 

aim of this study is to ascertain which patients will benefit 

from EFT monitoring versus manometry alone. Methods: 

Between December 2002, and September, 2004, all motility 

studies performed in the surgical esophageal physiology laboratory 

of Emory University were done with MII(Sandhill 

Scientific, Highland Ranch, CO) using a standard EFT probe. 

Studies were done in patients referred to surgery for evaluation 

of reflux disease or other esophageal symptom. All 

patient symptoms, study results and patient outcomes were 

recorded in a prospectively collected database. Results are 

reported as proportions. Results: During this time, 200 EFT?s 

were completed. Patient presented with dysphagia(38%), 

heartburn(50%), regurgitation(35%), chest pain(18%), and respiratory 

or laryngeal symptoms(18%). Fifty patients had at 

least one prior fundoplication. Based upon manometry, 

patients were diagnosed with achalasia(8%), nutcracker esophagus(9%), 

hypertensive LES(5%), ineffective esophageal motility 

or IEM(18%) and scleroderma(2%). The remaining patients 

had normal manometry with adequate peristalsis and contraction 

amplitudes. Abnormalities of the lower esophageal 

sphincter (LES) were noted in 30% of patients. Overall, by MII 

findings, 25% of patients had normal bolus transit despite 

poor peristalsis. On the other hand, 15% of those patients with 

normal peristalsis had poor bolus transit. Of the patients who 

complained of dysphagia, those with nutcracker esophagus or 

hypertensive LES had normal bolus transit through the esophagus. 

Those with achalasia had no bolus transport through the 

esophagus. Of patients who were post fundoplication, half 

complained of dysphagia, of which only half had completely 

normal EFT?s. Of the patients with IEM, half had abnormal 

bolus transit, however, half also had normal bolus transit 

despite poor motility. All of the patients with IEM as well as 

dysphagia had impairments of bolus transit. Conclusion: 

Combining impedance testing with traditional esophageal 

motility provides further insight into patient symptoms and 

disease primarily for those patients who are post fundoplication 

or have IEM. For other patients, esophageal manometry 

alone provides adequate evaluation of esophageal function. 



97

ABSTRACTS Friday, April 15, 2005 


S069 

RESULTS OF LAPAROSCOPIC FUNDOPLICATION AT 10 YEARS 

AFTER SURGERY, Bernard Dallemagne MD, Joseph Weerts 

MD,Constant Jehaes MD, Les Cliniques Saint Joseph 

Background: Several studies have demonstrate that laparoscopic 

antireflux surgery(LAS) is efficient at short or mid term 

follow-up for treatment of gastroesophageal reflux disease 

(GERD). The aim of this study was to evaluate the results of 

LAS at ten years after surgery. 

Methods: one hundred consecutive patients underwent LAS by 

a single surgeon in 1993 and were entered into a prospective 

database. Nissen fundoplication was performed in 68 patients; 

partial posterior fundoplication (modified Toupet procedure) 

was performed in 32 patients. Evaluations of the outcome 

were made at five years and ten years after surgery. A structured 

symptom questionnaire and upper GastroIntestinal barium 

series were used at 5 years. The same questionnaire and a 

quality of life questionnaire (Gastrointestinal Quality of Life 

Index: GIQLI) were used at 10 years. 

Results: Seven patients died from unrelated causes during the 

10 years period of time. Four patients underwent revision surgery: 

one patient for persisting dysphagia, three for recurrent 

reflux symptoms. Three patients are lost for any follow-up 

study. 

At five years, 93% of patients were free from significant reflux 

symptoms; at 10 years, 88% (91.8 % after Nissen, 78.2% after 

Toupet procedure) of patients were still free from significant 

reflux. Major side effects were related to ?wind?problems: flatulence, 

abdominal distension. They were reported by 60 % of 

patients at 5 years and decreased to 30% at 10 years followup. 

GIQLI scores at 10 years were significantly improved compared 

to the preoperative scores. 

Conclusions: elimination of GERD symptoms improved quality 

of life and eliminates the need for daily acid suppression in 

most patients. These results were apparent 5 years after the 

operation and were still valid 10 years later. 

S070 

HEATING AND HUMIDIFYING OF CARBON DIOXIDE DURING 

PNEUMOPERITONEUM IS NOT INDICATED: A PROSPECTIVE 

RANDOMIZED TRIAL., D J Mikami MD, M E Newlin MD,B J 

Needleman MD,M S Barrett MD,R B Fries MD,T B Larson BA,J 

M Dundon BS,M I Goldblatt MD,S S Davis MD,W S Melvin MD, 

The Ohio State University, Center for Minimally Invasive 

Surgery. 

Background: Carbon dioxide (CO2) pneumoperitoneum is usually 

created by a compressed gas source. This exposes the 

patient to cool dry gas, which has a temperature of 22 C and 

0% relative humidity. Various delivery methods are available to 

humidify and heat CO2 gas. We designed a study to determine 

the effects of dry and heated humidified gas in the intraabdominal 

environment. 

Methods: Forty-four patients undergoing laparoscopic Rouxen-Y 

gastric bypass were randomly assigned to one of four 

arms in a prospective, randomized, single blinded fashion: 

(g1): raw CO2, (g2): heated CO2, (g3): humidified CO2 and (g4): 

heated humidified CO2. A commercially available CO2 heater 

humidifier was used. Perioperative bladder temperature, intraabdominal 

humidity, operative time, volume CO2 used and 

lens fogging were monitored. Peritoneal biopsies were taken 

on 3 patients in each group, one at the beginning of the case 

and one prior to closure. Biopsies underwent H and E and 

Mason-trichrome histological staining as well as myloperoxidase 

and CD-68 immunohistochemical assays. Post-operative 

narcotic use and pain scale scores was recorded. The ANOVA 

test was used to compare groups. A p-value of less than 0.05 

was deemed significant. 

Results: Demographics, volume CO2 used, intra-abdominal 

humidity, bladder temperature, lens fogging and operative 

time were not significantly different. Overall mean operative 

times for all 4 groups were 84.5 minutes. Bladder temperatures 

after 60 minutes were (g1) 36.3 C, (g2) 36.3 C, (g3) 36.2 C 

and (g4) 36.3 C. Intra-abdominal humidity measured 100 % for 

all patients over the entire procedure. Total narcotic dosage 


and pain scale score showed no significant difference. Only 

one biopsy in the heated humidified group showed an 

increase in macrophage activity. Costs were $5 for standard 

tubing and $120 for heated humidified tubing. 

Conclusions: The intra-abdominal environment with respect to 

temperature and humidity showed no difference in all four 

groups. There was no significant difference in intra-operative 

body temperature, post-operative pain medication used or 

post-operative pain score. No histological or immunohistochemical 

changes were identified. Heating or humidifying CO2 

is not justified for patients undergoing laparoscopic surgery. 

S072 

IMPAIRED ESOPHAGEAL FUNCTION IN MORBIDLY OBESE 

PATIENTS WITH GERD: EVALUATION WITH MULTICHANNEL 

INTRALUMINAL IMPEDANCE, E Quiroga, F Cuenca-Abente,D 

Flum,E P Dellinger,B K Oelschlager, The Swallowing Center. 

Department of Surgery, University of Washington, Seattle, WA 

Morbid obesity is associated with GERD, and both have an 

independent association with motility disorders. Impaired 

esophageal function can play a role in the development of dysphagia 

after fundoplications and bariatric procedures (especially 

restrictive procedures). Multichannel intraluminal impedance 

(MII) evaluates the effective clearance of a swallowed 

bolus through the esophagus, thus in combination with 

manometry may be able to identify patients at risk for postoperative 

dysphagia. 

Material and Method: We performed simultaneous MII, 

manometry, and pH monitoring in 10 asymptomatic subjects, 

22 consecutive non-obese patients with GERD (GERD) and 22 

consecutive morbidly obese patients with GERD (MO-GERD) 

being evaluated for antireflux and bariatric surgery at the 

University of Washington. MII was defined as abnormal if less 

than 80% of swallowed liquid boluses cleared the esophagus 

completely. 

Results: All GERD and MO-GERD patients had abnormal pH 

monitoring. There were similar manometric findings between 

the GERD and MO-GERD patients (Table). Impedance detected 

many more patients with abnormal motility than did manometry. 

MO-GERD patients have significantly impaired esophageal 

clearance compared to both subjects and GERD patients. 

* vs. asymptomatic, p <0.01; GERD vs MO-GERD, 

p=0.11**Obese patients vs. Asymptomatic, p < 0.01; vs. 

GERD vs. MO-GERD, p = 0.01 Nutcracker esophagus 

(n=2), Ineffective esophageal Motility (n=2), Hypertensive LES 

(n=1) Aperistalsis(n=2), Diffuse esophageal 

spasm(n=1), Nutcracker esophagus(n=1), Hypertensive 

LES(n=1)Conclusions: In patients with GERD, impedance often 

detects impairments in esophageal motility not identified by 

manometry. Morbidly Obese patients with GERD have a very 

high incidence of impaired esophageal motility. This may have 

implications in bariatric procedures, especially those that are 

restrictive in nature. 

S073 

EARLY US OUTCOMES OF LAPAROSCOPIC GASTRIC BYPASS 

VERSUS LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING 

FOR MORBID OBESITY., Marc Bessler MD, Amna Daud 

MD,Mary DiGiorgi MPH,Akuezunkpa O Ude MD,Daniel Davis 

DO, Center for Obesity Surgery, New York-Presbyterian 

Hospital, Columbia University. New York, NY 

INTRODUCTION: Gastric bypass (GBP) is the most common 

bariatric procedure in the US and is increasingly being performed 

laparoscopically. The laparoscopic adjustable gastric 

banding (LAGB) is the preferred bariatric procedure worldwide. 

There is limited data available comparing the two procedure 

in the US. This study compares complcations, early outcomes 

of comorbiditY resolution and weight loss in patients 

who underwet LAGBP versus LAGB. METHODS: A review of 

prospectively collected data was performed on 332 patients 

undergoing primary laparoscopic gastric bypass LGBP ( n=192) 

and LASGB ( n=140) procedures between 2/2001 and 3/2004. 

Chi-square and ANOVA were performed to determine differ-


ences in gender, age and initial BMI. Differences in complications, 

resolution of co-morbidities ad percent excess weight 

lost (%EWL) at was compared between the surgical groups. 

(Table 1). A matched 1:1 case control study (matched for initial 

BMI , age and gender) was performed to control for potential 

confounders. A p value of



shorter hospital stay (4.1 vs. 6.2 days, p0.38). Patients with ruptured appendicitis had a shorter 

Time to Surgery (P=0.056). Patients with LA had a shorter LOS 

than OA (1.6 days reduction). This LOS was significantly shorter 

among those with ruptured appendicitis vs non-ruptured 

appendicitis (2.0 days vs 0.3 day reduction). Rank-order multiple 

regression analysis, controlling for all other factors, 

showed laparoscopy to have a significant effect on postoperative 

LOS in all appendicitis cases, especially ruptured appendicitis. 

Conclusions: The two-day reduction in LOS among those with 

ruptured appendicitis who underwent LA is significant enough 

to overcome the smaller benefit of LA in acute appendicitis. 

This is the largest prospective analysis of the effects of LA in 

ruptured appendicitis among adults in the U.S. Given these 

findings, LA is a superior approach for all patients with appendicitis. 

S078 

10 YEAR OUTCOME OF LAPAROSCOPIC COLORECTAL RESEC- 

TION FOR CANCER, C Sample MD, M Watson MD,A Okrainec 

MD,R Gupta MD,D Birch MD,M Anvari PhD, Centre for Minimal 

Access Surgery, McMaster University, Hamilton Ontario 

Canada 

Multiple reports have outlined the potential benefits of the 

laparoscopic approach to colon surgery. Recently, randomized 

control trials have demonstrated the safety of applying these 

techniques to colorectal cancer over a 5 year follow-up. We 

examined our results for laparoscopic colorectal cancer resections 

with a 10 year follow-up and compared them to a large 

prospective database of open resections. A total of 231 resections 

were performed for adenocarcinoma of the colon or rectum 

between November 1992 and November 2003. Of those 

resections, 93 were rectal (40.3%) and 138 were colonic 

(59.7%). 8 (3.2%) of the resections were performed as emergencies. 

27 (11.7%) were converted to open. Mean OR time 

was 150.1 (+/- 59.2) minutes. Overall complication rate was 

42.9% with 14 (5.6%) wound infections, 8 (3.2%) significant 

peri-operative bleeds, 1 (0.4%) ureteric injury and 1 (0.4%) 

anastomotic leak. There were 5 (2%) peri-operative deaths. 

Patients were followed up to 131.5 months. A total of 51 

(22.1%) of patients had recurrence prior to death with 14 

(6.1%) local and 37 (16%) distant recurrences. Only 2 patients 

had wound recurrences (0.8%) and both patients had widespread 

peritoneal recurrence at the time of diagnosis. Overall 

survival at 60 and 120 months was 65.3% and 60.3% respectively. 

Disease free survival at 60 and 120 months was 58% 

and 56% respectively. 

Conclusion: Laparoscopic techniques can be applied to a wide 

range of colorectal malignancies without sacrificing oncologic 

results at 10 year follow-up. 

S079 

A RETROSPECTIVE, MULTICENTER STUDY ON LAPAROSCOP- 

IC SURGERY FOR GASTRIC AND COLORECTAL CANCER IN 

JAPAN, Seigo Kitano MD, Tsuyoshi Eto MD,Akio Shiromizu 

MD,Koichi Ishikawa MD,Masafumi Inomata MD,Norio Shiraishi 

MD, Department of Surgery I, Oita University Faculty of 

Medicine 

Objective: Laparoscopic surgery for malignant disease technically 

is feasible, but not widely accepted because of the lack of 

large-series studies and data on long-term outcomes. We conducted 

a retrospective, multicenter study of a large series of 

patients in Japan to evaluate long-term results of laparoscopic 

surgery for malignancies of stomach and colorectum. 

Methods: The study group comprised 1491 patients undergoing 

laparoscopy-assisted distal gastrectomy (LADG) for early 

gastric cancer, and 2036 patients undergoing laparoscopic colorectal 

resection for colorectal cancer during the period 1993 

to 2002 in 18 participating surgical units (Japanese 

Laparoscopic Surgery Study Group). 

Results: In 1491 patients undergoing LADG, the morbidity and 

mortality rate was 12% and 0%. Recurrent rate was 0.4% and 

the 5-year disease free survival rate was 99.2%. In 1495 

patients with colon cancer, the morbidity and mortality rate 

was 13% and 1%. Recurrent rate was 4% and the 5-year survival 

rate was 96.7% for stage I, 94.8% for stage II, and 79.6% 

for stage III disease. In the 541 patients with rectal cancer, the 

morbidity and mortality rate was 14% and 2%. Recurrent rate 

was 6% and the 5-year survival rate was 95.2% for stage I, 

85.2% for stage II, and 80.8% for stage III disease. 

Conclusions: A retrospective, multicenter study demonstrates 

that laparoscopic surgery for early gastric and colorectal cancer 

is feasible in terms of long-term outcomes in Japan. 

S080 

EXTRA VS INTRA-CORPOREAL ANASTOMOSIS IN LAPARO- 

SCOPIC RIGHT HEMICOLECTOMY - A RETROSPECTIVE 

ANALYSIS, Gideon Sroka MD, Amir Szold MD,Samuel Eldar 

MD,Ibrahim Matter MD, Department of general surgery, 

laparoscopic surgery unit , Bnai-zion medical center, Haifa, 

Israel. 

Background: Laparoscopic right hemicolectomy (LRH) has 

emerged, in the last decade, as a feasible and safe procedure, 

for either benign or malignant disease. Recently it has been 

proven to be an acceptable alternative to open surgery for 

colon cancer. Technically, two main issues differ surgeons in 

addressing this operation: 1. Right colon dissection could 

either be medio-lateral or vice versa. 2. The anastomosis could 

be performed either intra or extra-corporealy (laparoscopic 

assisted). So far there is no proven benefit to either approach. 

The purpose of this study is to evaluate patient outcome and 

complication rate related to anastomotic technique. 

Methods: Between 01/02 and 07/04 34 patients went through 

LRH in our department, 26 of them due to carcinoma of the 

right colon, 7 due to adenomatous polyp that was not 

amenable to colonoscopic resection and 1 due to colonic lymphoma. 

In all of the patients the approach was medio-lateral 

with identification of the ureter before opening Taldt?s fascia, 



and early and high vascular ligation. 16 had extra-corporeall 

anastomosis and 18 went through a totally laparoscopic procedure 

according to surgeon preference. 

Results: Both groups were similar in patient age, sex, co-morbidities, 

operating time and blood loss. There was no difference 

in the number of lymph nodes dissected (mean 10, range 

5-22), the distance of tumor from specimen?s margins (mean 6 

cm, range 3-9.5 cm), or in pathological staging. In the laparoscopic 

assisted group 3 patients had anastomotic leak that 

mandated re-laparotomy and re-anastomosis. No patient had 

such a complication in the totally laparoscopic group.(p


gery.Patients and methods: From January 1994 to August 

2004, 229 laparoscopic adrenalectomies were performed in 

218 pts:201(87%) by an anterior approach (4 robotic), 10 (4%) 

by a submesocolic approach, 18 by a flank approach (8%). 

Indications were as follows: incidentaloma 73 (31%) Conn S. 

57 (25%), Cushing S. 51 (22%) 9 (17%) bilateral, pheochromocytoma 

34 (15%) 1 bilateral (3%), metastasis 9 (4%), androgen 

secreting adenoma 2 (1%), mielolipoma 3 (1%). The mean 

diameter was 6.2 cm (range 3-12). Nineteen (8%)? associated 

procedures were performed: cholecystectomy 13, ovariectomies 

4, uterus myomectomies 1, kidney cyst resection 1. 

Data analysis included age, operative time, complications, pain 

relief, length of stay. Results Mean operative times for right 

(103 pts)and left adrenalectomy (226 pts) was: 91 min (range 

70-150) and 121 min. (range 90-300), respectively. There were 

9(4%) conversion to open surgery: 4 due to bleeding, 2 due to 

technical difficulties (obesity), 1 colonic tear, 1 arrhythmia. One 

(0,5%) pt with emoperitoneum (hepatic tear) required relaparoscopy. 

There was 1 (0,5%) minor complication: 1 abdominal 

abscess. Mortality: 2 (0.8%)1 sepsis, 1 M.I. not related to 

the surgical procedure p.o. day 10th. All pts were ambulating 

freely and tolerating a clear liquid diet within 24 hours after 

surgery. Postoperative pain was minimal. Mean hospital stay 

was 2,5 days (range 2-5). At a mean follow-up of 62 months 

(range 1-122) out of the 134 pts with secreting adenoma, 48% 

had complete resolution of symptoms and 52% had an 

improvement. At a mean follow-up of 20 months (range 2-34) 

7 out of 9 pts with metastasis are alive and disease free at 10, 

11, 12, 13, 16, 18, 20 months after surgery respectively. The 

remaining 2 pts died 15 and 24 months after the operation 

from distant site metastasis.Conclusions: laparoscopic adrenalectomy 

and especially the anterior transperitoneal approach, 

that we privilege, is feasible and effective as a routine 

approach. The advantages include an early and unique identification 

of the fundamental anatomic landmarks and early legation 

of the main adrenal vein before any manipulation of the 

gland has occurred reducing the risk of catecholamines release 

in case of pheochromocytoma and limiting the oncological risk 

of dissemin in malignancy. 

S086 

PORTAL OR SPLENIC VEIN THROMBOSIS (PSVT) AFTER 

LAPAROSCOPIC SPLENECTOMY; ITS INCIDENCE AND MAN- 

AGEMENT, M Ikeda MD, M Sekimoto MD,S Takiguchi MD,M 

Yasui MD,T Hata MD,T Shingai MD,I Takemasa MD,H 

Yamamoto MD,M Ikenaga MD,M Ohue MD,M Morito MD, 

Deparment of Surgery and Clinical Oncology. Graduate School 

of Medicine, Osaka University 

Purpose: Thrombosis of the portal venous system has been 

reported as a possible cause of death after splenectomy. This 

complication was considered as an uncommon complication. 

However, with the improvement in diagnostic modalities and 

the increased interest in this disease entity, it is becoming 

apparent that the incidence of PSVT may be greater than clinically 

appreciated. 

Patients and Methods: We analyzed 33 patients who had 

undergone laparoscopic splenectomy and postoperatively 

examined PSVT either with contrast CT, ultrasound, or MRI. 

PSVT was classified according to the site of thrombus. dSVT: 

thrombus in the splenic vein distal to the junction of inferior 

mesenteric vein (IMV), pSVT: thrombi between the portal vein 

and IMV, SMVT: thrombi in the superior mesenteric vein. 

Portal vein thrombi were divided into intra- and extra-hepatic 

thrombosis (iPVT and ePVT, respectively). Portal vein branches 

involved with thrombus were also determined. 

Results: We found PSVT in 17 patients (52%). SMVT and ePVT 

were found in 1 and 2 patients, respectively. iPVT and dSVT 

were found in 12 patients, and pSVT was found in 7 patients. 

Spleen weight of patients with PSVT (median 218g, range 61- 

2315g) was heavier than that of patients without PSVT (median 

101g, range 11-350g). Anticoagulant therapy was performed 

in 16 patients, and all SMVT, ePVT, iPVT, and pSVT 

were successfully treated. 

Conclusion: PSVT is a common complication after laparoscopic 

splenectomy. Especially, patients with splenomegaly were at 

high risk for PSVT. PSVT was safely treated by prompt anticoagulant 

therapy. 



S087 

LAPAROSCOPIC SPLENECTOMY IN THE ELDERLY - A MORBID 

PROCEDURE?, Stephen M Kavic MD, Adrian E Park MD, 

University of Maryland 

Laparoscopic splenectomy (LS) has emerged as the gold standard 

for elective splenectomy. Few have critically evaluated 

the results of LS in elderly patients. We retrospectively 

reviewed LS performed between 8/19/98 and 6/8/04. Of 235 

procedures, 188 were performed in patients younger than age 

65 (Group I), and 45 were in patients 65 years or older (Group 

II). The average age was 34.7 years (Group I) and 72.3 years 

(Group II). Principal diagnoses were similar; ITP was the 

largest category for both (Group I, 53% vs. Group II, 51%). ASA 

Class III or IV was 18.6% of Group I but 60% of Group II. 

Operative data was similar for Group I versus Group II, including 

operative time, averaging 144 minutes vs 107; average 

spleen weight, 416g vs 487g; and blood loss, 179 cc vs 160cc. 

The average length of stay differed: 2.2 days for Group I and 

3.9 days for Group II (p


to be a routine part of imaging. 

S090 

TRAINING SURGEONS IN ERCP, Gary C Vitale MD, Carlos M 

Zavaleta MD,John C Binford,Gerald M Larson,David S Vitale, 

Department of Surgery and Center for Advanced Surgical 

Technologies, University of Louisville, Louisville, Kentucky 

40292, USA 

Upper GI endoscopy is commonly performed by surgeons outside 

major medical centers. Endoscopic training and experience 

with manipulation of the distal common bile duct are 

mandated by the American Board of Surgery. This report 

focuses on post-residency training in ERCP. 

Thirteen fellows have been trained since 1992 for periods of 6 

to 14 months. Fellows were involved in 2008 cases of the 3641 

ERCPs done in the intervals. Nine fellows had some previous 

endoscopy experience but none had ERCP training. Nine fellows 

had one-year training, two had 6 months, and one each 

had 8 and 14 months. As a mark of cannulation success, a 

benchmark of 85% was considered excellent. Fellows? training 

was evaluated in 3-month intervals. All fellows reached an 

85% success rate in at least one interval and some in more 

than one. The ability to achieve an 85% cannulation rate 

required, on average, 7.1 months and 102 procedures. Four of 

13 fellows (31%) reached the 85% mark in the first 3-month 

period, 2 of 13 (15%) in the second period, 5 of 11 (45%) in the 

third period, 7 of 10 (70%) in the fourth period, and 1 of 1 

(100%) in the fifth period of training. In the first period, attendings 

had a stronger hands-on introductory/assistant role with 

the fellows, which may explain the higher initial success. Prefellowship 

training in upper GI endoscopy facilitated earlier 

success with ERCP. The morbidity and mortality rates were 2.4 

and 0.006% respectively and did not differ between fellows 

and attendings. Twelve of 13 fellows entered practice (3 in academics). 

Ten have continued to perform ERCPs. 

ERCP training is possible within a surgical department that has 

a dedicated faculty with experience in the procedure. An 

added benefit was increased operative experience in pancreatic 

disease for general surgery trainees. The learning curve is 

steep enough that meaningful training would require at least 6 

months of dedicated effort. 

S091 

NATIONAL ANALYSIS OF IN-HOSPITAL CHOLEDOCHOLITHIA- 

SIS MANAGEMENT RESOURCE UTILIZATION USING PROPEN- 

SITY SCORES, B K Poulose MD, P G Arbogast PhD,M D 

Holzman MD, Vanderbilt Univ. School of Med. 

BACKGROUND: Two treatment options exist for choledocholithiasis 

(CDL): endoscopic retrograde cholangiopancreatography 

(ERCP) and common bile duct exploration (CBDE). 

Resource utilization measured by total in-hospital charges 

(THC) and length of stay (LOS) was compared using the 

propensity score (PS). In this study, PS was the probability that 

a patient received CBDE based on comorbidities, hospital 

traits, and demographics. The power of this method lies in balancing 

groups on variables by PS, resulting in 90% bias reduction 

and improved inferential validity compared to traditional 

analytic techniques. 

METHODS: Laparoscopic cholecystectomy (LC) patients with 

CDL who had ERCP or CBDE were identified in the 2002 U.S. 

Nationwide Inpatient Sample. Patients were ordered into 5 PSbased 

strata. Mean THC and LOS were compared. A linear 

regression model was used to estimate the contribution that 

LOS had on THC. 

RESULTS: 46,684 LC patients had CDL. Mean age was 52.6±0.2 

years (mean±SEM) with 70% women. ERCP was performed in 

44,053 (94%) and CBDE in 2,631 (6%). Mean THC was less for 

CBDE ($25,641±1,966) compared to ERCP ($31,158±871; 

p



size that the actual practice has deviated from this teaching. 

This study aims to discern what factors lead to actual practice 

when a CBD stone is discovered during laparoscopic cholecystectomy 

in the absence of cholangitis. 

Methods: This study was performed via an online survey of 

current members of SAGES. The survey was designed using 

web-based software that provided members with an anonymous 

link to the survey. General demographic information 

including training and hospital capability and intraoperative 

decisions for five increasingly complex clinical scenarios was 

collected. 

Results: 90 physicians responded. 85% of respondents to our 

survey were ?attending level? surgeons. 26% stated that they 

had completed a laparoscopic fellowship, 13% completed a 

training course in laparoscopic bile duct exploration . The 

majority (89%) do not perform ERCP. 27% of surgeons were 

willing to leave a single asymptomatic stone in place, in the 

presence of normal liver function tests (LFTs), and do nothing 

unless the patient developed symptoms. 8.1% responded that 

they would still leave a single small stone in place in the presence 

of an increased ALT and AST in an otherwise asymptomatic 

patient. This fell to 0% when faced with multiple stones 

in the presence of grossly elevated LFTs. Respondents who 

indicated having completed a Laparoscopic Fellowship and a 

training course in Lap-CBDE, were inclined to perform laparoscopic 

common bile duct exploration as the scenarios became 

increasing complex from 41% in Scenario #1 to 75% in 

Scenario #5 (most complex) and never opted to perform open 

CBDE. Conversely surgeons who had no formal laparoscopic 

training less often performed lap-CBDE, and were far more 

willing to perform open CBDE or utilize post op ERCP. 

In this survey of SAGES members, classic teaching has been 

abandoned in this era of minimally invasive surgery and therapeutic 

flexible endoscopy. There is a need to develop clear 

guidelines as to how CBD stones are to be managed in the 

context of their clinical, anatomic, and biochemical significance 

when varying bile duct management strategies are 

available. Once we figure out which stones need to be 

removed, training must not be the barrier to optimal stone 

management strategy 

S094 

SETTING NATIONAL BENCHMARK PROFICIENCY LEVELS FOR 

LAPAROSCOPIC PERFORMANCE USING SIMULATION: 

RESULTS FROM THE 2004 SAGES LEARNING CENTER MIST- 

VR STUDY, Kent R Van Sickle MD, Anthony G Gallagher PhD,E. 

Matt Ritter MD,David A McClusky MD,Andrew Ledermen 

MD,Mercedeh Baghai MD,C. Daniel Smith MD, Emory 

Endosurgery Unit, Emory University School of Medicine, 

Atlanta GA 

Background: The Minimally Invasive Surgical Trainer Virtual 

Reality (MIST-VR) (Mentice, Gottenberg, Sweden) has been 

well validated as a training device for laparoscopic skills. 

Training to a level of proficiency on the simulator has been 

demonstrated to significantly improve objectively assessed 

operating room performance during laparoscopic cholecystectomy. 

The purpose of this project was to establish a national 

standard of proficiency on the simulator based on the performance 

of experienced laparoscopic surgeons. Methods: 

Surgeons attending the SAGES 2004 Annual Meeting who had 

performed more than 100 laparoscopic procedures volunteered 

to participate and were tested in the SAGES Learning 

Center. All subjects completed a demographic questionnaire to 

assess laparoscopic and/or MIST-VR experience. Each subject 

performed two consecutive trials of the MIST-VR Core Skills 1 

program on medium settings (six basic tasks of increasing difficulty; 

acquire place (AP), transfer place (TP), traversal (TV), 

withdrawal insert (WI), diathermy task (DT), manipulate 

diathermy (MD)). Trial 1 was considered a ?warm-up? and Trial 

2 functioned as the test trial proper. Subject performance was 

scored for time, errors and economy of instrument movement 

for each task, and a cumulative total score was calculated. 

Results: 57 surgeons participated in the study, complete data 

is available for 42. Trial 2 data expressed as mean±SD; time in 

seconds; other values unitless. 


Conclusion: National benchmark proficiency levels for laparoscopic 

skills have now been established by experienced 

laparoscopic surgeons using the MIST-VR simulator. Residency 

programs, training centers and practicing surgeons can now 

use these data to identify how their skills compare to laparoscopic 

surgeons nationwide, and to set performance goals 

accordingly. 

S095 

SAFETY OF LAPAROSCOPIC INSTRUMENTS, Arman Albayrak 

MSc, Yuri A Casseres MD,Jaap H Bonjer MD,Kees A 

Grimbergen MSc,Cees Schot MSc,Dirk W Meijer MD, Erasmus 

Medical Center Rotterdam, Techical University Delft, Catharina 

Hospital Eindhoven, the Netherlands 

Background 

The safety of reusable laparoscopic instruments remains an 

issue as there are no guidelines for testing and maintenance. 

The Dutch Society of Endoscopic Surgery has started a Quality 

Assurance Program in order to improve patient safety. In order 

to quantify the magnitude of the problem the following tests 

were done in Dutch hospitals: 

1.Measuring the insulation failure of laparoscopic instruments. 

2.Measuring light quality by measuring the light loss in lightcables 

and in laparoscopes. 

Methods 

The tests were performed in a representative sample of 33 

Dutch hospitals (30% of all hospitals). All available reusable 

instruments with an insulation, were tested in a High Voltage 

Tester. A leakage in the insulation results in a visible corona, 

which points to the position of the insulation defect and an 

audio alarm sounds. 

A digital light meter, which measures the luminous intensity 

(lux), was used to test light transmission through light guide 

cables and laparoscopes. The light guide cables were also tested 

using a device which gives the percentage broken fibers. 

Results 

Of the 1438 insulated laparoscopic instruments, 267 had one 

or more insulation defects (18.6%). Of the 195 measured light 

guide cables had 35% more than 70% broken fibers. Of all 

laparoscopes (126), 69% had a light loss of more than 50% of 

the light input. 

Conclusion 

The study revealed a (too) large number of severe defects in 

the tested instruments. This is a serious issue as the safety of 

patients might be at risk. This is caused by the lack of guidelines 

and an appropriate maintenance program. 

The preliminary recommendations are: 

1.Laparoscopic instruments, light guide cables and laparoscopes 

have to be tested before each procedure. 

2.Replacement of all instruments with defected insulation 

3.Replacement of light guide cables with more than 70% broken 

fibers 

4.Replacement of laparoscopes with a light loss of more than 

50%. 

This studie will be extended to other countries as well as to 

other instruments like camera?s and monitors. Finally 

Guidelines should be developed, involving Endoscopic 

Surgeons, Engineers, Hospital staff and laparoscopic instrument 

manufacturers. 

S102 

DOES AGGRESSIVE HYDRATION REVERSE THE EFFECT OF 

PNEUMOPERITONEUM ON RENAL PERFUSION?, Sebastian V 

Demyttenaere MD, Liane S Feldman MD,Simon Bergman 

MD,Suad Gholoum MD,Franco Carli MD,Gerald M Fried MD, 

Steinberg-Bernstein Centre for Minimally Invasive Surgery, 

McGill University Health Centre, Montreal, Canada 

Introduction: Although pneumoperitoneum decreases renal 

blood flow, it remains unclear whether this impacts renal function. 

Our aim was to characterize the effects of pneumoperi-


toneum on renal perfusion and function and to evaluate two 

different strategies for fluid management. 

Methods: Twelve 30 kg pigs were randomized into two groups: 

Group 1: maintenance (3cc/kg/hr of NaCl) and Group 2: Bolus 

(15cc/kg/hr and a 20cc/kg NaCl bolus prior to induction of 

pneumoperitoneum). Pigs were studied in a blinded fashion 

for 30 minutes prior, 60 minutes during and 30 minutes after 

release of 15 mmHg CO2 pneumoperitoneum. Renal cortical 

perfusion (RCP) was measured using a laser doppler probe 

placed on the right kidney. Renal function was assessed using 

the fractional excretion of sodium (FeNa). Data are expressed 

as means (SD). Statistical analysis was done with ANOVA. 

(*p 30 minutes), whereas rapidly resolved in CO2 group 

(within 15 minutes). Parietal blood flow decreased in both 

groups (AIR group; 340.5 ?} 48.3 perfusion unit (PU) to 203.2 ?} 

26.1 PU, CO2 group; 381.0 ?} 35.1 PU to 181.0 ?} 27.6 PU), however, 

recovered within 5 minutes in CO2 group. 2) Continuous 

insufflation: during 5-mmHg insufflation, blood flow decreased 

in AIR group (404.8 ?} 15.5 PU to 253.1 ?} 14.1 PU; p = 0.0045), 

whereas significantly increased in early phase of insufflation in 

CO2 group (410.1 ?} 25.3 PU to 484.2 ?} 28.7 PU; p = 0.0487). 

Blood flow decreased in both groups during 15-mmHg insufflation, 

however, the decrease was still less in CO2 group (AIR 

group; 464.4 ?} 61.3 PU to 218.5 ?} 39.3 PU, CO2 group; 408.7 

?} 21.4 PU to 365.2 ?} 29.4 PU) (p = 0.0034). In 30-mmHg insufflation, 

blood flow decreased and difference was no longer 



105



observed between the two groups (AIR group; 448.9 ?} 55.9 PU 

to 172.3 ?} 12.4 PU, CO2 group; 401.3 ?} 38.8 PU to 165.3 ?} 

21.5 PU) (p = 0.2096). CONCLUSION: Bowel distension 

resolved more rapidly in CO2 insufflation compared to air 

insufflation. Parietal blood flow obstruction was significantly 

attenuated by CO2 especially in low pressure insufflation, indicating 

the possible involvement of vasodilating effect of CO2. 

S106 

ALTERED MMP-9/TIMP-1 CONCENTRATION IN THE EARLY 

POSTOPERATIVE PERIOD IN COLON CANCER PATIENTS, Irena 

Kirman PhD, Suvinit Jain DO,Vesna Cekic RN,Avraham Belizon 

MD,Richard L Whelan MD, Columbia University 

We have previously demonstrated that insulin-like growth factor 

binding protein 3 (IGFBP-3) is depleted in plasma after 

open (OS) but not laparoscopic surgery (LS). Post-surgical 

IGFP-3 cleavage is a rapid process likely due to altered plasma 

proteolytic activity. This study?s goal was to identify a protease/protease 

inhibitor system that is affected by surgical 

trauma. Methods: Plasma samples were taken from 78 patients 

diagnosed with stage I-III colorectal adenocarcinoma; 32 OS 

patients (mean incision size 18.7±5.3 cm) and 46 LS patients 

(mean incision 5.3±1.8 cm) preoperatively (pre-OP) and on 

postoperative days 1-3 (POD1-3). Plasma proteolytic activity 

was assessed via zymography; protease and protease inhibitor 

concentrations were measured in ELISA using specific antibodies. 

Statistical analysis was performed using Wilcoxon?s 

test. Results: Zymography revealed a predominant band representing 

a 92 kDa gelatinase corresponding to a pro-form of 

MMP-9, a protease known to cleave IGFBP-3. This was confirmed 

by Western blot analysis, which showed a single MMP- 

9 band. In OS patients, the mean concentration of plasma 

MMP-9 was significantly higher on POD1 (380.4±193.4 ng/ml) 

when compared to pre-OP levels (214.7±168.4 ng/ml, p


in 1991 and tumor cell seeding in 1994 it is supposed that the 

laparoscopic technique could deteriorate the prognosis of gallbladder 

cancer. 

These assumptions will be verified by the CAES/CAMIC- registry. 

Material and method: The Workgroup Surgical Endoscopy of 

the German Society of Surgery started in 1997 a registry of all 

cases of cholecystectomy -laparoscopic as well open- with a 

postoperative incidental finding of gallbladder cancer. The aim 

of our registry is to compare the prospectively collected follow 

up data on the outcome of these patients and to answer the 

questions whether laparoscopic cholecystectomy affects the 

prognosis of patients with incidental gallbladder cancer. 

Results:358 cases of incidental gallbladder cancer have been 

recorded. 

There are 194 patients treated by the laparoscopic procedure, 

109 by the open one, 55 with an intraoperative conversion 

from the laparoscopic to the open procedure and one without 

data about the method of operation. 

The median follow up is about 15,4(1- 140,3)months. 

Following the laparoscopic procedure we registered 14 port 

site metastases, following the open primary procedure 8 

wound recurrences. 

An intraabdominal recurrence is reported in 23 laparoscopic 

and in 11 primary open treated cases. 

122 of the 358 patients underwent a second radical surgery. 

It seems to be a tendency that reoperated T1-and T2 tumors 

have a better survival than those without a reoperation.(logrank> 

0.05) 

The survival- rate(Kaplan- Meier)shows a significant better survival 

for the laparoscopic procedure in comparison with the 

primary open(p=0,0096)or converted group(p=0,0215). 

The median survival for laparoscopic and open treated T1- 

tumors is about 55%, for laparoscopic treated T2- tumors 40% 

and open treated T2- tumors 30%. 

A postoperative chemotherapy has been done in 15 cases, a 

combination of radiotherapy and chemotherapy in 14 cases. 

79 patients already died due to the underlining disease divided 

up in both groups equally. 

Discussion:The incidence of port site/wound recurrences is 

twice as high in the laparoscopic group. 

The survival time is higher for the laparoscopic treated ones. 

The access technique open or laparoscopic does not seem to 

influence the prognosis of incidental gallbladder carcinoma. 

Until now we could not find a disadvantage for the laparoscopically 

operated group. 

S111 

THIRTEEN-YEARS EXPERIENCE WITH LAPAROSCOPIC TRAN- 

SCYSTIC COMMON BILE DUCT (CBD) EXPLORATION FOR 

STONES., Alessandro Maria Paganini MD, Mario Guerrieri 

MD,Jlenia Sarnari MD,Giancarlo D’Ambrosio MD,Emanuele 

Lezoche MD, Department of General Surgery, University of 

Ancona, Ancona, Italy; *II Clinica Chirurgica , Università La 

Sapienza, Roma, Italy. 

Aim: to evaluate the short and long-term results after laparoscopic 

transcystic CBD exploration for CBD stones. Methods: 

after patients? return to their normal activities, the follow-up 

study was conducted by yearly telephone contacts, ambulatory 

visits and laboratory exams. Ultrasound and /or Cholangio 

MRI were added whenever necessary. Results: from April 1991 

to August 2004, CBD stones were present in 344 out of 3212 

patients (pts) (10.7%) (131 males, 213 females, mean age 57.9 

years, range 12-96 years) who underwent laparoscopic cholecystectomy 

(LC). In 329 pts (95.6%) the procedure was completed 

laparoscopically. Trans-cystic CBD exploration was feasible 

in 191 pts (58.1%) who are the object of this study. Ductal 

stones were preoperatively suspected or proven in 104 (54.5%) 

and unsuspected in 87 pts (45.5%). At the end of the procedure 

a transcystic biliary drainage was positioned in 71 pts (37.2%) 

who had undergone instrumental maneuvers on the papilla 

(basket and/or lithotripsy) to avoid postoperative biliary stasis, 

while in 120 (62.8%) no biliary drainage was employed. Major 

complications were observed in 4 pts (2,1%) and minor complications 

were observed in 16 pts(8.4%). Retained CBD stones 

were present in 6 pts (3.1%) treated with postoperative 

ERCP/ES in 4 while 2 pts passed their stones spontaneously. 

Mortality was nil. No patient was lost to follow-up. At a median 

follow-up of 102 months, 182 pts out of 191 are alive with 

no evidence of recurrent ductal stones or biliary stricture. Nine 

elderly patients died from unrelated reasons with no evidence 

of recurrent biliary symptoms. 

The reported data confirm the short and long-term safety and 

efficacy of LC and transcystic bile duct exploration. The technique 

is simple to learn and it allows to avoid extensive preoperative 

workout or postoperative ERCP/ES in most patients 

with ductal stones, reducing the diagnostic and therapeutic 

burden for the patient as well as the costs. 

S113 

DOES HIDA SCAN EJECTION FRACTION PREDICT SPHINCTER 

OF ODDI HYPERTENSION AND CLINICAL OUTCOME IN 

PATIENTS WITH SUSPECTED CHRONIC ACALCULOUS CHOLE- 

CYSTITIS?, Susan B Young DO, Maurice E Arregui MD,Kirpal 

Singh MD, St. Vincent Hospital Indianapolis IN 

Introduction: Hepatobiliary iminodiacetic acid scan with ejection 

fraction(HIDA EF) is used to evaluate chronic acalculous 

cholecystitis(CAC). A presumed etiology of CAC is sphincter of 

Oddi hypertension (SOH). In this study we evaluate the value 

of HIDA EF to predict patient response to laparoscopic cholecystectomy 

and SOH. 

Material and Methods: A prospective study of 93 patients with 

biliary pain but without gallstones (CAC) who underwent preoperative 

HIDA EF was conducted. At laparoscopic cholecystectomy, 

transcystic antegrade biliary manometry was performed 

to determine the sphincter of Oddi pressure. Patients 

were evaluated post-operatively for response to cholecystectomy. 

The sensitivity, specificity, positive predictive value (PPV), 

and negative predictive value (NPV) were calculated. The outcomes 

were compared with clinical impression. 

Results: Of the 93 patients with both HIDA EF and sphincter of 

Oddi pressure (SOP) measurements, 50 had abnormal ejection 

fraction (less than 35%) and of these 29 had SOH (SOP greater 

than or equal to 40 mmHg). Of those 43 with normal HIDA EF , 

30 had SOH. The sensitivity was 49%, specificity 38%, PPV 

58% and NPV 30%. 

86 of the 93 patients returned for follow-up evaluation. Followup 

ranged from 0-99 months, with a mean of 26.4 months. 

Overall 73 (85%) improved. Of the 46 with abnormal HIDA EF, 

42 (91%) improved. Of the 40 with normal HIDA EF, 31 (77.5%) 

improved, see table. The sensitivity was 57.5%, the specificity 

69.2%, the PPV 91.3%, and NPV 22.5% 

Conclusion: Although the PPV of abnormal HIDA EF is high, it 

is not much better than clinical impression. The sensitivity and 

specificity is marginal. The NPV is poor. Based on the review 

of these 93 patients HIDA EF may not be a reliable indication 

that patients do not have CAC. We would recommend that 

patients with normal HIDA EF have additional testing or consultation 

before ruling out CAC. HIDA EF does not predict 

SOH. 

S114 

LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN WITH 

CHRONIC HEMOLITIC ANAEMIA: IS THE OUTCOME RELATED 

TO THE TIMING OF THE PROCEDURE?, Giuseppe Currò MD, 

Giuliano Iapichino MD, Cesare Lorenzini MD,Renato Palmeri 

MD,Eugenio Cucinotta MD, Department of Human Pathology, 

University of Messina, Messina, Italy 

Aims.The aim of our study was to evaluate if the outcome in 

children with chronic hemolitc anemia (CHA) and cholelithiasis 

undergoing laparoscopic cholecystectomy (LC) is related to the 

operating timing.Methods.From June 1995 to May 2004 45 

children with CHA (15 children with beta-thalassemia, 24 with 

sickle cell disease and 6 with different kinds of hemoglobinopathies) 

were referred to our Division of Surgery for 

cholelithiasis. All 45 children were asymptomatic at the time of 



107



the first visit. The mean age was 12 years (range,8 to 16). We 

proposed an elective LC to all children before the onset of 

symptoms. Splenectomy was previously performed in 5 children. 

The operation was accepted in the period of study by 24 

children and refused by 21. Among these 21 patients 12 decided 

to undergo elective LC after the first or second episode of 

biliary colic and 5 patients underwent emergency LC for acute 

cholecystitis. All 45 children were followed up for a mean period 

of 55 months (range, 2 to 93). We divided the patients in 

three groups on the basis of the treatment choosen (Group A: 

24 asymptomatic operated, Group B: 12 symptomatic operated 

after the onset of symptoms and Group C: 5 who underwent 

emergency LC for acute cholecystitis) and correlated the outcome 

with the treatment choosen and the operation timing.We 

excluded from the evaluation 4 patients who were still asymptomatic 

after a mean period of 18 months and who still refuse 

the operation.Results.Group A:no major complications reported; 

no conversion to open; one child developed wound infection 

and an other one had fever for two days; no trasfusion 

necessary; mean post-operative stay 3 days (range, 2 to 4). 

Group B:no major complications reported; no conversion to 

open; two children developed fever post-operatively; no transfusion 

necessary; mean post-operative stay 3.5 days (range, 3 

to 5). Group C:sphyncterotomy with endoscopic gallstones 

extraction necessary pre-operatively in 2 of them; one conversion 

to open; two of them developed sickle cell crisis during 

the post-operative stay; no further complications reported; 

mean post-operative stay 7 days (range, 3 to 

10).Conclusions.Elective LC is a safe procedure in children with 

hemoglobinopathies. It should be the gold standard in children 

with chronic hemolitic disorders and asymptomatic cholelithiasis 

in order to avoid the potential complications of cholecystitis 

and choledocholithiasis which lead to major risks, discomfort 

and longer hospital stay. 

S115 

RESULTS OF MAJOR AND MINOR HEPATECTOMIES BY 

LAPAROSCOPY, ERIC VIBERT MD, ALI KOUIDER MD,THIERRY 

PERNICENI MD,HUGUES LEVARD MD,CHRISTINE DENET 

MD,BRICE GAYET MD, INSTITUT MUTUALISTE 

MONTSOURIS, PARIS 

Aim of study: Assessment of feasibility and results of minor 

and major (>2 segments) laparoscopic liver resections for cancer 

and benign tumours (BT). 

Methods: Retrospective study of the outcome of patients with 

symptomatic or uncertain BT or with primitive or secondary 

malignant liver tumours treated by laparoscopy in a specialized 

department. 

Results: From 1995 to 2004, 70 hepatectomies were performed 

by laparoscopy: 19(27%) BT and 51(72%) cancer (15 hepatocellular 

carcinoma (HCC), 29 colo-rectal metastasis (CCM) and 9 

miscellaneous tumors). The liver resection was a major hepatectomy 

in 29 cases (22 right hepatectomies (RH), 3 extended 

RH, 1 left hepatectomy and 3 anatomical resections) and a 

minor hepatectomy in 41 cases (21 wedge resections, 20 

anatomical resections). 8(14%) patients were converted in 

laparotomy. 6(8.5%) patients were transfused with a postoperative 

morbidity of 11% and a mortality of 1.4% due to the postoperative 

death of a patient after a RH for HCC on a cirrhotic 

liver. For CRM (n=29 hepatectomies in 26 patients), overall and 

disease free survival at 36 months (mean follow-up of 25 

months) were 87% and 50%, respectively. For HCC (n=15), 

overall and disease free survival at 36 months (mean follow-up 

of 29 months) were 65% and 63%, respectively. No port-site 

metastasis occurred for patients with malignancy. 

Conclusions: If they are performed by surgeon specifically 

trained and specialized, laparoscopic liver resections, even 

major hepatectomy, are feasible with results which seem similar 

to laparotomy. 

S116 

LAPAROSCOPIC RADIOFREQUENCY THERMAL ABLATION 

FOR UNUSUAL HEPATIC TUMORS: OPERATIVE INDICATIONS 

AND OUTCOME, Eren Berber MD, Erhan Ari MD,Nora Herceg 

RN,Allan Siperstein MD, Department of General Surgery, The 

Cleveland Clinic Foundation, Cleveland, Ohio 

Objectives: There is an increasing experience with laparoscop- 


ic radiofrequency ablation (RFA) for the treatment of patients 

with hepatic metastasis from colorectal and neuroendocrine 

cancer as well as with hepatocellular cancer. Little is known 

about the outcome of patients with other tumor types. 

Methods: Between January 1996 and September 2004, 470 

patients were treated with RFA for unresectable primary and 

metastatic liver tumors. Ten % (49 patients) had cancers other 

than colorectal, neuroendocrine or hepatocellular including 

sarcoma (18 patients), breast (9 patients), esophagus (4 

patients), lung (3 patients), melanoma (3 patients), ovarian (2 

patients), pancreas (2 patients), unknown primary (2 patients), 

cholangiocarcinoma (2 patients), rectal squamous (2 patients), 

renal (1 patient) and hemangioendothelioma (1 patient). Unlike 

the criteria for treating the more usual tumor types, those 

patients had liver exclusive disease by preoperative imaging. 

They also failed chemotherapy. 

Results: The 49 patients underwent ablation of 184 lesions 

with 8 patients undergoing repeat treatment. Hospital stay 

averaged 1 day with no 30-day mortality and 1 postoperative 

hemorrhage, 1 liver abscess and 1 wound infection. Local 

recurrence of tumors occurred in 19% of lesions over a mean 

follow up of 24 months. Overall median survival was 33 

months with 45 months for breast cancer and 33 months for 

sarcoma. 

Conclusion: Laparoscopic RFA is able to safely and effectively 

treat hepatic metastasis in these unusual tumor types. We feel 

that this heterogenous group of patients, selected for their 

unusual presentation of liver exclusive disease, may benefit 

from cytoreduction of their tumor by laparoscopic RFA when 

other treatment methods have failed. 

S117 

RELATIONSHIP BETWEEN SUBJECTIVE AND OBJECTIVE 

OUTCOME MEASURES AFTER HELLER MYOTOMY AND DOR 

FUNDOPLICATION FOR ACHALASIA., Suad Gholoum MD, 

Simon Bergman MD,Sebastian Demyttenaere MD,Serge 

Mayrand MD,Donna Stanbridge RN,Liane S Feldman 

MD,Gerald M Fried MD, McGill University 

Objective: To assess how subjective evaluation (heartburn, 

dysphagia, quality of life, satisfaction) correlates with objective 

data after Heller myotomy and Dor fundoplication for achalasia. 

Methods: 45 consecutive patients with achalasia undergoing 

laparoscopic Heller myotomy and Dor fundoplication were 

studied prospectively. Subjective evaluation was done preop 

and postop using the GERD health related QOL scale (GERD- 

HRQL; 0=best to 45= worse), 4-point heartburn scale, 4-point 

dysphagia scale, patient satisfaction (0: very satisfied to 5: very 

dissatisfied), and SF-12 generic QOL scale. At 3 mo postop 

patients underwent 24hr pH testing, manometry, and 

endoscopy. Preop and postop data were expressed as median 

(IQR) or mean (SD) and analyzed by Wilcoxon signed rank test 

or paired t test. Results: Comparing preop to postop, improvements 

were found for dysphagia score from 4 (.2) to 1 (.3), 

GERD-HRQL from 13 (1.5) to 2 (1.6), heartburn score from 2 

(.4) to 1 (.3), satisfaction from 3 (.3) to 1 (.3), and mental QOL 

from 47 (11) to 55 (6) and physical QOL from 45 (10) to 51 (7) 

(all p


costs of Heller myotomy plus Dor fundoplication compared 

with Heller alone in patients with achalasia. The hypothesis is 

that the total costs to society of Heller plus Dor would be less 

than those of Heller alone because the higher operating room 

costs of Heller plus Dor would be compensated for by a 

decreased incidence of postoperative GERD and subsequent 

reduction in lifetime use of proton pump inhibitor (PPI) therapy. 

METHODS: 

We conducted a cost-utility analysis using specialized software 

that evaluated the long-term surgical management of achalasia. 

A Markov-cycle tree simulation model was used to examine 

the two treatment alternatives: (a) Heller plus Dor and (b) 

Heller alone. The model estimated the total expected costs of 

each strategy over a 10-year time horizon. Data for the model 

were derived from our prospective, randomized, double-blind, 

clinical trial in which patients with achalasia were assigned to 

undergo Heller alone or Heller plus Dor. A societal perspective 

was chosen, including all relevant direct medical costs (hospital 

costs and costs of outpatient care) and indirect costs. Drug 

costs represented the average wholesale price. The strategies 

were compared using the method of incremental cost-effectiveness 

analysis. 

RESULTS: 

The incidence of postoperative pathologic GERD was 47.6 % 

(10 of 21 patients) in the Heller group and 9.1 % (2 of 22 

patients) in the Heller plus Dor group using an intention-totreat 

analysis (P=0.005). Heller plus Dor was associated with a 

significant reduction in the risk of postoperative GERD (relative 

risk: 0.11; 95% confidence interval 0.02-0.59; P=0.01). The cost 

of operation was significantly higher for Heller plus Dor than 

for Heller alone (mean difference $942; P=0.04) secondary to a 

longer operating time (mean difference 40 minutes; P=0.01). At 

a time horizon of 10 years when PPI therapy costs are considered, 

the cost-utility analysis demonstrates that Heller plus Dor 

surgery is associated with a total cost of $6,861 per patient, 

whereas Heller alone surgery is associated with a cost of 

$9,541 per patient. 

CONCLUSIONS: 

In achalasia patients, Heller myotomy plus Dor fundoplication 

is preferred to Heller alone because is both more effective in 

preventing the occurrence of postoperative GERD and less 

expensive at a time horizon of 10 years. 

S119 

LAPAROSCOPIC HELLER MYOTOMY FOR THE TREATMENT OF 

ACHALASIA: EXPERIENCE WITH 101 CONSECUTIVE CASES., 

Michael J Rosen MD, Kent W Kercher MD,Yuri W Novitsky 

MD,William S Cobb MD,Andrew G Harrell MD,Brent Matthews 

MD,Timothy Kuwada MD,Ron F Sing MD,B. Todd Heniford MD, 

Carolinas Medical Center 

Introduction: The purpose of this study was to evaluate the 

clinical outcomes of patients undergoing laparoscopic 

esophageal myotomy for achalasia. 

Methods: A retrospective analysis of all patients undergoing 

laparoscopic Heller myotomy form January 1997 to June 2004 

was performed. Variables evaluated included preoperative 

symptoms, prior endoscopic interventions, preoperative 

manometric parameters, type of fundoplication, and perioperative 

outcomes. Symptoms were assessed postoperatively 

including the frequency and severity of reflux, dysphagia, 

chest pain, and regurgitation. 

Results: During the study period 101 patients underwent 

laparoscopic Heller myotomy. There were 47 males and 54 

females, with an average age of 45 years (14-84). Preoperative 

symptomatic complaints included severe dysphagia (97%), 

heartburn (20%), chest pain (29%), and regurgitation (52%). 

Prior to presentation 66% of patients had nonsurgical interventions 

including pneumatic dilatation (41%), bougie dilatation 

(11%), and Botox injection (29%). Manometric evaluation 

revealed a preoperative mean LES pressure of 44 mm Hg (12- 

168). A Toupet fundoplication was performed in 90 patients;11 

patients had no fundoplication due to short esophagus or 

other anatomic abnormality. Average operative time was 193 

minutes (100-344) and two patients were converted to an open 

procedure due to extensive intraabdominal adhesions. There 

were no intraoperative complications. Nine postoperative complications 

occurred including: C diff colitis (n=2), DVT (n=1), 

urinary retention (n=1), MI (n=1), atrial fibrillation (n=2), and reexploration 

for a twisted wrap (n=1). One patient who underwent 

emergent laparoscopic esophageal repair, myotomy, and 

fundoplication after endoscopic perforation during pneumatic 

dilatation developed a postoperative empyema. Postoperative 

follow up was completed in 82 patients for a mean of 37 

months (2-90). Reflux symptoms were reported in 16%. 

Occasional dysphagia was noted in 15% of patients. Eighty 

one percent of patients rated their outcome as excellent, 14% 

good, 4% fair, 1% poor. Ninety nine percent of patients would 

choose surgery over other treatment options again. 

Conclusion: Laparoscopic anterior esophageal myotomy is a 

safe and effective treatment for achalasia. Long-term follow-up 

demonstrates effective relief of dysphagia with outstanding 

patient satisfaction with the procedure. 

S120 

PROTON PUMP INHIBITORS REDUCE GALLBLADDER FUNC- 

TION, Mitchell A Cahan MD, Karen J Colton RN,Brittany A 

Palacioz,Kevin E Behrns MD,Timothy M Farrell MD, Division of 

Gastrointestinal Surgery, Department of Surgery, University of 

North Carolina School of Medicine, Chapel Hill, NC 27599-7081 

In a previous study of gallbladder (GB) function before and 

after fundoplication, 58% of patients studied by cholecystokinin-stimulated 

HIDA scan demonstrated preoperative GB 

motor dysfunction, and 86% of those retested after operation 

and cessation of proton pump inhibitors (PPIs) had normalization. 

Despite the amino acid homology of gastrin and CCK and 

the physiologic redundancy of these peptides in experimental 

models, no study has assessed GB function in patients taking 

PPIs. Therefore, we measured GB ejection fraction (GBEF) in 

healthy volunteers before and 30 days after initiation of PPI 

therapy. Methods: Volunteers were consented after screening 

for gastroesophageal reflux (GER), biliary disease, or chronic 

abdominal pain. Nineteen of 22 subjects completed the study, 

which included: (1) baseline determination of GBEF by CCK- 

HIDA scan, (2) 30 days of antisecretory therapy with omeprazole 

(40mg daily), and (3) repeat GBEF on day 30. Results: One 

month of PPI therapy diminished GB motility in 15 of 19 

patients (Figure). Mean GBEF decreased from 56.4 + 30.0% to 

42.8 + 32.3%, representing a 13.6% reduction (p

ABSTRACTS 

Friday, April 15, 2005 


lance programs in order to detect earlier and therefore potentially 

curable lesions. However, sampling error by missing 

invasive cancer lesions is a common problem. This study is 

aimed at identifying preferred spots within a segment of 

Barrett?s mucosa for the development of esophageal adenocarcinoma. 

Patients and Methods: The study group consisted of 213 

patients with histologically proven esophageal adenocarcinoma. 

Out of those there were 134 cases with early cancer and 

79 cases with locally advanced lesions. These patients 

received neoadjuvant chemotherapy. The frequency of intestinal 

metaplasia and the location of the tumor occurrence within 

the segment of intestinal metaplasia were assessed. 

Results: Intestinal metaplasia was found in 83% of the early 

lesions and in 98% of the advanced tumors after neoadjuvant 

chemotherapy. In 82.2% of the cases the tumor was located at 

the distal margin of the intestinal metaplasia in patients with 

early tumor manifestations. The remaining tumor mass after 

neoadjuvant therapy was as well located predominantly at the 

distal margin of the segment of intestinal metaplasia (85% of 

the cases). 

Conclusion: These results demonstrate that almost all adenocarcinoma 

of the esophagus are based on the development of 

a segment of intestinal metaplasia. The distal margin of the 

Barrett mucosa seems to be the most vulnerable spot for the 

development of invasive cancer. 

S122 

LONG-TERM EFFECTS OF LAPAROSCOPIC NISSEN FUNDO- 

PLICATION ON ESOPHAGEAL MOTILITY, Laurent Biertho MD, 

Herawaty Sebajang MD,Mehran Anvari PhD, Centre for 

Minimal Access Surgery, McMaster University, Hamilton, 

Ontario, Canada 

Background: Laparoscopic Nissen Fundoplication (LNF) has 

been shown to affect esophageal motility but its long-term 

effects have not been fully assessed. The aim of this study was 

to evaluate the long-term impact of LNF on esophageal motility 

in patients with pre-operative esophageal dysmotility. 

Methods: Prospective follow-up of 580 of patients after LNF 

between 1992 and 1999. Esophageal manometry was performed 

before surgery and at 6 months, 2 years and 5 years 

after surgery. 

Results: 8.1% of the patients (N=47) had low pre-operative 

esophageal contractile pressures (

ABSTRACTS 

Friday, April 15, 2005 

Conclusion: LNF provides an efficient treatment of GERD up to 

5 years, but can also be an effective treatment of associated GI 

symptoms. However, new bowel symptoms can develop after 

LNF and patients should be aware of that risk. 

S125 

MESH HIATOPLASTY FOR PARAESOPHAGEAL HERNIAS AND 

FUNDOPLICATIONS, Jason M Johnson DO, Alfredo M 

Carbonell DO,Brennan J Carmody MD,Mohammad K Jamal 

MD,Eric J DeMaria MD, Virginia Commonwealth University, 

Richmond, Virginia 

Little Grade A medical evidence exists to guide the foregut 

surgeon in the decision to use prosthetic material for hiatal 

closure in anti-reflux surgery. Therefore, we compiled and analyzed 

all available literature to determine if the use of prosthetic 

mesh for hiatoplasty in routine laparoscopic fundoplications 

(LF) or in the repair of large (> 5 cm) paraesophageal hernias 

(PEH) would decrease recurrence. 

A literature search was performed using an inclusive list of relevant 

search terms via Medline/PubMed to identify 

papers(n=19) in which prosthetic material was used in the 

repair of the crura for patients undergoing laparoscopic PEH 

reduction and/or LF. Case series(n=5), retrospective 

reviews(n=7), and prospective randomized(n=3) and non-randomized(n=4) 

trials were identified. Laparoscopic 

procedures(n=1312) were performed for either PEH, GERD, 

hiatal hernia or a combination of the three. Group A (n=679) 

were patients who had primary suture repair of the crura, and 

Group B (n=633) had repair with either interposition of mesh 

to close the hiatus or onlay of prosthetic material after closure. 

The use of mesh was associated with a decrease in recurrence 

when compared with primary suture repair in both the LF and 

PEH groups. Mean follow-up did not differ between groups 

(21.1 vs. 22.1 months). None of the papers cited any instance 

of prosthetic erosion into the gastrointestinal tract.The data 

support the use of prosthetic materials for hiatal repair for 

both routine LF and in the repair of large PEHs. Future randomized 

trials are needed to confirm that mesh repair is superior 

to simple crural closure, but the current study supports 

use of prosthetic material to improve outcomes in LF and PEH 

repair. Persistent concerns about prosthetic erosion, unconfirmed 

in this comprehensive review, suggest that biomaterials 

should be further evaluated to determine if they offer the benefits 

of improved hiatoplasty outcomes while avoiding the 

small risk of erosion. 



111

NOTES 



POSTER ABSTRACTS 

Posters of Distinction 

On display: Thursday & Friday, April 14-15, 2005 

P001 FIELDING, GEORGE “HIATAL CRURAL REPAIR AS MAN- 

AGEMENT OF SEVERE REFLUX FOLLOWING LAPAROSCOPIC 

ADJUSTABLE GASTRIC BANDING” 

P002 KOLAKOWSKI JR., STEPHEN “EFFECT ON ANASTOMOTIC 

LEAK RATE WITH THE USE OF CONTINUOUS POSITIVE AIRWAY 

PRESSURE IN ROUX-EN-Y GASTRIC BYPASS PATIENTS” 

P003 RICCIARDI, R “IMPROVED POSTOPERATIVE OUTCOMES 

AFTER LAPAROSCOPIC GASTRIC BYPASS: INSIGHTS FROM THE 

NATIONWIDE INPATIENT SAMPLE.” 

P004 TICHANSKY, DAVID “SUPER-SUPER OBESE PATIENTS 

UNDERGOING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS 

HAVE LESS POST OPERATIVE COMPLICATIONS COMPARED TO 

THOSE UNDERGOING OPEN ROUX-EN-Y GASTRIC BYPASS” 

P005 ARE, CHANDRAKANTH “CLINICAL CORRELATION OF 

LAPAROSCOPIC ULTRASOUND WITH EUS AND PATHOLOGIC 

STAGE IN PATIENTS UNDERGOING A CURATIVE RESECTION 

FOR GASTRIC CANCER” 

P006 KOBAYASHI, MICHIYA “THE LAPAROSCOPIC TECHNIQUE 

OF LYMPH NODE DISSECTION AROUND INFERIOR MESEN- 

TERIC ARTERY WITH PRESERVATION OF THE LEFT COLIC 

ARTERY.” 

P007 UCHIKOSHI, FUMIHIRO “MID-TERM RESULT OF LAPARO- 

SCOPIC SURGERY FOR CROHN’S DISEASE” 

P008 WILSON, ERIK “COMBINING THE PRIVATE PRACTICE AND 

ACADEMIC ENVIRONMENTS: A NEW MODEL FOR MINIMALLY 

INVASIVE SURGICAL FELLOWSHIP TRAINING” 

P009 STYLOPOULOS, NICHOLAS “IMAGE REGISTERED 

LAPAROSCOPIC ULTRASOUND (IRLUS) DECREASES THE 

FRUSTRATION AND THE WORKLOAD OF LAPAROSCOPIC 

ULTRASOUND” 

P010 BURRY, A “VARIATIONS IN ANTI-REFLUX SURGERY PRAC- 

TICE: A SURVEY OF 100 SURGEONS.” 

P011 CARVALHO, GUSTAVO “THE ROLE OF LAPARASCOPIC 

NISSEN FUNDOPLICATION IN GASTRO-ESOPHAGEAL REFLUX 

DISEASE IN PATIENTS WITH BARRETT¥S ESOPHAGUS - PRE- 

LIMINARY REPORT” 

P012 KHAJANCHEE, YASHODHAN “NAUSEA AND GASTROE- 

SOPHAGEAL REFLUX DISEASE: IS SURGERY THE CAUSE OR 

THE CURE” 

P013 LUTFI, RAMI “LARYNGOPHARYNGEAL REFLUX CAN 

EXIST WITH NORMAL DISTAL ESOPHAGEAL ACID EXPOSURE” 

P014 MOSER, FEDERICO “POUCH ENLARGEMENT AND BAND 

SLIPPAGE, TWO DIFFERENT ENTITIES” 

P015 PURI, VARUN “THE SHORT ESOPHAGUS: ANALYSIS OF 

VARIABLES” 

P016 SABNIS, ADHEESH “ANTERIOR GASTROPEXY ALONE MAY 

PREVENT RECURRENCE AFTER LAPAROSCOPIC PARAE- 

SOPHAGEAL HERNIA REPAIR” 

P017 SEKHAR, NIKHILESH “UNSEDATED TRANSNASAL ESOPH- 

AGOGASTROSCOPY. INITIAL OUTPATIENT EXPERIENCE WITH 

A 5MM GASTROSCOPE” 

P018 BELIZON, A “LAPAROSCOPIC CHOLECYSTECTOMY IN 

THE OCTOGENARIAN” 

P019 JELIN, ERIC “FIRST TRIMESTER PREGNANCY IS NOT A 

RELATIVE OR ABSOLUTE CONTRAINDICATION TO LAPARO- 

SCOPIC CHOLECYSTECTOMY” 

P020 SARMIENTO, JUAN “LAPAROSCOPIC LIVER RESECTION 

IN 49 PATIENTS” 

P021 SCHROEPPEL, THOMAS “AN ECONOMIC ANALYSIS OF 

HOSPITAL CHARGES FOR CHOLEDOCHOLITHIASIS BY DIFFER- 

ENT TREATMENT STRATEGIES” 

P022 KOK, NIELS “PROSPECTIVE EVALUATION OF LAPARO- 

SCOPIC VERSUS MINIMALLY INVASIVE OPEN DONOR 

NEPHRECTOMY” 

P023 REGAN, JOSEPH “LAPAROSCOPICALLY-ASSISTED 

RETROPERITONEAL SPINAL SURGERY: EXPERIENCE WITH 124 

CASES.” 

P024 SCHMIDBAUER, STEFAN “PROBLEMS OF PARATHYROID 

HORMONE MONITORING DURING MINIMALLY INVASIVE 

PARATHYROIDECTOMY” 

P025 ARELLANO, PAUL “LAPAROSCOPIC COLORECTAL 

SURGERY AND THE USE OF STAPLE LINE REINFORCEMENT 

MATERIALS” 

P026 CEPPA, FEDERICO “LAPAROSCOPIC TRANSGASTRIC 

ENDOSCOPY AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC 

BYPASS” 

P027 NOVITSKY, YURI “TRANSPLANTATION OF LAPAROSCOPI- 

CALLY-PROCURED RIGHT VERSUS LEFT KIDNEYS: COMPARA- 

TIVE ANALYSIS OF INTRAOPERATIVE GRAFT ISCHEMIA AND 

POSTOPERATIVE GRAFT FUNCTION AND SURVIVAL.” 

P028 PATEL, A “THE ROLE OF THORACOSCOPY FOR 

PENETRATING WOUNDS OF THE CHEST” 

P028-A KARPLUS, GIDEON “PNEUMOPERITONEUM-INDUCED 

OLIGURIA AND HEPATORENAL REFLEX” 

Bariatric Surgery 

On display: Thursday, April 14, 2005 

P029 BADGWELL, BRIAN “GASTRIC BYPASS AFTER SOLID 

ORGAN TRANSPLANTATION” 

P030 BAKER, MATTHEW “WEIGHT LOSS PRIOR TO LAPARO- 

SCOPIC GASTRIC BYPASS DOES NOT AFFECT OUTCOMES 

P031 BANOT, PARAG “PREOPERATIVE ENDOSCOPIC EVALULA- 

TION IN THE MORBIDLY OBESE POPULATION WITH GASTROE- 

SOPHAGEAL REFLUX DISEASE” 

P032 BHARGAVA, REENA “ACUTE RENAL FAILURE 

ASSOCIATED WITH LAPAROSCOPIC GASTRIC BYPASS 

SURGERY” 

P033 CAMACHO, DIEGO “THE UTILITY OF 

ESOPHAGOGASTRODUODENOSCOPY PRIOR TO 

LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS SURGERY” 

P034 CEPPA, FEDERICO “LAPAROSCOPIC REVISIONS OF 

ROUX-EN-Y GASTRIC BYPASS” 

P035 CHA, KAR-HUEI “GASTRO ESOPHAGEAL REFLUX DIS- 

EASE AFTER LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING 

IS CAUSED BY HIATAL HERNIA” 

P036 CHOUDRY, RASHAD “IMPROVED WOUND INFECTION 

RATES WITH ROUTINE SUBCUTANEOUS PORT SITE DRAINAGE 

IN LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS” 



113



P037 CHUN, JONATHAN “INTERNAL HERNIA FOLLOWING 

ROUX-EN-Y GASTRIC BYPASS: ACCURACY OF DIAGNOSTIC 

TESTING” 

P038 COLLINS, JOY “LAPAROSCOPIC VERSUS OPEN ROUX-EN- 

Y GASTRIC BYPASS AFTER FAILED OPEN VERTICAL BANDING 

GASTROPLASTY” 

P039 DAHIYA, SHYAM “LAPRA-TY APPLICATION ON 

LAPAROSCOPIC GASTRIC BYPASS SURGERY,AN ALTERNATIVE 

TO KNOT TYING” 

P040 DALLAL, RAMSEY “INTERNAL HERNIAS ARE MUCH 

MORE COMMON AFTER PERFORMING LAPAROSCOPIC GAS- 

TRIC BYPASS SURGERY WHEN THE ANTECOLIC ROUX LIMB IS 

ORIENTED TO THE LEFT COMPARED TO THE RIGHT.” 

P041 DAMANI, TANUJA “EVOLUTION OF SURGERY FOR 

MORBID OBESITY: FROM OPEN TO LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS” 

P042 DUKKIPATI, N “LAPAROSCOPIC ADJUSTABLE GASTRIC 

BANDING FOR THE TREATMENT OF MORBID OBESITY: A SIN- 

GLE INSTITUTION EXPERIENCE WITH THE LAP BAND AT 2 1/2 

YEARS” 

P043 FARKAS, DANIEL “HOW MUCH OF THE WEIGHT LOSS 

AFTER LAPAROSCOPIC GASTRIC BYPASS SURGERY IS FAT?” 

P044 FARKAS, DANIEL “PATIENTS 12 MONTHS AFTER 

LAPAROSCOPIC GASTRIC BYPASS HAVE BODY COMPOSITIONS 

SIMILAR TO CONTROLS” 

P045 FELIX, EDWARD “DRAINS AND TESTING DURING LRYGB: 

DOGMA OR NECESSITY?” 

P046 FINNELL, CHRISTOPHER “UNEXPECTED PATHOLOGY IN 

LAPAROSCOPIC BARIATRIC SURGERY” 

P047 FORRESTER, GLENN “ETHNICITY AND WEIGHT LOSS 

FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS” 

P048 GALVAO NETO, MANOEL “SIMPLIFIED GASTRIC BYPASS 

APPROACH TO MORBID OBESITY – 1000 INITIAL CASES” 

P049 GALVAO NETO, MANOEL “LAP BARIATRIC SURGERY- A 

TAILORED APPROACH IN A 2843 SINGLE CENTER PATIENT 

SERIES” 

P050 GENCO, ALFREDO “SLEEVE GASTRECTOMY VS BIB 

PLACEMENT IN SEVERE MORBID OBESITY PATIENTS: PRELIMI- 

NARY RESULTS” 

P051 GONZALEZ, RODRIGO “INITIATING A BARIATRIC 

SURGERY FELLOWSHIP TRAINING PROGRAM: IMPACT ON 

OPERATIVE OUTCOMES” 

P052 GORECKI, PIOTR “QUALITY OF LIFE, WELL-BEING AND 

PATIENT SATISFACTION AFTER A LAPAROSCOPIC GASTRIC 

BYPASS. PROSPECTIVE ANALYSIS OF 222 CONSECUTIVE 

PATIENTS.” 

P053 GOYAL, AJAY “LAPAROSCOPIC BARIATRIC SURGERY IS 

FEASIBLE AFTER OPEN SPLENIC SURGERY.” 

P054 GOYAL, AJAY “LESSONS LEARNED IN ESTABLISHING A 

SUCCESSFUL BARIATRIC PROGRAM IN A NON-TEACHING COM- 

MUNITY HOSPITAL” 

P055 GRIFFITH, LARRY “THE ROLE OF DIAGNOSTIC 

LAPAROSCOPY IN THE DIAGNOSIS AND MANAGEMENT OF THE 

POST-OPERATIVE COMPLICATIONS OF GASTRIC BYPASS 

PATIENTS” 

P056 GUMBS, ANDREW “JEJUNOJEJUNAL ANASTOMOTIC 

OBSTRUCTION FOLLOWING LAPAROSCOPIC ROUX-Y GASTRIC 

BYPASS DUE TO NON-ABSORBABLE SUTURE: A REPORT OF 

SEVEN CASES” 

P057 HAVERAN, LIAM “RESOLUTION OF HYPERTENSION AND 

DIABETES FOLLOWING LAPAROSCOPIC ADJUSTABLE GASTRIC 

BANDING.” 

P058 HSU, GLORIA “DOES THE SF-36 PREDICT POST- 

OPERATIVE WEIGHT LOSS?” 

P059 IM, ALBERT “INFECTION RATES USING WOUND 

PROTECTORS IN LAPAROSCOPIC GASTRIC BYPASS” 

P060 KAUL, ASHUTOSH “LIVER DISEASE IN OBESE PATIENTS – 

IS IT THE HEP C OF NEXT DECADE?” 

P061 KAUL, ASHUTOSH “RADIOLOGICAL FINDINGS IN 

INTERNAL HERNIAS IN PATIENTS OF LAPAROSCOPIC GASTRIC 

BYPASS?” 

P062 KAUL, ASHUTOSH “LESSONS FROM HISTORY AND NEW 

YORK STATE: TRENDS IN OBESITY SURGERY” 

P063 KENNEDY, COLLEEN “LAPAROSCOPIC ROUX EN Y 

GASTRIC BYPASS AFTER THE AGE OF 60: A SAFE 

ALTERNATIVE FOR WEIGHT LOSS” 

P064 KUYKENDALL, SAMUEL “MALLORY-WEISS TEAR AFTER 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS” 

P065 LEE, CRYSTINE “AMELIORATING THE SHORTCOMINGS 

OF PERCENTAGE EXCESS WEIGHT LOSS (EWL): THE 

‘BARIATRIC SURGERY SUCCESS RATE’ (BSSR) AS A NEW 

WEIGHT LOSS METRIC FOLLOWING BARIATRIC SURGERY” 

P066 LEE, CRYSTINE “THE BEST BARIATRIC OPERATION FOR 

PATIENTS OF BMI


P076 MURPHY, JASON “QUALITY OF LIFE PRIOR TO LAPARO- 

SCOPIC ROUX-EN-Y GASTRIC BYPASS DOES NOT VARY WITH 

BODY MASS INDEX” 

P077 MYERS, JONATHAN “PREGNANCY OUTCOME FOLLOWING 

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING: WHAT IS 

THE OPTIMAL BAND ADJUSTMENT REGIMEN?” 

P078 NELSON, LANA “FIBRIN SEALANT REDUCES SEVERITY 

OF ANASTOMOTIC LEAKS FOLLOWING ROUX-EN-Y GASTRIC 

BYPASS” 

P079 O’ROURKE, ROBERT “ALTERATIONS IN PERIPHERAL 

BLOOD LYMPHOCYTE FREQUENCY IN OBESE PATIENTS” 

P080 PAIGE, J “USE OF 48 HOUR CONTINUOUS INFUSION 

LOCAL ANESTHETIC SYSTEM IN LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS APPEARS TO REDUCE POSTOPERATIVE 

PAIN” 

P081 PINHEIRO, JOSE “REINFORCING GASTRIC STAPLE LINE 

WITH A BODEGRADABLE MEMBRANE FROM PORCINE 

INTESTINAL SUBMUCOSA DURING LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS.” 

P082 PINHEIRO, JOSE “LAPAROSCOPIC GASTRIC BYPASS AND 

PHYSICIANS. A CONTRAINDICATION?” 

P083 PODKAMENI, DAVID “OUTCOME OF SIMULTANEOUS VS. 

DEFERRED LAPAROSCOPIC CHOLECYSTECTOMY FOR 

CHOLELITHIASIS IN BARIATRIC SURGERY” 

P084 QURESHI, FAISAL “RADIO FREQUENCY ABLATION 

(STRETTA) IN PATIENTS WITH PERSISTENT GERD AFTER ROUX- 

EN-Y GASTRIC BYPASS” 

P085 REARDON, PATRICK “USE OF THE GASTRIC ANTRUM IN 

LAPAROSCOPIC ROUX-Y GASTRIC BYPASS” 

P086 REICHENBACH, DANIEL “GASTROTOMY WITH ANVIL 

“DUNK”: A NOVEL TECHNIQUE FOR GASTROJEJUNOSTOMY 

DURING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS” 

P087 SABNIS, ADHEESH “REVISIONAL BARIATRIC SURGERY: 

LESSONS LEARNED” 

P088 SANDOR, ANDRAS “AVOIDANCE OF SELECTIVE COINCI- 

DENT CHOLECYSTECTOMY IN PATIENTS UNDERGOING 

LAPAROSCOPIC BARIATRIC SURGERY” 

P089 SHORE, REBECCA “AVOIDING OBSTRUCTION AT THE 

JEJUNO-JEJUNOSTOMY DURING LAPAROSCOPIC GASTRIC 

BYPASS” 

P090 TAGAYA, NOBUMI “A NEW DEVICE BY USING OMENTUM 

FOR PREVENTING COMPLICATIONS DURING LAPAROSCOPIC 

ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY” 

P091 TAKATA, MARK “GASTRIC BYPASS IN PATIENTS 55 YEARS 

AND OLDER: A COMPARISON OF YOUNG VS OLD AND THE 

LAPAROSCOPIC VS OPEN TECHNIQUE” 

P092 TAYLOR, CRAIG “LAPAROSCOPIC ADJUSTABLE GASTRIC 

BANDING: RESULTS OF THE FIRST 500 CASES USING THE 

PARS FLACCIDA TECHNIQUE” 

P093 TERNOVITS, CRAIG “PREDICTIVE VALUE OF UPPER 

GASTROINTESTINAL STUDIES VERSUS CLINICAL SIGNS FOR 

LEAKS AFTER LAPAROSCOPIC GASTRIC BYPASS” 

P094 TICHANSKY, DAVID “LAPAROSCOPIC BARIATRIC 

PATIENTS’ WILL TO HELP: THE FOUNDATION OF CLINICAL 

RESEARCH” 

P095 TISHLER, DARREN “VISUAL IDENTIFICATION OF LIVER 

PATHOLOGY DURING LAPAROSCOPIC BARIATRIC 

PROCEDURES” 

P096 YADEGAR, JOHN “THE RELATIONSHIP OF GASTRIC 

EMPTYING & POSITION OF THE GASTROJEJUNOSTOMY (GJ) 

IN THE LAPAROSCOPIC ROUEX-EN-Y GASTRIC BYPASS 

(LRYGBP) PATIENTS, ANTEGASTRIC VS. RETROGASTRIC; IS 

THERE A DIFFERENCE?” 

P097 YU, SHERMAN “THE INCIDENCE OF SMALL BOWEL 

OBSTRUCTION AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC 

BYPASS USING AN ANTECOLIC ROUX LIMB” 

P098 ZOHAR, DAN “PORT COMPLICATIONS FOLLOWING 

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING FOR MORBID 

OBESITY” 

Colorectal/Intestinal Surgery 


P099 AL DOHAYAN, ABDULLAH “LAPAROSCOPIC LIGASURE 

SMALL BOWEL ANASTOMOSIS” 

P100 ANNAMANENI, RAVINDER “LAPAROSCOPIC RESECTION 

FOR COMPLETE AND INTERNAL RP” 

P101 ANVARI, MEHRAN “SAME DAY DISCHARGE AFTER 

LAPAROSCOPIC COLON RESECTION” 

P102 MARA ARENAS SANCHEZ, MARIA “LAPAROSCOPY HAS A 

PLACE IN THE REVERSAL OF HARTMANN PROCEDURE” 

P103 CHEN, WEI-SHONE “THE POSSIBLE INFLUENCE OF 

LAPAROSCOPIC SURGERY ON INTRA-ABDOMINAL TUMOR 

SPREADING IN PATIENTS OF COLORECTAL CANCER —- CLINI- 

CAL AND ANIMAL STUDY” 

P104 CHO, MINYOUNG “PRELIMINARY EXPERIENCE OF 

LAPAROSCOPY-ASSISTED EXPLORATION OF OBSCURE INTES- 

TINAL BLEEDING AFTER CAPSULE ENDOSCOPY; THE KOREAN 

EXPERIENCE” 

P105 DAY, AMY “LONG-TERM SURVIVAL AFTER LAPAROSCOPIC 

COLECTOMY FOR ADENOCARCINOMA” 

P106 FELLINGER, ERIKA “COST COMPARISON OF LOOPED 

VERSUS STAPLED LAPAROSCOPIC APPENDECTOMY” 

P107 FRANKLIN, JS “LAPAROSCOPIC COLON RESECTION: A 

SINGLE INSTITUTION RETROSPECTIVE REVIEW” 

P108 GAGNÈ, JEAN-PIERRE “LAPAROSCOPIC COLON SURGERY 

CAN BE PERFORMED SAFELY BY GENERAL SURGEONS IN A 

COMMUNITY HOSPITAL. A REVIEW OF 154 CONSECUTIVE 

CASES.” 

P109 HARNED, MICHAEL “LAPAROSCOPIC TREATMENT OF 

SMALL BOWEL OBSTRUCTION FROM MECKEL’S 

DIVERTICULUM” 

P110 HARRELL, ANDREW “LAPAROSCOPIC SIMPLE 

CECECTOMY: MINIMALLY INVASIVE THERAPY FOR CECAL 

POLYPS” 

P111 HEISE, CHARLES “LAPAROSCOPIC ASSISTED 

PROCTOCOLECTOMY WITH ILEAL-S-POUCH 

RECONSTRUCTION: IS THERE BENEFIT?” 

P112 KESSLER, HERMANN “VARIETY OF LAPAROSCOPIC 

SURGERY IN CROHN‚ÄÔS DISEASE” 



115



P113 KISSNER, MATTHEW “THREE TROCAR TECHNIQUE FOR 

LAPAROSCOPIC-ASSISTED REVERSAL OF HARTMANN’S PRO- 

CEDURE” 

P114 KOKUBA, YUKIHITO “PROSPECTIVE EVALUATION OF 

LAPAROSCOPIC SURGERY FOR RECTAL CARCINOMA” 

P115 KONDO, JURI “LAPAROSCOPIC SURGERY FOR 

COLORECTAL CANCER -THE SHORT- AND LONG-TERM 

OUTCOMES-” 

P116 KY, ALEX JENNY “RECTOURETHRAL FISTULAS: A 

DIFFICULT PROBLEM EVEN FROM A MINIMALLY INVASIVE 

PROCEDURE” 

P117 LEZOCHE, EMANUELE “LAPAROSCOPIC VS OPEN COLO- 

RECTAL RESECTION FOR CANCER: LONG TERM RESULTS 

ELEVEN YEARS ON” 

P118 LEZOCHE, EMANUELE “LONG TERM RESULTS OF 

LAPAROSCOPIC VS OPEN COLO-RECTAL RESECTIONS FOR 

CANCER IN 235 PATIENTS WITH A MINIMUM FOLLOW-UP OF 5 

YEARS” 

P119 LIN, EDWARD “SURGEON-INITIATED SCREENING 

COLONOSCOPY PROGRAM BASED ON SAGES AND ASCRC REC- 

OMMENDATIONS IN A GENERAL SURGERY PRACTICE” 

P120 LIRICI, MARCO MARIA “DYNAMIC GRACILOPLASTY VER- 

SUS IMPLANT OF ARTIFICIAL SPHINCTER FOR TOTAL ANOREC- 

TAL RECONSTRUCTION AFTER LAPAROSCOPIC ABDOMINOPER- 

INEAL EXCISION” 

P121 LÓPEZ-KÖSTNER, FRANCISCO “COMPARATIVE STUDY 

BETWEEN LAPAROSCOPIC AND OPEN ELECTIVE SURGERY FOR 

DIVERTICULAR DISEASE.” 

P122 MARU, SANDIP “PPH: A COMMUNITY HOSPITAL 

EXPERIENCE.” 

P123 MATZKE, GREGORY “SURGICAL MANAGEMENT OF 

INTESTINAL MALROTATION IN ADULTS: COMPARATIVE 

RESULTS OF OPEN AND LAPAROSCOPIC LADD PROCEDURES” 

P124 MIRANDA, LEONIDAS “ABNORMAL LIPID PROFILE-RISK 

FACTOR FOR THE FORMATION OF COLONIC DIVERTICULOSIS 

AMONG YOUNG PATIENTS” 

P125 MONTEFERRANTE, E “LAPAROSCOPIC COLECTOMY FOR 

ATTENUATED FAMILIAL ADENOMATOUS POLYPOSIS (AFAP)” 

P126 MUNAKATA, YASUHIRO “LAPAROSCOPIC LOW ANTERIOR 

RESECTION FOR ADVANCED RECTAL CANCER” 

P127 NAITO, MINORU “LAPAROSCOPIC-ASSISTED ABDOMINO- 

PERINEAL RESECTION FOR RECTAL CANCER BY 4 PORTS 

METHOD” 

P128 NAITOH, TAKESHI “CLINICAL OUTCOME OF LAPARO- 

SCOPIC COLORECTAL CANCER SURGERY” 

P129 NGUYEN, SCOTT “LAPAROSCOPIC SURGERY FOR 

DIVERTICULAR DISEASE COMPLICATED BY ENTERIC 

FISTULAS” 

P130 OHARA, HIROTSUGU “LESS INVASIVE SURGERY ON 

THE PATIENTS WITH SEVERE CONSTIPATION” 

P131 OTA, MITSUYOSHI “A CASE OF PERITONEAL DISSEMINA- 

TION ACCOMPANIED BY PORT SITE METASTASIS EIGHT 

MONTHS AFTER INITIAL LAPAROSCOPIC RESECTION OF SIG- 

MOID COLON CANCER.” 

P132 REICHENBACH, DANIEL “LAPAROSCOPIC COLON 

RESECTION PERFORMED IN A COMMUNITY-BASED TEACHING 

HOSPITAL” 

P133 ROSEN, MICHAEL “LAPAROSCOPIC VERSUS OPEN 

COLOSTOMY REVERSAL: A COMPARATIVE ANALYSIS” 

P134 ROSIN, DANNY “SHORT AND LONG TERM RESULTS IN 

306 LAPAROSCOPIC COLORECTAL PROCEDURES” 

P135 SACKS, BETHANY “TOTALLY LAPAROSCOPIC COLON 

RESECTION WITH INTRACORPOREAL ANASTOMOSIS FOR 

BENIGN AND MALIGNANT DISEASE” 

P136 SEBAJANG, HERAWATY “THE LEARNING CURVE OF 100 

LAPAROSCOPIC COLORECTAL RESECTIONS: TWO COMMUNITY 

SURGEONS’ EXPERIENCE” 

P137 SEKIMOTO, MITSUGU “A SURVEY OF LAPAROSCOPIC 

SURGERY FOR COLORECTAL CANCER IN JAPAN” 

P138 STITES, THOMAS “LAPAROSCOPIC APPENDECTOMY: 

LOOP LIGATION OR ENDOSCOPIC STAPLING? A COMPARISON 

OF TWO TECHNIQUES” 

P139 SUGA, HIROYASU “CLINICAL AND EXPERIMENTAL STUDY 

ON ENDOSCOPIC HEMOSTASIS BY LOCAL INJECTION OF FIB- 

RIN GLUE-HISTOPATHOLOGICAL OBSERVATION OF ITS HEMO- 

STATIC AND WOUND HEALING EFFECTS” 

P140 TAKADA, MORIATSU “EFFECTIVENESS OF ELEC- 

TROTHERMAL BIPOLAR VESSEL SEALER IN LAPAROSCOPIC 

COLECTOMY” 

P141 VIBERT, ERIC “SURGERY OF RECTAL CANCER : 

LAPAROSCOPY DECREASE THE LONG TERM MORTALITY BY 

CANCER.” 

P142 WANG, HM “LAPAROSCOPIC SURGERY FOR COLORECTAL 

CANCER: EXPERIENCE IN 500 SUCCESSFUL CASES” 

P143 WEXNER, STEVEN “LAPAROSCOPIC COLORECTAL 

SURGERY: EARLY AND LATER EXPERIENCE” 

P144 YAMAGUCHI, SHIGEKI “SHORT TIME RESULTS OF 

LAPAROSCOPIC COLORECTAL RESECTION BY DIFFERENT SUR- 

GEONS” 

P145 YAVUZ, NIHAT “LAPAROSCOPIC APPROACH TO A JEJU- 

NAL STROMAL TUMOR.” 

Education/Outcomes 


P146 AGGARWAL, R “TASK DECONSTRUCTION FOR TRAINING 

ON A LAPAROSCOPIC VIRTUAL REALITY SIMULATOR” 

P147 AGGARWAL, R “TAXONOMY OF DIDACTIC RESOURCES IN 

VIRTUAL REALITY SIMULATION” 

P148 AGGARWAL, R “DEXTERITY ANALYSIS FOR THE 

ASSESSMENT OF LAPAROSCOPIC PROCEDURES IN THE 

OPERATING ROOM” 

P149 BERCH, BARRY “EXPERIENCE WITH THE OPTICAL 

ACCESS TROCAR FOR SAFE AND RAPID ENTRY IN 

PERFORMING THE LAPAROSCOPIC GASTRIC BYPASS” 

P150 CARBONELL, ALFREDO “TELEMENTORING VERSUS ON- 

SITE MENTORING IN SIMULATION TRAINING” 

P151 CHEKAN, ED “WEBSITE NAVIGATION AND SURGICAL 

EDUCATION” 



P152 CHOKKI, ADEL “THE PRE-VESICAL SEAT OF THE 

HYDATID CYST, AN EXCEPTIONAL LOCALIZATION : CASE 

REPORT AND LITERATURE REVIEW” 

P153 CHOKKI, ADEL “A PRIMARY HYDATID CYST OF THE 

GLUTEAL MUSCLE : A CASE REPORT” 

P154 FRASER, SHANNON “CHARACTERIZING THE LEARNING 

CURVE FOR A BASIC LAPAROSCOPIC DRILL.” 

P155 GRANTCHAROV, TEODOR “OBJECTIVE ASSESSMENT OF 

LAPAROSCOPIC SKILLS USING A VIRTUAL REALITY SIMULATOR 

– CORREALTION WITH PERFORMANCE IN THE OPERATING 

ROOM” 

P156 HARMON, CARROLL “IMPROVEMENT IN SUTURING AND 

TYING TIMES IN PEDIATRIC SURGERY FELLOWS ATTENDING A 

WORKSHOP FOR AN ADVANCED LAPAROSCOPIC PROCEDURE” 

P157 HASHIZUME, MAKOTO “EFFECTIVENESS OF TRAINING 

WITH ROBOTIC SYSTEM ON ENDOSCOPIC SURGERY” 

P158 KAWADA, MICHIHIRO “POTENTIAL FORAMEN ALONG THE 

ATTACHMENT OF THE DIAPHRAGM TO THE LOWER RIBS DUR- 

ING LAPAROSCOPIC RENAL AND ADRENAL SURGERY” 

P159 KIMURA, TAIZO “VALUES OF A VIRTUAL SIMULATOR AND 

TRAINING BOX IN TRAINING FOR ENDOSCOPIC SURGERY” 

P160 KORNDORFFER JR., J “VALIDITY AND RELIABILITY OF A 

VIDEOTRAINER LAPAROSCOPIC CAMERA NAVIGATION SIMULA- 

TOR” 

P161 KORNDORFFER, JR, J “PROFICIENCY-BASED TRAINING 

FOR LAPAROSCOPIC SUTURING: VR, VT, OR BOTH?” 

P162 KUNDHAL, PAVI “OCCUPATIONAL EXPOSURES AMONG 

SURGICAL RESIDENTS DURING LAPAROSCOPIC SURGERY: 

INCIDENCE AND ATTITUDES” 

P163 LAU, HUNG “EARLY VERSUS DELAYED INTERVAL 

LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYS- 

TITIS: A META-ANALYSIS” 

P164 MCINTYRE, THOMAS “TELESURGERY ENHANCES 

EDUCATION OF MEDICAL STUDENTS” 

P165 RIVERA, LOUIS “VIRTUAL REALITY TESTING ON THE 

EFFECTS OF SLEEP DEPRIVATION” 

P166 RO, CHARLES “THE IMPACT OF HAPTIC EXPECTATIONS 

ON INITIAL LAPSIMÆ PERFORMANCE: PRIOR LAPAROSCOPIC 

EXPERIENCE DOES NOT PREDICT PERFORMANCE” 

P167 SARKER, SUDIP “SELF-APPRAISAL OF CONSULTANT 

SURGEONS PERFORMING LAPAROSCOPIC 

CHOLECYSTECTOMIES USING HIERARCHAL TASK ANALYSIS” 

P168 SARKER, SUDIP “CONSTRUCT VALIDITY OF ASSESSORS 

OF STRUCTURED SURGICAL TECHNICAL SKILLS ASSESSMENT 

IN LAPAROSCOPIC SURGERY” 

P169 SARKER, SUDIP “DEVELOPMENT OF A STRUCTURED 

GLOBAL TECHNICAL SKILLS ASSESSMENT TOOL IN OPEN & 

LAPAROSCOPIC SURGERY” 

P170 SAVU, MICHELLE “ANALYSIS OF PSYCHOMOTOR SKILLS 

USED IN LEARNING TEP” 

P171 SHERMAN, VADIM “VALIDATION OF SUMMARY METRICS 

FOR THE LAPSIM VIRTUAL REALITY (VR) SIMULATOR” 

P172 SHIMIZU, SHUJI “INTERNATIONAL TRANSMISSION OF 

UNCOMPRESSED ENDOSCOPIC SURGICAL IMAGES OVER 

BROADBAND INTERNET” 

P173 SIERRA, R “PROFICIENCY-BASED TRAINING: A NEW 

STANDARD FOR LAPAROSCOPIC SIMULATION” 

P174 STANBRIDGE, DONNA “THE ROLE OF OBSERVATION IN 

THE ACQUISITION OF LAPAROSCOPIC TECHNICAL SKILLS” 

P175 STEFANIDIS, DIMITRIOS “INTEGRATING BASIC SKILLS IS 

COST-EFFECTIVE FOR TEACHING LAPAROSCOPIC SUTURING” 

P176 TALARICO, JOSEPH “CONTRIBUTION OF TIME, ERRORS, 

AND ECONOMY TO MIST-VR SCORE IS INDEPENDENT OF 

DIFFICULTY LEVEL” 

P177 THAPAR, PINKY “PREVENTING COMMON BILE DUCT 

INJURIES IN LAPAROSCOPIC CHOLECYSTECTOMY - A TEACH- 

ING INSTITUTE EXPERIENCE” 

P178 UCHAL, MIRO “OPERATIVE END-PRODUCT QUALITY AND 

PROCEDURE EFFECTIVENESS COMPARING ROBOTIC CAMERA 

HOLDER TO HUMAN CAMERA HOLDER IN A LAPAROSCOPIC 

INANIMATE SIMULATOR” 

P179 VAN SICKLE, KENT “LARGE-SCALE ASSESSMENT OF 

LAPAROSCOPIC SKILLS USING SIMULATION: ANALYSIS FROM 

THE 2004 SAGES LEARNING CENTER MIST-VR STUDY” 

P180 VASSILIOU, MELINA “CANNULATION: A POTENTIAL 

ADDITION TO THE FLS PROGRAM” 

P181 VILLEGAS, LEONARDO “RESULTS OF A CHANGE TO 

MANDATORY LAPAROSCOPIC SKILLS CRITERIA AMONG SURGI- 

CAL RESIDENTS.” 

P182 YEUNG, SHIRLEY “A COMPARISON OF NURSES’ 

ATTITUDES TOWARDS LAPAROSCOPIC AND CONVENTIONAL 

SURGERY” 

P183 ZUCKERMAN, RANDALL “RURAL/NON-RURAL 

DIFFERENCES IN SURGEON PERFORMED ENDOSCOPY; 

RESULTS OF A NATIONAL SURVEY” 

Hepatobiliary/Pancreatic Surgery 


P184 AHMED, SYED “TO DETERMINE THE VALUE OF DIAG- 

NOSTIC LAPAROSCOPY IN PATIENTS WITH POTENTIALLY 

RESECTABLE ADENOCARCINOMA OF PANCREAS” 

P185 ALUKA, KANAYOCHUKWU “LAPAROSCOPIC DISTAL PAN- 

CREATECTOMY WITH SPLENIC PRESERVATION FOR SEROUS 

CYSTADENOMA OF THE PANCREAS: A CASE REPORT AND LIT- 

ERATURE REVIEW” 

P186 BUI, PHIET “THE EFFECTS OF PRE-OPERATIVE 

ROFECOXIB, METOCLOPRAMIDE HYDROCHLORIDE 

DEXAMETHASONE, AND ONDANSETRON ON POST OPERATIVE 

PAIN AND NAUSEA IN PATIENTS UNDERGOING LAPAROSCOPIC 

CHOLECYSTECTOMY” 

P187 CARVALHO, GUSTAVO “MINILAPAROSCOPIC CHOLECYS- 

TECTOMY – REDUCING ORIFICE SIZE WITHOUT INCREASING 

SURGERY COST.” 

P188 CHOI, IN SEOK “LAPAROSCOPIC CBD EXPLORATION 

WITHOUT T-TUBE” 

P189 ESCALONA, ALEX “LAPAROSCOPIC LIVER RESECTION IN 

PORCINE: DEVELOPMENT OF AN EXPERIMENTAL MODEL” 

P190 FINAN, KELLY “IMPROVEMENT IN GASTROINTESTINAL 

SYMPTOMS AND QUALITY OF LIFE FOLLOWING 

CHOLECYSTECTOMY” 



117



P191 FREZZA, ELDO “MINIMALLY INVASIVE INCISION FOR 

CYSTGASTROSTOMY IN LARGE PANCREATIC PSEUDOCYSTS” 

P192 FURUTA, KAZUNORI “LAPAROSCOPIC　PANCRE- 

ATIC CYSTGASTOROSTOMY” 

P193 GAL, ISTVAN “QUALITY OF LIFE AFTER LAPAROSCOPIC 

AND OPEN CHOLECYSTECTOMY-A COMPUTER BASED ANALY- 

SIS USING THE GASTROINTESTINAL QALITY OF LIFE (GIQLI ) 

INDEX” 

P194 GAMBLIN, T “ENDOSCOPIC ULTRASOUND EVALUATION 

DIRECTS LAPAROSCOPIC RESECTION OF PANCREATIC 

NEOPLASMS” 

P195 HAMAD, GISELLE “MIRIZZI SYNDROME AFTER 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS” 

P196 HAN, HO-SEONG “TOTALLY LAPAROSCOPIC RIGHT POS- 

TERIOR SECTIONECTOMY (SEGMENTS VI-VII) FOR HEPATO- 

CELLULAR CARCINOMA” 

P197 HERRERA, MIGUEL “LAPAROSCOPIC MANAGEMENT OF 

INSULINOMAS” 

P198 HOXHA, FATON “SURGICAL TREATMENT OF BILE DUCT 

INJURIES FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY” 

P199 INAGAKI, HITOSHI “LAPAROSCOPIC HEPATECTOMY FOR 

METASTATIC LIVER TUMOR AFTER LAPAROSCOPIC COLECTO- 

MY - REPORT OF 2 CASES.” 

P200 JANG, JY “TOTALLY LAPAROSCOPIC MANAGEMENT OF 

CHOLEDOCHAL CYST USING 4 HOLES METHODS” 

P201 KIM, JIN “CALCULOUS CHOLECYSTITIS AFTER LIVER 

TRAUMA IN A CHILD” 

P202 KURANISHI, FUMITO “NEEDLESCOPIC CHOLECYSTECTO- 

MY” 

P203 KURANISHI, FUMITO “POST LAPAROSCOPIC CHOLECYS- 

TECTOMY BODY TEMPERATURE” 

P204 MARTIN, ROBERT “INTRAOPERATIVE MAGNETIC 

RESONANCE IMAGING ABLATION OF HEPATIC TUMORS” 

P205 MISRA, MEGHNA “LAPAROSCOPIC CHOLECYSTECTOMY 

IN PATIENTS WITH SEVERE CARDIAC DISEASE” 

P206 PAGANINI, ALESSANDRO MARIA “CRYOABLATION OF 

HEPATIC TUMORS: A COMPARATIVE STUDY BETWEEN TWO 

INSTRUMENTS” 

P207 SCHMIDT, BRIAN “ACUTE ACALCULOUS CHOLECYSTITIS: 

INCIDENCE, TREATMENT OPTIONS AND EVENTUAL OUTCOME” 

P208 SCHRAIBMAN, VLADIMIR “LAPAROSCOPIC ENUCLEATION 

OF PANCREATIC INSULINOMAS” 

P209 SHIMABUKU, MASAMORI “INFLUENCE FOR HEMODINAM- 

ICS OF THE HEPATIC ARTERIAL BLOOD CIRCURATION BY 

PNEUMOPERITONEUM IN LAPAROSCOPIC 

CHOLECYSTECTOMY.” 

P210 SINGHAL, TARUN “GALLSTONES: BEST SERVED HOT” 

P211 TAGAYA, NOBUMI “NEEDLESCOPIC CHOLECYSTECTOMY 

VS NEEDLESCOPE-ASSISTED LAPAROSCOPIC CHOLECYSTEC- 

TOMY” 

P212 TALEBPOUR, MOHAMMAD “NEW ASPECTS IN LAPARO- 

SCOPIC CHOLECYSTECTOMY” 

P214 WENNER, DONALD “LCBDE USING THE MULTI-CHANNEL 

INSTRUMENT GUIDE” 

P215 YOON, YOO-SEOK “LAPAROSCOPIC ANATOMICAL LIVER 

RESECTION IN A PADIATRIC PATIENT WITH BENIGN CYSTIC 

LESION” 

P216 YOON, YOO-SEOK “THE USEFULNESS OF CUSA DURING 

LAPAROSCOPIC LIVER RESECTION” 

P217 YOON, YOO-SEOK “CLINICAL OUTCOMES AFTER 

LAPAROSCOPIC CBD EXPLORATION” 

Basic Science 

(cellular bio, physiology) 

On display: Friday, April 15, 2005 

P218 COBB, WILLIAM “NORMAL INTRA-ABDOMINAL 

PRESSURE IN HEALTHY ADULTS” 

P219 FUENTES, JOSEPH “CARBON DIOXIDE PNEUMOPERI- 

TONEUM POSTTREATMENT ATTENUATES IL-6 PRODUCTION” 

P220 KIRMAN, IRENA “OPEN SURGERY TRAUMA-RELATED 

INCREASE IN TIMP-1/MMP-9 CONCENTRATION IN THE EARLY 

POSTOPERATIVE PERIOD” 

P221 MANSON, ROBERTO “MODELING CAUSES OF HUMAN 

GASTROESOPHAGEAL REFLUX: AUTOLOGOUS CANINE LUNG 

TRANSPLANTATION.” 

P222 SHAH, MEGHA “INCLUSION OF A NITRIC OXIDE DONOR 

IN THE INSUFFLATING GAS DOES NOT ALTER GASTRIC EMPTY- 

ING FOLLOWING PNEUMOPERITONEUM” 

Complications of Surgery 


P223 CARVALHO, GUSTAVO “LAPAROSCOPIC REPAIR OF A 

URETER DAMAGED DURING INGUINAL HERNIORRAPHY.” 

P224 CARVALHO, GUSTAVO “ENDOSCOPIC TREATMENT OF 

ESOPHAGO-PLEURAL FISTULA BY APPLYING FIBRIN GLUE” 

P225 EL-BANNA, MOHEY “PITFALLS AND COMPLICATIONS OF 

LAPAROSCOPIC NISSEN FUNDOPLICATION” 

P226 FECHER, ALISON “BLADELESS TROCAR HERNIA RATE IN 

UNCLOSED FASCIAL DEFECTS IN BARIATRIC PATIENTS” 

P227 FORTUNATO, RICHARD “DELAYED PRESENTATION OF 

SPLENIC RUPTURE AFTER COLONOSCOPY” 

P228 HAMAD, GISELLE “INCIDENCE OF INTERNAL HERNIA 

FOLLOWING LAPAROSCOPIC RETROCOLIC RETROGASTRIC 


P229 HAMAD, GISELLE “INCIDENCE OF STOMAL STENOSIS 

FOLLOWING LAPAROSCOPIC RETROCOLIC-RETROGASTRIC 


P230 HUGUET, K “LATE GASTRIC PERFORATIONS AFTER 

LAPAROSCOPIC FUNDOPLICATION” 

P231 KITANI, KOTARO “PANCREATIC COMPLICATIONS AFTER 

LAPAROSCOPIC SPLENECTOMY” 

P232 MAALOUF, MAJED “PORTAL VEIN THROMBOSIS AFTER 

LAPAROSCOPIC SPLENECTOMY FOR SYSTEMIC MASTOCYTO- 

SIS” 

P233 SAXE, J “DOES LAPAROSCOPIC APPENDECTOMY 

INCREASE THE RISK OF INTRAABDOMINAL ABSCESS” 

P234 SWIERZEWSKI, DAVID “CASE REPORT OF DELAYED 

SMALL BOWEL OBSTRUCTION FOLLOWING LAPARASCOPIC- 

ASSISTED HEMICOLECTOMY” 



P235 YASUI, M “LAPAROSCOPIC SPLENECTOMY FOR THE 

TREATMENT OF SPLENIC AND HEMATOLOGIC DISORDERS. -A 

RISK OF ENLARGED OR MASSIVE SPLENOMEGALY-” 

Ergonomics/Instrumentation 


P236 BOWERS, STEVEN “SURGICAL ENDOSCOPY AT THE EDGE 

OF THE WORLD” 

P237 BUESS, GERHARD “SOLO-SURGERY USING THE 

ENDOFREEZE SYSTEM” 

P238 HOWELL, DANIEL “OBJECTIVE ASSESSMENT OF KNOT 

QUALITY SCORE” 

P239 OZAWA, SOJI “DEVELOPMENT OF A NEW FLAT NEEDLE 

AND TIGHTER THREAD FOR ENDOSCOPIC SUTURING” 

P240 SHINOHARA, KAZUHIKO “FAILURE MODE AND EFFECTS 

ANALYSIS ON THE LAPAROSCOPIC CHOLECYSTECTOMY” 

P241 ZHENG, BIN “ASSESSING ENDOSCOPIC CUTTING PER- 

FORMANCE WITH AND WITHOUT THE TARGET BEING HELD 

WITH THE NONPREFERRED HAND” 

Esophageal/Gastric Surgery 


P242 BEDARD, ERIC “LAPAROSCOPIC RESECTION OF GASTRIC 

GISTS: NOT ALL TUMORS ARE CREATED EQUAL” 

P243 BIERTHO, LAURENT “THE INFLUENCE OF 

PSYCHOLOGICAL DISORDERS ON THE OUTCOMES OF 

LAPAROSCOPIC NISSEN FUNDOPLICATION: PRELIMINARY 

RESULTS” 

P244 BONNOR, RICARDO “NISSEN FUNDOPLICATION WITH 

GASTROSTOMY TUBE IN LUNG TRANSPLANT PATIENTS WITH 

POOR ESOPHAGEAL MOTILITY” 

P245 CARVALHO, GUSTAVO “LAPAROSCOPIC TREATMENT OF 

POST-DILATION ESOPHAGIC ENDOSCOPIC PERFORATION IN A 

PATIENT WITH IDIOPATHIC ACHALASIA BY THAL ESOPHA- 

GOGASTROPLASTY WITH DOR ANTIREFLUX VALVE” 

P246 CARVALHO, GUSTAVO “LAPARASCOPIC RE-FUNDOPLICA- 

TION IN THE TREATMENT OF GERD - AN ANALYSIS OF 18 

CASES.” 

P247 CHEN, KUO-HSIN “LAPAROSCOPIC RESECTION OF A 

TUBULOVILLOUS ADENOMA ARISING IN THE DUODENAL 

BULB” 

P248 DAVIS, S “LAPAROSCOPIC NISSEN FUNDOPLICATION 

AFTER FAILED STRETTA PROCEDURE” 

P249 DUDAI, MOSHE “EVOLUTION OF THE EPTFE SOFT BELT 

NONINFLATABLE LAPAROSCOPY GASTRIC BANDING (SBNLGB), 

MULTICENTERS 10 YEARS COMPARATIVE EVOLUTION STUDY” 

P250 EDWARDS, MELANIE “LAPAROSCOPIC RESECTION OF 

GASTROINTESTINAL STROMAL TUMORS” 

P251 FERNANDEZ, HIOSADHARA “POSTOPERATIVE ACHALA- 

SIA, AS AN ANTIREFLUX SURGERY COMPLICATION” 

P252 FREZZA, ELDO “THE ROLE OF SELECTIVE VAGOTOMY 

DURING NISSEN FUNDOPLICATION” 

P253 GORECKI, PIOTR “LAPAROSCOPIC GASTRIC BYPASS – AN 

EFFECTIVE TREATMENT FOR COMPLICATED GERD. A CASE 

REPORT.” 

P254 GRANGER, STEVEN “LESSONS LEARNED FROM 

LAPAROSCOPIC TREATMENT OF ESOPHAGEAL AND GASTRIC 

SPINDLE CELL TUMORS” 

P255 JAMAL, MOHAMMAD “SYMPTOMATIC OUTCOMES AFTER 

LAPAROSCOPIC MODIFIED HELLER MYOTOMY AND DOR FUN- 

DOPLICATION (MHMDF) FOLLOWING FAILED MEDICAL MAN- 

AGEMENT OF ACHALASIA.” 

P256 JOHNSON, JASON “THE USE OF ACELLULAR DERMAL 

MATRIX FOR MESH HIATOPLASTY” 

P257 KATADA, NATSUYA “FUNCTIONAL EVALUATION OF 

LAPAROSCOPIC HELLER MYOTOMY WITH TOUPET FUNDOPLI- 

CATION FOR ACHALASIA” 

P258 KUWADA, TIMOTHY “LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS WITH COMBINED HELLER MYOTOMY FOR 

THE TREATMENT OF ACHALASIA AND MORBID OBESITY” 

P259 LOMBARDO, VITTORIO “OUTCOMES OF LAPAROSCOPIC 

PARAESOPHAGEAL HERNIA REPAIR: 49 CONSECUTIVE CASES 

IN A RURAL CENTER” 

P260 LOPUSHINSKY, STEVEN “ANTI-REFLUX SURGERY: A 

SMALL AREA VARIATION ANALYSIS” 

P261 MAZZAGLIA, PETER “PERCUTANEOUS ENDOSCOPIC 

GASTROGASTROSTOMY CORRECTS GASTRIC OUTLET 

OBSTRUCTION FOLLOWING VERTICAL-BANDED 

GASTROPLASTY” 

P262 MCGRAW, PATRICK “PERCUTANEOUS ENDOSCOPIC 

GASTROSTOMY WITH T-BAR FIXATION IN CHILDREN AND 

INFANTS” 

P263 MEHTA, S “DIVISION OF THE SHORT GASTRIC VESSELS 

DURING LAPAROSCOPIC NISSEN FUNDOPLICATION” 

P264 MÜLLER-STICH, BEAT “LAPAROSCOPIC MESH-AUGMENT- 

ED HIATOPLASTY AND ANTERIOR GASTROPEXY: A REMAKE OF 

AN OLD PRINCIPLE” 

P265 NAGAI, YUGO “LAPAROSCOPY-ASSISTED DISTAL 

GASTRECTOMY WITH LYMPHNODE DISSECTION FOR EARLY 

GASRTRIC CANCER” 

P266 NIMURA, HIROSHI “SENTINEL NODE NAVIGATION 

LAPAROSCOPIC SURGERY WITH THE INFRARED RAY 

LAPAROSCOPY SYSTEM FOR GASTRIC CANCER” 

P267 OKADA, KAZUYUKI “LAPAROSCOPY- ASSISTED TOTAL 

GASTRECTOMY FOR GASTRIC CANCER” 

P268 OKRAINEC, ALLAN “LAPAROSCOPIC WEDGE 

GASTRECTOMY ESOPHAGEAL LENGTHENING PROCEDURE: 

CLINICAL AND PHYSIOLOGICAL FOLLOW-UP” 

P269 OMORI, TAKESHI “LAPAROSCOPIC INTRAGASTRIC SUR- 

GERY UNDER CARBON DIOXIDE PNEUMOSTOMACH” 

P270 PUNTAMBEKAR, SHAILESH “LAPROSCOPIC ASSISTED 

TOTAL GASTRECTOMY” 

P271 RAMKUMAR, KRISHNAMOORTHY “EVALUATION OF 

LAPAROSCOPIC ANTI-REFLUX SURGERY WITHOUT A BOUGIE 

USING A POSTOPERATIVE VALIDATED SYMPTOM SCORE” 

P272 REARDON, PATRICK “USE OF A LEFT HEMIDIAPHRAGM 

RELAXING INCISION FOR A TENSION FREE CRURAL CLOSURE 

IN THE REPAIR OF LARGE HIATAL HERNIAS.” 

P273 RICHARDSON, WILLIAM “MIDTERM FOLLOW UP AFTER 

LAPAROSCOPIC HELLER MYOTOMY ALONE VERSUS TOUPET, 

DOR AND MODIFIED DOR FUNDOPLICATION” 



119



P274 ROSEMURGY, ALEXANDER “BMI IMPACTS PRESENTING 

SYMPTOMS OF ACHALASIA AND OUTCOME AFTER HELLER 

MYOTOMY” 

P275 ROSEMURGY, ALEXANDER “OUTCOMES PROMOTE REDO 

HELLER MYOTOMY FOR SYMPTOMS OF ACHALASIA” 

P276 SAVELLI, ALFREDO “LAPAROSCOPIC REPAIR OF A 

LARGE HIATAL HERNIA FIRST REPORT ON THE USE OF 

CRURASOFT‚ PATCH IN ITALY” 

P277 SEBAJANG, HERAWATY “OUTCOME OF 100 

LAPAROSCOPIC NISSEN FUNDOPLICATIONS PERFORMED IN A 

RURAL HOSPITAL” 

P278 SEBAJANG, HERAWATY “THE LEARNING CURVE OF 

LAPAROSCOPIC NISSEN FUNDOPLICATIONS PERFORMED BY A 

COMMUNITY SURGEON” 

P279 SEGAN, ROSS “A NOVEL CONCEPTUAL MODEL OF THE 

CURRENT SURGICAL CLASSIFICATION OF PARAESOPHAGEAL 

HERNIAS USING DYNAMIC THREE-DIMENSIONAL 

RECONSTRUCTION” 

P280 SHIMOMURA, KAZUYUKI “LAPAROSCOPIC HAND- 

ASSISTED NISSEN FUNDOPLICATION” 

P281 TAKEMOTO, HIROTOSHI “HAND-ASSISTED LAPAROSCOP- 

IC SURGERY FOR A HUGE GASTROINTESTINAL STROMAL 

TUMOR OF THE STOMACH:REPORT OF TWO CASES” 

P282 TAYLOR, CRAIG “LAPAROSCOPIC GASTRIC RESECTION: 

THE RESULTS OF NINETEEN CONSECUTIVE CASES” 

P283 VAKILI, CYRUS “IDENTIFICATION OF A LARGE SYMPA- 

THETIC NERVE AT THE GASTROESOPHAGEAL JUNCTION DUR- 

ING LAPAROSCOPIC NISSEN FUNDOPLICATION.” 

P284 VISWANATH, YKS “FEASIBILITY OF LAPAROSCOPIC FUN- 

DOPLICATION AFTER FAILED ENDOSCOPIC ANTIREFLUX 

THERAPY” 

P285 WEIGEL, TRACEY “LAPAROSCOPIC IVOR LEWIS 

ESOPHAGECTOMY IN THREE PATIENTS WITH ABERRENT 

RIGHT SUBCLAVIAN ARTERIES” 

P286 WILMOTH, ROBERT “LAPAROSCOPIC NISSEN 

FUNDOPLICATION IN INFANTS LESS THAN 10KG” 

P287 YAMADA, HIDEO “EXPERIENCE WITH DEVELOPMENT 

AND CLINICAL USE OF A SMALL OPENER FOR LAPAROSCOPIC 

ASSISTED GASTRIC SURGERY” 

P288 YARTSEV, PETER “PERFORATED PYLORODUODENAL 

ULCERS” 

P289 ZENI, TALLAL “LAPAROSCOPIC REDO NISSEN 

FUNDOPLICATION” 

Flexible Diagnostic & Therapeutic 

Endoscopy 


P290 BUADZE, MERAB “ENDOSCOPE DIAGNOSIS AND TREAT- 

MENT OF SEVERAL PEDIATRIC GASTROINTESTINAL DISEASES 

:A SINGLE CENTER EXPERIENCE” 

P291 COSGROVE, JOHN “THE USEFULNESS OF 

INTRAOPERATIVE ENDOSCOPY” 

P292 DUNCAN, TITUS “ULTRASOUND GUIDED PRE-OPERATIVE 

LOCALIZATION OF THE THYROID GLAND AS A TOOL FOR 

ENDOSCOPIC AXILLARY THYROID AND PARATHYROIDECTOMY” 

P293 DUNCAN, TITUS “ENDOSCOPIC PARATHYROIDECTOMY 

AND THYROIDECTOMY USING AN AXILLARY APPROACH: A 

VIABLE ALTERNATIVE TO THE OPEN APPROACH” 

P294 FRANCIS, DONNA “THE CASE FOR PREOPERATIVE 

ESOPHAGOGASTRODUODENOSCOPY IN BARIATRIC PATIENTS” 

P295 GALVAO NETO, MANOEL “INTERFACE OF ENDOSCOPY X 

ADJUSTABLE GASTRIC BAND (AGB). 356 ENDOSCOPIES IN 

1111 BANDS” 

P296 GONZALVO, JP “1000 COLONOSCOPIES IN OCTOGENAR- 

IEANS” 

P297 GUZZO, JAMES “PERCUTANEOUS ENDOSCOPIC 

GASTROSTOMY IN THE COMPLICATED OBESE PATIENT CAN BE 

PERFORMED SAFELY” 

P298 HERRERA, JOSE “IS THERE ALWAYS AN HIPERTONIC 

LOWER ESOPHAGEAL SPHINCTER IN ACHALASIA?” 

P299 HERRERA, JOSE “ESOPHAGEAL DIFFUSE SPASM. A 

MOTOR PATTERN THAT PRECEDE ACHALASIA” 

P300 IDANI, HITOSHI “EFFICACY OF ENDOLUMINAL GASTRO- 

PLICATION FOR GASTROESOPHAGEAL REFLUX DEVELOPED 

AFTER LYMPH NODES DISSECTION ALONG THE LESSER CUR- 

VATURE OF THE STOMACH” 

P301 JABER, SAED “INTERVAL COMMON BILE DUCT STENTING 

FOR NON EXTRACTABLE CBD STONES” 

P302 KLEEMANN, MARKUS “FLEXIBLE ENDOSCOPIC SUTUR- 

ING AT THE CARDIA: DETERMINATION OF DEPTH” 

P303 LANE, BRIAN “SYMPTOMATIC MESOCOLIC STRICTURE 

AFTER RETROCOLIC LAPAROSCOPIC ROUX-EN-Y GASTRIC 

BYPASS: TREATMENT BY ENDOSCOPIC DILATION” 

P304 MCNELIS, JOHN “ACUTE CHOLECYSTITIS FOLLOWING 

COLONOSCOPY: TWO CASE REPORTS AND LITERATURE 

REVIEW” 

P305 PALACIOS-RUIZ, J “ENDOSCOPIC FINDINGS ON COMPLI- 

CATIONS AFTER GASTRIC BAND” 

P306 SELIM, NIAZY “ENDOSCOPIC IDENTIFICATION OF THE 

JEJUNUM FACILITATES MINIMALLY INVASIVE JEJUNOSTOMY 

TUBE INSERTION IN SELECTED CASES.” 

P307 SHEPPARD, MATTHEW “ENDOSCOPIC APPEARANCE OF 

A SURVIVAL PORCINE MODEL OF THE POST GASTRIC BYPASS 

STATE” 

P308 SILLIMAN, WILLIAM “THE ROLE OF EARLY ERCP IN 

BLUNT HEPATIC INJURY WITH BILIARY FISTULA: A CASE 

SERIES AND REVIEW OF THE LITERATURE” 

P309 TRUONG, SON “POSTER: IS ITRAOPERATIVE ENDOSCOPY 

STILL IMPORTANT FOR THE MANAGEMENT OF OBSCURE 

INTESTINAL BLEEDING” 

P310 WIRSING, K “ENDOSCOPIC REMOVAL OF SIGMOID 

COLON FOREIGN BODY: WHAT TO DO WITH A TRAPPED 

BREAD BAG CLIP?” 

Hernia Surgery 


P311 AGGARWAL, SANDEEP “COMPARATIVE STUDY OF INCI- 

DENCE OF WOUND INFECTION, PAIN AND QUALITY OF LIFE IN 

PATIENTS UNDERGOING INGUINAL HERNIA MESH REPAIR BY 

LAPAROSCOPY AND OPEN METHOD” 



P312 AGRESTA, FERDINANDO “MINILAPAROSCOPIC INGUINAL 

HERNIA REPAIR” 

P313 ANDREW, C “LAPAROSCOPIC VS. OPEN INCISIONAL 

HERNIA REPAIR: A COMPARATIVE STUDY.” 

P314 CASATI, ANNIBALE “LAPAROSCOPIC TREATMENT OF THE 

POSTOPERATIVE HERNIAS” 

P315 CHOPRA, AJAY “LAPAROSCOPIC MESH REPAIR OF AN 

INTERCOSTAL ABDOMINAL HERNIA” 

P316 COSKUN, HALIL “COMPARISON OF PROSTHETIC 

MATERIALS IN INCISIONAL HERNIA REPAIR WITH 

LAPAROSCOPIC TECHNIQUE REGARDING TO ADHESION 

FORMATION AND HISTOPATHOLOGICAL FINDINGS: AN 

EXPERIMENTAL STUDY” 

P317 DUDAI, MOSHE “10 YEARS CONTROLLED 

STUDYCOMPARING LAPAROSCOPIC TRANSABDOMINAL 

PREPERITONEAL TO LICHTENSTEIN INGUINAL HERNIA 

REPAIR” 

P318 ELLIS, TAMARA “OUTCOMES OF LAPAROSCOPIC 

VENTRAL HERNIA REPAIR IN A TEACHING INSTITUTION” 

P319 HARRELL, ANDREW “COMPOSIX SEPARATION: A REPORT 

OF THREE CASES” 

P320 HUR, KYUNG YUL “LAPAROSCOPIC TOTALLY EXTRAPERI- 

TONEAL (TEP) REPAIR OF RECURRENT HERNIA WITH PREVI- 

OUS MESH AND PLUG REPAIR” 

P321 IYER, SHRIDHAR “TEP INGUINAL HERNIA REPAIR: 

WHICH MESH AND HOW TO FIX IT?” 

P322 GUPTA, NIKHIL “LAPAROSCOPIC TOTAL EXTRAPERI- 

TONEAL (TEP) INGUINAL HERNIA REPAIR UNDER EPIDURAL 

ANAESTHESIA: A DETAILED EVALUATION” 

P323 MCKAY, ROBERT “LAPAROSCOPIC LOW ABDOMINAL 

HERNIA FIXATION TO COOPER’S LIGAMENT” 

P324 NIMERI, ABDELRAHMAN “5MM PORT TECHNIQUE WITH 

ALTERNATIVE METHOD FOR MESH INSERTION DURING 

LAPAROSCOPIC INCISIONAL HERNIA REPAIR” 

P325 NIMERI, ABDELRAHMAN “USE OF PERI-OPERATIVE FLO- 

MAX TO PREVENT POST-OPERATIVE URINARY RETENTION FOL- 

LOWING LAPAROSCOPIC INGUINAL HERNIA REPAIR” 

P326 PERRUCCHINI, GIOVANNI “HERNIAL RELAPSE IN 

LAPAROSCOPY: PERSONAL EXPERIENCE” 

P327 PONSKY, TODD “A MODIFIED, OPEN, VENTRAL HERNIA 

REPAIR WITH FENESTRATED MESH: LESSONS LEARNED FROM 

LAPAROSCOPY” 

P328 REMICK, KYLE “LAPAROSCOPIC VERSUS OPEN 

EPIGASTRIC HERNIA REPAIR” 

P329 ROSIN, DANNY “THE USE OF PERICARD FOR LAPARO- 

SCOPIC REPAIR OF VENTRAL HERNIAS” 

P330 SCHRAIBMAN, VLADIMIR “POLIPROPILENE MESH 

REPAIR FOR HIATAL HERNIAS – A CENTER EXPERIENCE” 

P331 SHABBIR, ASIM “LAPAROSCOPIC VS OPEN VENTRAL 

HERNIA REPAIR: A PROSPECTIVE STUDY” 

P332 SHABTAI, MOSHE “LAPAROSCOPIC AND OPEN GROIN 

HERNIA REPAIR – A CHANGING PATTERN IN A BUDGET-CON- 

STRAINED PUBLIC HOSPITAL” 

P333 SINGHAL, TARUN “EARLY EXPERIENCE WITH 

LAPAROSCOPIC INGUINAL HERNIA REPAIR” 

P334 TACHIBANA, MASASHI “LAPAROSCOPIC TREATMENT OF 

PARAESOPHAGEAL HIATAL HERNIA WITH AN INCARCERATION 

OF PANCREAS AND JEJUNUM: A CASE REPORT” 

P335 TAYLOR, CRAIG “LONG TERM RESULTS OF 

LAPAROSCOPIC TOTALLY EXTRAPERITONEAL INGUINAL MESH 

HERNIORRAPHY” 

Minimally Invasive Other 


P336 AGGARWAL, R “A RELIABILITY ANALYSIS OF VIDEO- 

BASED RATING SCALES FOR TECHNICAL SKILLS 

ASSESSMENTS IN LAPAROSCOPIC SURGERY” 

P337 AGGARWAL, R “THE OPTIMAL METHOD OF TRAINING ON 

A VIRTUAL REALITY LAPAROSCOPIC SIMULATOR” 

P338 AL DAHIAN, ABDULLAH “LAPAROSCOPIC LIGASURE 

APPENEDICECTOMY IN EXPERIMENTAL ANIMALS” 

P339 ALKHAMESI, NAWAR “AEROSOLIZED BUPIVACAINE 

REDUCES POST-LAPAROSCOPIC PAIN: A RANDOMIZED 

CONTROLLED DOUBLE BLINDED CLINICAL TRIAL” 

P340 BLESSING, WALTER “LAPAROSCOPIC ASSISTED 

PERITONEAL DIALYSIS CATHETER PLACEMENT, AN 

IMPROVEMENT ON THE SINGLE TROCAR TECHNIQUE” 

P341 BOZUK, MICHAEL “COSMETIC LAPAROSCOPIC 

CHOLECYSTECTOMY-A 7 YEAR REVIEW OF RESULTS” 

P342 CARLETON, JOHELEN “SYMPTOMATIC ADRENAL HEM- 

ORRHAGE FOUND DURING ELECTIVE ADRENALECTOMY” 

P343 CHOI, YOO SHIN “LAPAROSCOPIC FUNCTION PRESERV- 

ING SURGERY FOR NON-PARASITIC SPLENIC CYST” 

P344 CHOI, GYU-SEOG “LAPAROSCOPIC RESECTION OF 

LYMPH NODE POSITIVE COLON AND RECTAL CANCER: 24- 

MONTH FOLLOW-UP OF 90 PATIENTS” 

P345 DAMANI, TANUJA “COMPARATIVE THERMAL SPREAD OF 

THREE RADIOFREQUENCY BIPOLAR VESSEL SEALING 

DEVICES” 

P346 ERNEST, ALEXANDER “THE ROLE OF LAPAROSCOPY IN 

THE DIAGNOSIS AND MANAGEMENT OF CHRONIC SMALL 

BOWEL OBSTRUCTION: A CASE REPORT.” 

P347 FAYEK, SAMEH “THE ROLE OF ERYTHROPOIETIN IN 

SURGERY” 

P348 GIOVANNI, JEANNINE “DEFINING THE ROLE OF 

DIAGNOSTIC LAPAROSCOPY IN PATIENTS WITH ABDOMINAL 

PAIN” 

P349 HAYASHI, KEN “THE EFFICUSY OF LAPAROSCOPIC 

SURGERY FOR THE OBSTRUCTION BOWEL” 

P350 HOGLE, NANCY “LOCAL ANESTHESIA REDUCES POST- 

LAPAROSCOPY PAIN: A PROSPECTIVE, RANDOMIZED TRIAL” 

P351 IBRAHIM, I “LAPAROSCOPIC MANAGEMENT OF 

IATROGENIC COLONIC PERFORATION” 

P352 IWATA, TAKASHI “LAPAROSCOPIC BIOPSY OF PARA-AOR- 

TIC LYMPHNODE-COMPARISON BETWEEN TRANSPERITONEAL 

APPROACH AND EXTRAPERITONEAL APPROACH” 

P353 LAMASTERS, TERESA “CAN INTRAOPERATIVE LAPARO- 

SCOPIC ULTRASOUND REPLACE INTRAOPERATIVE CHOLAN- 

GIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY?” 



121



P354 LINOS, DIMITRIOS “BILATERAL LAPAROSCOPIC ADRENA- 

LECTOMY IN CHILDREN” 

P355 MARICA, SILVIU “COMBINED HAND-ASSISTED 

LAPAROSCOPIC RIGHT HEMICOLECTOMY AND DISTAL 

PANCREATECTOMY” 

P356 MATONE, JACQUES “OUTCOME OF LAPAROSCOPIC 

SPLENECTOMY FOR THE TREATMENT OF HEMATOLOGICAL 

DISEASES” 

P357 MOCCIA, ROGER “LAPAROSCOPIC SPLENECTOMY IN 

SEVERE THROMBOCYTOPENIA” 

P358 NISHIOKA, MASANORI “A SIMULTANEOUS LAPAROSCOPY- 

ASSISTED HEPATECTOMY AND SIGMOID COLECTOMY FOR A 

PATIENT WITH COLON CANCER AND LIVER METASTASIS : A 

CASE REPORT” 

P359 OLEYNIKOV, DMITRY “LAPAROSCOPIC ARTICULATED 

GRASPER” 

P360 PUCCI, ANTHONY “PERCUTANEOUS 

GASTROJEJUNOSTOMY AFTER LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS FOR MALNUTRITION” 

P361 RICCIARDI, R “WHO GETS LAPAROSCOPY FOR 

APPENDICITIS, DO DISPARITIES EXIST?” 

P362 ROSSI, SAM “LAPAROSCOPIC SUTURING OF TENCKHOFF 

CATHETER TO PREVENT RE-OPERATION FOR DISPLACEMENT” 

P363 SADEK, RAGUI “FASCIAL AND PERITONEAL INJECTION 

OF LOCAL ANALGESIA AT TROCAR SITES PRIOR TO INCISION 

SIGNIFICANTLY DECREASES POST-OPERATIVE PAIN AFTER 

LAPAROSCOPIC SURGERY” 

P364 SATHEESAN, RADHAKRISHNAN “TIMING OF 

LAPAROSCOPIC APPENDECTOMY IN ACUTE APPENDICITIS IN 

CHILDREN - A COMMUNITY HOSPITAL EXPERIENCE.” 

P365 SCHMIDBAUER, STEFAN “100 LAPAROSCOPIC ADRENA- 

LECTOMIES - A CRITICAL APPRAISAL” 

P366 SEGAN, ROSS “THE UTILITY OF LAPAROSCOPY IN THE 

DIAGNOSIS AND MANAGEMENT OF VENTRICULOPERITONEAL 

SHUNT COMPLICATIONS: A CASE SERIES AND REVIEW OF THE 

LITERATURE.” 

P367 SWAFFORD, CRAIG “TOTALLY EXTRAPERITONEAL 

LAPAROSCOPIC LYMPH NODE BIOPSY FOR LYMPHOMA” 

P368 TAKEMASA, I “OUTCOME OF ELECTIVE LAPAROSCOPIC 

SPLENECTOMY IN 89 CONSECUTIVE PATIENTS.” 

P369 UZUNKOY, ALI “IS THE LAPAROSCOPIC SURGERY AFFECT 

THYROID FUNCTIONS?” 

P370 YAVUZ, NIHAT “LAPAROSCOPIC APPENDECTOMY WITH 

LIGASURE” 

P371 YAVUZ, NIHAT “LAPAROSCOPIC REPAIR OF MORGAGNI 

HERNIA” 

P372 YAVUZ, NIHAT “LAPAROSCOPIC REPAIR OF VENTRAL AND 

INCISIONAL HERNIAS:OUR EXPERINCE IN 150 PATIENTS” 

New Techniques 


P373 BALAGUE, CARMEN “ARE ANTROPOMETRIC AND VOL- 

UME MEASUREMENT PREOPERATIVE PREDICTORS OF OPERA- 

TIVE DIFFICULTY AND CONVERSION NEED DURING LAPARO- 

SCOPIC APPROACH TO RECTAL DISEASES? PRESENTATION OF 

PROTOCOL AND PRELIMINAR RESULTS.” 

P374 BUESS GERHARD “ADVANTAGES OF A NEW MANUAL 

SUTURING SYSTEM INCLUDING ADDITIONAL DEGREES OF 

FREEDOM” 

P375 EDELMAN, DAVID “SIS MESH FOR LAPAROSCOPIC 

INGUINAL HERNIA REPAIR- 5 YEAR FOLLOW UP” 

P376 KAVIC, STEPHEN “REPAIR OF A COMPLEX FOREGUT 

HERNIA AIDED BY NOVEL THREE-DIMENSIONAL SURGICAL 

RECONSTRUCTION” 

P377 LEE, CRYSTINE “LAPAROSCOPIC VERTICAL SLEEVE GAS- 

TRECTOMY (VG) FOR MORBID OBESITY: A NEW RESTRICTIVE 

BARIATRIC OPERATION” 

P378 MACKEY, RICHARD “PERCUTANEOUS TRANS- 

ESOPHAGEAL GASTROSTOMY TUBE: DECOMPRESSION FOR 

MALIGNANT OBSTRUCTION” 

P379 OISHI, HIDETO “A NEW ENDOSCOPIC TECHNIQUE FOR 

DIFFICULT CASES OF PERCUTANEOUS ENDOSCOPIC 

GASTROSTOMY” 

P380 PERRONE, JUAN “COMPARISON OF HOLDING STRENGTH 

OF SUTURE ANCHORS FOR HEPATIC AND RENAL 

PARENCHYMA” 

P382 UCHIDA, KAZUNORI “THUMBS UP! TECHNIQUE-APPLICA- 

TION TO THE CONVENTIONAL SUTURING METHOD” 

P383 WHITTEN, MATTHEW “A NOVEL APPROACH TO 

LAPAROSCOPIC BILATERAL HAND-ASSISTED NEPHRECTOMY 

FOR AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE” 

Robotics 


P384 ALI, MOHAMED “TEACHING ROBOTIC SURGERY: A 

STEPWISE APPROACH” 

P385 DE, SUVRANU “IMPORTANCE OF HAPTICS IN MINIMALLY 

INVASIVE SURGICAL SIMULATION AND TRAINING” 

P386 ELLIOTT, STEVEN “ROBOTIC ADRENALECTOMY FOR 

MALIGNANCY IN CHILDREN” 

P387 GALVANI, CARLOS “ROBOTIC-ASSISTED HELLER MYOTO- 

MY REDUCES THE INCIDENCE OF ESOPHAGEAL PERFORA- 

TION” 

P388 HEBRA, ANDRE “LAPAROSCOPIC ROBOTIC ASSISTED 

SWENSON PULL-THROUGH FOR HIRSCHSPRUNG’S DISEASE IN 

INFANTS” 

P389 KLEEMANN, MARKUS “LAPAROSCOPIC ULTRASOUND 

NAVIGATION IN LIVER SURGERY - TECHNICAL ASPECTS AND 

ACCURACY” 

P390 NARAZAKI, KENJI “THE EFFECTS OF TRAINING ON THE 

PERFORMANCE OF ROBOTIC SURGERY: WHAT ARE THE 

OBJECTIVE VARIABLES TO QUANTIFY LEARNING?” 

P391 OGUMA, JUNYA “ANALYSIS OF THE RELATIONSHIP 

BETWEEN THE KNOT-TYING FORCE DURING SUTURING AND 

WOUND HEALING IN THE GASTROINTESTINAL TRACT.” 

P392 OLEYNIKOV, DMITRY “IN VIVO ROBOTIC CAMERAS CAN 

ENHANCE IMAGING CAPABILITY DURING LAPAROSCOPIC 

SURGERY” 

P393 RASO, MICHAEL “USING ROBOTIC NISSEN 



FUNDOPLICATION TO MANAGE GASTROESOPHAGEAL REFLUX 

DISEASE” 

P394 RAWLINGS, ARTHUR “ROBOTIC ASSISTED COLON RESEC- 

TIONS: 23 CASES” 

P395 RO, CHARLES “A NOVEL DRILL SET ALLOWS ASSESS- 

MENT OF ROBOTIC SURGICAL PERFORMANCE” 

P396 SHIH, SAMUEL “150 ROBOTIC CASES - ONE SURGEON” 

P397 SHIH, SAMUEL “ROBOTIC ILEOCOLECTOMY FOR 

CROHN’S DISEASE – COMPARABLE?” 

P398 STRONG, VIVIAN “EFFICACY OF NOVEL ROBOTIC CAM- 

ERA VERSUS A STANDARD LAPAROSCOPIC CAMERA” 

P399 YIENGPRUKSAWAN, ANUSAK “ROBOT-ASSISTED SURGERY 

- A COMMUNITY HOSPITAL EXPERIENCE” 

Solid Organ Removal 


P400 AL DAHIAN, ABDULLAH “LAPAROSCOPIC 

SPLENECTOMY” 

P401 MARA ARENAS SANCHEZ, MARIA “EVALUATION OF VIR- 

TUAL REALITY PATIENT RECONSTRUCTION IN THE ASSESS- 

MENT OF VOLUME OF ADRENAL TUMORS: AN INITIAL EXPERI- 

ENCE OF 15 CASES” 

P402 DALVI, ABHAY “BILATERAL LAPAROSCOPIC 

ADRENALECTOMY - INDIAN EXPERIENCE” 

P403 DEMYTTENAERE, SEBASTIAN “LAPAROSCOPIC VERSUS 

OPEN SPLENECTOMY FOR SPLENOMEGALY” 

P404 EL-BANNA, MOHEY “STAPLELESS LAPAROSCOPIC 

SPLENECTOMY: A PILOT STUDY” 

P405 INO, HIDEO “A ROLE OF LAPAROSCOPIC ADRENALECTO- 

MY FOR SOLITARY METACHRONOUS ADRENAL METASTASES 

FROM LUNG CANCER, TWO CASE REPORTS.” 

P406 PUCCI, EDWARD “LAPAROSCOPIC SPLENECTOMY FOR 

DELAYED SPLENIC RUPTURE FOLLOWING EMBOLIZATION” 

P407 RUBACH, EUGENE “LAPAROSCOPIC VS. OPEN DONOR 

NEPHRECTOMY: COMPARISON OF DONOR AND RECIPIENT 

OUTCOMES” 

P408 SALAMEH, J “LAPAROSCOPIC RESECTION OF GIANT 

OVARIAN CYST” 

P409 SALAMEH, J “LAPAROSCOPIC BILATERAL ADRENALEC- 

TOMY FOR ECTOPIC ACTH-DEPENDENT CUSHING’S SYN- 

DROME” 

P410 TALEBPOUR, MOHAMMAD “SURGICAL AUDIT OF FIRST 

48 LAPAROSCOPIC SPLENECTOMIES,” 

P411 TSENG, DANIEL “EARLY IN-HOSPITAL SPLENECTOMY 

MAY IMPROVE OUTCOMES IN IDIOPATHIC THROMBOCYTOPE- 

NIA PURPURA (ITP).” 

P412 YANO, HIROSHI “HAND-ASSISTED LAPAROSCOPIC 

SPLENECTOMY FOR A HUGE SPLENIC CYST: TECHNIQUE AND 

CASE REPORT.” 

P413 YAVUZ, NIHAT “LAPAROSCOPIC TRANSPERITONEAL 

ADRENALECTOMY USING LIGASURE” 

P414 ZACHAROULIS, DIMITRIS “RADIOFREQUENCY ABLATION 

FOR PARTIAL LAP SPLENECTOMY. AN EXPERIMENTAL STUDY.” 

Thoracoscopy 


P415 BURNS, JUSTIN “FIFTY-TWO CONSECUTIVE 

THORACOSCOPIC SYMPATHECTOMIES FOR PALMARIS 

HYPERHIDROSIS OR COMPLEX REGIONAL PAIN SYNDROME” 

P416 CHANG, YI-CHEN “CASE REPORT: MEDIASTINITIS AND 

EMPYEMA ARISING FROM INFECTED PANCREATIC PSEUDO- 

CYST SUCCESSFULLY TREATED BY VATS” 

P417 EDELMAN, DAVID “ENDOSCOPIC TRANSTHORACIC 

SYMPATHECOTOMY FOR PALMAR HYPERHIDROSIS” 

P418 FITZSULLIVAN, E “TRANSCERVICAL MEDIASTINAL 

LYMPH NODE DISSECTION FOR ESOPHAGEAL CANCER” 

P419 MURASUGI, MASAHIDE “VIDEO-ASSISTED SEGMENTAL 

RESECTION FOR LUNG TUMORS WITH COMPUTED TOMOGRA- 

PHY GUIDED LOCALIZATIONLUNG TUMORS WITH COMPUTED 

TOMOGRAPHY GUIDED LOCALIZATION.” 

P420 WHITSON, BRYAN “THORACOSCOPIC LINGULECTOMY IN 

AN IMMUNOCOMPROMISED PATIENT WITH PULMONARY 

ASPERGILLOSIS” 



123



P001–Posters of Distinction 

HIATAL CRURAL REPAIR AS MANAGEMENT OF SEVERE 

REFLUX FOLLOWING LAPAROSCOPIC ADJUSTABLE GASTRIC 

BANDING, GEORGE A FIELDING, WESLEY HOSPITAL, BRIS- 

BANE, AUSTRALIA 

The majority of symptomatic failures leading to removal of 

laparoscopic adjustable gastric bands (LAGB), previously 5% 

in this series of 2,450 LAGB’S, are due to reflux or dysphagia. 

Many have normal barium studies at band removal despite 

severe symptoms. Recently it was realised that these patients 

had large hiatal crural defects. They are now offered crural 

repair and repair of slip if indicated, rather than band removal, 

on the presumption that this was the cause of their symptoms. 

Twenty-three patients presented with severe reflux a mean 44 

+/- 22 months (10-101) after LAGB. At time of banding mean 

weight was 131 +/- 29 kg (90-211), mean BMI 44 +/- 9 kg/m2 

(35- 62). All were on PPI’s, 9 were considering band removal, 4 

had severe dysphagia. Barium studies showed normal 8, hiatus 

hernia/concentric dilatation 9, slip 6. At presentation, mean 

weight was 90 +/- 20 kg (73-154), BMI 34 +/- 5 kg/m2 (24-44) 

and EWL 51 +/- 20% (21-91). They had 15 +/- 9 visits (5-32) 

since banding and mean fill of only 1 cc. - 9 patients had 

empty bands. Three patients had failed weight loss - 20% EWL, 

empty band, 20 visits, due to inability to tolerate band tightening. 

Crural repair alone was performed in 13 patients, with change 

to an 11cm band in the 4 with severe dysphagia and with 

repair of concurrent slip in 6 patients. Mean follow-up is 13 +/- 

12 months (4-39), weight 95 +/- 16 kg, BMI 33 +/- 4 kg/ms, EWL 

54 +/- 18%. There have been a mean 4 post-op visits, with 2 +/- 

0.7 cc fill in the standard bands. All 23 patients are asymptomatic, 

off PPI’s and happy with the band. There have been no 

band removals in the last 14 months, compared to mean 10 

per year previously. 

Many of the symptomatic failures of LAGB due to reflux and 

dysphagia may be due to undiagnosed hiatal hernia or large 

crural defects that have previously been filled with fat. Repair 

of these defects will cure reflux symptoms and greatly reduce 

the need for band removal. Furthermore, patients can then 

have their bands tightened appropriately. These large crural 

defects should be sought at the original LAGB surgery and 

repaired. 


EFFECT ON ANASTOMOTIC LEAK RATE WITH THE USE OF 

CONTINUOUS POSITIVE AIRWAY PRESSURE IN ROUX-EN-Y 

GASTRIC BYPASS PATIENTS, Stephen Kolakowski Jr. MD, 

Alan L Schuricht MD,David S Wernsing MD,Matt L Kirkland 

MD, Pennsylvania Hospital 

OBJECTIVE: The purpose of this study was to assess the effect 

of postoperative continuous positive airway pressure (CPAP) 

on anastomotic leak rates in patients undergoing roux-en-y 

gastric bypass. In addition, a comparison was made between 

those patients who were supported using their personal CPAP 

units and those using hospital-supplied units. 

MATERIALS AND METHODS: Eight hundred fifty two consecutive 

patients undergoing roux-en-y gastric bypass at our institution 

between January 2001 and December 2003 were included. 

Four hurndred ten of these patients were previously diagnosised 

with obstructive sleep apnea (OSA) and 104 were 

CPAP dependent. The patients were then stratified into 4 

groups: Non OSA, OSA without CPAP, hospital-issued CPAP 

and patient?s own CPAP. Clinical outcomes were compared 

between groups using a one way ANOVA test. 

RESULTS: Postoperatively, 24 anastomatic leaks (2.81%) were 

identified. When comparing all cpap patients vs. non cpap 

patients, there was no statistically significant difference in the 

number of leaks observed. The intragroup leak rates were Non 

OSA (13/443) (2.93%), OSA without CPAP (6/306) (1.96%), 

Hospital CPAP (4/24) (16.7%), and own CPAP (1/80) (1.25%). 

Between group analysis revealed significantly higher leak rates 

with mean differences between: Hospital CPAP vs. own CPAP 

(.1542) (p-value


In two groups of 56 LGB and 70 OGB patients, there were no 

differences in demographics, preop BMI, distribution of BMI, 

or incidence of comorbidities. The overall risk of having a 

postoperative complication was greater for OGB patients than 

LGB patients (57.1% vs. 14.3%, p



ments that LAS has a risk to miss or underestimate the intestinal 

lesions. However, there were no differences in the recurrence 

or re-operation rates between OS and LAS in the postoperative 

period of four years. 


COMBINING THE PRIVATE PRACTICE AND ACADEMIC ENVI- 

RONMENTS: A NEW MODEL FOR MINIMALLY INVASIVE SUR- 

GICAL FELLOWSHIP TRAINING, Erik B Wilson MD, Terry K 

Scarborough MD,Patrick R Reardon MD,Philip L Leggett 

MD,Morris E Franklin MD, The University of Texas Health 

Science Center at Houston, Minimally Invasive Surgeons of 

Texas 

Background: Minimally invasive surgical (MIS) fellowships are 

in high demand by general surgical residents with 95 MIS 

training programs in North America. Fellowship candidates are 

seeking programs that provide exceptional opportunities in 

clinical experience, case volume, research support, and educational 

programs. This study reveals a new model of MIS training, 

combining the efforts of academic and private practice fellowships 

into a ?superfellowship?. 

Methods: In 2003, three independent MIS fellowships affiliated 

with the University of Texas Health Science Center at Houston 

were combined to create a common fellowship of 5 clinical fellows. 

The fellows rotated between 1 academic practice attended 

by 2 surgeons and 3 private practices attended by 1 surgeon 

each. Fellows were organized together for combined 

research and educational activities. Case volumes and variety 

were examined, and satisfaction surveys were reviewed from 

all fellows to determine the advantages of academic and private 

practice training. 

Results: The fellows reported very high opinions of the combined 

fellowship with an overall mean satisfaction score of 9 

on a scale of 1 to 10. The academic practice rotation averaged 

a score of 8 as did private practice rotations. Fellows reported 

the overall fellowship strengths to be the large diversity of 

education, clinical and operative experiences. The private practice 

rotations excelled in high surgical case volume whereas 

the academic rotation excelled in extensive educational opportunities. 

Case volumes per fellow for the academic rotations 

averaged 28 cases per month with a distribution of 33% 

bariatric, 16% nonbariatric laparoscopic, 40% endoscopic, and 

11% open procedures. This compares to the private practice 

rotations averaging 46 cases per month with a distribution of 

5% bariatric, 47% nonbariatric laparoscopic, 26% endoscopic, 

and 21% open procedures. 

Discussion: The combination of individual academic and private 

practice fellowships into a common superfellowship 

proved highly successful in expanding the MIS training opportunities. 

This new model broadened the bariatric surgical 

experience and educational opportunities for the fellows during 

the academic rotations, while the private practice rotations 

improved overall case volume and provided a diverse nonbariatric 

laparoscopic surgical experience. With this new 

model, the MIS training environments of private practice and 

academics combine the best of both worlds. 


IMAGE REGISTERED LAPAROSCOPIC ULTRASOUND (IRLUS) 

DECREASES THE FRUSTRATION AND THE WORKLOAD OF 

LAPAROSCOPIC ULTRASOUND, Nicholas Stylopoulos MD, 

Ashley H Vernon MD,Sonia Pujol PhD,Ivan Bricault MD,Raul 

San Jose Estepar MS,Karl Krissian PhD,Matthew 

Graziano,David W Rattner MD,Kirby G Vosburgh PhD, 

Massachusetts General Hospital, Center for Integration of 

Medicine and Innovative Technology, Brigham and Women’s 

Hospital, Harvard Medical School 

Introduction and Aim of the Study: Although laparoscopic 

ultrasound (LUS) is a promising tool, it has not been widely 

embraced by surgeons due to difficulties in image interpretation, 

orientation and the resultant increased frustration and 

mental workload. We have recently developed a novel LUS 

system with enhanced visual feedback and augmented reality 

display that provides extensive orientation information (IRLUS- 

Image Registered Laparoscopic Ultrasound). The aim of this 

study was to examine the effect of this novel system on the 

stress, the mental workload and the efficiency of performing 


traditional LUS. 

Materials and Methods: IRLUS aligns in real time preoperative 

CT images with intraoperative LUS images and the operators 

are provided with a novel 3D display and important spatial 

cues that show them how the plane of the LUS is oriented relative 

to the patient’s anatomy. In this crossover study, surgeons 

at different level of training were asked to perform an in 

vivo comprehensive examination of the liver of anesthetized 

pigs and identify malignant tumors with a traditional LUS system 

or with IRLUS. The tumors consisted of synthetic material 

that had been implanted in the porcine liver. A sensor that was 

mounted on the laparoscopic ultrasound probe allowed the 

tracking and recording of the motion of the probe during the 

task. These recordings were then used to calculate the efficiency 

of performing a surgical task, which is based on a set of 

kinematic parameters that we have used and validated extensively 

in previous studies. For the assessment of the mental 

workload we used the NASA TLX instrument. 

Results: IRLUS decreased the mental demands of LUS by 40% 

(NASA TLX score 35 for IRLUS vs 57.8 for LUS, p=0.02) and 

the temporal demands by 53% (30.7 vs 65, p=0.002). It is especially 

important that IRLUS decreased the frustration caused 

by LUS by 61% (24.2 vs 62.1, p=0.002), while the total workload 

was decreased by 40% (35.8 vs 59.3, p= 0.006). IRLUS 

increased the efficiency of LUS by significantly improving the 

economy of movements (path length), the smoothness of 

motion, the response orientation and the depth perception of 

the operator. 

Conclusions: Performing laparoscopic ultrasound is a demanding 

task. However, the use of augmented reality and enhanced 

visual feedback substantially improves the efficiency, decreases 

the frustration and the mental workload and makes laparoscopic 

ultrasound systems more user-friendly. 


VARIATIONS IN ANTI-REFLUX SURGERY PRACTICE: A SUR- 

VEY OF 100 SURGEONS., A F Burry MD, J L Harnish MA,P 

Shah MD,D R Urbach MD, Department of Surgery, University 

of Toronto and University Health Network. 

Introduction. Gastroesophageal reflux disease (GERD) is common 

and appears to be increasing in incidence. Anti-reflux surgery 

(ARS) is a well-described procedure for the treatment of 

GERD. Our goal was to examine the surgical practices of 

Canadian surgeons who perform ARS. Methods. Canadian 

general and thoracic surgeons were identified from professional 

association mailing lists, and were mailed a short survey 

regarding their ARS practices, opinions and experiences. 

Significance tests were performed as appropriate. P values 

less than 0.05 were considered statistically significant. Results. 

A total of 134 surgeons were mailed the questionnaire, and 

100 responded (response rate of 74.6%). 57% of the respondents 

were thoracic surgeons and 43% were general surgeons. 

82% of respondents performed ARS, and 74.4% performed 

most of their procedures laparoscopically. Thoracic surgeons 

were more likely to perform ARS than were general surgeons 

(91.2% vs. 69.8%, P


Carvalho PhD, Debora S Carvalho,Gildo O Passos Jr,Frederico 

P Santos,Gilvan Loureiro MD,Carlos H Ramos MD,Frederico W 

Silva MD, Clínica Cirúrgica Videolaparoscópica Gustavo 

Carvalho, UPE - Universidade de Pernambuco, Recife - BRAZIL 

BACKGROUND: Barrett´s Esophagus (BE) is a complication of 

Gastro-esophageal Reflux Disease (GERD) and can be a premalignant 

condition. Anti-reflux laparascopic surgeries (ARLS) 

significantly correct physiological and anatomical abnormalities 

in patients with GERD; nevertheless, there is no consensus 

with respect to its effectiveness in preventing malignant transformation 

in patients with BE. The impact of ARLS on those 

suffering from BE and in particular its effect not only on the 

regression of metaplasia but also on the progression of metaplasia 

and dysplasia towards adenocarcinoma, remain barely 

transparent. 

OBJECTIVE: To analyze clinical, endoscopic and histopathological 

results after ARLS in patients suffering from BE. 

PATIENTS & METHOD: In the period from January 2000 to 

June 2004, a group of 142 patients suffering from GERD 

underwent ARLS performed by the same surgeon. Among 

these, 42 patients (29,5%) suffered from BE. All the patients 

underwent Nissen fundoplication by laparascopic means. 

There were no conversions to open surgery. All patients were 

discharged within 24 hours. Post-operative follow-up using 

endoscopy and biopsy was carried out in all 42 patients with 

BE. 

RESULTS: After follow-up which varied from 3 to 40 months, 

symptomatic control was good in most patients: three patients 

developed recurrence of the symptoms and are making regular 

use of proton pump inhibitor, thus BE remains unaltered in 

these patients. Partial or complete regression of BE occurred 

in 25 patients with 14 of them not showing any further signs of 

BE in endoscopic or histopathological examination. And in 1 

patient who remained asymptomatic after surgery, the degree 

of dysplasia increased, which led to his undergoing endoscopic 

mucosectomy of the BE area. No patient presented adenocarcinoma 

after surgery. No-one died or suffered any significant 

complication as a result of surgery. 

CONCLUSIONS: Laparoscopic Nissen fundoplication is safe 

and effective in the symptomatological control of a significant 

number of patients with BE. Regression of BE occurred at a 

randomly high percentage level in patients operated despite 

the control of GERD attained by most patients. 


NAUSEA AND GASTROESOPHAGEAL REFLUX DISEASE: IS 

SURGERY THE CAUSE OR THE CURE, Yashodhan S 

Khajanchee MD, Barbara Lockhart RN,Lee L Swanstrom MD, 

Department of MIS, Legacy Health System, Portland, OR 

Objective: Nausea is a common symptom in GERD patients 

referred for antireflux surgery (ARS). Postoperative nausea can 

lead to devastating complications and failure of the surgery. 

The aim of this study is to determine the incidence and patient 

characteristics of nausea as a presenting complaint and to 

document the effect of ARS on it. 

Methods: 671 patients undergoing ARS were selected from a 

prospective database of patients undergoing various 

esophageal surgeries at our institution. Exclusion criteria were: 

surgery before 1993 (early technique), Heller myotomy, < 6 

months follow-up, or failure to complete nausea portion of the 

symptom assessment tool. Symptoms were recorded on a 

scale of 0-4 with higher ordinal values representing greater 

frequency of symptoms. Logistic regression modeling was 

performed to identify factors most significant for persistent 

nausea following ARS. Comparisons were done using chisquare 

test or t-test as appropriate. 

Results: Overall 185 (27.2 %) patients had some nausea preoperatively 

(mean severity score 2.0 [±0.88]). Women, younger 

patients, and patients with other associated GI symptoms or 

PEH had significantly higher incidence of nausea (p < 0.05). 

After surgery 498 (74.2%) patients had some degree of nausea 

at early post-operative visit (median 3.5 weeks). At long-term 

follow-up (median 9 months) 149 (22.2%) patients experienced 

nausea (45 persistent nausea, 104 new onset nausea, overall 

mean severity score 1.75 [±0.82]). Odds of persistent nausea 

were higher among women (odds ratio [OR] 3.5), in patients 

undergoing Toupet repair (OR-6.5), Collis gastroplasty (OR 3.4), 

or redo ARS (OR 1.5), and in those having preoperative nausea 

(OR 1.14) or functional GI disorders (OR 1.17). However, none 

of the factors were found to be statistically significant. 

Conclusion: Nausea is a frequent presenting component of 

GERD. It can also be a devastating postoperative complication 

leading to failure. Our data shows that majority (75.6%) of 

patients with preoperative nausea are cured with fundoplication. 

However, there are a significant number of patients who 

develop new onset nausea after surgery. It is difficult to predict 

who will develop nausea after surgery, so surgeons should 

counsel all patients about this possibility. 


LARYNGOPHARYNGEAL REFLUX CAN EXIST WITH NORMAL 

DISTAL ESOPHAGEAL ACID EXPOSURE, Rami E Lutfi MD, 

Alfonso Torquati MD,Nikhilesh Sekhar MD,William O Richards 

MD, Vanderbilt University 

Laryngopharyngeal reflux (LPR) has been detected in patients 

with gastroesophageal reflux disease (GERD). The prevalence 

of GERD in patients with LPR remains unknown. 

Aim: to determine if pathologic proximal esophageal reflux 

can exist without pathologic distal reflux. 

Methods: Database was reviewed for triple probe pH studies. 

Each included manometry and 24-hr pH study using 3 probes 

(distal, middle, located 5 and 15cm proximal to lower 

esophageal sphincter, LES, and extraesophageal located at 

2cm above the upper sphincter). Comparison was made using 

Student t test for continuous, and chi square for independent 

variables. 

Results: 113 triple probe studies were performed for different 

LPR symptoms (laryngitis, 31%; chronic cough, 19%; hoarseness, 

9%; vocal cord nodules, 11%; and subglottic stenosis, 

4%). Pathologic LPR was defined according to our previous 

study on healthy volunteers as >4 reflux episodes detected by 

the extraesophageal probe. 45 patients had pathologic LPR; of 

those, only 24 (53%) had abnormal distal acid exposure time 

(>4.1%) with elevated DeMeester score (¡Y22). The difference 

in incidence of abnormal distal acid exposure or DeMeester 

score was not statistically significant between patients with or 

without pathologic LPR. Mean DeMeester score and distal acid 

exposure time were both higher in LPR group, but the difference 

did not reach statistical significance (34+/-30 vs. 27+/-34, 

p=0.238, and 6.5+/-5.9% vs. 5.2+/-6.4, p=0.277, respectively). 

Using t test, LES pressure, contraction amplitudes, and peristalsis 

were compared between the same two groups (with or 

without LPR); no statistically significant difference was found. 

No correlation was found between the severity of LPR and 

GERD severity when Pearson Correlation test was run between 

the number of proximal reflux episodes and DeMeester score 

(r=0.073, p=0.443). Conclusion: Pathologic LPR can exist without 

pathologic distal acid exposure. To accurately diagnose 

LPR, a hypopharyngeal sensor must be used with the standard 

distal pH sensors located at 5, and 15 cm from the LES. 


POUCH ENLARGEMENT AND BAND SLIPPAGE, TWO DIFFER- 

ENT ENTITIES, Frederico Moser MD, Santiago Horgan MD,M V 

Gorodner MD,C Galvani MD,M Baptista MD,A. Arnold MD, 

University of Illinois at Chicago 

Background: pouch enlargement (PE) and band slippage (BS) 

are the most common late complications of the laparoscopic 

adjustable gastric banding (LAGB). Often, confusion exists 

among surgeons regarding the denomination or even the 

treatment for these two different entities. 

Objectives: to establish the differences in clinical presentation, 

radiological features and management between PE and BS. 

Hypothesis: a) PE can be managed non operatively (band 

deflation); b) BS is an acute complication that requires surgical 

treatment; c) tailored adjustment allows earlier diagnosis of PE 

in asymptomatic patients. 

Methods: From 3/01 to 7/04, 470 patients underwent LAGB 

placement. Barium swallow was performed pre, postoperatively 

and during band adjustments (?tailored adjustment?). PE 

was defined as dilatation of the pouch; BS was considered 

when band and stomach were prolapsed. PE was divided in 4 

radiologic types. 1) PE, band 45?; 2) PE, covering the band, 

band 45?; 3) PE, band 0? and 4) PE, band < 0?. 



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Results: 1400 barium swallows were performed in 470 

patients. PE was diagnosed in 26 patients (5%) and BS in 7 

(1.5%). 

Conclusion: a) PE is a chronic complication that can be managed 

conservatively, with 81% success rate in our series. 

Surgical treatment should be considered when medical treatment 

fails. B) BS is an acute complication that requires surgical 

treatment 100% of the times. C) Tailored adjustment allows 

early diagnosis of PE; therefore preventing adjustments in 

undiagnosed PE patients. 


THE SHORT ESOPHAGUS: ANALYSIS OF VARIABLES, Ziad T 

Awad MD, Varun Puri MD, Sean Connolly PhD,Charles J Filipi 

MD,Sumeet K Mittal, Creighton University Medical Center, 

Omaha, NE 

THE SHORT ESOPHAGUS : ANALYSIS OF VARIABLES 

Ziad T. Awad, M.D., FRCSI 

Varun Puri, M.D. 

Sumeet K. Mittal, M.D. 

Sean Connolly, Ph.D. 

Charles J. Filipi, M.D., FACS. 

Department of Surgery, Creighton University School of 

Medicine, Omaha, NE,USA 

Introduction: With the increasing utilization of antireflux surgery 

for gastroesophageal reflux disease (GERD) accurate 

assessment of the short esophagus (SE) is a necessity. Various 

preoperative tests may assist surgeons in determining the 

presence of a short esophagus but intra-operative assessment 

after esophageal mobilization remains the gold standard. 

Methods: Seventy-eight patients, primary reflux (n=50), failed 

antireflux surgery (n=28) were suspected to have a short 

esophagus. In all, an intraoperative evaluation procedure for 

determination of esophageal length after esophageal mobilization 

was performed. Tests performed preoperatively were 

upright esophagram, manometry and esophago-gastroscopy. 

Stepwise logistic regression was conducted using Statistical 

Package for the Social Sciences (SPSS) to estimate the probability 

of a patient having a normal length esophagus. The independent 

variables considered were: age, sex, height, weight, 

obesity, manometric esophageal length (MEL), Barrett’s esophagus 

or stricture formation (abnormal endoscopy), hiatal hernia 

larger than 5 cm (abnormal esophagram), defective lower 

esophageal sphincter pressure (DLESP) and a motility disorder. 

Results: Eighteen patients were determined to have a SE upon 

intra-operative evaluation. All but one of these patients underwent 

a gastroplasty (esophageal lengthening procedure). 

Manometric esophageal length (MEL) and presence or 

absence of obesity were the only variables that had discriminatory 

power in predicting a SE. For two patients presenting 

with the same value of MEL, the odds of a normal esophageal 

length are 11.24 times higher for an obese patient. For two 

patients with the same obesity status, the odds of having a 

normal esophageal length increase with higher MEL. An equation 

developed using obesity and MEL as variables predicted 

SE with a sensitivity of 73% and specificity of 77%. 

Conclusion: The possibility of a short esophagus and the need 

for a gastroplasty can be predicted preoperatively using the 

equation proposed. 


ANTERIOR GASTROPEXY ALONE MAY PREVENT RECUR- 

RENCE AFTER LAPAROSCOPIC PARAESOPHAGEAL HERNIA 

REPAIR, A Sabnis MD, B Mirza MD,B Chand MD,J Ponsky MD, 

Department of General Surgery, Minimally Invasive Surgery 

Center, Cleveland Clinic Foundation 


ANTERIOR GASTROPEXY ALONE MAY PREVENT RECUR- 

RENCE AFTER LAPAROSCOPIC PARAESOPHAGEAL HERNIA 

REPAIR 

A Sabnis MD, B Mirza MD, B Chand MD, J Ponsky MD 

Department of General Surgery, Minimally Invasive Surgery 

Center, Cleveland Clinic Foundation 

Objective: The purpose of this study is to determine if gastropexy 

alone versus gastropexy with an anti-reflux procedure 

could prevent recurrence after laparoscopic paraesophageal 


Methods: A series of 55 patients underwent laparoscopic 

repair of hiatal hernias between July 2000 and July 2004 at the 

Cleveland Clinic Foundation by one surgeon. Of those patients, 

8 patients underwent reduction of hernia, crural repair and 

anterior gastropexy. An esophageal wrap was not done on 

these 8 patients secondary to a short esophagus or lack of 

reflux symptoms preoperatively. The remaining 47 patients 

had an esophageal wrap as a component of the procedure. 

They all had a video esophagram 24 h after surgery, then at 3-, 

6-, and 12-month follow-up visits and annually thereafter. 

Symptomatic outcomes were assessed at each follow-up visit. 

Outcomes are reported from an IRB approved prospective 

database. 

Results: In this study, 6 women and 2 men with a mean age of 

73 years (range, 61-83 years) underwent successful laparoscopic 

paraesophageal hernia repair. One complication 

occurred: a patient had an esophageal tear with leak identified 

on the video esophagram done 24 h after surgery. At this writing, 

all the patients have undergone video esophagram at 24 h 

follow-up. Of the 8 patients, 5 have undergone video esophagram 

at 3-month follow-up and 4 at 6-month follow-up. All 

were asymptomatic and all examinations were normal. At this 

writing, there were no radiographic recurrences. In the remaining 

47 patients there were 3 (6.4%) radiographic recurrences. A 

chi-squared analysis showed no statistical significance 

(p=0.464) between gastropexy alone versus gastropexy with 

fundoplication. 

Conclusion: These early results suggest that anterior gastropexy 

could be the key component in reducing the recurrence 

rate after laparoscopic paraesophageal hernia repair. 


UNSEDATED TRANSNASAL ESOPHAGOGASTROSCOPY. INI- 

TIAL OUTPATIENT EXPERIENCE WITH A 5MM GASTRO- 

SCOPE., Nikhilesh R Sekhar MD, Alfonso Torquati MD,Rami E 

Lutfi MD,William O Richards MD, Vanderbilt University, School 

of Medicine 

BACKGROUND: We instituted a program at our institution to 

evaluate a 5mm transnasal endoscope that can be placed without 

sedation in a conscious and alert patient. METHODS: 

Twenty-one patients were evaluated for symptoms of GERD or 

dysphagia. The patients nares and back of throat are numbed 

with cetacaine. Tetracaine, phenylephrine and viscous lidocaine 

are applied to the nostril to aid with dilation and passage 

of the scope. The scope which is 60 cm in length can visualize 

the esophagus, stomach and GE junction but not the duodenum 

in most patients RESULTS: Of the twenty-one patients 

who underwent endoscopy none experienced adverse effects. 

In one patient we were unable to pass the scope past the 

nares , possibly due to a lack of phenylephrine and tetracaine. 

All were able to resume normal function immediately and 

there were no complications. Biopsies were taken from 6 

patients. Two patients revealed Barrett?s esophagus. Two 

revealed esophagitis and two are currently pending. Due to 

normal findings in the remaining 15 patients biopsies were not 

obtained. Average length of procedure was 15 +/-4 minutes. 

CONCLUSION:Transnasal unsedated esophagogastroscopy is 

a safe and well tolerated endoscopic modality that can be 

done without sedation in an outpatient setting. This procedure 

can be integrated easily into a surgeon?s outpatient clinic. 


LAPAROSCOPIC CHOLECYSTECTOMY IN THE OCTOGENARI- 

AN, A Belizon, K Alexander,AE Pelta,GR Gecelter, Long Island 

Jewish Medical Center 

Introduction: As the life expectancy increases and our population 

gets older it is important to assess the safety of our opera-


tive procedures on the elderly. Recently laparoscopic cholecystectomy 

(LC) has been increasingly accepted as a safe and 

effective procedure in elderly patients with gallbladder disease. 

Using our large patient database we set out to determine 

the safety of laparoscopic cholecystectomy in patients over the 

age of 80. 

Methods: Using our extensive patient database we identified 

the patients that had undergone LC between December 1994- 

May 2003. Charts were retrospectively reviewed for age, medical 

history, previous surgery, conversion rate, length of stay, 

operating time, anesthesia time, intraoperative findings, and 

postoperative morbidity and mortality. 

Results: A total of 4843 patients underwent LC at Long Island 

Jewish Medical Center between December 1994 and May 

2003. Of those patients 184 (3.7%) of them were over the age 

of 80 (mean age 87.2). We found a significant increase in conversion 

rate in the elderly group compared to the younger 

patients (12.3% vs. 3.7%). However, when we analyzed the 

elective procedures alone the conversion rate was 4.9% not 

significantly different from the control group. Morbidity was 

significantly increased if conversion to open procedure took 

place after 30 minutes of operating time. This was mostly in 

the form of wound infection(3% vs. 0.5%). Overall mortality 

was higher in the elderly group but not statistically significant 

(1.9% vs 1.4%). Other parameters were not significantly different 

between the two groups. 

Conclusion: We continue to show that LC is a safe procedure 

in octogenarian patients. The morbidity and mortality of the 

procedure is similar between elderly and young patients. 

Every effort should be made to operate under elective conditions 

rather than emergent ones. In addition our data strongly 

supports early conversion (



operative intervention is the most economically advantageous 

approach. 


PROSPECTIVE EVALUATION OF LAPAROSCOPIC VERSUS 

MINIMALLY INVASIVE OPEN DONOR NEPHRECTOMY, Niels 

Kok MD, May Lind MD,Khe Tran MD,Larissa Tseng MD,Jaap 

Bonjer PhD,Jan IJzermans PhD, Erasmus MC, Rotterdam, The 

Netherlands 

Currently, living donor organ donation is the best solution to 

overcome cadaveric organ shortage. The increasing number of 

living related kidney transplantations demands optimal operative 

techniques that minimise discomfort to the donor. Since 

its introduction, laparoscopic donor nephrectomy (LDN) has 

gradually replaced the open donor nephrectomy (ODN) via a 

classical flank incision. However, ODN has improved as well; a 

15-20 cm incision dividing all abdominal wall muscles and 

sometimes requiring dissection of the 12th rib has been 

replaced by a 8-12 cm muscle split rib-saving incision. Most 

comparative studies between LDN and ODN concerned classical 

flank incisions or hand assisted LDN. 

We compared 48 cases of ?full? LDN with 52 cases of ODN 

operated on between May 2001 and September 2004. Primary 

outcomes concerned length of operation time and recovery as 

measured by resumption of diet and time to discharge. 

Considering the baseline characteristics, ASA classification, 

age, choice for left either right kidney, presence of one or multiple 

renal veins and arteries, did not significantly differ 

between both groups. Two out of 48 laparoscopies were converted 

to open procedures. None of the flank incisions were 

enlarged. Warm ischemia time (LDN 7·1 vs. ODN 2·9 minutes) 

and skin-to-skin time (LDN 248 vs. ODN 162 minutes, p


invasive procedures, namely bariatric and thoracic. At the 

Texas Endosurgery Institute, we have applied SLR with the 

PGA\TCA material to laparoscopic colorectal surgery. 

Methods: 

Since July 2003, we?ve performed 7 LARs, 12 right hemicolectomies, 

5 sigmoid colectomies, 3 total colectomies, 2 partial 

colon resections and one colostomy closure with SLR with 

Seamguard. All cases were performed totally laparoscopically 

or laparoscopically assisted with intracorporeal anastomoses. 

SLR material was applied to the endoscopic linear staplers at 

the ends of the bowel that were used for the anastomosis If 

circular staplers were used for anastomoses, the anvil was 

brought through the two staple lines containing the SLR. 

When linear staplers were used to create the anastomoses, 

SLR was applied to the staplers once again. All patients are 

followed by the attending surgeon and endoscopy done when 

indicated and biopsies performed. 

Results 

Of these 30 cases, there have been no leaks, no bleeding complications, 

no pelvic abscesses and no anastomotic strictures. 

14 cases were done for malignancy and the rest for other 

benign processes. Six anastomoses have been evaluated postoperatively 

with flexible endoscopy. The anastomoses have 

been inspected at intervals ranging from 3 weeks to 6 months. 

To date there have been no tumor re-implants and we have 

found that the anastamoses appeared to be more widely 

patent than expected at each interval. 

Conclusion 

Our initial data with the use of this SLR product has been very 

promising. As we employ its use in our minimally invasive colorectal 

cases we will be able to collect more data and follow 

the progress of these patients. Although meticulous surgical 

technique is still most important, the staple line reinforcement 

with SeamGuard appears to aide in preventing leaks, bleeding 

and may result in a more widely patent anastomosis. 


LAPAROSCOPIC TRANSGASTRIC ENDOSCOPY AFTER 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS, Federico 

Ceppa MD, Pavlos Papasavas MD,Daniel Gagné MD,Philip 

Caushaj MD, The Western Pennsylvania Hospital, Temple 

University Medical School Clinical Campus 

Objective: Access and endoscopic evaluation of the bypassed 

stomach is difficult after laparoscopic Roux-en-Y gastric 

bypass (LRYGBP). We propose a minimally invasive technique 

to access the bypassed stomach after RYGBP for endoscopic 

diagnosis and treatment. 

Description: CO2 pneumoperitoneum is established to a pressure 

of 12-15 mmHg. A 12mm umbilical, 5mm RUQ, 5mm LLQ, 

and 15mm LUQ trocars are placed. A purse string suture is 

placed on the anterior wall of the stomach. A gastrotomy is 

made using ultrasonic shears and the 15-mm trocar is placed 

into the stomach. The endoscope is then inserted through the 

15-mm trocar and the pneumoperitonium is decreased to 10 

mmHg. Once the evaluation is complete, the gastrotomy is 

closed with a running suture or linear stapler. 

Results: Eight patients at our institution have undergone 

laparoscopic transgastric endoscopy. Four patients had biliary 

pathology. Three of these patients underwent successful ERCP 

and papillotomy; the fourth was unsuccessful due to stone 

impaction at the ampulla. Three patients were evaluated for GI 

bleeding. One patient was diagnosed with a duodenal gastrointestinal 

stromal tumor; one patient was diagnosed with a 

bleeding duodenal ulcer, requiring surgical exploration; the 

3rd patient had a negative endoscopy. One patient evaluated 

for chronic abdominal pain had a negative endoscopy. There 

were no complications. 

Conclusion: Laparoscopic transgastric endoscopy is a safe and 

minimally invasive approach for the evaluation of the gastric 

remnant, duodenum, and biliary tree in patients who have 

undergone a RYGBP. 


TRANSPLANTATION OF LAPAROSCOPICALLY-PROCURED 

RIGHT VERSUS LEFT KIDNEYS: COMPARATIVE ANALYSIS OF 

INTRAOPERATIVE GRAFT ISCHEMIA AND POSTOPERATIVE 

GRAFT FUNCTION AND SURVIVAL., Yuri W Novitsky MD, Wil 

S Cobb MD,Michael J Rosen MD,Andrew G Harrell MD,Lon 

Eskind MD,B. Todd Heniford MD,Kent W Kercher MD, 


Background: The feasibility and safety of laparoscopic right (R) 

live donor nephrectomy (LDN) has been established. However, 

the technical challenges of R kidney harvest and potential difficulties 

with the recipient operation continue to limit its use. 

We hypothesized that the use of laparoscopically-procured R 

kidneys does not result in increased perioperative donor/recipient 

morbidity, prolonged graft ischemia or decreased graft 

survival. 

Methods: Retrospective analysis of consecutive laparoscopic 

LDN and respective transplant operations performed at a tertiary 

care hospital. Donor and recipient demographics, operative 

time and blood loss, allograft extraction time, time of cold 

and warm ischemia, graft function and survival were compared 

for left (L) and R LDN and transplantations. 

Results: Between August 2000 and July 2004, 117 laparoscopic 

LDN, including 20 R (17%), were performed. There were no differences 

in OR time, blood loss, extraction time or length of 

stay between L and R LDN. There were no conversions, reoperations, 

or deaths in either donor group. The recipients of L 

and R kidneys were of similar age, sex, and BMI. There were 

no significant differences between L and R groups in cold 

ischemia (37.6±15.2 v 34.5±17.3 min), warm ischemia 

(37.7±11.2 v 36.4±10.8 min), or EBL (322 v 228 cc). There were 

no major intraoperative complications in either group. One 

patient (5%) in the R and 3 patients (2.9%) in the L groups had 

transient ATN. There was one early graft loss in the L LDN 

group. One patient (5%) in the R and 5 patients (4.8%) in the L 

groups had early allograft rejection that was treated medically. 

Postoperative major complications occurred in 12% of L and 

10% of R kidney recipients. There were no differences between 

the groups in the discharge, 6- and 12-month creatinines (2.86 

vs 2.16 g/dL, 1.50 vs 1.46 g/dL, and 1.48 vs 1.55 g/dL, respectively). 

One-year graft survival in L and R recipient groups was 

98% and 100%, respectively. 

Conclusion: Laparoscopic right LDN is a safe approach to 

organ harvest. Despite the perceived difficulty of procuring 

and implanting a laparoscopically-harvested R kidney, it does 

not result in either increased perioperative donor/recipient 

morbidity or increased graft ischemia times. In addition, graft 

function and long-term survival are equivalent for transplanted 

R and L kidneys. We advocate the selective use of laparoscopically-procured 

R kidneys as a means for safe extension of the 

available donor pool. 


THE ROLE OF THORACOSCOPY FOR PENETRATING WOUNDS 

OF THE CHEST, A Patel MD, J Whelan MD,N Ahmed MD,R 

Chung MD, Huron Hospital, Cleveland Clinic Health System, 

Cleveland, OH 

Although many non life-threatening penetrating wounds of the 

thorax can be treated by tube thoracostomy, incomplete 

removal of clots or even development of empyema may result. 

We hypothesized that thoracoscopy in the same setting may 

have a better outcome. METHOD. The study, approved by IRB, 

was done in a Level II trauma service. Penetrating wounds of 

the hemithorax with stable vital signs were initially treated 

with tube thoracostomy. If open thoracotomy was not indicated 

by vital sign changes or the amount and rate of drainage, 

the patient was offered thoracoscopy (n=8). Under general 

anesthesia, without one lung ventilation, blood evacuation and 

pleural lavage through thoracoscopy was done. Hemostasis 

and foreign body removal was accomplished when indicated. 

The diaphragm was assessed for defects which, when present, 

was followed by laparoscopy. The outcome was compared 

with 21 patients treated with chest tube alone in the same 

institution. 

Additionally, 3 patients developed late empyema in the chest 

tube group and none in the thoracoscopy group. 

CONCLUSION Thoracoscopy provided a means to assess or 



131



effect hemostasis, to remove clots, foreign bodies or contamination, 

to identify diaphragmatic defects for timely intervention 

in the abdomen. Thoracoscopy thus reduced complications 

and hospitalization. 

P028-A–Posters of Distinction 

PNEUMOPERITONEUM-INDUCED OLIGURIA AND HEPATORE- 

NAL REFLEX, Gideon Karplus MD, Avi Vinbroom MD,Amir 

Szold MD, Tel Aviv Sourasky Medical Center 

Mini-Abstract: 

The study investigates the role of the hepatorenal reflex in 

pneumoperitoneum induced oliguria. Blocking the hepatorenal 

reflex, by phenol hepatic denervation, significantly reduced the 

effect of pneumoperitoneum on renal function. 

Abstract: 

Objective: To investigate the role of the hepatorenal reflex in 

pneumoperitoneum induced oliguria. 

Summary of Background Data: Hepatic blood flow is known to 

decrease during pneumoperitoneum. Studies have shown that 

changes in hepatic blood flow affect renal urodynamics 

through a sympathetic pathway known as the hepatorenal 

reflex. We therefore decided to investigate the role of the 

hepatorenal reflex in pneumoperitoneum induced oliguria. 

Methods: Hepatic phenol denervation was performed on 15 

rats. A 90% aqueous phenol solution was applied circumferentially 

to the portal vein and Vena Cava. The control group consisted 

of 15 sham operated rats. After recovery the rats were 

exposed to co2 pneumoperitoneum. Preinsufflation and 

postinsufflation urine output and renal functions were analyzed. 

Statistical analysis was performed using the standard 

student t-test and ANOVA. 

Results: Denervation had no significant effect on baseline 

urine output. There was a significant difference in the postinsufflation 

mean urine output between the denervated and control 

group p=0.0006. Hepatic denervation also reduced the 

effect of pneumoperitoneum on creatinine clearance. While in 

sham operated rats creatinine clearance dropped significantly 

p=0.02 denervation preserved renal function with creatinine 

clearance dropping insignificantly from a mean of 

0.46mg/ml/min to a mean of 0.33mg/ml/min (p=0.83). 

Conclusion: Our study indicates that hepatorenal reflex plays 

an important role in the pathophysiology of pneumoperitoneum 

induced oliguria. 

P029–Bariatric Surgery 

GASTRIC BYPASS AFTER SOLID ORGAN TRANSPLANTATION, 

B Badgwell MD, W S Melvin MD,B Needleman MD, Dept. of 

Surgery and the Center for Minimally Invasive Surgery, The 

Ohio State University 

Introduction: Bariatric surgery provides excellent results for 

weight loss in morbid obesity but is unproven in the transplant 

population. The purpose of our study was to determine the 

effects of gastric bypass in transplant recipients. 

Methods: Between January 2003 and January 2004, 359 

patients underwent Roux-en-Y gastric bypass at our institution. 

7 patients had previously undergone solid organ transplantation. 

Comparisons were made between the groups using 

chi-square tests of association and nonparametric Wilcoxon 

rank sum tests. Repeated measures models were applied to 

the data in order to assess any trends in weight loss over time. 

Results: The mean BMI among non-transplant patients was 

52.7 and 52.4 among transplant patients (p = 0.82). 71.4% of 

the operations in the transplant population were performed 

laparoscopically which was similar to the general population 

at 74.2% (p = 1.0). Length of operation was not statistically significant 

(p = 0.78). Hospital stay among transplant patients was 

increased with a mean of 4.0 days compared to 3.2 in the general 

population (p = 0.03). Weight loss between the two groups 

did not differ significantly at 30, 60, or 120 days, however, at 

200 days the transplant patients did show an estimated group 

weight loss difference of 20 pounds (p = 0.0025). 

Conclusions: Patients who have undergone organ transplantation 

are acceptable candidates for Roux-en-Y gastric bypass 

although weight loss appears slightly less than non-transplant 

patients at long-term follow-up. 


WEIGHT LOSS PRIOR TO LAPAROSCOPIC GASTRIC BYPASS 

DOES NOT AFFECT OUTCOMES, Matthew T Baker MD, 

Pamela J Lambert RN,Michelle A Mathiason MS,Shanu N 

Kothari MD, Gundersen Clinic 

Objective: The goal of this study was to determine if weight 

loss prior to laparoscopic gastric bypass (LGB) impacted postoperative 

outcomes. 

Methods: All patients undergoing LGB between September 

2001 and July 2004 were entered into a prospective database. 

Based on body habitus, patients were selectively encouraged 

and/or required to lose weight prior to surgery. Patients who 

lost at least 10 lbs prior to surgery were compared to those 

patients who gained or maintained a stable weight. The 2 

groups were evaluated to see if there was a difference in outcomes 

using Student’s t-test. Patient demographics were compared 

using Chi-square analysis and Student’s t-test. 

Results: A total of 281 patients (240 female, 41 male) were 

included. Fifty patients (18%) lost at least 10 lbs prior to surgery. 

At 1 year postop, this group lost more weight overall, but 

this was not significant after correcting for the initial weight 

and sex differences. 

Conclusions: Preoperative weight loss in LGB patients does 

not affect operative times, length of stay, incidence of postoperative 

complications, or % excess weight loss at one year. 

Our data do not support the recommendation of weight loss 

prior to LGB. 


PREOPERATIVE ENDOSCOPIC EVALULATION IN THE MORBID- 

LY OBESE POPULATION WITH GASTROESOPHAGEAL REFLUX 

DISEASE, Parag Banot MD, Reena Bhargava MD,Calvin A 

Selwyn MD,Keith S Gersin MD, University of Cincinnati 

OBJECTIVE: Gastroesophageal reflux disease (GERD) is common 

in the morbidly obese population. Surveillance of the 

gastric remnant after laparoscopic Roux-en-Y gastric bypass is 

difficult and may require operative intervention. Preoperative 

endoscopic evaluation may help identify occult gastritis, 

ulcers, and other pathologic abnormalities in this selective 

symptomatic group. 

METHODS: A retrospective review of sixty four patients who 

underwent endoscopic evaluation at a single institution from 

June 2003 to May 2004 was performed. These patients all had 

symptoms of GERD treated with daily proton pump inhibitors 

(PPI). Biopsy was performed when abnormal pathology was 

encountered. 

RESULTS: Sixty-four patients underwent upper endoscopic 

evaluation at a single institution. A normal study was found in 

thirty-six patients (56.3%). Twenty-eight patients (43.7%) were 

noted to have abnormal endoscopy or pathologic findings confirmed 

by biopsy. Eight patients were noted to have a hiatal 

hernia and required no further intervention. Esophagitis was 

identified in seven patients (two had Barrett?s esophagus), 

twelve had gastritis (two had prepyloric ulcers), and one had 

duodenitis. Repeat endoscopy showed resolution of initial 

findings in all patients after diagnostic appropriate treatment. 

Patients with ulcer disease and those with severe gastritis 

and/or esophagitis were instructed on the importance of PPI 

compliance. 

CONCLUSION: GERD is commonly found in the morbidly 

obese population. The adherence to a regimen of proton 

pump inhibitors is effective in the resolution of occult findings 

such as ulcer disease and severe gastritis or esophagitis. The 

use of endoscopy was not studied in all morbidly obese 

patients, however its selective use in the GERD population 



allows identification and treatment of occult endoscopic 

pathology prior to gastric bypass. 


ACUTE RENAL FAILURE ASSOCIATED WITH LAPAROSCOPIC 

GASTRIC BYPASS SURGERY, Melissa M Schnell MD, Reena 

Bhargava MD, Calvin A Selwyn MD,Keith S Gersin MD, 

University of Cincinnati 

Hospital acquired acute renal failure (ARF) increases the risk of 

morbidity and mortality. Roux-en-Y laparoscopic gastric 

bypass is a common surgical treatment for morbid obesity. 

Comorbid conditions such as heart disease, hypertension, and 

diabetes increases the risk of post-operative ARF in these 

patients. Treatment of comorbidities with agents that impair 

renal autoregulatory responses can potentially exacerbate 

peri-operative ARF. 

We present a case series of five laparoscopic gastric bypass 

surgery patients who experienced post-operative ARF between 

November 2003 and May 2004. Our hospital performs approximately 

500 laparoscopic gastric bypasses per year. There was 

one male and four female patients with body mass index 

between 45-73. The baseline serum creatinine ranged from 

0.6mg/dl to 1.2mg/dl. None of these patients received other 

nephrotoxic agents. Anaesthetic records did not show any evidence 

of intra-operative hypotension. The magnitude of 

increase in serum creatinine by post-operative day two ranged 

from 60% to 350% above baseline. Of the five patients, four 

were on either an angiotensin converting enzyme (ACE) 

inhibitor or angiotensin receptor blocker (ARB) and a diuretic 

preoperatively. Three patients were also taking a COX-II 

inhibitor. These patients were instructed to take a clear liquid 

diet 24 hours prior to surgery and the standard overnight fast 

and continued scheduled medications. All five patients 

resolved their ARF and no other patients undergoing laparoscopic 

Roux-en-Y gastric bypass had ARF. 

Peri-operative volume depletion, insensible fluid loss, and the 

hemodynamic effects of laparoscopic surgery may create a 

setting for the development of ischemic renal injury. This risk 

can be exacerbated by use of ACE inhibitors or an ARB in 

combination with prostaglandin inhibitors and diuretics by 

impairing renal autoregulation and blunting the sympathetic 

nervous system response to volume depletion. In patients 

undergoing elective bypass surgery, it may be prudent to discontinue 

such medications 48-72 hours prior to surgery to 

minimize the risk of post-operative ARF. Further studies are 

necessary to evaluate the appropriate period for discontinuation 

of these medications prior to laparoscopic Roux-en-Y gastric 

bypass. 


THE UTILITY OF ESOPHAGOGASTRODUODENOSCOPY PRIOR 

TO LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS SURGERY, 

D Camacho MD, D J Reichenbach MD,C Badgwell BA,W Fisher 

MD,J F Sweeney MD, Michael E. DeBakey Department of 

Surgery, Baylor College of Medicine 

PURPOSE: The need for routine esophagogastroduodenoscopy 

(EGD) prior to laparoscopic gastric bypass surgery 

(LGBS) remains controversial. The current study was undertaken 

to determine the prevalence of upper gastrointestinal disease 

(UGD) in morbidly obese patients prior to LGBS. METH- 

ODS: 51 patients (43 female, 8 male) with a mean age of 44 

years and a mean BMI of 46.7 kg/m2 underwent LGBS for morbid 

obesity. All patients underwent pre-operative EGD. A retrospective 

chart review was conducted to document the presence 

of UGD symptoms or known UGD prior to surgery. Preoperative 

EGD interpretations and biopsy results were 

reviewed to document the presence of UGD prior to LGBS. 

Pre-operative findings where compared to pathology reports 

from gastric tissue collected at the time of surgery. RESULTS: 

Thirty-three of 51 (64.7%) patients reported symptoms of UGD 

prior to surgery. Of the 33 symptomatic patients, 28 (84.8%) 

had positive findings on EGD and were placed on acid suppressive 

medications. Eighteen of 51 (36%) patients reported 

no symptoms of UGD prior to surgery, of which 11 (61.1%) 

had UGD on EGD. Out of all 51 patients screened, 39 (76.4%) 

showed positive endoscopic findings at the time of pre-operative 

EGD. Of the 39 patients with evidence of UGD, chronic 

gastritis was present in 10 (25.6%) patients, active gastritis was 

present in 13 (33.3%) patients, and esophagitis was present in 

17 (43.5%) patients. One patient (2.6%) had chronic gastritis 

and esophagitis. Three patients (7.6%) had both active gastritis 

and esophagitis. Pre-operative biopsy revealed H. pylori in 5 

(12.8%) patients, one of whom also had non-dysplastic 

Barrett?s. All patients with H. pylori were treated prior to 

LGBS. Seven (13.7%) of the operative biopsies showed evidence 

of chronic gastritis; none demonstrated active gastritis 

or H. pylori. CONCLUSIONS: In light of the significant amount 

of gastrointestinal pathology observed prior to surgery in 

symptomatic and asymptomatic patients, upper endoscopy 

with biopsy should be considered integral in the pre-operative 

evaluation of candidates for gastric bypass surgery. 


LAPAROSCOPIC REVISIONS OF ROUX-EN-Y GASTRIC 

BYPASS, Federico Ceppa MD, Daniel Gagné MD,Pavlos 

Papasavas MD,Philip Caushaj MD, The Western Pennsylvania 

Hospital, Temple University Medical School Clinical Campus 

Introduction: We investigated whether laparoscopic revisional 

surgery following failed Roux-en-Y gastric bypass (RYGBP) is 

safe and effective in achieving further weight loss. 

Methods: Retrospective chart review of all patients undergoing 

revisional surgery following failed RYGBP. Failed RYGBP was 

determined by



sumed concentric or eccentric gastric prolapse. At that time, 

all patients were found to have moderate to large crural defect 

requiring 1 to 2 figure-of-eight sutures. Ten underwent posterior 

crurapexy and 2 underwent anterior crurapexy. Eleven 

patients experienced resolution of GERD without antireflux 

medication. One patient redeveloped GERD symptoms due to 

recurrent HH and pouch dilatation. 

Severe GERD after LAGB is caused by HH. Radiographic examination 

may not reflect diagnosis. Symptoms of GERD appear 

to be the only reliable indication of HH. 


IMPROVED WOUND INFECTION RATES WITH ROUTINE SUB- 

CUTANEOUS PORT SITE DRAINAGE IN LAPAROSCOPIC 

ROUX-EN-Y GASTRIC BYPASS, Rashad Choudry MD, Jocelyn 

Ho MD,Jennifer Denne MD,Dawn Stepnowski 

CRNP,Christopher Kowalski MD, Temple University Hospital, 

Philadelphia, PA 

Laparoscopic Roux-En-Y Gastric Bypass (LGBP) is a safe and 

effective approach in the treatment of morbid obesity. 

Technical modifications of the procedure include the trans-oral 

passage of the circular stapler anvil (25mm EEA, United States 

Surgical) via a modified Salem sump tube for the creation of 

the gastrojejunostomy. Port site wound infection at the 

retrieval site of the trans-oral placement device, the left subcostal 

port site (LSPS), is a recognized complication of this 

technique. In addition, this is the site into which the EEA is 

inserted to create the gastrojejunostomy. 

We aimed to study the incidence of LSPS wound infection in 

patients receiving LGBP with and without the use of a subcutaneous, 

wound drain. 

A review of all patients who underwent a LGBP with trans-oral 

passage of the EEA anvil was performed. The incidence LSPS 

wound infection was compared in those patients receiving 

subcutaneous wound drainage at wound closure versus those 

closed without drainage. 83 consecutive patients underwent a 

LGBP. 35 patients did not have a subcutaneous drain. 48 

patients had a LSPS drain for 24 hours. All patients received 

pre and post-operative antibiotic prophylaxis. All port sites 

were closed with staples. 

The average age of all patients was 42 years (undrained 45; 

drained 40). The average BMI for all patients was 50.3 

(undrained 48; drained 52). Gender distribution was equal with 

a predominance of women in both groups (undrained 86%; 

drained 85%). Co-morbid conditions were equally represented 

across both groups. Operative time was less than 120 minutes 

for all patients. In the undrained group, the incidence of LSPS 

infection was 29% (10/35). In the drained group, the incidence 

of LSPS infection was 4% (2/48). Analysis of those patients 

developing wound infection in both groups revealed no significant 

confounding variables. Each cohort had one patient with 

diabetes. All 12 patients who developed LSPS infection were 

treated with incision and drainage along with oral antibiotics. 

Routine use of a subcutaneous LSPS drain for 24 hours significantly 

decreases the incidence of infection. The development 

of LSPS wound infection is likely related to contamination with 

oral and gastric fluid delivered to the site along with the transoral 

placement device. The drain appears to disperse the seroma 

that often forms at port sites in morbidly obese patients, 

eliminating a potential culture environment. 


INTERNAL HERNIA FOLLOWING ROUX-EN-Y GASTRIC 

BYPASS: ACCURACY OF DIAGNOSTIC TESTING, Jonathan S 

Chun MD, Karen M Flanders MS,Tanya Brown,Paresh Shah 

MD,David M Brams MD, Lahey Clinic Medical Center 

Introduction: Internal hernia is a well-known potential complication 

following Roux-en-Y gastric bypass. The diagnosis is a 

clinical one, and radiologic studies and laboratory values are 

frequently unhelpful. High index of suspicion and low threshold 

for operative exploration are critical in making the diagnosis. 

Methods: From 2000 to 2004, 360 Roux-en-Y gastric bypasses 

have been performed at LCMC. The twelve patients who subsequently 

developed internal hernia requiring re-operation 

were reviewed, looking specifically at clinical presentation, 

white blood cell count, radiologic studies, and operative find- 


ings. Ten patients were post-laparoscopic gastric bypass, two 

patients were post-open gastric bypass. 

Results: Patients presented three months to two years following 

Roux-en-Y gastric bypass. All reported crampy abdominal 

pain, with six patients reporting nausea and emesis. Postbypass 

weight loss ranged from ninety to two hundred 

pounds. White blood cell count was elevated in one patient. 

Four patients had CT scan or abdominal plain films showing 

dilated stomach or small bowel. Radiologic studies were unremarkable 

in the remaining patients. 

Eight patients underwent diagnostic laparoscopy, with the 

remaining patients undergoing exploratory laparotomy. Eleven 

patients were found to have an internal hernia, with two 

patients having Peterson?s hernias. One patient had a gastric 

volvulus around a previous gastrostomy tube site. No patients 

were found to have ischemic bowel or stomach, and none 

required bowel resections. 

Conclusion: Internal hernia following Roux-en-Y gastric bypass 

is a potentially difficult diagnosis to make. Clinical symptoms 

and radiologic studies are often non-specific, and laboratory 

values are often normal. To avoid bowel compromise, prompt 

diagnosis based on a high index of suspicion and a low 

threshold for laparoscopic or open exploration is critical. 


LAPAROSCOPIC VERSUS OPEN ROUX-EN-Y GASTRIC 

BYPASS AFTER FAILED OPEN VERTICAL BANDING GASTRO- 

PLASTY, Joy Collins MD, F Qureshi MD,L Velcu MD,P Thodiyil 

MD,B Lane MD,P Yenumula MD,T Rogula MD,B Sacks MD,D 

Taylor RN,S Mattar MD,P Schauer MD, University of Pittsburgh 

Introduction: Previous reports have demonstrated that failure 

after vertical gastric banding (VBG) can be effectively treated 

by conversion to Roux-en-Y gastric bypass (RYGBP). Although 

laparoscopic principles have been applied to this operation, 

the potential benefits of this approach are unknown. Methods: 

A retrospective chart review was utilized to study the incidence 

of complications in all patients who underwent conversion 

surgery from 1999 to 2004. Comparisons were made 

between the laparoscopic and open patient groups. Chi-square 

test was used for statistical analysis. Results: There were 41 

patients with a median age of 51 years (range 33 to 71 years) 

who underwent revision surgery. Mean BMI at revision was 47 

kg/m2 (range 22 to 69 kg/m2). The most common indications 

for conversion after VBG were weight loss failure (76%) and 

reflux symptoms (33%). Eighteen operations (44%) were completed 

laparosopically, while the remaining 23 (56%) were 

done in an open fashion. Early complications occurred in 13 of 

41 patients (32%). Seven gastrojejunal anastomotic leaks 

occurred, with 4 of these in the laparoscopic conversion group 

and 3 in the open conversion group (p=1.00). Three patients 

who had open operations developed early strictures at the 

gastrojejunostomy anastomosis requiring balloon dilatation, 

and one patient developed adhesive small bowel obstruction. 

One patient in each group developed a marginal ulcer that was 

treated medically. One patient in the laparoscopic group developed 

a port-site hernia that was repaired laparoscopically, 

while ventral hernia occurred in 30% of patients in the open 

conversion group. Conclusions: The laparoscopic approach to 

conversion from VBG to Roux-en-Y gastric bypass is a valid 

option associated with a similar early complication profile to 

the open approach, but with less incidence of ventral hernia 

formation. 


LAPRA-TY APPLICATION ON LAPAROSCOPIC GASTRIC 

BYPASS SURGERY,AN ALTERNATIVE TO KNOT TYING, Shyam 

L. Dahiya,M.D., MBA, Stephen J. McColgan, M.D.,MBA, 

Amelia M. Barcenas, BSN, Bellflower Medical Center 

Since the 1980’s laparoscopic procedures have become commonplace 

in day-to-day surgery. The most prevalent being 

laparoscopic cholecystectomy. This procedure requires clip 

application not sewing. More advanced procedures such as 

laparoscopic nissen fundoplication require a minimal amount 

of sewing, where as laparoscopic gastric bypass requires a lot 

of sewing. Procedures like this, which require a lot of sewing, 

have stayed out of the mainstream and are limited to only 

highly skilled surgeons.


Laparoscopic gastric bypass procedure requires anastomosis 

of the bowel or closure of the mesentery, requiring stitching. 

Stitching itself is a complicated maneuver. A primary requirement 

of stitching is knot tying. Laparoscopic procedures are 

two dimentional in their view. Two-dimensional procedures 

make knot tying a daunting task. If the knots are not tied 

securely and adequately, an anastomotic leak would then be a 

natural consequence. It is because of this dreaded complication 

that we looked at an alternative to knot tying. The main 

focus of this study was to look for an easy alternative to suturing. 

To accomplish this we used a device called Lapra-Ty 

(Eithicon-Endosurgery). 

Lapra-Ty is an absorbable device that once snapped/locked 

around a suture, it stays in place. There is little to no slippage. 

The dissolution time is longer than six weeks; therefore, it 

allows the completion of the anastomosis healing. A common 

fear is that if it dissolves early the anastomosis would leak. 

Another complication would be internal hernia. 

Lapra-Ty was used in 300 consecutive laparoscopic gastric 

bypass cases. Both anastomotic suture, as well as suturing 

the entire mesenteric defect was done with the use of Lapra- 

Ty. The suturing material was used as absorbable or nonabsorbable. 

Suturing was done with the running lock style. 

All 300 cases were then carefully followed for any sign or 

symptom of complication. The follow up on these 300 cases 

has been 3 months to 3 years. No untoward complications, 

secondary to the use of Lapra-Ty were noted. 

Conclusion: This study’s results validate that the use of Lapra- 

Ty obviates the complicated knot-tying maneuver and at the 

same time presents no increased complications related to the 

Lapra-Ty. 


INTERNAL HERNIAS ARE MUCH MORE COMMON AFTER PER- 

FORMING LAPAROSCOPIC GASTRIC BYPASS SURGERY 

WHEN THE ANTECOLIC ROUX LIMB IS ORIENTED TO THE 

LEFT COMPARED TO THE RIGHT., Ramsey M Dallal MD, Brian 

B Quebbemann MD, The N.E.W. Program of Orange County, 

California 

Background: The antecolic Roux en Y technique has been 

developed to eliminate the incidence of herniation of bowel 

through the transverse mesocolon. Herniations through 

Peterson’s defect or through the jejunojejunostomy mesentery 

defect are still possible . 

Hypothesis: Internal hernias underneath the roux limb mesentery 

(Peterson’s space) occur more frequently when the roux 

limb is oriented such that the cut end is toward the lesser 

curve of the pouch and the bowel curves to the patient’s left 

(Figure 1) compared with the opposite orientation (Figure 2). 

Methods: A retrospective chart review was performed. A 

change in surgical technique occurred June 2003 in attempt to 

reduce internal hernia formation. We examined the 200 consecutive 

antecolic, left-oriented-Roux gastric bypass procedures 

performed immediately previous to June 2003 (group A) 

and compared them with 200 consecutive antecolic, right-oriented-Roux 

gastric bypass procedures performed after June 

2003 (group B).Results: The average length of follow-up was 

2.4 and 1.5 years in Groups A and B, respectively. Thirteen 

internal hernias were identified. There was a 6.0 percent rate 

of internal hernia formation in Group A and a zero rate of 

internal hernia formation in group B. Internal hernias were 

repaired an average of 12±4 months after surgery (range 

4-19 months). The difference in hernia rate was statistically 

significant with p<0.05.Conclusions: With a simple change in 

technique, the incidence of internal herniation underneath the 

Roux limb mesentery may be significantly reduced or eliminated. 


EVOLUTION OF SURGERY FOR MORBID OBESITY: FROM 

OPEN TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS, 

Damani T, MD, Fogato L, MD, Tedesco P, MD, Gorodner MV, 

MD,Galvani C, MD, Ostroff JW, MD, Bagatelos KC, RN, Lobo E, 

MD, Posselt A,MD, Rogers S, MD, and Patti MG, MD, 

Department of Surgery, Medicine and Anesthesia, University 

of California, San Francisco 

Objective of the study: We hypothesized that: a) in an established 

Bariatric Center, the change from open Roux-en-Y gastric 

bypass (O-RYGB) to laparoscopic Roux-en-Y gastric bypass 

(L-RYGB) is feasible and is not associated with an increased 

complication rate;b) L-RYGB is as effective as O-RYGB in 

weight loss and resolution of comorbid conditions. 

Methods and procedures: Retrospective study in an academic 

tertiary care center. 

Between December 1998 and May 2004, 432 patients (median 

age 41 years, 377 women / 55 men) who met NIH criteria for 

bariatric surgery underwent RYGB. The median preoperative 

body mass index (BMI) was 48 kg/m2. Follow-up was 12 ± 8 

months in 272 patients (63%). 

Main outcome measures were length of hospitalization, postoperative 

complications, 

change in BMI, change in co morbid conditions. 

Results: Results are expressed as median value and P value 



with a VG band for symptomatic dysphagia with a normal 

radiologic and endoscopic evaluation, 1 band replacement for 

erosion (0.3%), and 12 port replacement or revisions (3.7%). 

Overall reoperation rate was 10.4%, and 2.7% of patients have 

had their bands removed. Weight loss, expressed as percent 

excess BMI lost, was 19% at 3 months, 32% at 6 months, 44% 

at one year, 50% at 18 months, and 61% at 2 years. 

Conclusions: Laparoscopic adjustable gastric banding with the 

Lap-Band® system produces excellent weight loss with low 

major morbidity. 


HOW MUCH OF THE WEIGHT LOSS AFTER LAPAROSCOPIC 

GASTRIC BYPASS SURGERY IS FAT?, D Farkas MD, S Laker 

MD,V Iannace MD,A Wasielewski RN,D Ewing MD,A Trivedi 

MD,H Schmidt MD,G Ballantyne MD, Hackensack University 

Medical Center 

Introduction: The objective of this study was to determine the 

changes in body composition after gastric bypass surgery. 

There is an abundance of data regarding overall weight loss 

after surgery. However, little is known about the composition 

of this weight loss. How much of this weight loss is made up 

of fat? 

Methods: 100 consecutive patients undergoing laparoscopic 

gastric bypass surgery were examined. Body composition was 

analyzed using a bipedal bioelectrical impedance analyzer 

(TBF-310, Tanita, Tokyo, Japan). Measurements were obtained 

prior to surgery as well as postoperatively, at regularly scheduled 

followup visits. 

Results: Median excess body weight loss after surgery was 

69% after one year. In actual weight, the median weight loss 

was 96 pounds. This consisted of 77 pounds of fat mass lost, 

and 19 pounds of lean body mass lost. Fat loss made up a 

median of 79% of the total weight loss for each patient. Body 

fat percentage decreased from 51% to 34%. The following 

table shows the changes over time. 

Conclusion: In addition to losing weight after laparoscopic gastric 

bypass surgery, patients also significantly lower their percentage 

of body fat. Fat mass loss accounts for a major portion 

of the total weight loss, while lean body mass lost only 

accounts for a small portion. These results are helpful in 

understanding the many health benefits seen after gastric 

bypass surgery. 


PATIENTS 12 MONTHS AFTER LAPAROSCOPIC GASTRIC 

BYPASS HAVE BODY COMPOSITIONS SIMILAR TO CON- 

TROLS., D Farkas MD, S Laker MD,V Iannace MD,A 

Wasielewski RN,D Ewing MD,A Trivedi MD,H Schmidt MD,G 

Ballantyne MD, Hackensack University Medical Center 

Introduction: After gastric bypass surgery patients undergo 

changes in their body composition. The objective of this study 

was to compare the body composition of patients having 

undergone gastric bypass surgery, with the body composition 

of control patients not undergoing this surgery. 

Methods: 100 consecutive patients undergoing laparoscopic 

gastric bypass surgery were examined. Body composition was 

measured using a bipedal bioelectrical impedance analyzer. 

Measurements were obtained prior to surgery and at followup 

visits postoperatively. These measurements were compared 

with 100 patients seen in consultation for non-bariatric surgery. 

The relationship between BMI and body fat percentage 

was compared between the different groups using the heterogeneity 

of regression test. 

Results: Prior to gastric bypass, patients in the study group 

had a median BMI of 47 and 51% body fat. By 12 months postoperatively 

this group had a median BMI of 29 and 32% body 

fat. The control group had a median BMI of 28 and 34% body 

fat. Regression analysis demonstrated that while the preoperative 

bariatric patients were different from the other two 

groups, postoperatively they were similar to the control 

patients. 


Conclusion: Patients undergo significant body composition 

changes following laparoscopic gastric bypass surgery. By 12 

months postoperatively these patients not only have similar 

BMIs as the non-bariatric controls, they have similar 

body composition as well. This implies that the body composition 

abnormalities seen in morbidly obese patients are corrected 

by gastric bypass surgery. 


DRAINS AND TESTING DURING LRYGB: DOGMA OR NECES- 

SITY?, Edward L Felix MD, Daniel E Swartz MD,Richard Hwang 

MD, Advanced Bariatric Center of Fresno 

Background: Are prophylactic drains, intra-operative testing & 

postoperative contrast studies mandatory when performing 

laparoscopic Roux-en-Y Gastric Bypass (LRYGB)? The purpose 

of this study was to determine if laparoscopic gastric bypass 

can be performed safely without employing such measures. 

Methods: We retrospectively reviewed the records of all 

patients undergoing laparoscopic roux-en-y gastric bypass at 

our center between 4/99 and 7/04. The gastrojejunostomy was 

laparoscopically hand sewn in 2 layers and the pouches were 

constructed using a 3.5 mm endo-stapler. Routine intra-operative 

leak tests, drains and post-operative contrast studies were 

not used. Intra-operative leak studies with air were performed 

in only suspicious cases selected by the operating surgeon. 

Results: In 2369 patients, 7 developed a postoperative pouch 

leak; 0.2% (5/2297) of LRYGB and 3% (2/72) of patients converted 

to an open RYGB. No leaks occurred post-operatively in the 

last 800 patients, including 3 patients that required conversion 

because of an air leak on selective testing. Because of symptoms, 

5 patients had post-operative radiological studies, but all 

were interpreted as negative. In all patients the leak was confirmed 

by laparoscopy and in 5 an open exploration was 

required to manage the leak. No patients died as a result of a 

leak, but 3 had prolonged hospitalizations that were greater 

than 2 weeks. Long term follow-up of all 7 patients that developed 

a leak from the pouch has been uneventful. 

Conclusion: Despite not using routine drains, intra-operative or 

post-operative testing, leaks after laparoscopic roux-en-y gastric 

bypass using our technique were rare and safely managed 

when they occurred. The risk of a leak, however, increased if 

the patient required conversion to an open bypass. Intra-operative 

testing was found to be beneficial when used in suspicious 

cases. If a leak was suspected postoperatively, immediate 

laparoscopic surgical intervention and open exploration 

when necessary successfully managed all patients. The routine 

use of contrast studies and drains can be avoided when performing 

laparoscopic gastric bypass potentially reducing confusion, 

cost, and morbidity associated with these measures 

without jeopardizing the safety of the procedure. 


UNEXPECTED PATHOLOGY IN LAPAROSCOPIC BARIATRIC 

SURGERY, Christopher W Finnell MD, Atul K Madan MD,Craig 

A Ternovits MD,Suraj J Menachery MD,David S Tichansky MD, 

University of Tennessee, Memphis 

Background: The popularity of bariatric surgery in recent years 

has increased with the escalating incidence of morbid obesity 

in our society. The improvement in minimally invasive technology 

and increased number of laparoscopic bariatric procedures 

being performed has resulted in the discovery of unexpected 

pathology that was not suspected preoperatively. We 

hypothesized that the occurrence of unexpected pathology is 

not associated with immediate adverse outcomes during 

laparoscopic bariatric procedures. 

Methods: From December 2002 to June 2004, 398 patients 

underwent laparoscopic bariatric surgery for morbid obesity. A 

retrospective chart review was performed to determine the 

incidence of unexpected findings and their effect on patient 

results.


Results: A total of 9 unexpected pathologic lesions were found 

in 8 (2%) patients. The findings include lesions on the small 

bowel (3), stomach (4), and liver (2). In all except one case 

(which was biopsied), the abnormal findings were found and 

removed laparoscopically. The final pathology revealed: gastric 

leiomyomas (2), gastric gastrointestinal stromal cell 

tumors (2) ectopic pancreatic tissue (2), arteriovenous malformation 

(1), biliary adenoma (1) and fibrosed hemangioma (1). 

All patients underwent completion of their planned bariatric 

procedures without incident, had no complications postoperatively, 

and were discharged in 1-3 (mean = 2) days. 

Conclusions: Unexpected findings occur relatively frequently 

during laparoscopic bariatric procedures. Biopsy and/or 

removal of these lesions does not increase complications nor 

preclude continuation of the planned bariatric procedure. 


ETHNICITY AND WEIGHT LOSS FOLLOWING LAPAROSCOPIC 

ROUX-EN-Y GASTRIC BYPASS, Glenn J Forrester MD, Karen E 

Gibbs MD,Larry Griffith MD,Babak Moeinolmolki MD,Pratibha 

Vemulapalli MD,Julio Teixeira MD, Montefiore Medical Center 

and Albert Einstein College of Medicine, Bronx, NY 

INTRODUCTION Several studies have attempted to predict 

weight loss outcomes based on various preoperative criteria; 

however, few have focused on ethnic background. The purpose 

of this study was to compare the outcomes of patients 

based on ethnicity following laparoscopic Roux-en-Y gastric 

bypass (LRYGBP) for the treatment of morbid obesity. 

METHODS A retrospective analysis was conducted on all 

patients who underwent LRYGBP between April 2001 and 

August 2004. Patients were classified into four ethnic groups; 

Black (B), Hispanic (H), White (W) and Other (O). Patients were 

compared for percent excess weight loss (%EWL) at the 6- and 

12-month postoperative visits. Statistical analysis was performed 

using ANOVA. 

RESULTS Of the total patients studied, 86.7% were women 

and 13.3% were men, ranging from 18 to 65 years of age. 

Preoperative BMI ranged from 39 to 96 (mean 54). Six-month 

%EWL ranged from 26 to 88 (mean 49) and twelve-month 

%EWL ranged from 33 to 107 (mean 63) with the individual 

groups shown in the table below. Difference in %EWL at 6 

months reached statistical significance (p=0.033) while at 12 

months was not significant (p=0.224). 

CONCLUSIONS Short-term results suggest that ethnicity may 

initially influence weight-loss following LRYGBP; however, 

subsequent follow-up does not support these differences. 

Longer-term follow-up data are necessary to validate these 

preliminary results. 


SIMPLIFIED GASTRIC BYPASS APPROACH TO MORBID OBESI- 

TY ? 1000 INITIAL CASES, Almino C Ramos MD, Manoel P 

Galvao Neto MD, Manoela S Galvao MD,Andrey Carlo 

MD,Edwin Canseco, Gastro Obeso Center ? Sao Paulo, Brazil 

BACKGROUND: The gastric bypass is considered the golden 

standard in the treatment of morbid obesity. It is considered 

one of the most complex procedures in laparoscopy. So, any 

maneuver, or approaches who can improve it´s feasibility are 

welcome. AIM: Evaluate initial results of Simplified Gastric 

Bypass (SGB) approach. CASUISTIC: From December of 2001 

to March of 2004, 1000 SGB patients records were analyzed in 

a retrospective manner, 651 were female , age range from 13 a 

65y (M= 38,5y), weight range from 85 a 220 Kg (M= 137 Kg) 

and BMI were between 36 a 68 Kg/m2 (M= 45,8 Kg/m2). The 

Simplified technique (to be presented) is based in doing all of 

the anastomosis in the supra-mesocolic floor with the trocars 

in similar position of lap Nissen procedure. RESULTS: There 

was no convertion to laparotomy at this series. BMI came from 

a mean of 45,8 to 27,4 Kg/m2 (75,1% EWL). Operative time 

stays between 39 to 154 min (M= 70 min), Hospital stay within 

1,5 to 6d (M= 3d). Complications occurred in 2% of ulcers, 

5,2% of gastrojejunostomy strictures, 1,2% of leakage, 0,7% of 

digestive bleeding, 0,3% bowel obstruction. Re-operation was 

done in 1,5% and there were 0,5% of deaths (3p with pulmonary 

embolism. e 2p with sepsis due to gastrojejunostomy 

leakage). CONCLUSION: The Simplified Gastric Bypass proved 

to be at it?s initial results; safe, with low operative time and 

efficient in reducing patients BMI with low complication and 

death rates. 


LAP BARIATRIC SURGERY- A TAILORED APPROACH IN A 2843 

SINGLE CENTER PATIENT SERIES, Almino C Ramos MD, 

Manoel P Galvao Neto MD, Manoela S Galvao MD,Andrey 

Carlo MD,Edwin Canseco, Gastro Obeso Center ? São Paulo ? 

Brazil 

BACKGROUND: Lap bariatric surgery is quickly taking its place 

around the world with the benefits of minimally invasive surgery. 

The three main techniques done by lap are the 

Adjustable Gastric Band (AGB), Gastric Bypass (GBP) and the 

Bilio Pancreatic Diversion (BPD). To choose the best option to 

each patient our group tailored the surgical due to patient profile. 

AIM: Analyze the results and indication of each technique in 

this series. CASUÍSTIC: Between December of 1999 and July of 

2004, 2843 patients were submitted to lap bariatric procedures, 

being: 1111AGB (Mean 34,5y; 128Kg; 45,2BMI) 1107GPB (Mean 

36,5y; 137Kg; 44,7BMI) plus 486 with Fobi-Capella Bypass - 

FCB (Mean 37,5y; 129Kg; 46,1BMI) and 139 with BPD (Mean 

40y; 162Kg *; 49BMI * ) - (*p>0,005) . 

RESULTS: (see table), complementary to table, there was zero 

mortality rate on AGB * , 0,43% on GBP, 0,33% on FCB and 

1,6% on BPD. (*p > 0,05 ). 

2843 TAILORED LAP BARIATRICS - RESULTS 

BMI - FINAL COMPLIC RE-OP 

AGB 30,1Kg/m2 5,1%* 5,3%* 

GBP 27,4Kg/m2 7,7% 1,51% 

FCB 28Kg/m2 6,7% 0,66% 

BPD 26,8Kg/m2 10,2%* 1,8% 

CONCLUSION: Comparing the numbers, goods results with 

low complications and mortality rates can be achieved with 

different Lap bariatric surgeries in a tailored approach 


SLEEVE GASTRECTOMY VS BIB PLACEMENT IN SEVERE 

MORBID OBESITY PATIENTS: PRELIMINARY RESULTS, Alfredo 

Genco MD, Luca Musmeci MD,Luigi Raparelli 

MD,Massimiliano Cipriano MD,Alessandro Pecchia MD,Nicola 

Basso MD, Department of Surgery “P. Stefanini” 

Background 

Laparoscopic biliopancreatic diversion/duodenal switch (BPD- 

DS) is indicated in severe morbid obesity patients. The technique 

combines gastric restriction achieved by sleeve gastrectomy 

and intestinal malabsorption by BPD-DS. 

Due to the high incidence of postoperative complications a 

two-stage technique has been proposed: sleeve gastrectomy 

first in order to achieve an initial weight loss with reduction of 

moribidity and mortality rates and BPD-DS after a 6 -12 month 

period. 

Preliminary reports on Bioenterics Intragastric Balloon (BIB) 

placement have suggested that it can lead to significant 

weight loss especially in the short term period. 

The aim of this retrospective study was to evaluate the effect 

on excess weight and comorbidities of BIB placement (6 

months) or sleeve gastrectomy (6 months) in severe obese 

patients. 

Method 

We reviewed our computer database charts of patients treated 

at the Department of Surgery ?P. Stefanini? Policlinico 

Umberto I, Rome (Italy). From March 1998 to May 2004, 18 

patients candidate to BPD-DS and 17 patients candidate to 

endoscopic BIB placement were selected on the base of age, 

sex and BMI for a matched cohort study. The mean preoperative 

weight was 156.8 Kg in the sleeve gastrectomy patients 

group and 155.2 Kg in the BIB patients group, with mean BMI 



137



of 57.42 and 55.84 respectively. The two groups of patients 

were homogeneous for age and sex and incidence of comorbidities. 

Results 

At the end of the study period there was no statistically significant 

difference in the incidence of arthropathy, diabetes, osas, 

hypertension, dislipidemia between the two groups, while the 

hyperinsulinemia was higher in the BIB group of patients. 

Excess weight loss averaged 26.6% in the sleeve gastrectomy 

group and 21.5 % in the BIB group (n.s.). 

Conclusions 

Malabsorption surgery seems to be the most effective treatment 

for severe obesity. In BPD-DS surgery the two-stage tecnique 

lowers morbility and mortality by inducing a significant 

excess weight loss and decreases incidence of comorbidities 

during the time period between first and second stage. The 

preliminary results of this study suggest that similar results 

may be obtained by the BIB placement. A prospective study 

comparing results in BPD-DS (two stages) and preoperative 

BIB followed by BPD-DS in one stage may be of interest. 


INITIATING A BARIATRIC SURGERY FELLOWSHIP TRAINING 

PROGRAM: IMPACT ON OPERATIVE OUTCOMES, Rodrigo 

Gonzalez MD, Lana G Nelson MD,Sharon Boback,Michel M 

Murr MD, Department of Surgery, University of South Florida, 

Tampa, FL , USA. 

BACKGROUND: Both open (ORYGB) and laparoscopic (LRYGB) 

Roux-en-Y gastric bypass have long learning curves, which 

may reflect on operative outcomes when initiating fellowship 

training programs. The aim of this study was to assess 

whether training a fellow has any impact on operative outcomes. 

METHODS: We reviewed prospectively collected data 

on the last 130 consecutive patients before (Group 1) and 130 

patients after initiating the fellowship program (Group 2). 

Patient demographics, operative data, and outcomes were 

compared between groups using either Mann-Whitney U-test 

or Fisher’s exact test. Linear regression was used to correlate 

between number of operation in our experience and operative 

times. A p



LESSONS LEARNED IN ESTABLISHING A SUCCESSFUL 

BARIATRIC PROGRAM IN A NON-TEACHING COMMUNITY 

HOSPITAL., Ajay Goyal MD, James M Houston, PAC,Charles 

Tollinche MD, Department of Surgery, St. Mary Hospital, 

Hoboken, NJ 

Background: The aim of this paper is to document obstacles 

involved in establishing a successful bariatric practice at a 

non-teaching community hospital by a laparoscopic fellowship 

trained surgeon (AG). Methods: From 3/03 to 6/04, 100 

bariatric cases (75% LGB & 25% LB) were prospectively analyzed. 

Patients were interviewed and filled out questionnaires 

to evaluate improvements in co-morbid conditions. 

Complications and excess weight loss were compared with literature. 

Results: There were 88 women and 12 men with mean 

age of 38.5 (range 21 to 70). Mean preoperative BMI and 

weight were 135.5 kg and 48.9 kg/m2 (range 36 to 87). Overall 

mean hospital stay was 2.7 days with 2.0 days for LB and 3 

days for LGB. Percent excess weight loss (EWL) at 3, 6 and 12 

months was 25.6%, 46.4% and 60% respectively with greater 

than 80% follow-up. 3 pts had early complications: 2 pts had 

distal SBO due to a kink distal to J-J anastomosis requiring 

surgical revision, and 1 pt had wound infection at one trocar 

site. 8 pts presented with late complications: 3 pts had partial 

SBO (1 required surgical correction due to SB herniation 

through transverse colon mesentery and 2 were treated conservatively), 

3 had gastrojejunostomy stricture (endoscopic 

balloon dilatation), and 2 patients required lap chole. There 

was zero open conversion, anastomotic leak and mortality rate 

in this series. Improvements in co-morbid conditions included 

HTN (30% resolved/96% improved), NIDDM (50%/100%), GERD 

(50%/100%), hypercholesterolemia (60%/90%), medications 

(7%/98%), joint pain (10%/90%) and sleep apnea (47%/100%). 

Overall, 75% had complete resolution and 100% of the patients 

had significant improvements in their co-morbid conditions. 

Conclusions: With laparoscopic fellowship training, LGP and 

LB can be performed safely with comparable benefits and 

complication rate at a non-teaching community hospital without 

significant costly outside resources. Program set-up time is 

approximately 6 months prior to 1st case and continues 6 

months after with on-the-job training of hospital OR staff. In 

addition, tapping into current resources available at the hospital 

reduces start-up cost for the program. A successful practice 

is the result of significant time and long-term commitment 

from both the surgeon and the hospital. 


THE ROLE OF DIAGNOSTIC LAPAROSCOPY IN THE DIAGNO- 

SIS AND MANAGEMENT OF THE POST-OPERATIVE COMPLI- 

CATIONS OF GASTRIC BYPASS PATIENTS, Larry F Griffith MD, 

Glenn J Forrester MD,Babak Moeinolmolki MD,Pratibha 

Vemulapalli MD,Karen E Gibbs MD,Julio Teixeira MD, 

Montefiore Medical center and Albert Einstein College of 

Medicine, Bronx, NY 

INTRODUCTION Roux-en-y gastric bypass is now the most frequently 

performed surgical procedure for the treatment of 

morbid obesity in the US. The number of these procedures is 

increasing exponentially. Post-operative abdominal pain in 

these patients presents a difficult diagnostic challenge. 

Currently there is no consensus on the best diagnostic modality 

to assess this subgroup. The objective of this study is to 

determine the value of the CAT scan versus Diagnostic 

Laparoscopy (DL) in this patient population. 

METHODS A retrospective analysis was performed on 32 diagnostic 

laparoscopy cases between January 1, 2001 and 

September 1, 2004. All had a history of Roux-en-y gastric 

bypass. Of them, 26 were also evaluated by CAT scanning during 

the initial work-up. We report the efficacy of DL and compare 

intra-operative findings with the CAT scan results. 

RESULTS The CAT scan was positive in 59% of patients. 

Overall the CAT scan had a false positive rate of 50% and false 

negative rate of 35% based on operative findings. There was 

correlation between the two modalities in 14% of cases. The 

DL found a cause for pain in 38% of cases. The most common 

findings in the two groups were internal hernias and small 

bowel obstruction. 

CONCLUSIONS The CAT scan was less accurate than DL especially 

when evaluating internal hernias. DL allowed therapy in 

addition to diagnosis and is a more useful modality in evaluating 

this patient subgroup. 


JEJUNOJEJUNAL ANASTOMOTIC OBSTRUCTION FOLLOW- 

ING LAPAROSCOPIC ROUX-Y GASTRIC BYPASS DUE TO 

NON-ABSORBABLE SUTURE: A REPORT OF SEVEN CASES, 

Andrew A Gumbs MD, Rohit Chadwani MD,Andrew J Duffy 

MD,Robert Bell MD, Yale University School of Medicine, 

Department of Surgery, New Haven, CT, 06520 

Introduction: Small bowel obstruction is a well-known complication 

of laparoscopic Roux-Y gastric bypass (LGBP). We 

describe seven cases of jejunojejunal anastomotic obstruction 

related to adhesion formation, a cause of SBO previously 

described in the literature, more commonly in association with 

open gastric bypass. 

Methods: All patients undergoing LGBP from October 2002 

until June 2004 were entered into a prospective, longitudinal 

database. All patients who subsequently presented with small 

bowel obstruction were analyzed. 

Results: Jejunojejunal anastomotic obstruction occurred in 

seven out of 152 patients (4.6%) on whom LGBP was performed 

from October 2002 to February 2004. Since February 

2004, suture used to close the jejunojejunal mesenteric 

?leaves? defect was changed from non-absorbable Dacron 

(Surgidac?) to absorbable suture material. Of the 76 patients 

who have since undergone LGBP, none have presented with 

small bowel obstruction. These seven patients ranged in age 

from 23 to 53 years, with preoperative BMI ranging from 41 to 

90, which was similar to the other patients. Six patients were 

female and 1 was male. For each patient, the initial LGBP operation 

was uncomplicated, without anastomotic leak, prolonged 

operative time, or conversion to open operation. All presented 

with nausea and vomiting and four of the seven patients also 

reported abdominal pain. The mean interval between initial 

LGBP and subsequent SBO was 153 days. Following initial history 

and physical examination for each patient, the diagnosis 

of small bowel obstruction was confirmed via imaging, either 

by abdominal x-ray (3/7), small bowel follow-through (1/7), or 

CT scan (3/7). Operative findings common to all seven cases 

were dilated loops of proximal small bowel, and a single adhesion 

just distal to the Roux-Y anastomosis. Following adhesiolysis, 

each patient had prompt return of bowel function without 

recurrence of obstruction. 

Conclusions: This paper describes seven cases of SBO occurring 

after laparoscopic Roux-Y gastric bypass. The rate of SBO 

(4.6%) is consistent with the previous literature, though the 

incidence of adhesions specifically at the jejunojejunal anastomosis 

is higher than that previously encountered. It appears 

that the incidence of postoperative SBO at the jejunojegunal 

anastomosis is directly linked to the choice of suture intraoperatively. 

As such, absorbable suture should be used to close the 

jejunojejunal mesenteric leaves defect. 


RESOLUTION OF HYPERTENSION AND DIABETES FOLLOW- 

ING LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING., Liam 

A Haveran DO, Patrick McEnaney MD,Andras Sandor 

MD,Donald R Czerniach MD,Rich A Perugini MD,Demetrius E 

Litwin MD,John J Kelly MD, Department of Surgery, UMASS 

Memorial Health Care Center 

Laparoscopic Adjustable Gastric Banding (LAGB) is the most 

common bariatric operation worldwide. It results in a nearly 

50% reduction in excess body weight at 1 year. However, the 

effects of LAGB on the resolution of medical co-morbidities 

are less established. We evaluated our experience with resolution 

of hypertension and diabetes in patients after LAGB. 

METHODS: We retrospectively analyzed data that was collected 

on consecutive morbidly obese patients who underwent 

LAGB. Patient demographics, medical co-morbidities, preoperative 

body mass index (BMI), and postoperative (>6 months) 

resolution of hypertension and diabetes were analyzed. 

Resolution of co-morbidities was defined by the absence of 

anti-hypertensive or diabetic medications in the follow up period. 



139



RESULTS: Between October 2001 through June 2004, 106 

patients underwent LAGB at our institution. There were 81 

women and 25 men with an average age of 45 years (range 

26-76 years) and an average body mass index (BMI) of 45 

kg/m2 (range 34-64 kg/m2). Of the 106 patients, 39 (37%) suffered 

from hypertension and 26 (25%) suffered from diabetes 

preoperatively. Hypertension resolved in 12% (3 of 25) and diabetes 

resolved in 45% (9 of 20) of patients with a follow up of 

at least six months. There were no incidences of newly developed 

diabetes or hypertension in the postoperative period. 

CONCLUSION: : In this study we present data showing resolution 

of hypertension and diabetes with a follow up of at least 

six months postoperatively. Laparoscopic adjustable gastric 

banding appears to be an effective bariatric procedure leading 

to the reduction of serious co-morbidities. These results compare 

favorably to those outside the United States. 


DOES THE SF-36 PREDICT POST-OPERATIVE WEIGHT LOSS?, 

Gloria P Hsu BS, John M Morton MD,Li Jin BS,Bassem S 

Safadi MD,Myriam J Curet MD, Department of Surgery, 

Stanford University School of Medicine 

Objective: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is 

an effective treatment option for obesity that carries inherent 

risks. As a result, efforts have been made to distinguish which 

patients may benefit the most from LRYGB. The SF-36 is a 

well-validated and easily administered quality of life survey. 

We hypothesized that the SF-36 would predict post-operative 

weight loss in LRYGB. 

Methods: Pre-operative SF-36 surveys were administered and 

demographic, intra-operative, and weight data were collected 

(n=44). Multiple regression analysis was performed for percent 

of post-operative excess weight loss and BMI loss while controlling 

for confounding variables. P-values were considered 

significant at p < 0.05. 

Results: The total SF-36 score was positively predictive of percent 

excessive weight loss at 6 months. At 2 weeks, the general 

health score was positively predictive of BMI loss while both 

emotional well-being and social functioning scores were negatively 

predictive of percent excessive weight loss. At 6 weeks, 

social functioning score was negatively predictive while the 

energy level score was positively predictive of BMI loss. 

Ultimately, only the preoperative BMI was predictive of both 

6mth and 1yr BMI losses. 

Conclusions: The SF-36 score may be useful for predicting 

post-operative weight loss in LRYGB. Individual scores were 

more useful for predicting weight loss earlier post-op, with the 

total score having a positive predictive result at 6 months. 

Further investigation will incorporate more patients, and 

attempt to determine additional correlations as well as a 

threshold score at which these correlations take effect. 


INFECTION RATES USING WOUND PROTECTORS IN LAPARO- 

SCOPIC GASTRIC BYPASS, Albert Im MD, Keith Zuccala 

MD,Pierre Saldinger MD, Danbury Hospital 

There is an increase wound infection rate associated with 

being morbidly obese. The increase incidence of wound infections 

is multifactorial including decrease oxygen tension due 

to the thickness of the abdominal wall to contamination of the 

wound from enteric contents. The use of laparoscopic techniques 

has decreased the incidence of wound infections from 

15 to 5%. At our institution we have tried to document the 

change in wound infection rate with using a wound protector(Alexis 

wound retractor - Applied Medical ref:c8301 2.5-6 

cm) at the left lower quadrant incision. This is the largest port 

site where we remove tissue that results from the gastrotomy 

and enterotomy closure. Additionally, we also use this site to 

introduce the EEA when we are creating the gastrojejunostomy 

anastomosis. Thus at no time is the subcutaneous tissue in 

contact with enteric contents and we feel there is less tissue 

trauma. To prevent leakage of CO2 after we have extended the 

incision to introduce the wound protector, we use a ballontipped 

trocar to keep an airtight seal. We have noticed a 

decrease in the incidences of wound infection after using the 

wound protector at our trocar site. 



LIVER DISEASE IN OBESE PATIENTS ? IS IT THE HEP C OF 

NEXT DECADE?, Ashutosh Kaul MD, Karl Strom MD,Joanne 

Weiskopf,Edward Yatco MD,Xun Li MD,Gita Ramaswamy 

MD,Thomas Cerabona MD, New York Medical College. New 

York 

Aim of this presentation is to highlight the increasing prevalence 

of liver disease in obese population. In a prospective 

study of 184 patients undergoing laparoscopic bariatric surgery 

liver biopsy was done. Their BMI ranged from 37 to 70 

(mean 50.1) and age from 23 to 67 years (mean42.7 years. Of 

these 147 were females and 37 male patients. 

Pathologic evidence of NASH (Non-Alcoholic Steatohepatitis) 

was found in 67 patients. Of these 15 had low grade (1 +2) 

steatosis and 52 had high grade (3+4) steatosis. Low grade 

inflammation (1 +2) was present in 65 cases and high grade 

(3+4) in 2 cases. In our series we found NASH with fibrosis in 

19 cases but 48 of the patients had NASH with fibrosis. Thus 

36.4% of all patients undergoing bariatric surgery had NASH. 

In our presentation we plan to highlight the significant correlation 

we found with pre-op Body Mass index, duration of obesity, 

diabetic and medication status. The high prevalence of 

NASH is a cause of concern. If by conservative estimates 

about 30 million Americans are morbidly obese and our data 

is representative of the national disease burden then over 10 

million Americans presently are at risk of NASH. We plan to 

discuss the risk of developing liver failure based on published 

literature in patients with NASH. In view of these statistics 

NASH and resulting liver failure may be a major health problem 

in US in the coming decade. There have been recent 

reports to suggest improvement in liver biopsy findings after 

weight reduction. If so then Bariatric surgery may be one of 

the strategies which should be emphasized for potential to 

limit this epidemic in the coming decade. 

In 8 cases we took repeat biopsies during reexploration for 

other causes. Our data on change in liver biopsy findings is 

too small to make any broad generalizations. 

Thus we plan to highlight the high incidence of NASH in our 

patient population despite minimal liver function tests abnormalities. 

We did find significant direct co relationship with 

patient?s diabetic status and duration of obesity. We feel that 

this may be the tip of the iceberg and in the coming decades 

Obesity related liver disease may be a major health problem 

with significant financial burden on the nations health 

resources. Attempts to loose weight may thus be important to 

prevent long-term liver failure. If there is also co relationship 

with duration of obesity then it becomes paramount for all 

health care personals and HMOs to encourage early weight 

loss. 


RADIOLOGICAL FINDINGS IN INTERNAL HERNIAS IN 

PATIENTS OF LAPAROSCOPIC GASTRIC BYPASS?, Ashutosh 

Kaul MD, Glorimer Atiles MD,Frank Nami MD,Edward Yatco 

MD,Thomas Cerabona MD, New York Medical College. New 

York 

Aim of this presentation is to critically analyze our findings of 

internal hernias in laparoscopic Gastric bypass. At our center 

we bring our roux loop in laparoscopic gastric bypasses in a 

retro colic and retro gastric fashion. Despite stitching the 

defect we still have had 16 cases of internal hernias over the 

last 3 years. Aim of this presentation is to highlight the presentation 

of these patients and to clinically analyze the radiologic 

findings in these cases. CT scans were done in 14 of these 

cases and in only one of them was the finding of internal hernia 

entertained by the radiologic service. Certain findings were 

noted on retrospective analysis of these patients and they 

included small bowel massing on left side, caecum displaced 

towards the midline, delayed/non filling of distal small bowel, 

thickened proximal small bowel, presence of air in the biliarypancreatic 

limb of small bowel. All except one were repaired 

laparoscopically and patients stayed a mean of 2 days post 

operatively in the hospital. Two of the patients were rehospitalized 

subsequently for abdominal pain. 

In conclusion we aim to present our clinical and radiologic 

findings in patients presenting with internal hernias after


laparoscopic Gastric Bypass. In view of absence of clear-cut 

radiologic findings in these cases even subtle radiologic signs 

can be of great importance. It is important for all clinicians taking 

care of bariatric patients to understand these subtle signs 

and to use them as an aid to their clinical judgment. As the 

consequences of missing an internal hernia can be catastrophic 

recognition and knowledge of these signs is of great importance. 


LESSONS FROM HISTORY AND NEW YORK STATE: TRENDS 

IN OBESITY SURGERY, Ashutosh Kaul MD, Laura Choi 

MD,Thomas Sullivan BS,Edward Yatco MD,Thomas Cerabona 

MD, New York Medical College. New York 

Aim of this presentation is to analyze data from Statewide 

Planning And Research Cooperative Systems (SPARCS) that is 

a database maintained by New York State. We analyzed the 

data by DRG, patient demographics and trends in complications 

and mortality. We further analyzed institutions based on 

high volume (i.e. > 50 cases per year). According to data the 

total number of cases of bariatric surgery in New York State 

increased seven fold from about 500 in 1991 to 3500 in 2001. 

Though the female to male ratio of patients remained stable to 

about 4:1, the average age of patients undergoing bariatric 

surgery increased from about 35 years in 1995 to 41 years in 

2001. The number of institutions doing Bariatric surgery also 

doubled from about 31 in 1995 to 62 in 2001. Interestingly 

though the number of high volume institutions remained stable 

around 30 to 40, the number of low volume centers has 

mushroomed from a low of 2 in 1993 to about 22 in 2001. The 

average mortality rate in the state has gone down from a high 

of 0.8% in 1998. However, on analyzing the date the average 

mortality in high volume centers was 0.4% in comparison to 

1.2% in low volume centers. Surgical history has shown from 

days of budding cardiac surgery to introduction of laparoscopic 

Cholecystectomy that when there is a rapid increase in the 

number of a procedure, initially the complication rate increases 

more rapidly than the volume of cases. This can be seen in 

the mushrooming of low volume centers in New York State 

and their higher complication rates. As a surgical society we 

have thus to make sure that sharply increasing numbers of 

bariatric surgeries do not translate into dramatically increasing 

complication rates. 


LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS AFTER THE 

AGE OF 60: A SAFE ALTERNATIVE FOR WEIGHT LOSS, 

Colleen Kennedy MD, Samuel Szomstein MD,Emmanuele 

LoMenzo MD,David Podkameni MD,Alexander Villares 

MD,Flavia Soto MD,Raul Rosenthal MD, Cleveland Clinic 

Florida 

Background: Bariatric surgery has traditionally been limited to 

patients between the ages of 18-55. With the advancing age of 

our population and the advancement of laparoscopic techniques 

for surgery this age limitation needs to be re-evaluated. 

We report a series of patients over age 60 who underwent the 

Roux-en-Y gastric bypass for treatment of morbid obesity. 

Methods: A retrospective review was performed examining 

patients over the age of 60 who met the criteria for laparoscopic 

gastric bypass and underwent the procedure. 

Results: Two surgeons at our institution performed 814 gastric 

bypass procedures over 3 years, 25 were performed on 

patients greater than 60 years of age. The average age of the 

patients undergoing the procedure was 66 (60-75). The average 

BMI of the patients was 48 kg/mm2 (35-64). Comorbidities 

preoperatively included diabetes mellitus (65%), hypertension 

(80 %), sleep apnea (25%), GERD (30%) and depression (60%). 

The excess weight loss was 54% at 6 months, 68% at 1 year. 

Diabetes resolved in 75% of the patients, hypertension in 35% 

and sleep apnea in 80%. The postoperative morbidity rate was 

20%, mortality was 0%. 

Conclusion: Laparoscopic gastric bypass is a feasible and safe 

option for weight loss in patients over the age of 60 with proper 

preoperative evaluation and screening. With the prolonged 

life span and overall aging of our population, it is becoming 

more evident that this population will require a reliable solution 

for treatment of morbid obesity. 


MALLORY-WEISS TEAR AFTER LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS, Samuel J Kuykendall BS, Atul K Madan 

MD,Craig A Ternovits MD,David S Tichansky MD, University of 

Tennessee, Memphis 

In the United States, the most common surgical procedure for 

morbid obesity is Roux-en-Y gastric bypass. Pulmonary 

embolism, leak, bowel obstruction, and gastrointestinal bleed 

are some of the early and potentially fatal complications. Early 

post-operative bleeding after laparoscopic bypass, although 

uncommon, presents a dilemma due to the danger of postoperative 

endoscopy and the inability to easily access the gastric 

remnant. The usual sites of gastrointestinal hemorrhage 

after gastric bypass are at the gastrojejunostomy site, the gastric 

pouch, the gastric remnant, or the jejunojejunostomy. 

We encountered a case of massive upper gastrointestinal hemorrhage 

one week after laparoscopic Roux-en-Y gastric bypass. 

She had been discharged on post-operative day three from her 

original surgery. After failure of endoscopy and multiple blood 

transfusions, the patient was taken to the operating room. 

During exploration, the hemorrhage was found to be from a 

disrupted blood vessel secondary to a Mallory-Weiss 

esophageal tear. Oversewing the vessel resulted in hemostasis. 

The patient stabilized after the procedure and was discharged 

without any evidence of continued hemorrhage. In 

retrospect, both the patient and her family recalled that she 

had continual retching at home before her massive hemorrhage. 

Mallory-Weiss tears are an uncommon cause of upper gastrointestinal 

hemorrhage after laparoscopic gastric bypass. 

Bariatric surgeons need to consider this diagnosis especially 

when encountering a patient with a history of significant retching 

after gastric bypass. 


AMELIORATING THE SHORTCOMINGS OF PERCENTAGE 

EXCESS WEIGHT LOSS (EWL): THE ?BARIATRIC SURGERY 

SUCCESS RATE? (BSSR) AS A NEW WEIGHT LOSS METRIC 

FOLLOWING BARIATRIC SURGERY, Crystine M Lee MD, Janos 

Taller MD,John J Feng MD,Paul T Cirangle MD,Gregg H 

Jossart MD, Dept. of Surgery, California Pacific Medical Center, 

San Francisco, CA. 

INTRODUCTION: Bariatric surgery weight loss is often quantified 

using EWL. Sole use of EWL however can be misleading 

because percent weight lost is expressed as a function of 

preop weight. A new metric, BSSR, is introduced to complement 

EWL. 

METHODS: Data analysis after laparoscopic vertical gastrectomy 

(VG), R-en-Y gastric bypass, and duodenal switch (DS) was 

done. EWL = weight lost/(preop weight - ideal body weight). 

BSSR was defined as the % of patients that successfully lost 

enough weight such that they no longer met the NIH criteria 

for bariatric surgery (BMI




THE BEST BARIATRIC OPERATION FOR PATIENTS OF 

BMI



AN ANALYSIS OF GASTROJEJUNOSTOMY STRICTURES IN 

222 CONSECUTIVE PATIENTS UNDERGOING LAPAROSCOPIC 

ROUX-EN-Y GASTRIC BYPASS, John C Lohlun MD, Piotr J 

Gorecki MD, Won Sohn MD,Rahel Bernstein,Leslie Wise MD, 

Departments of Surgery and Gastroenterology, New York 

Methodist Hospital, Brooklyn, New York, USA 

Introduction: Stenosis of the gastrojejunostomy after Roux en 

Y gastric bypass is a complication that has been reported with 

all surgical techniques used to construct the gastroenterostomy 

and occurs between 2 to 27% of patients after gastric 

bypass. The incidence, management, and outcomes of gastrojejunostomy 

strictures in 222 consecutive patients undergoing 

laparoscopic Roux-en-Y gastric bypass were analyzed. 

Materials and Methods: 222 consecutive patients underwent 

laparoscopic Roux-en-Y gastric bypass at our institution 

between August 2001 and August 2004. Data was entered 

prospectively into the database. The gastrojejunostomy was 

performed in all patients with the same technique using a 25- 

mm circular stapler inserted transorally. Anastomotic stricture 

was defined as a combination of symptoms of progressive 

inability to tolerate solid food with the endoscopic finding of 

stenosis that did not permit the passage of a 9 mm endoscope. 

Results: Sixteen patients suspected to have stenosis of the 

gastrojejunostomy underwent 24 upper gastrointestinal endoscopies. 

The average interval between surgery and the diagnosis 

of stricture was 6 weeks (2-22 weeks) and the mean time 

from the onset of symptoms to the time of endoscopy was 1.3 

weeks (0.5 to 6.5 weeks). Stricture was found in 14 out of 222 

patients (6.3%). Two patients suspected to have stenosis were 

diagnosed with marginal ulceration. Two patients with diagnosed 

stricture had concomitant marginal ulceration. The average 

size of the stenotic anastomosis was 4.6 mm (3mm ? 7 

mm). All patients with stricture underwent balloon dilatation at 

the time of endoscopy. Eight patients required one dilatation, 

four patients required two dilatations, and two patients 

required three dilatations. Four patients were admitted to hospital 

for IV hydration. There were no complications associated 

with dilatations and no need for reoperation in any of the 

patients. There were no deaths in these 14 patients. All 

patients with stricture resumed tolerance to solid food and no 

further recurrences were noted at the mean follow up of 20.35 

months (2 ? 37 months). 

Conclusion: Balloon dilatation is an effective treatment for gastrojejunostomy 

stenosis. Controlled radial expansion with cessation 

of further dilatation if any evidence of trauma becomes 

evident, is important to avoid perforation. It is not necessary to 

dilate the anastomosis beyond 9 mm to achieve a satisfactory 

long-term result. 


RESOLUTION OF OBSTRUCTIVE SLEEP APNEA SYMPTOMS 

AFTER LAPAROSCOPIC GASTRIC BYPASS, Mario Longoria 

MD, Trung Bui MD,Sara Chalifoux BS,Ninh T Nguyen MD, 

University of California, Irvine Medical Center, Orange, CA 

Introduction: Obstructive sleep apnea is a common respiratory 

condition in the morbidly obese. Medical therapy includes the 

use of continuous positive airway pressure (CPAP); however, 

weight reduction is the ideal treatment for obese patients suffering 

from obstructive sleep apnea. The aim of this study was 

to characterize the effect of weight loss after Roux-en-Y gastric 

bypass on the symptoms of sleep apnea. 

Methods: The charts of 24 morbidly obese patients with documented 

obstructive sleep apnea based on sleep polysomnography 

were reviewed for demographics, the use of CPAP, and 

weight loss. Symptoms of sleep apnea were measured preoperatively 

and postoperatively based on the scores of Epworth 

sleepiness scale (ESS). An ESS score greater than 7 was considered 

abnormal. 

Results: There were 19 females and 5 males with a mean age 

of 41 years. The mean preoperative body mass index 

decreased from 46 kg/m2 preoperatively to 33 kg/m2 at 6 

months postoperatively. The mean preoperative ESS 

decreased from 12 ± 2 preoperatively to 4 ± 1at 6 months postoperatively 

(p



i.e. 23%, 52%, and 68% for Groups 1, 2, and 3, respectively. 

Conclusion. Age is not a significant determinant of post-surgical 

vitamin and mineral deficiencies for gastric bypass surgery 

patients, particularly for individuals taking dietary supplements. 


IS RESOLUTION OF HYPERTENSION FOLLOWING LAPARO- 

SCOPIC GASTRIC BYPASS RELATED TO INSULIN RESIS- 

TANCE?, Patrick McEnaney MD, Richard Perugini MD,Andras 

Sandor MD,Liam Haveran DO,Donald R Czerniach 

MD,Demetrius Litwin MD,John J Kelly MD, Department of 

Surgery, UMASS Memorial Medical Center 

INTRODUCTION: Laparoscopic Roux-en-Y Gastric Bypass 

(LRGB) has become one of the major treatment options for 

individuals with morbid obesity, a proportion of which have 

insulin resistance. Insulin may act to increase sympathetic tone 

as well as sodium reabsorption with resultant impact on 

hypertension. Based on some data from our institution, individuals 

with insulin resistance have significantly improved 

insulin sensitivity 12 days postoperatively where as those with 

lesser insulin resistance have early worsening of their insulin 

sensitivity. The purpose of our study was to determine if individuals 

undergoing LGB with insulin resistance would have 

better resolution of their hypertension as compared to those 

undergoing the same procedure with less perturbations in 

insulin glucose metabolism. 

METHODS: We retrospectively reviewed the medical records of 

patients with hypertension who had preoperative fasting 

insulin and glucose levels to determine their metabolic profile. 

Patients were categorized as insulin resistant if their preoperative 

HOMA-IR level was greater than 3.8. Patients were defined 

as being hypertensive if they were taking one or more medications 

for blood pressure control. The records were subsequently 

reviewed to evaluate for resolution of their hypertension 

while not requiring antihypertensives. 

RESULTS: Of the 72 patients who underwent LGB between 

June 2003 and June 2004, 24 of these were hypertensive preoperatively 

and 11 of these were insulin resistant. Of the six 

patients with six month follow up postoperatively, three were 

cured of their hypertension, where as one of the eleven 

patients who had not yet reached the 6-month follow up visit 

was cured of hypertension. Of the thirteen patients with hypertension 

and HOMA-IR levels0.05). 

CONCLUSION Short-term follow-up suggests that bariatric surgery 

is safe and effective in patients over 50. Older patients 

had higher preoperative co-morbidities, but that did not negatively 

affect their outcome. Longer-term follow-up data are 

necessary to validate these preliminary results. 


QUALITY OF LIFE PRIOR TO LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS DOES NOT VARY WITH BODY MASS 

INDEX, Jason G Murphy MD, Ruth R Leeth MPH,Teresa D 

Leath RN,Ronald H Clements MD, Department of Surgery, 

Section of Gastrointestinal Surgery, The University of Alabama 

at Birmingham, Birmingham, AL 

Introduction - Quality of life (QOL) has been shown to be 

markedly diminished due to morbid obesity. However, there is 

little data comparing the effects of morbid obesity (MO), super 

morbid obesity (SMO) and super, super morbid obesity 

(SSMO) on QOL. 

Methods - 370 patients seeking laparoscopic Roux-en-Y gastric 

bypass for morbid obesity between 8/01 and 8/04 were included 

in this study to assess preoperative quality of life, measured 

by the SF-36 Health Survey version 2. Participants were 

grouped into 3 categories according to body mass index (BMI): 

MO (BMI between 35 with severe co-morbidities and 50, 

n=226), SMO (BMI 50-59, n=114), and SSMO (BMI >60, n=30). 

Demographic information was collected in regards to gender 

(n=322 women and n=48 men), race/ethnicity (n=316 White, 

n=53 Black, and n=1 Hispanic), and pre-existing co-morbidities, 

including HTN (n=211), sleep apnea (n=201), DM (n=135) and 

GERD (n=113). Two-tailed Student?s t-test were used to compare 

the mean values of the 8 SF-36 scales for the 3 BMI categories 

to each other and to national normal values for women 

and men ages 35-44. Multiple linear regression analysis 

(MLRA) of the full model including both demographic and comorbidity 

patient variables was performed to test for the 

impact of BMI on QOL at each of the 8 SF-36 measures. 

Results - All patients had significantly worse QOL score in all 8 

scales compared to national normal values for women and 

men age 35-44. There were significant differences in the mean 

QOL among patients in the 3 BMI categories, specifically on 

physical function (PF) scale. In the full model using MLRA, 

QOL scores for the PF and role of physical scales were significantly 

lower for patients with a BMI>60 compared to patients 

with a BMI


becomes increasingly popular, more information is needed to 

determine the effect of rapid maternal weight loss on pregnancy 

and childbirth. Specifically, management of patients who 

have undergone laparoscopic adjustable gastric banding 

(LAGB) requires vigilant follow-up to define the optimal balance 

between maternal weight loss and appropriate fetal 

growth with relation to band adjustments during pregnancy. 

Methods: A retrospective study of 331 patients who underwent 

(LAGB) between November 2001 and August 2004 was performed. 

Women of childbearing age were identified and further 

surveyed for history of pregnancy. Patients who had 

become pregnant since LAGB were questioned regarding their 

pre and post-banding obstetric history, maternal complications, 

neonatal history, and band management during pregnancy. 

Results: Of the 216 women who underwent LAGB, 14 pregnancies 

among 12 women were identified resulting in 7 live births 

and 1 miscarriage. Six women are currently pregnant. Patients 

became pregnant an average of 7 months after their banding 

surgery (1-27 months). They had lost 25.9 kg prior to becoming 

pregnant (2.3-45.5 kg) resulting in an average BMI of 38.2 

(30.1-60.0 kg/m2) at conception. During pregnancy, the average 

weight gain was 4.8 kg (-11.8 to 22.7kg), and the patients 

underwent an average of 1 band adjustment (0-3). The only 

maternal complication occurred in 1 patient who developed 

gestational diabetes. The average birth weight was 3.6 kg (2.8- 

4.5 kg) with delivery at 39 weeks (38-40 weeks). 

Conclusions: Morbidly obese patients undergoing LAGB have 

no increased incidence of maternal complications relating to 

pregnancy. In our patient population, weight gain or loss during 

pregnancy is not an indication of fetal health. Although 

close follow-up is essential, removal of fluid from the band is 

not mandated in asymptomatic patients. 


FIBRIN SEALANT REDUCES SEVERITY OF ANASTOMOTIC 

LEAKS FOLLOWING ROUX-EN-Y GASTRIC BYPASS, Lana G 

Nelson DO, Rodrigo Gonzalez MD,Krista Haines BA,Taylor 

Martin BA,Scott F Gallagher MD,Michel M Murr MD, 

Department of Surgery, University of South Florida, Tampa, 

FL, USA. 

INTRODUCTION: Anastomotic leaks contribute significantly to 

morbidity and mortality of Roux-en-Y gastric bypass (RYGB). 

We hypothesized that intraoperative application of fibrin 

sealant to the cardiojejunostomy decreases the incidence and 

severity of leaks after RYGB. METHODS: Prospectively collected 

data on 144 consecutive patients who underwent RYGB 

using fibrin sealant (Tiseel, Baxter) (Group 1) were compared 

to our last 158 consecutive patients who underwent RYGB 

without fibrin sealant (Group 2). Clinical characteristics and 

operative outcomes were compared. Data are mean±SD. 

RESULTS: Patients in Group 1 and 2 had similar age (46±11 vs. 

45±9 years), BMI (51±10 vs. 51±10 kg/m2) and gender distribution 

(81% vs. 81% women) (all p=NS). A significantly higher 

percentage of patients in Group 1 underwent laparoscopic 

RYGB (Table). The incidence of leaks was similar in both 

groups. However, 3/6 leaks in Group 1 and 3/5 leaks in Group 

required operative treatment. Of the 3 patients in Group 2 who 

required operative treatment, 2 were found to have diffuse 

peritonitis. The 3 patients who required operative treatment in 

Group 1 had localized peritonitis. The remaining patients were 

treated non-operatively. Length of stay was significantly shorter 

in Group 1. CONCLUSION: Applying fibrin sealant to the 

cardiojejunostomy reduces the severity of leaks in patients 

undergoing RYGB and significantly reduces length of hospital 

stay, which may translate into cost savings, and supports the 

ongoing use of fibrin sealant. 

Laparoscopic Leaks Length of stay 

Group 1 52%* 4% 12±5** 

Group 2 41% 3% 43±27 

*p=0.049; **p=0.01 


“ALTERATIONS IN PERIPHERAL BLOOD LYMPHOCYTE FRE- 

QUENCY IN OBESE PATIENTS”, Robert W O’Rourke MD, 

Thomas Kay BS,Clifford W Deveney MD,Lewinsohn David 

MD,Antony Bakke MD, Oregon Health and Science University 

Background: 

Recent data suggests that obesity is associated with a state of 

immunocompromise. The mechanisms of altered immune 

function in obesity are unknown. Lymphocyte function is 

altered in many co-morbidities of obesity. Lymphocytes are 

therefore excellent targets for study of the mechanisms of 

obesity?s effects on immunity. 

Methods: 

A panel of antibodies directed against lymphocyte cells surface 

CD markers was used to study peripheral blood lymphocyte 

phenotype in obese patients and lean controls. 

Results 

Obese patients demonstrate elevated total lymphocytes (mean 

difference = 17%, p < 0.001) and monocytes (mean difference = 

1.4%, p= 0.001), and decreased frequency of CD8+ cells (mean 

difference = 8%, p = 0.02). Obese patients also demonstrated 

alterations in expression of CD95 and CD62L on a CD4dim 

lymphocyte subset, likely a monocyte population based on forward 

and side scatter characteristics. 

Conclusion: 

These data support the hypothesis that lymphocyte phenotype 

and function is altered in obese patients. These alterations 

affect primarily monocytes and CD8+ lymphocytes. Alterations 

in CD95 and CD62L expression on monocyte subsets suggest 

accompanying functional abnormalities in lymphocytes in 

obese patients. 


USE OF 48 HOUR CONTINUOUS INFUSION LOCAL ANES- 

THETIC SYSTEM IN LAPAROSCOPIC ROUX-EN-Y GASTRIC 

BYPASS APPEARS TO REDUCE POSTOPERATIVE PAIN, J T 

Paige MD, B P Gouda MPH,P G Scalia MD,T E Klainer MD,W J 

Raum MD,L F Martin MD, The Weight Management Center at 

St. Charles General Hospital and Louisiana State Health 

Sciences Center, New Orleans, LA USA 

Background: Laparoscopic Roux-en-Y gastric bypass (RNYGB) 

is currently a very popular bariatric procedure in the United 

States. Although less painful than an open incision, lap 

RNYGB port sites can cause postoperative discomfort. Since 

2003, we have been using a 48 hour continuous infusion local 

anesthetic system (On-Q®) from I-Flow Corporation at our 

largest port incision in an attempt to reduce postop discomfort. 

We have reviewed our experience using this system. 

Methods: A retrospective, single institution review of 80 

patients undergoing lap RNYGB was performed. Thirty-nine 

patients were selected from those undergoing the procedure 

between July to Dec. 2002 (without On-Q®). Forty-one were 

selected from July to Dec. 2003 (with On-Q®). Patient hospital 

records were reviewed for collection of data. 

Results: Patients undergoing lap RNYGB in 2002 were on average 

younger (39.6 vs. 42.2 yrs) with slightly more comorbidities 

(8.2 vs. 7.8) and higher BMI (46.7 vs. 46.2) than those in 

2003. Patients from 2002, had, on average, lower admission 

post anesthesia care unit (PACU) pain scores (1.6 vs. 2.2) but 

higher discharge PACU pain scores (1.1 vs. 1.0) compared to 

2003. Finally, on average, post-op pain scores for 2002 patients 

were lower on admission to the floor (1.4 vs. 2.1), but higher at 

8 hr (1.1 vs. 1.0), 16 hr (0.9 vs. 0.7), 24 hr (1.1 vs. 0.9), and 48 

hr (1.0 vs. 0.6) following arrival to the floor. 

Conclusion: Use of a 48 hour continuous infusion local anesthetic 

system at the largest port incision site after lap RNYGB 

appears to decrease postoperative pain immediately in the 

PACU as well as up to 48 hours after arrival on the hospital 

floor. Further validation of these findings via a randomized 

prospective trial would be useful. 


REINFORCING GASTRIC STAPLE LINE WITH A BODEGRAD- 

ABLE MEMBRANE FROM PORCINE INTESTINAL SUBMUCOSA 

DURING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS., 

Ricardo Cohen MD, Jose S Pinheiro MD, Jose Correa 

MD,Carlos A Schiavon MD, Center for the Surgical Treatment 

of Morbid Obesity, Hospital Sao Camilo, Sao Paulo, Brazil 

Introduction: The purpose of this study was to evaluate the 

ease of use, efficacy and safety of a porcine small intestinal 

submucosa membrane applied over gastric staple lines. Acute 

staple line leak after divided Roux-en-Y gastric bypass (RYGB) 



145



is reported to occur in 1% to 6% of cases and can be devastating. 

The true incidence, however, is not known. Many authors 

do not distinguish between staple line failure and anastomotic 

leak. Another complication of lesser consequence than leak, is 

staple line bleeding, that may require transfusion or reoperation. 

In most cases, it’s a situation that can increase operative 

time, requiring measures to stop the bleeding. We have been 

using a biomembrane derived from porcine small intestinal 

submucosa (SIS) to decrease staple line failure and bleeding. 

SIS membrane was already used in Urology and even reinforcing 

the gastojejunal anastomosis in laparoscopic RYGB. 

Methods: The SIS biomembrane was used in 25 patients 

undergoing laparoscopic Roux-en-Y gastric bypass. SIS membrane 

was employed on a blue 45 mm Endogia cartridge (US 

Surgical Instr, Norwalk, CT, USA) during the creation of the 

gastric pouch. Operative time, intraoperative complications, 

visual staple line bleeding, operative blood loss, postoperative 

drainage output, and staple line leaks were recorded. Data was 

compared to 25 non-SIS cases performed during the same 

period. 

Results: The average operative time in both groups was similar 

(mean of 48 minutes). There were no intraoperative complications 

in both groups. SIS patients had no visual staple line 

bleeding and mean intraoperative blood loss was 25 ml. The 

non-SIS group had 2 cases of staple line bleeding requiring 

cauterization and longer operative time. Operative blood loss 

in these patients was 75 ml. Drain output was significantly 

lower in the SIS group. No staple line leaks were found in both 

groups. 

Conclusions: SIS device was easy and safe to use. Staple line 

bleeding was non existant and intraoperative bleeding was 

less after SIS application. Although no staple line leaks were 

observed in both groups, handling the gastric reservoir was 

much easier with SIS reinforcement. Postoperative drain output 

was considerably lower in the SIS buttressed group. The 

use of SIS reinforcement is quicker than oversewing the staple 

line and less costly than using fibrin glue, while more practical 

than covering it with omentum or jejunal limb coverage. 


LAPAROSCOPIC GASTRIC BYPASS AND PHYSICIANS. A CON- 

TRAINDICATION?, Jose S Pinheiro MD, Ricardo Cohen 

MD,Jose Correa MD,Carlos A Schiavon MD, Center for the 

Surgical Treatment of Morbid Obesity, Hospital Sao Camilo, 

Sao Paulo, Brazil 

Introduction: The purpose of this study was to compare the 

results of laparoscopic Roux-en-Y gastric bypass (LRYGB) in 

physicians and in non-physician patients. Physicians are a 

?special? group of patients. Generally, they are reluctant in 

receiving and following medical instructions. LRYGB for the 

treatment of morbid obesity requires multiple patient commitments 

and a strict and life-long follow-up. 

Methods: We reviewed the data of 19 physicians who underwent 

LRYGB in our Institution (1.7% of our patients). OR time, 

intraoperative and postoperative complications, length of hospital 

stay, drain output, EWL, cure of comorbidities and followup 

were compared to non-physicians patients data when possible. 

Results: Most patients were women (15) and mean age was 38 

(30 to 45). Mean preoperative BMI was 42. Patients presented 

with a mean of 2 comorbidities. One general surgeon, 1 

endocrinologist, and 17 from other medical specialties formed 

the group. There were 3 revisional bariatric procedures. Two 

due to adjustable gastric band erosion and one due to failed 

open gastric bypass (weight regain). Mean OR time was 51 

minutes. There were no intraoperative complications. There 

was 1 pulmonary embolism. Mean length of hospital stay was 

39 hours. These results were similar to non-physician patients. 

Drain was removed in the first preoperative visit (a Jackson- 

Pratt drain is placed in all patients). After this one visit, only 1 

patient continued the regular follow-up (the endocrinologist). 

This patient?s BMI is 24 and diabetes and GERD are cured. 

Comparison of EWL and cure of comorbidities was impossible. 

Conclusions: OR time, intraoperative complications, length of 

hospital stay, and drain output were similar to non-physician 

patients. Follow-up was extremely low resulting in a shocking 

and worrisome situation. 



OUTCOME OF SIMULTANEOUS VS. DEFERRED LAPAROSCOP- 

IC CHOLECYSTECTOMY FOR CHOLELITHIASIS IN BARIATRIC 

SURGERY, Raul J Rosenthal MD, David Podkameni MD,Flavia 

E Soto MD,Priscilla Antozzi MD,Fernando Arias MD,Natan 

Zundel MD,Samuel Szomstein MD, Bariatric Surgery, 

Cleveland Clinic Florida 

Introduction: Lithogenesis and cholesterolosis are well-recognized 

side effects after bariatric procedures. Prophylactic 

cholecystectomy at the time of surgery remains controversial. 

The aim of this study was to analyze the outcome of laparoscopic 

cholecystectomy (LC) for cholelithiasis performed concomitant 

with bariatric surgery or deferred until after bariatric 

surgery when symptoms ensue. Materials & Methods: The 

medical records of 820 patients undergoing Laparoscopic 

Roux En-Y Gastric Bypass (LRYGBP) between January 2000 

and October 2003 were retrospectively reviewed. All patients 

were considered morbidly obese and had sonographic documented 

cholelithiasis. Patients were divided into 2 groups: 

Group A: patients underwent simultaneous LRYGBP + LC and 

Group B: patients underwent deferred LC weeks or months 

after LRYGBP due to cholecystitis. Results: 190 patients (23%) 

presented with gallstones at the time of preoperative evaluation. 

In Group A, 50 patients (26.3%) had simultaneous LC 

while in Group B, 23 patients (16.4%) underwent deferred LC. 

In group A, one patient (4.3%) developed a bile leak and was 

successfully treated by laparoscopic assisted gastrostomy, 

transgastric ERCP and stent placement. In Group B, one 

patient (1%) developed acute cholecystitis and obstructive 

jaundice and underwent successful LC and transcystic common 

bile duct exploration. Conclusions: There appears to be 

no significant difference in complications after simultaneous 

LRYGBP+LC when compared to LRYGBP and deferred LC. 

Complications of LC after LRYGBP require advanced laparoendoscopic 

skills in order to be diagnosed and managed. 

Indications for simultaneous versus deferred LC remain controversial. 


RADIO FREQUENCY ABLATION (STRETTA) IN PATIENTS WITH 

PERSISTENT GERD AFTER ROUX-EN-Y GASTRIC BYPASS, 

Faisal G Qureshi MD, Joy Collins MD,Debra Taylor RN,Laura 

Velcu MD,Pandu Yenumula MD,Brian Lane MD,Tomasz Rogula 

MD,Philip R Schauer MD,Samer G Mattar MD, University of 

Pittsburgh, Department of Surgery 

Background: Morbid obesity is associated with gastroesophageal 

reflux disease (GERD), which in the majority of 

cases, completely resolves after Roux-en-Y gastric bypass 

(RYGB). Patients with persistent symptoms have limited surgical 

options. We sought to evaluate the application of the 

STRETTA procedure in these patients. Methods: The medical 

records of all patients who underwent STRETTA for GERD following 

RYGB were reviewed. Demographic, preoperative and 

postoperative reflux data were collected. Follow up was 

12.6±2.2 months. Data are mean±SEM; t-test was used for 

comparison purposes. Results: Seven patients received 

STRETTA 27±6.1 months after RYGB. All were women with a 

mean age of 49.4 years ±2.5 yrs, All patients had pre-bypass 

GERD symptoms for a duration of 45.6±8.0 months. Mean prebypass 

BMI was 45.9±2.3 kg/m2 and this was reduced to 

29.3±2.4 kg/m2 after RYGB (p


MD,Ajay K Chopra MD, Patrick R Reardon, MD, Wiljon Beltre, 

MD, Ajay K Chopra, MD, Department of Surgery, University of 

Texas Health Science Center at Houston, The Methodist 

Hospital, Houston, Texas 

Introduction: Laparoscopic roux-y gastric bypass (RYGB) is a 

frequently performed procedure. We present our technique for 

using the gastric antrum as an anchor point for the roux limb 

during and after the operation. 

Methods: During RYGB we perform the creation of the roux 

limb as the first portion of the operation. The patient is in a 

flat, supine position during this portion of the surgery. We routinely 

use an antecolic, antegastric approach for the roux limb. 

During creation of the gastric pouch and gastrojejunostomy, 

we place the patient in a steep head-up, reverse Trendelenburg 

(RT) position. This position makes retrieval of the proximal end 

of the roux limb difficult later in the surgery. Therefore, once 

the roux limb has been created, the greater omentum is divided 

in its midportion. The roux limb is then properly oriented 

and the proximal end brought up and sutured to the gastric 

antrum. The patient is then placed in RT position and the 

suture holds the roux limb in proximity and properly oriented 

without interfering with the gastric pouch creation. When the 

gastric pouch has been created, the roux limb is then cut loose 

from the antrum and advanced to create the gastrojejunostomy. 

When the gastrojejunostomy is complete, the roux limb is 

then sutured to the adjacent antrum as it passes over this 

area, keeping slack on the portion of the roux limb proximal to 

the anchor suture. When the patient is in an upright position 

postoperatively, this should let the antrum bear the weight of 

the roux limb instead of the gastrojejunostomy anastomosis 

doing so. 

Conclusion: Suturing the roux limb to the gastric antrum is 

beneficial during and after laparoscopic RYGB. We believe that 

our described technique makes it easier to find the proximal 

roux limb at the time of antecolic, antegastric, roux-Y limb formation. 

In addition, we believe that, postoperatively, it will 

cause the antrum of the gastric remnant to bear the weight of 

the roux limb when the patient is upright, and not the gastrojejunotsomy 

anastomosis. This may lead to fewer leaks and a 

lower stenosis rate. 


GASTROTOMY WITH ANVIL ?DUNK?: A NOVEL TECHNIQUE 

FOR GASTROJEJUNOSTOMY DURING LAPAROSCOPIC 

ROUX-EN-Y GASTRIC BYPASS, M B Peters MD,H F Ojeda 

MD,S Cooper BS,W E Fisher MD,D Camacho MD, D J 

Reichenbach MD, J F Sweeney MD, Michael E. DeBakey 

Department of Surgery, Baylor College of Medicine 

OBJECTIVE: Many techniques for performing the gastrojejunostomy 

required in the laparoscopic roux-en-Y gastric 

bypass (LRYGB) have been described. The current study presents 

the results of a previously unreported method. METH- 

ODS: Twenty-one patients (2 males and 19 females) with morbid 

obesity underwent laparoscopic roux-en-y gastric bypass 

over a 5-month period. The gastrojejunostomy was created by 

performing a gastric transection to form a 20-30cc pouch using 

a linear stapler, followed by gastrotomy with an ultrasonic 

scalpel along the anterior surface of the pouch. A purse string 

suture is then placed circumferentially using standard laparoscopic 

intracorporeal suturing with an endo-stitch device. (US 

Surgical Corporation, Hartford, Connecticut) Finally a 25mm 

circular stapler anvil is placed within the abdomen via the 

15mm left lower quadrant port site. The shaft of the anvil is 

grasped, and the head of the anvil is ?dunked? into the gastrotomy. 

The purse string is then tied intracorporeally. RESULTS: 

A total of 21 patients have undergone LRYGB at our institution 

using this technique. The early results have been excellent in 

all cases with no leaks, no strictures, and no obstructions. 

CONCLUSION: The gastrotomy with anvil dunk is a reproducible 

and safe method of constructing the gastrojejunostomy. 

It is an advanced laparoscopic technique, which closely 

resembles open surgical techniques and provides a safe alternative 

to existing methods. 


REVISIONAL BARIATRIC SURGERY: LESSONS LEARNED, 

Adheesh A Sabnis MD, Bipan Chand MD, Department of 

General Surgery, Minimally Invasive Surgery Center, Cleveland 

Clinic Foundation 

Introduction: A historical review of bariatric operations reveals 

surgeries that have fallen out of favor as a result of poor outcomes 

and complications. Complications include mal-absorptive 

syndromes, severe gastroesophageal reflux, anastomatic 

strictures, and inadequate long-term weight loss. Revisional 

surgery has itself many complications including sepsis and 

failure to improve on weight loss. 

Methods: A series of 20 patients underwent revisional operations 

over a three year period at the Cleveland Clinic 

Foundation. Previous operations included vertical banded gastroplasty 

(11), roux-en-y gastric bypass (4), horizontal gastroplasty 

(3), bilopancreatic diversion (1) and jejunal-ileal bypass 

(1). Indications for revision included poor weight loss (9), 

severe gastroesophageal reflux (7), anastomatic stricture or 

intestinal obstruction (6) and failure to thrive (1). Some 

patients had multiple indications for surgery. Pre-operative 

workup included esophageal manometry, esophageal pH studies, 

EGD, and upper GI series in the majority of patients. 

Outcomes are reported from an IRB approved prospective 

database. 

Results: All 20 patients, including 18 women and 2 men, 

underwent successful operations. The mean pre-op BMI for 

the entire group was 45.7 kg/m2 with a mean reduction of 12% 

of BMI. Nine patients underwent revisional surgery for failed 

weight loss (BMI >30). All nine patients had prior gastroplasty. 

Seven patients underwent revision for severe gastroesophageal 

reflux. Preoperatively, all had normal esophageal 

manometry studies and abnormal esophageal pH studies. Five 

patients have complete resolution of symptoms while two 

patients have occasional breakthrough symptoms requiring 

intermittent anti-reflux medications. Five patients underwent 

either revision of an anastomatic stricture, alleviation of an 

internal hernia, or lysis of adhesions for obstructive systems. 

One patient underwent reversal of a jejunal ileal bypass for 

failure to thrive. Most patients in the series had a RYGB as the 

revisional surgery. Complications include ventral hernia (1), 

wound infection (1) and splenic injury (1). There were no anastomotic 

leaks in our group. 

Conclusion: When weight loss is inadequate or complications 

occur after bariatric surgeries, we found that RYGB is an effective 

revisional procedure. Surgeons must have a thorough 

knowledge of the various surgical techniques employed, both 

past and present, in order to deal with their complications. 


AVOIDANCE OF SELECTIVE COINCIDENT CHOLECYSTECTO- 

MY IN PATIENTS UNDERGOING LAPAROSCOPIC BARIATRIC 

SURGERY, Andras Sandor MD, Donald R Czerniach MD,Patrick 

McEnaney MD,Liam Haveran DO,Richard A Perugini 

MD,Demetrius E.M. Litwin MD,John J Kelly MD, Department of 

Surgery, UMASS Memorial Medical Center, Worcester, MA, 

USA 

The association between rapid weight loss after bariatric surgery 

and the development of cholelithiasis is well established. 

Simultaneous laparoscopic cholecystectomy (LC) coincident 

with laparoscopic Roux-en-Y gastric bypass (LGBP) has been 

advocated but can be technically challenging. Our objective 

was to evaluate the risk associated with avoiding simultaneous 

LC in bariatric patients either with negative or positive preoperative 

US for the presence of gallstones. 

Prospectively collected data in a tertiary care academic medical 

center entered into a patient database was retrospectively 

reviewed. 268 consecutive pts underwent LGBP for morbid 

obesity between 6/30/99 and 10/30/02. Pts with previous cholecystectomy 

(n=71) were excluded from the study. All pts with 

intact gallbladder had preoperative transabdominal US to rule 

out cholelithiasis. Patients were divided to two groups. In 

Group I (6/30/99 ? 11/25/01) all pts with a positive preoperative 

US underwent selective LC coincident with the LGBP. In Group 

II (11/26/01 ? 10/30/02) all pts were treated conservatively 

regardless of the preoperative US result. Patients in Group II 

with symptomatic cholelithiasis at the time of surgery (n=1) 

underwent coincident LC and were excluded from the followup. 

In Group I (n=123) 26 pts with a positive US underwent selec- 



147



tive LC. Of the 97 pts with an initial negative US 13 pts (13.4%) 

developed symptomatic cholelithiasis and underwent subsequent 

LC after a median follow-up period of 48.5 months. The 

mean delay period from the LGPB to LC was 14 months. In 

Group II (n=73; median follow-up=28.5 months) 17 pts were 

identified with cholelithiasis preoperatively, of whom 3 pts 

(17.6%) developed symptomatic disease requiring LC after a 

mean delay of 21 months. Of the pts with negative US (n=56) 7 

pts (12.5%) developed symptomatic disease requiring LC 

(mean delay = 17 months). The two ratios are not significantly 

different with 95% confidence (CI=-16.86 to 27.06). None of the 

interval cholecystectomies had any complications and one pt 

underwent successful lap common bile duct exploration. 

Simultaneous LC coincident with laparoscopic bariatric surgery 

can be difficult due to trocar positioning and anatomic 

constraints. Patients with or without preoperative evidence of 

cholelithiasis can be followed clinically for the development of 

symptomatic gallstone disease. LC can be performed safely at 

a later time in this population should symptoms arise. 


AVOIDING OBSTRUCTION AT THE JEJUNO-JEJUNOSTOMY 

DURING LAPAROSCOPIC GASTRIC BYPASS, Rebecca Shore 

MD, Scott Shikora MD,Julie Kim MD,Michael Tarnoff MD, 

Center for Minimally Invasive Surgery, TUFTS-New England 


Introduction: Laparoscopic gastric bypass (LGB) is rapidly 

gaining popularity in the treatment of morbid obesity in the 

United States. Many technical variations of the operation currently 

exist. Commonly a side to side anastomosis is created 

between the bilio-pancreatic limb and the roux limb with a 

60mm Endo GIA (USSC, Norwalk, CT). The entry site for the 

stapler must then be closed. Initially, we closed this opening 

linearly, along the length of the jejuno-jejunostomy (JJ), with 

this technique we encountered a 4.8% JJ obstruction rate. 

Subsequently, we changed our technique in an attempt to 

decrease this troubling complication. This abstract describes a 

bi-directional stapled JJ to assure a wide opening between the 

two limbs. 

Method: After the 60mm Endo GIA is used to create the side to 

side anastomosis a 30 mm Endo GIA is positioned in the 

opposite direction and fired creating a 90mm anastomosis. 

The opening is then closed transversely similar to the Heineke- 

Mikulicz pyloroplasty with a single firing of the 60 mm Endo 

GIA. The stapled jejunal specimen is removed and inspected 

to assure continuity of the serosal layer. We then close the 

mesenteric defect with a running suture and incorporate an 

anti-obstruction stitch. 

Results: A review of our institution?s data reveals that with the 

unidirectional closure we had a 4.8% anastomotic obstruction 

rate (6/125 cases). Four of these six patients required operative 

intervention. Since implementing the bi-directional anastomosis 

our obstruction rate is 0% (0/733 cases). 

Conclusion: Bi-directional stapling of the JJ results in a wide 

opening, is technically feasible and decreases the incidence of 

obstruction. 


A NEW DEVICE BY USING OMENTUM FOR PREVENTING 

COMPLICATIONS DURING LAPAROSCOPIC ROUX-EN-Y GAS- 

TRIC BYPASS FOR MORBID OBESITY, Nobumi Tagaya PhD, 

Kazunori Kasama MD,Yasuharu Kakihara MD,Shoujirou 

Taketsuka MD,Kenji Horie MD,Norio Suzuki MD,Keiichi Kubota 

PhD, 1) Department of Surgery, Horie Hospital, Gunma, Japan, 

2) Second Department of Surgery, Dokkyo University School of 

Medicine, Tochigi, Japan 

Laparoscopic Roux-en-Y gastric bypass has emerged as a standard 

surgical treatment for morbid obesity. However, the prevention 

of postoperative complications related with bariatric 

surgery is necessary. To reduce postoperative complications 

and achieve the adequate body weight loss, we introduce a 

new device using separated omentum during laparoscopic 

Roux-en-Y gastric bypass. The actual aim of these devices is to 

prevent the gastro-gastric fistula due to the re-entry of alimentary 

tract and the leakage from gastric pouch or anastomosis. 

Between February 2002 and August 2004 we have performed 

laparoscopic Roux-en-Y gastric bypass for morbid obesity in 


21 cases. Recent 8 cases were introduced our new device 

using separated omentum. They were one male and seven 

females. Their mean age was 33 years old (range, 18-50), and 

mean BMI was 40 Kg/m2 (range, 34-46). At surgery, omentum 

is routinely separated using laparoscopic coagulating shares 

before performing gastro-jejunostomy to reduce the tension of 

anastomosis. After performing hand-sewn gastro-jejunostomy, 

a left side of separated omentum is moved cranially and interposed 

between a gastric pouch and a residual stomach. And 

then omentum was sutured to the posterior aspect of the gastric 

pouch, or the gastric pouch was rapped by omentum circumferentially. 

Our procedure using omentum during bariatric 

surgery is feasible and safe to obtain better outcomes without 

artificial materials. Although the long-term outcome of this 

technique is still unclear, we believe that this technique will 

provide to decrease the particular complications related with 

laparoscopic Roux-en-Y gastric bypass for morbid obesity. 


GASTRIC BYPASS IN PATIENTS 55 YEARS AND OLDER: A 

COMPARISON OF YOUNG VS OLD AND THE LAPAROSCOPIC 

VS OPEN TECHNIQUE, Mark Takata MD, Suhail Shaikh 

MD,Bruce Bernstein PhD,Martindale Carolyn RN,Manuel 

Lorenzo MD,Richard Newman MD,Carlos Barba MD, 

Department of Surgery, St. Francis Hospital and Medical 

Center, University of Connecticut School of Medicine 

The purpose of this study is to compare the safety and efficacy 

of Roux-en Y gastric bypass (RYGB) surgery for morbid obesity 

between patients 55 years and older with patients younger 

than 55 years and to evaluate whether or not the laparoscopic 

approach provides a better outcome in the older age group. 

A retrospective chart review was conducted at a single tertiary 

care institution. Morbidly obese patients 55 years and over 

were included if they underwent laparoscopic (lap) or open 

RYGB surgery between January 1999 and March 2004. A random 

sample of 122 patients were selected from a total of 494 

patients younger than 55 who had lap or open RYGB during 

the same study period. Demographics, preoperative body 

mass index (BMI), comorbidities, length of stay (LOS), perioperative 

complications, and percent weight loss were compared 

between the two age groups. 

A total of 61 consecutive patients 55 years and over underwent 

RYGB surgery during the study period. There were no significant 

differences between the two age groups with respect to 

gender, preoperative BMI, LOS, and percent weight loss at 3, 

6, and 12 months. When comparing comorbidities (young vs 

old), there were significant differences (p < 0.05) in the prevalence 

of coronary artery disease (3.3 vs 13.1%), diabetes mellitus 

(20.7 vs 39.3%), and hypertension (39.8 vs 77.0%). There 

were no significant differences between the prevalence of 

COPD and sleep apnea. There were two perioperative mortalities 

in the younger group and one in the older group. When 

comparing perioperative complications between the two age 

groups (young vs old) there were no significant differences in 

the rates of cardiopulmonary complications (1.6 vs 6.6%), 

anastomotic leaks (4.1 vs 4.9%), postoperative bleeding (0 vs 

3.3%), and wound infections (15.0 vs 18.0%). The lap approach 

was utilized in 49.2% of the younger group and 29.5% of the 

older group (p < 0.05). When comparing the lap and open 

approach in the older age group there were no significant differences 

in demographics (except BMI), LOS, and perioperative 

complications. 

Despite the higher rate of comorbidities in the older age 

group, this study demonstrates that RYGB surgery for morbid 

obesity in properly selected patients age 55 years and over 

can safely and efficaciously be performed when compared to 

younger patients. In addition, the lap approach in patients 55 

and over does not result in a shorter LOS or less perioperative 



LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING: RESULTS 

OF THE FIRST 500 CASES USING THE PARS FLACCIDA TECH- 

NIQUE., craig J taylor MD, Laurent Layani MD, Gold Coast 

Obesity Surgery Centre, Gold Coast Queensland Australia 

INTRODUCTION. Whilst the Pars Flaccida technique of LAGB 

placement has been shown by experienced bariatric surgeons


to have a fewer complications and similar efficacy to the perigastric 

approach, it is unclear what results can been achieved 

by general surgeons using the pars flaccida technique without 

extensive previous gastric banding experience. We sought to 

clarify this by analysing the results of all LAGB’s placed using 

the pars flaccida approach by a general surgeon pars flaccida 

technique is an intrinsically better technique or Laparoscopic 

Adjustable Gastric banding is now the technique of choice in 

the surgical treatment of morbid obesity in Europe and 

Australasia, and is rapidly gaining popularity in North 

America. Previously, the perigastric approach was used for 

band placement, but an unacceptably high incidence of band 

related complications lead to the change to the pars flaccida 

approach, which has been shown by with similar efficacy. We 

sought to investigate the results achievable using the pars 

flaccida technique when adopted by a. 

METHODS. The first 500 consecutive cases of laparoscopic 

adjustable gastric banding performed by a single surgeon 

using the Pars Flaccida technique were retrospectively 

reviewed, with particular reference to the incidence of band 

slippage, erosion and reoperation. 

RESULTS. Five hundred patients (79% female) with a mean 

age of 45 years and mean preoperative body mass index of 

44.5 underwent laparoscopically placed adjustable gastric 

banding. Percentage excess weight lost was 40%, 51%, 48% 

and 54.5% at 1,2,3,and 4 years follow-up respectively. Band 

slippage occurred in 5 (1%), erosion in 2 patients (0.4%). 

Twenty two patients (4.4%) required reoperation for band 

related problems in 10 (2%) and port related problems in 12 

(2.4%). There was one death (0.2%) 

CONCLUSION. The Pars flaccida technique is inherently associated 

with a low incidence of complications whilst producing 

effective weight loss, and is the preferred approach for band 

placement. Our results provide the laparoscopic surgeon 

preparing to embark on gastric banding with an indication of 

those achievable using the technique. 


PREDICTIVE VALUE OF UPPER GASTROINTESTINAL STUDIES 

VERSUS CLINICAL SIGNS FOR LEAKS AFTER LAPAROSCOPIC 

GASTRIC BYPASS, Craig A Ternovits MD, Holbrook H 

Stoecklein,David S Tichansky MD,Atul K Madan MD, 

Department of Surgery, University of Tennesse Health Science 

Center - Memphis 

Introduction: The topic of utility of upper gastrointestinal (UGI) 

studies immediately after laparoscopic gastric bypass is of 

great debate. Since the morbidity and mortality of an unrecognized 

postoperative leak is high after gastric bypass, diagnosis 

of a postoperative leak earlier would be of benefit. However, 

clinical signs may make the diagnosis of a postoperative leak 

obvious. This study explored the hypothesis that UGI studies 

were more predictive than clinical signs for the early diagnosis 

of laparoscopic gastric bypass. 

Methods: All laparoscopic gastric bypasses performed at our 

institution were included in this study. Charts were reviewed 

to examine immediate clinical signs (heart rate, temperature, 

and white blood cell count within the first 24 hours), UGI studies, 

and clinical course. Sensitivity (Sens), specificity (Spec), 

positive predictive value (PPV), negative predictive value 

(NPV), and efficiency (EFF) of clinical signs and UGI studies 

were calculated. 

Results: There were 245 patients in this study with a 3% rate of 

leak. The overall positive and negative predictive value of the 

UGI studies and clinical signs are demonstrated in the table. 

Conclusions: According to our data, UGI studies are the most 

predictive of the early diagnosis of a leak. Clinical signs are 

not as useful in predicting leaks early after laparoscopic gastric 

bypasses. UGI studies should be performed early after laparoscopic 

gastric bypasses. 


LAPAROSCOPIC BARIATRIC PATIENTS? WILL TO HELP: THE 

FOUNDATION OF CLINICAL RESEARCH, David S Tichansky 

MD, Craig A Ternovits MD,Kimberly Turman,Atul K Madan MD, 

Department of Surgery, University of Tennessee Health 

Science Center, Memphis, TN 

INTRODUCTION: Bariatric surgery is one of the fastest growing 

surgical specialties. Clinical research is essential to its safe 

delivery. Studies subjectively refer to bariatric patient enthusiasm 

for research participation. However, this has never been 

objectively measured. Our hypothesis is that most laparoscopic 

bariatric surgery patients will participate in and comply with 

obesity related clinical research. 

METHODS: Postoperative laparoscopic bariatric surgery 

patients were given a fifteen-question survey querying their 

commitment to participate in studies and then quantified the 

level of time, effort, and commitment they would comply with. 

Responses were analyzed and Fisher?s Exact and chi-square 

tests was used to determine statistically significant differences. 

RESULTS: Eighty-nine of the 97 (92%) patients were willing to 

participate. Willingness was independent of race (30/33 [91%] 

of black patients vs. 59/64 [92%] of white patients, p=ns). 

Diabetics were not more likely than non-diabetics to participate 

(29/32 [91%] of diabetics vs. 60/65 [92%] of non-diabetics, 

p=ns). 93% agreed to additional blood tests done during to 

routine blood draws, but only 75% would have additional 

blood draws. 100% agreed to donate fat samples during surgery, 

but only 80% would donate one-month post-op. 57% 

agreed to catheterization for sample collection. 82% would 

spend 6 hours in the hospital for preoperative research. This 

decreased to 58% and 57% for 12 and 24 hours, respectively 

(p=0.001). 74% committed to 6 hours per month in the hospital 

for postoperative research. This decreased to 61% and 55% for 

12 and 24 hours (p=0.004). There were no trends in the financial 

reimbursement that patients desired for this hospital time. 

CONCLUSION: Almost all laparoscopic bariatric surgery 

patients will participate in obesity related research, including 

invasive procedures, when it coincides with their surgery. 

Enthusiasm depreciates with increasing time commitment in 

the pre- and post-operative period but remains in the majority 

of patients. Weight loss surgery patients? strong willingness to 

promote obesity related research is the backbone of successful 

clinical research in this field. 


VISUAL IDENTIFICATION OF LIVER PATHOLOGY DURING 

LAPAROSCOPIC BARIATRIC PROCEDURES, Darren S Tishler 

MD, Toni Leeth MPH,Teresa Leath RN,Brandon Roy MD,Gary 

Abrams MD,Ronald H Clements MD, University of Alabama at 

Birmingham 

BACKGROUND: Liver disease, particularly non-alcoholic 

steatohepatitis, is commonly encountered in the morbidly 

obese patient. There are currently no clear-cut recommendations 

as to the appropriate management of liver pathology 

when encountered at laparoscopy for obesity surgery. It has 

been recommended that because of the hight prevelence of 

liver disease, biopsies should be taken in all patients to guide 

further management. The relationship between the visual 

appearance of a diseased liver and actual pathology in the 

morbidly obese patient is undefined. 

METHODS: A total of thirty-seven morbidly obese patients 

undergoing laparoscopic Roux-en-Y gastric bypass were 

enrolled in a prospective study. The appearance of their livers 

were independently scored by two surgeons on a 4 point scale 

based on the degree of fat deposition visualized (>67% fat - 

severe; 33-66% fat - moderate;




CONCLUSION: Although surgeons commonly comment on the 

degree of liver disease at the time of obesity surgery, the ability 

to reliably identify liver pathology without biopsy in the 

morbidly obese patient is limited. Even in patients with no 

visually appreciable liver disease, it is commonplace for a 

biopsy to histologically demonstrate steatosis, fibrosis, or 

steatohepatitis. Because of the increased prevelence of liver 

disease in the morbidly obese patient, we recommend that a 

liver biopsy be routinely performed on all patients at the time 

of obesity surgery to guide further monitoring, risk stratification, 

and future treatment options. 


THE RELATIONSHIP OF GASTRIC EMPTYING & POSITION OF 

THE GASTROJEJUNOSTOMY (GJ) IN THE LAPAROSCOPIC 

ROUEX-EN-Y GASTRIC BYPASS (LRYGBP) PATIENTS, ANTE- 

GASTRIC VS. RETROGASTRIC; IS THERE A DIFFERENCE?, 

John Yadegar MD, Oliver Block MD,William Bertucci MD,Todd 

Drasin MD,Eric Dutson MD,Salvador Valencia MD,Debbie 

Frickel RN,Barbara Kadell MD,Carlos Gracia MD,Amir Mehran 

MD, UCLA Medical Center, Los Angeles, California 

Introduction: It is often claimed that retrogasric GJ, is more 

anatomical/physiological & hence drains better. It was our contention 

to assess this in the LRYGBP group. 

Method: From 1/2003 to 6/2004, one hundred of each Retrcolic- 

Retrogastric (RC/RG) vs. Antecolic-Antegastric (AC/AG), RYGBP 

were performed by the UCLA bariatric group. The data pertaining 

to gastric emptying, time to discharge, comorbidities & 

any complications were collected in to a prospective database. 

All the patients obtained an upper GI swallow on postoperative 

day one. Same radiological techniques were used in all 

the cases, and same group of radiologists reviewed the films. 

All the studies with delayed emptying, i.e.: contrast hold up of 

various degree, were labeled as such. The patient records 

were subsequently reviewed and the data was then analyzed. 

Results: There were 12 delayed gastric emptying in the RC/RG 

group vs. 19 in the AC/AG group. Statistical analysis of the 

data using Chi-Square test, showed no significant difference 

between the 2 groups, with a P=0.17. There was also no association 

with relation to Body Mass Index (BMI), diabetes or 

hospitalization period. 

Conclusion: Our data suggests that there does not appear to 

be a statistically significant difference, between the gastric 

emptying , in the RC/RG vs. AC/AG group in the RYGBP population. 

This may also hold true in the Gastrojejunostomies performed 

in the non-bariatric patient population, although a larger 

study group should be reviewed. 


THE INCIDENCE OF SMALL BOWEL OBSTRUCTION AFTER 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS USING AN 

ANTECOLIC ROUX LIMB, Sherman Yu MD, Michael Snyder 

MD,Patrick Sawyer, PA-C, University of Colorado Health 

Sciences Center and Rose Medical Center 

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) 

is a safe and effective alternative to standard open Roux-en-Y 

gastric bypass. Reports suggest that a retrocolic roux limb in 

LRYGB may result in as high as a 5% incidence of small bowel 

obstruction (SBO) due to internal hernias and mesocolonic 

constrictions. The placement of the roux limb in an antecolic 

position will eliminate the mesocolon as a source of SBO. We 

hypothesized that an antecolic roux limb would result in a 

decreased incidence of SBO in patients undergoing LRYGB. 

Methods: The charts from the first 400 consecutive LRYGB 

patients operated on from 3/01-2/04 at a university affiliated 

community hospital were retrospectively reviewed. All cases 

were performed using an antecolic, antegastric roux limb 

placed through a small defect made in the omentum. A circular 

stapler with transoral placement of the anvil was used for 

the creation of the gastrojejunostomy. Omental and mesomesenteric 

defects were not closed. 

Results: Four hundred patients underwent LRYGB with a mean 

BMI of 48 (34-79). The average age was 45 years. Eighty-six 

percent of the patients were female. Five patients developed 

SBO (1.3%). Three obstructions occurred at the omental window, 

1 obstruction was secondary to a stricture at the jejunaljejunostomy, 

and 1 obstruction occurred from an incarcerated 

umbilical hernia resulting in an anastamotic leak. One additional 

anastamotic leak occurred unrelated to a SBO. All 

patients underwent operative repair of the SBO with no resultant 

mortality. 

Conclusions: In our series of 400 patients undergoing LRYGB, 

the incidence of SBO was 1.3 %. The antecolic placement of 

the roux limb eliminated the mesocolon as a source of SBO. 

However, we did observe 3 omental window hernias (0.8%) 

that resulted in SBO. Therefore, we conclude that the antecolic 

placement of the roux limb decreases the risk of SBO compared 

to a retrocolic roux limb. 


PORT COMPLICATIONS FOLLOWING LAPAROSCOPIC 

ADJUSTABLE GASTRIC BANDING FOR MORBID OBESITY, 

Subhi Abu-Abeid MD, Andrei Keidar MD,Dan Bar-Zohar 

MD,Joseph Klausner MD, Department of Surgery B, Tel-Aviv 

Sourasky Medical Center 

Objectives: Laparoscopic adjustable gastric banding (LAGB) is 

gaining widespread acceptance, but the technique has disadvantages 

secondary to the material wear and tear around the 

port and the connecting tubing, that can lead to system failure. 

Port site complications are considered common; however, only 

few authors analyze them, and no optimal technique of port 

implantation and management is suggested. 

Method and Procedure: LAGB includes placement of an 

adjustable band, 2 cm below the gastroesophageal junction, 

thus restricting the gastric reservoir. The inner part of the band 

is a silicon sleeve connected to a subcutaneous port 

(Bioenterics®, Carpenteria, CA, USA), which enables band 

width adjustment. All patients who suffered from complications 

involving the tubing or the access port were included in 

the study. Their preoperative complaints, operative notes and 

hospitalization files were retrospectively reviewed. 

Results: Only 1272 patients (of a total of 2134 operated on) 

were available for a mean follow-up of 57 months. During this 

period, 91 (7.1%) patients suffered from port complications 

that required 103 revisional operations. 63/91 suffered from 

system leak, 17/91 from infectious problems and 10/91 from 

miscellaneous problems. Overall, port complications led to 

band removal in 6/91 patients and port replacement in one. 

Conclusions: Although among the most common complications 

of LAGB, access port complications are the most annoying 

ones, rendering the device susceptible to failure. The combination 

of careful surgical technique, routine use of radiological 

guidance for band adjustment and improvement of the 

port design may be the keys for minimizing complications, 

obviating further, unnecessary surgical procedures. 

P099–Colorectal/Intestinal Surgery 

LAPAROSCOPIC LIGASURE SMALL BOWEL ANASTOMOSIS, 

Abdullah Al Dohayan MD, King Khalid University Hospital 

Ligasure is a machine used to seal vessels. The same concept 

is applied to use the diathermy capiblity in cutting and sealing 

the mucosa of small bowel. The procedure was done in 3 dogs 

using 3 trocars size 5 mm. A loop of small bowel was choosen 

and side to side anastomosis was carried out in two layers 

with outer continous seromuscular suture using silk. 

Entromtomy is done in both edge of the small bowel. The jaws 

of the ligasure was introduced in both stomas and closed 

diathermy is carried out followed by cutting of the coagulated 

tissue. The procedure was completed, anterior seromuscular 

suture was done. During the 3 months follow up no leak was 

reported or vomiting. 


LAPAROSCOPIC RESECTION FOR COMPLETE AND INTERNAL 

RP, Ravinder K Annamaneni MD, John H Marks MD,Thomas 

Curran BA,Gerald Marks MD, The Lankenau Hospital and 

Lankenau Institute of Medical Research, Wynnewood, PA,USA. 

OBJECTIVE: The aim of this study is to assess the efficacy and 

safety of laparoscopic (lap) resection for rectal prolapse (RP). 

METHODS: From 1996 to 2004, 32 consecutive patients (27 

women) had lap resection with rectopexy for complete (CRP) 

(N=16), or hidden (HRP) (N=16) rectal prolapse. Data was analyzed 

from a prospective database.


RESULTS: The mean age was 56 years (range, 28-84). Primary 

complaints were transanal protrusion (16), impaired fecal 

extrusion (13) and fecal incontinence (3). Preoperative assessment 

included clinical examination, selective imaging including 

barium enema, defecography, colonoscopy and transit 

studies. Twenty five pts (78%) had sigmoidectomy with dissection 

rectopexy, 5 pts (16%) had a left colectomy with rectopexy, 

and 2 pts (6%) had total abdominal colectomy and rectopexy. 

There were no conversions to open. Mean estimated 

blood loss was 205 (range, 50-800) cc. No pt needed blood 

transfusion. Mean number of incisions was 3.5 (range, 3-5). 

Mean length of largest incision was 4 (range, 3-6.1) cm. There 

was no mortality. Complications noted in 4 pts (12%): two 

developed small bowel obstruction, one requiring surgery; one 

instance of minor incisional bleeding and one urinary tract 

infection. Mean follow-up was 15.3 (4-52) months. Mean postoperative 

hospitalization was 4.5 (range, 2-8) days. Two (6%) 

pts developed full thickness recurrence: one in 10 months and 

another in 18 months after surgery, both of which were 

repaired by a Delorme procedure without recurrence. Pts with 

fecal extrusion impairment required a transanal mucosal excision, 

in 7/16 pts, all successfully treated. Twenty pts (62.5%) 

had complete resolution and 12 (37.5%) while improved had 

minor residual functional complaints. 

CONCLUSION: Colectomy with rectopexy for CRP or HRP can 

be safely performed laparoscopically with low morbidity and 

acceptable functional outcome. As in open surgery mucosal 

redundancy with fecal extrusion difficulty is a frequent sequel 

to anterior resection and rectopexy for HRP and transanal 

mucosal excision should be planned with anticipation of satisfactory 

results. Long term follow up studies are needed to 

properly assess the recurrence rates. 


SAME DAY DISCHARGE AFTER LAPAROSCOPIC COLON 

RESECTION, Mehran Anvari PhD, Allan Okrainec MD,Cliff 

Sample MD,Herawaty Sebajang MD,Ann Brannigan MD, 

Centre for Minimal Access Surgery, McMaster University, 

Hamilton, Ontario, Canada 

Laparoscopic colon resection has been associated with 

reduced length of stay. We have initiated a program of discharging 

patients within the same day (24 hours) after laparoscopic 

colon resection and with a pain pump to provide local 

analgesic control to the extraction excision site. 

5 patients with a mean age of 65.4 (range 44-83) underwent 

laparoscopic colon resection (3 Right Hemicolectomy for cancer, 

1 Anterior Resection for cancer, 1 sigmoid resection with 

stomal closure). The mean OR time was 131±9 mins and the 

median ASA Score was 3 (range 2-4). The mean time to discharge 

was 20.6±0.7 hours. Prior to discharge, 2 patients 

required oral narcotics for abdominal pain. There were no 

peri-operative complications and all patients were satisfied 

with early discharge and had unremarkable recoveries. 

Conclusion: Same day discharge after laparoscopic colectomy 

is safe and feasible in select patients with good home support. 

Use of a local pain pump helps reduce the need for post-operative 

narcotics. 


LAPAROSCOPY HAS A PLACE IN THE REVERSAL OF HART- 

MANN PROCEDURE, George Bouras MD, Maria Mara Arenas 

Sanchez, MD,Harutaka Inoue MD,Joel Leroy MD,Francesco 

Rubino MD,Didier Mutter PhD,Antonello Forgione MD,Jacques 

Marescaux MD, IRCAD/EITS, University Hospital of Strasbourg, 

France 

Background: It has been suggested that laparoscopic reversal 

of Hartmann procedure (LRHP) is associated with less patient 

morbidity and shorter hospital stay compared to open surgery. 

The aim of this study was to evaluate the outcomes of LRHP in 

order to assess whether such advantages are conveyed in our 

experience. 

Methods: A retrospective analysis of all patients who underwent 

reversal of Hartmann procedure between August 1998 

and August 2004 was performed. Data collection included preoperative 

(age, sex, ASA score, BMI, diagnosis, interval to 

reversal), intra-operative (operative time, intra-operative findings, 

conversion) and post-operative (morbidity, mortality, hospital 

stay, follow-up) data. 

Results: Reversal of Hartmann procedure was performed in 36 

patients. Twenty-two cases were performed by laparoscopy 

and 14 cases were performed by open surgery. There was no 

significant difference between laparoscopic and open groups 

in terms of age, sex, ASA score, BMI, diagnosis, follow-up and 

time to reversal. For the laparoscopic group, the male to 

female ratio was 13:9, mean age was 59.6 years (range 40-82), 

mean ASA score was 2.09 (range 2-3), mean BMI was 26.1 

kg/m2 (range 21.2-33.1), mean interval to reversal was 5.8 

months (range 1-13), and mean follow-up was 10.1 months 

(range 1-72). The mean BMI was lower for the laparoscopic 

group compared to the open group (26.1 vs 29.1 kg/m2, 

p=NS). Laparoscopic RHP was completed in 21/22 patients 

(conversion rate 4.5%), the only conversion being due to due 

to severe adhesions. Compared to open surgery, the mean 

operative time was less (174 vs 223 minutes, p




PRELIMINARY EXPERIENCE OF LAPAROSCOPY-ASSISTED 

EXPLORATION OF OBSCURE INTESTINAL BLEEDING AFTER 

CAPSULE ENDOSCOPY; THE KOREAN EXPERIENCE, MINY- 

OUNG CHO MD, JIN KIM MD,JEOUNG WON BAE,JONG SUK 

KIM,YOUNG CHUL KIM,CHEONG WUNG WHANG,SUNG OCK 

SUH, Surgery, College of Medicine, Korea University 

Background: Obscure intestinal bleeding (OGB) is generally 

defined as recurrent acute or chronic bleeding for which no 

source has been identified by routine radiologic and endoscopic 

examination. The aim of this study was to report our 

early experiences detecting small bowel bleeding by capsule 

endoscopy (CE), and the results of laparoscopy-assisted operations 

for OGB. 

Materials and Methods: 75 patients with obscure gastrointestinal 

bleeding were examined by CE. Twelve patients of the 

active bleeding group underwent laparoscopy-assisted operation, 

and we carried out intra-operative enteroscopy to find the 

focus of the bleeding. 

Results: Laparoscopic localization of the lesion was successful 

only for 4 patients?those with Meckel’s diverticulum, gastrointestinal 

stromal tumor, lymphoma, and ischemic necrosis. In 3 

cases in which there was no natural passage of the capsule 

endoscope, lesions were identified by small bowel exploration 

through simple palpation. Intra-operative enteroscopy was 

performed in 5 cases, in order to localize the lesions. The 

lesions that were identified by CE pre-operatively were resected 

successfully, via laparoscopic or laparoscopy-assisted operation. 

The gastrointestinal bleeding has not recurred during 

the post-operative follow-up period (mean 10.6 months). 

Conclusion: Intraoperative enteroscopy needs to identify small 

mucosal lesions that cannot be detected by laparoscopy, or by 

conventional small bowel exploration. Our results suggest that 

laparoscopic or laparoscopy-assisted surgery is a feasible 

method for managing OGB patients whose lesions are identified 

by pre-operative CE. The laparoscopy-assisted operation 

is effective in explorations of the intra-abdominal cavity and 

the identification of some lesions. It can also be performed as 

an adequate ?mini-laparotomy? 


LONG-TERM SURVIVAL AFTER LAPAROSCOPIC COLECTOMY 

FOR ADENOCARCINOMA, Tom Paluch MD,Michael J Clar 

MD,Jon Greif DO, Amy L Day MD, Kaiser Foundation Medical 

Center, San Diego 

Controversy regarding the oncologic efficacy of laparoscopic 

colectomy (LC) for colorectal carcinoma (CRC) has precluded 

its widespread application. The greatest concern remains 

availability of long-term survival data. Few series extend to 

five years and almost none beyond. We reviewed the records 

of 134 patients who underwent attempted LC for CRC at our 

institution between 1992 and 1998. In 114 of 134 (85%), the 

operation was completed laparoscopically. Operations performed 

were right hemi-colectomy (n = 54; 47%), sigmoid 

colectomy (n = 35%), left hemi-colectomy (n = 11), and other (n 

= 9). Mean operating time for those procedures was 142 mins 

(range 75 - 308 mins). Peri-operative mortality was 0.9%. 

Pathologic stages were Stage A: 17 (15%), Stage B1: 16 (14%), 

Stage B2: 37 (32%), Stage C1: 3 (3%), Stage C2: 34 (30%), 

Stage D: 7 (6%). There was no significant difference in stage 

between cases completed closed and those converted to open. 

Follow-up ranged from 72 to 139 mos (mean: 84 mos; median: 

78 mos). Overall 80/114 (70%) are alive and NED. Crude survival 

at 6 through 10 years post-op were 75%, 73%, 66%, 63%, 

and 58% respectively. 34 pts (30%) had recurrent disease. 

Mean time to recurrence was 29.5 mos (range 2 - 75 mos). The 

mean survival of pts with recurrent disease was 40.7 mos 

(range 0 - 101 mos). There was 1 (0.9 %) port site/ incisional 

recurrence. We conclude that LC for CRC is a safe and oncologically 

sound operation and should be offered to all pts with 

CRC. 


COST COMPARISON OF LOOPED VERSUS STAPLED LAPARO- 

SCOPIC APPENDECTOMY, Erika Fellinger MD, Alexander Perez 

MD,Neal Seymour MD,David Earle MD, Baystate Medical 


Center 

Objective: There is variability in technique when performing 

laparoscopic appendectomy, particularly for uncomplicated 

cases. We hypothesized that the use of relatively high cost 

items such as disposable staplers does not add clinical or 

financial value to the procedure. 

Methods: All patients with uncomplicated appendicitis (defined 

by a length of stay of 2 days or less) undergoing laparoscopic 

appendectomy between 10/1/01 and 6/1/04 (N= 326) were identified 

and stratified into one of two groups according to the 

use of a commercially available, pre-tied Roeder?s knot (EL), 

or use of selected, high cost, disposable items (SS = staplers 

and reloads, Ligasure?, ultrasonic coagulating shears). Total 

hospital cost, OR time in minutes, and supply cost for each 

group were compared using ANOVA and Cox proportional 

hazards tests. 

Results: The total OR supply cost was less for EL compared 

with SS laparoscopic appendectomy ($790 vs. $1070, p


surgeons working in a community hospital, were reviewed. 

Data extracted from the charts included patients’ demographics, 

surgical indications and procedures, conversion rate, past 

history, operative time, post-operative recovery time and complication 

rates. 

Results: Of the 154 patients, 70 were men. The mean age was 

60. Overall, 62% of the patients had a history of prior abdominal 

surgery. The majority of cases (77%) were done for benign 

disease. Segmental resection involving the left colon was done 

in 122 patients and right hemicolectomy in 32. The rate of conversion 

to open surgery was 9,6%, and 12% for diverticulitis 

(n=83). For LCR, the median operative time was 120 minutes 

and median hospital stay 5 days. The complication rate was 

21,6% for LCR. Mortality rate was 2,1%. 

Conclusion: Outcomes of LCR done by a team of general surgeons 

working together in a community hospital are similar to 

historical results from academic health science centers. 


LAPAROSCOPIC TREATMENT OF SMALL BOWEL OBSTRUC- 

TION FROM MECKEL?S DIVERTICULUM, Robert J Wilmoth 

MD, Michael E Harned MD, Craig S Swafford MD,Matthew L 

Mancini MD, Department of General Surgery, University of 

Tennessee Medical Center, Knoxville, TN 

Objective: Laparoscopy is an effective means for the evaluation 

of uncertain intra-abdominal pathology. We present a 

case-report utilizing laparoscopy for diagnosis and treatment 

of a mechanical small bowel obstruction secondary to a 

Meckel?s diverticulum. 

Case Report: Patient is a 14-year-old male who initially presented 

with non-specific abdominal pain, nausea, and vomiting 

in December, 2003. CT scan of the abdomen and pelvis 

revealed a normal appendix with a small amount of free fluid 

in the pelvis. There was suggestion of mechanical small bowel 

obstruction with transition zone in the pelvis. The patient was 

taken to the operating room for diagnostic laparoscopy. 

Results: Operative exploration revealed a large inflamed 

Meckel?s diverticulum with an adhesive band to the retroperitoneum 

creating an internal hernia and resultant small bowel 

obstruction. The hernia was reduced laparoscopically and 

intracorporeal resection of the Meckel?s was performed. The 

patient improved and was discharged home on post-operative 

day one. 

Conclusion: Meckel?s diverticulum is the most common congenital 

abnormality of the small intestine. When symptomatic, 

its most common presentations are bleeding or obstruction. 

Meckel?s diverticulum and its complications can be safely and 

effectively managed via the laparoscopic approach. 


LAPAROSCOPIC SIMPLE CECECTOMY: MINIMALLY INVASIVE 

THERAPY FOR CECAL POLYPS, Andrew G Harrell MD, Kent W 

Kercher MD,William S Cobb MD,Michael J Rosen MD,Yuri W 

Novitsky MD,Timothy S Kuwada MD,B. Todd Heniford MD, 


Background: Cecal cap polyps may be endoscopically unresectable 

due to size or position. Previously, a right hemicolectomy, 

along with its inherent risks, had been the surgical procedure 

for this problem. We hypothesized that the laparoscopic 

resection of the appendix and cecal cap, leaving the ileocecal 

value intact, could provide safe and definitive surgical 

management of cecal cap polyps without the risks of a full 

colonic resection and anastomosis. 

Methods: A retrospective review of all patients with endoscopically 

unresectable, proximal cecal cap polyps (not involving 

the ileocecal valve) who underwent a laparoscopic cecectomy 

was performed. A simple cecectomy for this study was defined 

as complete resection of the appendix and the cecal cap to 

encompass the underlying polyp with a negative margin while 

preserving the ileocecal valve. Frozen section was performed 

intra-operatively to ensure complete resection and the absence 

of malignancy. 

Results: Thirteen patients with cecal cap polyps underwent a 

laparoscopic simple cecectomy. The average age was 64 (46- 

80), and four patients had moderate to severe comorbidities. 

Sixty two percent (n=8) of the patients were identified on routine 

screening colonoscopy. The mean operative time was 87 

minutes (46 min to 184 min), including frozen section. The 

average length of stay was 1.6 days (1 to 3 days). There were 

no intraoperative or postoperative complications. The polyps 

average size was 2.4 cm (range 1 to 4.5 cm). Two were carcinoma 

in-situ, 2 had moderate to severe dysplasia, and the 

remainer were villous or tubulovillous polyps. All margins 

were negative. No invasive malignancy was identified in any 

patient. No patients required conversion to open operation or 

subsequent hemicolectomy. The average follow-up was 11.25 

months (range 2 weeks to 31 months). 

Conclusion: Patients that have endoscopically unresectable 

polyps in the cecal cap often undergo segmental intestinal 

resection. Management of large, sessile cecal polyps generally 

requires either multiple endoscopic piecemeal polypectomies 

or segmental intestinal resection. Laparoscopic simple cecectomy 

offers patients with benign disease a minimally invasive 

operation that can provide additional diagnostic and therapeutic 

treatment without the morbidity or prolonged recovery of a 

major intestinal resection, or the risks of repeated attempts at 

endocsopic management. 


LAPAROSCOPIC ASSISTED PROCTOCOLECTOMY WITH ILEAL- 

S-POUCH RECONSTRUCTION: IS THERE BENEFIT?, Charles P 

Heise MD, Aimen Shabaan MD,Jon C Gould MD,Bruce A 

Harms MD, University of Wisconsin, Madison 

Introduction: Restorative Proctocolectomy has revolutionized 

the surgical management of Ulcerative Colitis (UC) and 

Familial Adenomatous Polyposis (FAP). This procedure has 

dramatically improved the quality of life for these patients and 

has evolved to include laparoscopic techniques for further 

patient satisfaction. However, this approach is seldom 

described for ileal-S-pouch reconstruction. 

Methods: Since 1984, the University of Wisconsin Section of 

Colorectal Surgery has successfully performed over 650 

restorative procedures. While many centers have adopted a 

double-stapled ileal-J-pouch technique, we continue to utilize 

the ileal-S-pouch construction based on our experience with 

its excellent capacity/compliance properties and pouch outlet 

reach. This report combines the laparoscopic approach with 

the S-Pouch design. We describe our technique and early 

experience with laparoscopic-assisted total proctocolectomy 

and ileal-S-pouch anal anastomosis (TPC + ISPAA). 

Results: Review of the University of Wisconsin Colorectal 

Database identified 13 laparoscopic-assisted TPC + ISPAA procedures. 

These were performed in 3 males and 10 females. 

Surgery was performed for UC in 11 cases and FAP in the 

remaining 2 patients. A hand-assist device was utilized early in 

our experience comprising 5 of the 13 procedures. There was 

one conversion to open. Our current technique incorporates a 

complete laparoscopic mobilization and intracorporeal colectomy 

followed by minimally invasive proctectomy, ileal-S-pouch 

construction and anastomosis (with or without mucosectomy). 

With a mean length of 8 cm, a low vertical or transverse incision 

was used for colon extraction, proctectomy and pouch 

construction. In comparison to the open approach, the operative 

time for the laparoscopic assisted procedure was longer 

with a mean of 425 vs 339 minutes (p=0.0004). However, this 

minimally invasive technique allowed for a shorter hospital 

stay (mean of 5.4 vs. 7.8 days, p



ileostomy or bowel exploration was performed, mostly for 

perianal disease. In 13 uncomplicated cases, ileocecal resection, 

hemicolectomy or ileal resection was carried out, eventually 

combined with strictureplasties or appendectomy. In 20 

patients, there was recurrent disease (8) and/or complications 

had occurred as ileus, sealed perforations, abscess formations 

(4) and fistulas (10) to other organs. 

RESULTS: In the 13 uncomplicated cases, median operative 

time was 195 min (120-250). The median length of hospital 

stay was 8 days (6-27). There was one postoperative anastomotic 

leak demanding reoperation in a patient who had been 

treated by high-dosage immunosuppressives. In the 20 complicated 

cases, the small bowel was explored completely after 

adhesiolysis. In 13 cases, small and large bowel was resected, 

in 4 of these with extended segments of ileum or colon. In 5 

cases, two separate segments of ileum and colon were resected. 

In 2 cases of recurrent Crohn’s disease, only small bowel 

was resected, in one of them with 6 additional strictureplasties. 

There were no intraoperative complications and no reoperations. 

The median length of hospital stay was 9 days (6-18). 

CONCLUSIONS: Even complicated cases of Crohn’s disease 

with previous surgery, fistulas, abscesses and sealed perforations 

may be treated safely by laparoscopic technique. 


THREE TROCAR TECHNIQUE FOR LAPAROSCOPIC-ASSISTED 

REVERSAL OF HARTMANN’S PROCEDURE, Matthew K Kissner 

MD, Abdelkader Hawasli MD,Ahmed A Meguid MD, 

Department of Minimally Invasive Surgery, St. John Hospital 

and Medical Center, Detroit, MI 

Introduction: The aim of this study was to examine the feasibility 

and results of the laparoscopic approach to Hartmann’s 

reversal as compared to the open technique. Reversal of 

Hartmann’s procedures has historically been associated with a 

high risk of morbidity and mortality. In addition, open reversals 

are associated with hospital stays nearing that of the initial 

procedure with even longer operative times. 

Methods: This study was a prospective review of 4 patients 

who had undergone Hartmann’s procedure for various 

pathologies. All 4 patients underwent laparoscopic-assisted 

reversal of Hartmann’s procedure by one surgeon in a community 

hospital setting. This was done using a technique that 

employed three 5 mm trocars. This group of patients was subsequently 

compared to a cohort of patients who had undergone 

open reversal of colostomies at the same institution during 

the previous 3 years. 

Results: Four patients with a mean age of 59 years (range 34 - 

81 yrs) had laparoscopic reversal of their colostomies. There 

were 2 males and 2 females with mean ages of 60 and 58 yrs, 

respectively. The mean operative time was 178 minutes (range 

148 - 220 min). No cases were converted to an open procedure. 

All patients were started on a diet on post-operative day 

1. The average length of stay (LOS) was 3 days (range 2 - 4 

days). There were no morbidities or mortalities in this group. 

This group was compared to a cohort of patients who underwent 

open reversals of Hartmann’s procedures. There were 10 

patients in this group with a mean age of 59 years (range 19 - 

85 yrs). There were 4 males and 6 females with mean ages of 

63 and 53 yrs, respectively. The mean operative time was 204 

minutes (range 81 - 299 min). The average LOS was 6.4 days 

(range 4 - 11 days). 

Conclusion: Laparoscopic-assisted reversal of Hartmann’s procedure 

using three 5 mm trocars can be done with minimal 

morbidity and mortality. In addition, this can be done with 

operative times that are comparable to the open approach 

with much lower lengths of stay and faster recovery. 


PROSPECTIVE EVALUATION OF LAPAROSCOPIC SURGERY 

FOR RECTAL CARCINOMA, Yukihito Kokuba MD, Takeo Sato 

MD,Heita Ozawa MD,Takatosi Nakamura MD,Atushi Ihara 

MD,Yosimasa Otani MD,Masahiko Watanabe MD, Kitasato 

Univ Hospital 

PURPOSE: This study was designed to examine the short-term 

results of laparoscopy in the treatment of curable cases of rectosigmoidal 

and rectal carcinoma. METHODS: A prospective 


registry of 78 patients who underwent curative laparoscopic 

resection for rectosigmoidal and rectal carcinoma between 

July 1998 and June 2004 was reviewed. In 1998, we expanded 

the application of laparoscopy to include T2 cancers located 

anywhere in the rectum. Mesorectal transection was performed 

at least 5 cm below the tumor for rectosigmoidal and 

upper rectal lesions, and total mesorectal excision was performed 

for lower tumors. Primary anastomosis by a doublestapling 

technique or per anum handsewn coloanal anastomosis 

was performed. Patient demographics and outcomes were 

recorded prospectively. RESULTS: The median follow-up time 

was 22 months. The median number of postoperative days on 

which oral intake was resumed was 3, and the median length 

of hospitalstay was 12 days. A total of 10 postoperative complications 

occurred in 8 patients (11.1 percent) and included 

anastomotic leakage in 4 (5.5 percent) and bowel obstruction 

in 2 (2.7 percent). Reoperation was required in 4 patients. One 

patient developed a recurrence of the cancer in the pelvic cavity. 

CONCLUSION: The results of this study demonstrate the 

feasibility and safety of laparoscopic surgery for selected 

patients with rectal carcinoma. The morbidity and mortality 

rates and oncologic outcome appear to be comparable to 

those of conventional surgery. 


LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER -THE 

SHORT- AND LONG-TERM OUTCOMES-, Juri Kondo MD, 

Hideo Yamada MD, Toho University Sakura Hospital 

We started laparoscopic colorectal surgery 10 years ago. We 

reviewed our short- and long-term outcomes retrospectively. 

PATIENTS : The indication were defined as the range from M 

to SE. Between June 1994 and August 2004, 363 patients with 

colorectal cancer underwent laparoscopic surgery with the 

retroperitoneal approach method. The patient?fs average age 

was 65.6 (range: 18-96). RESULTS: Ten cases (2.8%) were converted 

to laparotomy, and nine of them were in the first 100 

cases (9.0%). Two cases with ureter trauma were experienced 

before the introduction of the retroperitoneal approach 

method. After the first 100 cases, one case(0.4%) was converted 

to laparotomy due to damage to the internal iliac vein during 

the obturator lymph node dissection. With regard to postoperative 

complications, there were 21 cases with ileus (5.8%). 

Two of them were treated surgically and the other 19 cases 

improved conservatively. Suture failure was experienced in 7 

cases (1.9%) . The 5 year survival rate was 93.4%. There were 

no port site implantaion. 

This report presents a laparoscopic colectomy with the 

retroperitoneal approach method that we have developed and 

established as an approach to blood vessels for the treatment 

of colon cancer. The short- and long-term outcomes of the 

laparoscopic surgery we have perfomed were excellent. 


RECTOURETHRAL FISTULAS: A DIFFICULT PROBLEM EVEN 

FROM A MINIMALLY INVASIVE PROCEDURE, Alex Jenny Ky 

MD, Randolph Steinhagen MD,Donald Summers MD, Mount 

Sinai School of Medicine 

Purpose:Rectourethral fistula (RUF) is a relatively uncommon 

condition, which can occur as the result of several etiologies. 

The most common cause is iatrogenic injury related to the 

management of prostatic disease. Repair of these fistulas can 

be difficult and frustrating. We report our experience utilizing 

gracilis muscle interposition for repair. 

Method:Between 2001 and 2003 we treated four patients with 

RUF following laparoscopic prostatectomy. The mean age of 

the patients was 59. None of the 4 had received external beam 

radiation prior to prostatectomy. One had evidence of residual 

or recurrent cancer at the time of repair. The average interval 

between prostatectomy and repair was four months. All 

repairs were done via a perineal approach and utilized the 

technique of gracilis muscle interposition. All of the 4 patients 

had a stoma constructed prior to, or at the time of the repair. 

The surgical team included a plastic surgeon, a urologist, and 

a colorectal surgeon. 

Result:The four patients required a total of five gracilis muscle 

interposition procedures to obtain successful healing of the fistula. 

One patient required repeat operation for re-fistulization.


One patient had undergone a previous non-diverted transanal 

repair, which failed. All four patients were doing well after 

their initial laparoscopic prostatectomy until one week postop 

whereby pneumoturia and fecaluria occurred. The injury 

occurred during dissection at the initial laparoscopic procedure. 

This is most likely a result of heat transfer which lead to 

the fistulas to open a week later. 

Conclusion: RUF is rare, but since the etiology is associated 

with therapy for a very common disease, they will continue to 

be encountered. Despite performing the prostatectomy laparoscopically, 

there is still a risk of rectourethral injury. The perineal 

approach with gracilis muscle interposition is a reliable 

although relatively complex method of RUF repair which 

results in healthy, well vascularized tissue between the rectum 

and urethra, while at the same time affording optimal opportunity 

for urethral mobilization and repair. 


LAPAROSCOPIC VS OPEN COLO-RECTAL RESECTION FOR 

CANCER: LONG TERM RESULTS ELEVEN YEARS ON, 

Emanuele Lezoche MD, Mario Guerrieri MD,Angelo De Sanctis 

MD,Roberto Campagnacci MD,Alessandro Maria Paganini 

MD,Ylenia Sarnari MD,Maddalena Baldarelli MD,Giovanni 

Lezoche MD, 1 ?Paride Stefanini? Department of Surgery, 2nd 

Surgical Institute, ?La Sapienza? University, Rome, Italy 2 

Department of Laparoscopy and Minimally-invasive Surgery, 

University of Ancona, ?Umberto I? Hospital, Ancona, Italy 

Aims of this clinical study were to compare the long-term outcome 

with a minimum follow-up of 12 months between 

laparoscopic and open approach for the treatment of colo-rectal 

cancer. 

Between 1992 and 2003, of 397 patients (pts) with colonic cancer, 

274 underwent Laparoscopic Resection (LR), whereas 123 

were treated by Open Resection OR. Three hundred two pts 

were included in this study (207 LR, 95 OR); we excluded pts 

who underwent a palliative resection (39 LR, 20 OR), perioperative 

mortality (3 LR, 1 OR), conversion to open surgery (8), 

pts lost to follow-up (4 LR, 2 OR) and pts died from causes not 

related to cancer (13 LR, 5 OR). Mean follow-up was 53.6 

months during which time we observed 1 case of port-site 

metastases (0.5%) in Dukes? stage C. No Statistically 

Significant Difference (SSD) was observed in the Local 

Recurrences rate (3.4% after LR and 7.3% after OR) (p=0.24) 

and in the incidence of Distant Metastases (11.6% after LR and 

10.5% after OR) (p=0.96). At 84 months of follow-up cumulative 

survival probability in LR was 0.927 as compared to 0.842 

after OR (p=0.65). One hundred-seventy-two pts in the laparoscopic 

group (83.1%) and 78 in the open group (82.1%) are disease 

free. 

Between 1992 and 2003, of 156 pts with rectal cancer, 110 

underwent LR and 46 OR. One hundred-twenty-four pts were 

included in this study (85 LR, 39 OR); we excluded pts who 

underwent a palliative resection (10 LR, 6 OR), conversion to 

open surgery (12), pts lost to follow-up (1 LR) and pts died 

from causes not related to cancer (2 LR, 1 OR). Mean follow-up 

was 51.8 months. No SSD was observed in the Local 





after OR (p=0.57). Sixty-five pts (76.5%) in the laparoscopic 

group and 26 in the open group (66.6%) are disease free. The 

higher local recurrences rate in our pts with rectal cancer is 

related to the had little or no response to neoadjuvant therapy 

(?oncologically unfavourable patient group?); a selected group 

of pts who had demonstrated a better response to neoadjuvant 

therapy was underwent Transanal Endoscopic 

Microsurgery (TEM) where the local recurrence rate was 1,5%. 

We conclude that laparoscopic surgery could guarantee an 

oncological radicality. 


LONG TERM RESULTS OF LAPAROSCOPIC VS OPEN COLO- 

RECTAL RESECTIONS FOR CANCER IN 235 PATIENTS WITH A 

MINIMUM FOLLOW-UP OF 5 YEARS, Emanuele Lezoche MD, 

Mario Guerrieri MD,Angelo De Sanctis MD,Roberto 

Campagnacci MD,Alessandro Maria Paganini MD,Ylenia 

Sarnari MD,Maddalena Baldarelli MD,Giovanni Lezoche MD, 1 

?Paride Stefanini? Department of Surgery, 2nd Surgical 

Institute, ?La Sapienza? University, Rome, Italy 2 Department 

of Laparoscopy and Minimally-invasive Surgery, University of 

Ancona, ?Umberto I? Hospital, Ancona, Italy 

This study aimed to compare the long-term outcome with a 

minimum follow-up of 5 years between laparoscopic or open 

approach for the treatment of colo-rectal cancer. 

Between 1992 and 1999, 312 patients (pts) were operated: 192 

underwent laparoscopic colo-rectal resection (LR) whereas 120 

were treated by open surgery (OR). 

Of 207 pts with colonic cancer, 125 underwent LR, whereas 82 

were treated by OR. One hundred fourty nine pts have been 

studied (85 LR, 64 OR); we excluded pts who underwent a palliative 

resection (16 LR, 11 OR), perioperative mortality (3 LR, 1 

OR), conversion to open surgery (4), pts lost to follow-up (4 

LR, 2 OR) and pts died from causes not related to cancer (13 

LR, 4 OR). Mean follow-up was 62.8 months. No Statistically 

Significant Difference (SSD) was observed in the Local 





after OR (p=0.990). Seventy-two pts in the laparoscopic group 

(84.7%) and 53 in the open group (82.8%) are disease free. 

Of 105 pts with rectal cancer, 67 underwent LR and 38 OR. 

Eighty six pts were included in this study (52 LR, 34 OR); we 

excluded pts who underwent a palliative resection (4 LR, 3 

OR), conversion to open surgery (8), pts lost to follow-up (1 

LR) and pts died from causes not related to cancer (2 LR, 1 

OR). Mean follow-up was 58.7 months. No SSD was observed 

in the Local Recurrences rate (19.2% after LR and 17.6% after 

OR) (p=0.900) and in the incidence of Distant Metastases 

(15.3% after LR and 20.5% after OR) (p=0.815). At 84 months of 

follow-up cumulative survival probability in LR was 0.711 as 

compared to 0.617 after OR (p=0.819). Thirty six pts (69.2%) in 

the laparoscopic group and 21 in the open group (61.7%) are 

disease free. Regard the higher incidence of local recurrences 

in the present series of pts with rectal cancer we must take 

into account that the majority of this pts represent an oncologically 

?unfavourable? patient group because they had little or 

no response to neoadjuvant therapy; a selected group of pts 

who had demonstrated a better response to neoadjuvant therapy 

was underwent Transanal Endoscopic Microsurgery (TEM) 

where the local recurrence rate was 1,5%. 

We conclude that no adverse long-term oncologic outcomes of 

laparoscopic resections for colorectal cancer were observed. 


SURGEON-INITIATED SCREENING COLONOSCOPY PROGRAM 

BASED ON SAGES AND ASCRC RECOMMENDATIONS IN A 

GENERAL SURGERY PRACTICE, Edward Lin DO, Leena 

Khaitan MD,Dianne Williams RN,C. Daniel Smith MD, Emory 

University School of Medicine and Emory Crawford Long 

Hospital 

PURPOSE:To determine the utility of a screening colonoscopy 

program initiated by general surgeons in an academic center. 

METHODS: New patients who meet screening colonoscopy 

indications presenting to three general surgeons were asked if 

they have had colorectal cancer (CRC) screening. Patients who 

did not have CRC screening were offered screening colonoscopies 

or referred to their gastroenterologists. RESULTS: In 

the first 9-month period of the program, 200 patients who met 

the SAGES/ASCRC indications for CRC screening were asked if 

they have had screenings, but only 46% (92) had any prior 

appropriate screenings. Of the patients who elected CRC 

screening by the surgeons, 55 patients underwent full-colonoscopies 

(2 concurrently with hemorrhoidectomies) and 2 

patients had flexible sigmoidoscopies. Ten patients (18%) 

required treatment as a result of screening; 7 patients had 

polypectomies, 2 patients required partial colectomies, and 1 

patient with indication for surgery deferred treatment. CON- 

CLUSIONS: The majority of patients presenting to the general 

surgeon likely have not had CRC screening and diligence in 

making appropriate recommendations should be routine. 

Colonoscopic findings requiring intervention is not insignificant. 



155




DYNAMIC GRACILOPLASTY VERSUS IMPLANT OF ARTIFICIAL 

SPHINCTER FOR TOTAL ANORECTAL RECONSTRUCTION 

AFTER LAPAROSCOPIC ABDOMINOPERINEAL EXCISION, 

Marco Maria Lirici MD, Massimiliano Di Paola MD,Cecilia 

Ponzano MD,Yoshinori Ishida MD,Cristiano Hüscher MD, 

Department of Surgery. San Giovanni Hospital. Rome. Italy 

Abdominoperineal resection (APR) is still the standard treatment 

of cancers close to the dentate line. Unfortunately a permanent 

iliac colostomy is a severe limitation of the quality of 

life. Attempts to construct a continent perineal colostomy after 

anorectal excision have been done over the past 15 years with 

uncertain benefits. The early results of 2 procedures consisting 

of a laparoscopic approach to APR or reversal of APR, fashioning 

of a perineal colostomy with dynamic graciloplasty or 

implant of an artificial sphincter are herein reported. 

Methods: Overall 6 patients underwent laparoscopic APR or 

laparoscopic APR reversal and construction of perineal 

colostomy with dynamic graciloplasty (3 pts) or implant of an 

artificial bowel sphincter (AMS), in the last 4 years. All patients 

had a diverting loop ileostomy at the time of surgery. Data 

concerning operative management, morbidity and mortality 

and the function of total anorectal reconstruction at the time of 

operation, at postoperative month 1 and after ileostomy closure 

were collected and analysed (SF36 form) in a prospective 

non randomised fashion. 

Findings: No postoperative complications occurred in the 

group of dynamic graciloplasty (DG), whilst 1 patient of the 

artificial sphincter (AS) group died for myocardial infartion 

after ulceration of the prosthesis through the transposed colon 

wall. Postoperative stay of remaining patients ranged 9 to 27 

days. After 3 months the ileostomy was closed in all patients 

but 1 in the DG group who died one day before rehospitalisation 

for ostomy closure because of accidental not 

disease/operation related reason. Follow-up of patients of the 

DG and AS group ranged 3 to 24 and 2 to 8 months respectively. 

Patients in the DG group had no complication and satisfactory 

continence was showed at follow-up whereas all 

patients in the AS group had early or late local complication 

with ulceration of the prosthesis through the wall and consequent 

removal and fashionin of a permanent iliac colostomy. 

Interpretation: There are no published data on laparoscopic 

APR and APR reversal with total anorectal reconstruction with 

either dynamic graciloplasty or implant of artificial sphincter. 

Preliminary results showed that laparoscopic APR or APR 

reversal with continent perineal colostomy and dynamic 

graciloplasty is a possible option in selected patients whilst 

the implant of an artificial sphincter should be considered as 

an unsafe procedure in such patients. 


COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN 

ELECTIVE SURGERY FOR DIVERTICULAR DISEASE., Francisco 

López-Köstner MD, Gonzalo Soto D. MD,Angélica García- 

Huidobro D. MD,Francisca León G. MD,Maria Francisca 

Arancibia,George Pinedo M. MD,María Elena Molina P. 

MD,Demian A. Fullerton MD,Alvaro Zuñiga D MD, Department 

of Digestive Surgery. Hospital Clínico Pontificia Universidad 

Católica de Chile. Santiago. Chile 

INTRODUCTION. Laparotomy has been the classical access to 

the abdomen in elective surgery for diverticular disease (DD). 

During the last decade, laparoscopic surgery of the colon has 

showed a progressive development with results comparable to 

open surgery. The aim of this study is to compare early results 

of patients who underwent elective surgery for DD. 

METHODS AND PROCEDURES. In 1998, we started a prospective 

protocol on laparoscopic colorectal surgery. At present 

(July 2004), we have operated on 139 patients and the surgical 

indication was recurrent diverticulits in 51 of them. This group 

was compared to the laparotomy group in the same period of 

time. We excluded emergency surgery, and patients with 

colonic fistulas. Fifty nine patients were operated on via 

laparotomy (OS), and 51 laparoscopically (LS). Both groups 

were statistically comparable in gender, previous laparotomies, 

type of surgery performed, length of surgical specimens 

and degree of histopathologic inflammation. The LS 


group was nevertheless significantly younger than the OS 

group (53 v/s 59 years; p< 0,05). The continuous variables 

were analyzed with the Student?s t test, and the categorical 

variables with the Chi-square test, considering statistically significant 

a p value < 0.05. 

RESULTS. The mean operative time was significantly longer in 

LS group (219 min. v/s 166 min.; p


operative time, narcotic requirement, time to oral intake, 

length of hospital stay, and outcome. Comparison between 

groups (open vs.laparoscopic) was analyzed using two-sample 

t-tests and Wilcoxon rank sum tests. 

Results 

The two groups were similar in terms of age, clinical presentation 

and diagnostic tests performed. The most common presenting 

symptoms were chronic abdominal pain, nausea and 

repeated vomiting. Symptoms such as chronic diarrhea, constipation, 

weight loss and gastroesophageal reflux disease 

(GERD) were also present but uncommon. Upper gastrointestinal 

barium studies (UGI/SBFT) were diagnostic in all patients 

with malrotation as compared to computed tomography (CT) 

scanning which were falsely negative in 25%. Twenty-one 

patients underwent the Ladd procedure, either open (n = 10) or 

laparoscopic (n = 11). Three laparoscopic procedures were 

converted to open but were analyzed in the laparoscopic 

group in an intent-to-treat fashion. Overall, the laparoscopic 

group resumed oral intake earlier than the open group (1.8 vs 

2.7 days; p = 0.092), had a shorter hospital stay (4.0 vs. 6.1 

days; p = 0.050) and required less narcotics on the first postoperative 

day (4.9 vs 48.5 mg; p = 0.002). The laparoscopic group 

underwent a longer operation (194 vs. 143 minutes; p = 0.053). 

Follow-up ranged from 2 weeks to 97 months (mean, 42 

months) and was complete in 18 of 21 (86%) patients. Sixteen 

patients reported complete resolution of symptoms, while 2 

felt greatly improved. No patient required a second operation 

related to volvulus or recurrent symptoms. 

Conclusions 

The laparoscopic Ladd procedure is feasible, safe, and as 

effective as the standard open Ladd procedure to treat adults 

with intestinal malrotation without midgut volvulus. Patients 

also benefit from this minimally invasive approach as manifested 

by earlier oral intake, a decreased need for intravenous 

narcotics and an earlier dismissal from the hospital. 


ABNORMAL LIPID PROFILE-RISK FACTOR FOR THE FORMA- 

TION OF COLONIC DIVERTICULOSIS AMONG YOUNG 

PATIENTS?, Leonidas S Miranda MD, Kenneth Lee MD, 

Fairview Hospital, Cleveland Clinic Health System, Department 

of Surgery 

Purpose: Colonic diverticulosis among young patients may 

have different risk factors when compared to the known factors 

for the disease affecting the elderly. Because obesity has 

been reported as comorbidity, we hypothesized that abnormal 

lipid profile (also related to obesity) is a risk factor for the disease 

among young patients. 

Methods: Following IRB approval, patients aged 45 years and 

younger (107) admitted at a teaching hospital with diverticulitis 

between January 1997 and December 2001 as well as 

healthy adults (controls) were invited for a fasting lipid profile 

test (results analyzed using an unpaired t-test). 

Results: The mean age of the study group was 38.5 years (22- 

45) at the time of initial admission to the hospital, 64% males 

and 36% females. Values for 9 patients were available from the 

hospital records and 24 responded to the invitation (N = 33). 

Of these patients, 20 (60.6%) showed dyslipidemia. The mean 

age of the control group (N=27) was 32.5 years (19-45); 5 

(18.5%) of them had dyslipidemia. 

Conclusions: Abnormal lipid profile may represent a risk factor 

for colonic diverticulosis among young patients. Obesity is a 

common comorbidity, but our data suggest no significant difference 

between the study and control groups. Dyslipidemias 

may serve as a marker of the primary effects of increased 

dietary fats on the colonic mucosa. 


LAPAROSCOPIC COLECTOMY FOR ATTENUATED FAMILIAL 

ADENOMATOUS POLYPOSIS (AFAP), E Monteferrante MD, N 

Pitrelli MD,E Liberatore MD,G Palka* MD,G Colecchia MD, 

Department of Surgery “Santo Spirito” Hospital Pescara , 

*Department of Medical and Molecular Genetics Chieti 

University Italy 

Introduction 

Over the last decades has been described a variant of familial 

adenomatous polyposis (FAP) called attenuated FAP (AFAP). 

AFAP is not well-defined as a disease entity and the diagnostic 

criteria and methods of investigation differ markedly. The incidence 

and frequency of AFAP is unknown. The mutations in 

APC gene, associated with AFAP, have mainly been detected in 

three parts of the gene: in the 5’ end (the first five exons), in 

exon 9 and in the distal 3’ end. The main features of AFAP are 

100 or less colorectal adenomas with a tendency to rectal sparing, 

a delay in onset of adenomatosis and bowel symptoms of 

20-25 years, a delay in onset of colorectal cancer (CRC) of 10- 

20 years and death from CRC of 15-20 years, and although the 

lifetime penetrance of CRC appears to be high, CRC doesn?t 

seem to develop in nearly all affected patients. A more limited 

expression of the extracolonic features is seen, but gastric and 

duodenal adenomas are frequently encountered. 

Case Report: 

The patient is a female, aged 41 years, with a diagnosis of 

AFAP characterized by a mutation in the distal 3? end of APC 

gene, undergoing annualy colonoscopy with polipectomy from 

about ten years. The biopsy (histologic test) of a polyp in the 

distal trasverse, ablated not with endoscopy, evidentiated 

areas of severe dysplasia . The patient underwent total colectomy 

with ileorectal anastomosis (IRA) with laparoscopic surgery 

. Five trocards has been used and an incision according 

to Pfannenstiel. Duration of surgery has been 350 minutes and 

no complications have been recorded during and after surgery. 

In ninth day the patient has been discharged with 3-4 daily 

evacuations. Besides the presence of multiple adenomatous 

polyps ( < 20 ) the definitive histologic exam has also evidentiated 

, in the previous polyp, areas of adenocarcinomatosis, 

which infiltrated the muscolaris mucosae. The examinated 36 

lymphnodes have not been infiltrated. The rettoscopy performed 

after 6-12 months has resulted negative 

Conclusion 

Prophylactic colectomy with IRA is recommended in most 

patients with AFAP . Laparoscopic surgery is possible, safe 

and efficacy. 


LAPAROSCOPIC LOW ANTERIOR RESECTION FOR ADVANCED 

RECTAL CANCER, YASUHIRO MUNAKATA MD, HITOSHI SEKI 

MD,YUSUKE MIYAGAWA MD,HIROSI SAKAI,KEN HAYASHI, 

NAGANO MUNICIPAL HOSPITAL 

[purpose] 

The Japanese RCT of laparoscopic and open surgical therapy 

for the advanced colon cancer is going to begin by main institutions 

of the whole country since autumn, 2004. In most of 

the past RCT for colon cancer , treatment outcome was similar 

between laparoscopic and open surgery. 

If operative procedure is good, the superiority of laparoscopic 

surgery for advanced rectal cancer will be similar with colon 

cancer, although the operation procedure for rectal cancer is 

more complicated than colon cancer. Therefore, we reviewed 

low anterior resection for the advanced rectal cancer treated 

under laparoscopic and open procedure. 

[subjects and methods] We performed laparoscopic low anterior 

resection in 34 cases of curative advanced rectal cancer 

(LLAR), and open low anterior resection in 20 cases (OLAR). 

We reviewed about operation results, complications and long 

term prognosis. 

[results ] There were 34 cases of curative laparoscopic low 

anterior resection among 85 cases of rectal cancer treated by 

endoscopic surgery . We compared LLAR with OLAR. We performed 

lymph node dissection of D2 or D3 under pneumoperitoneum 

in LLAR. We experienced 3 examples of transient urination 

disorder, 2 examples of wound infection and a bowel 

obstruction for a complication of LLAR. A complication of 



157



OLAR showed 2 cases of anastomotic leakage, 2 wound infection, 

2 paralytic ileus and one atelectasis . In long-term results 

of LLAR, there were one lung metastasis, one lymph metastasis 

and one death from the other disease . We showed a recurrence 

in 5 cases in OLAR, and including one peritoneal and 

peritoneal metastasis and 4 liver metastases. In LLAR, the 

number of removed lymph node was greater than OLAR, and 

mean blood loss was less than OLAR. There was no difference 

to operation time and days of hospitalization in both groups. 

[conclusion s] LLAR showed better curability and safeness of 

treatment for advanced rectal cancer by its good long term 

prognosis , little quantity of operative haemorrhage and complications. 

However, from a complication such as transient urination 

disorder, the hospitalization was equal with OLAR. By 

further improvement of operative procedure such as nerve 

preservation utilizing magnifying view under laparoscopy, 

LLAR could become the standard therapy for advanced rectal 

cancer. 


LAPAROSCOPIC-ASSISTED ABDOMINO-PERINEAL RESEC- 

TION FOR RECTAL CANCER BY 4 PORTS METHOD, Minoru 

Naito MD, Hideo Ino MD,Masakazu Murakami MD,Nobuyoshi 

Shimizu MD, Department of Cancer and Throcic Surgery 

,Okayama University Graduate School of Medicine and 

Dentistry,Okayama,Japan 

We have performed 5 cases laparoscopic-assisted 

abdominoperineal resection for patients with rectal cancer 

between May 1999 and August 2004. All cases were successfully 

performed laparoscopically without intraoperative complication. 

The patient was placed in the lithotomic position 

with Trendelenburg position.We used four ports,initial port for 

a laparoscope was inserted just right side of the 

umbilicus,then CO2 pneumoperitoneum was created.After 

pneumoperitoneum was initiated,three ports were 

placed(suprapubic and bilateral pararectal). We used a medial 

approach for colorectal mobilization and had performed all 

cases with autonomic nerve preservation.Finally a 3cm circular 

incision was made over the port site in the left lower quadrant 

and the stapled bowel end was pulled through extraperitoneal 

for colectomy. Results:The mean age was 78years .The male to 

female ratios were 1:1.5.The mean operative time was 360minutes 

.The mean hospital stay was 12days . Conversion to open 

surgery was none?DNo operative mortality, no portsite metastasis 

and morbidity.All patients are alive without recurrence. 

Laparoscopy affords improved visualization of the rectum in 

the confined space of the pelvis. Laparoscopic-assisted 

abdominoperineal resection for patients with rectal cancer is a 

feasible and safe operation . Recurrence rate or long term 

functional outcome needs longer follow up. 


CLINICAL OUTCOME OF LAPAROSCOPIC COLORECTAL CAN- 

CER SURGERY, Takeshi Naitoh MD, Takashi Tsuchiya 

MD,Satoshi Akaishi MD,Hiroshi Honda MD,Masao Kobari MD, 

Department of Surgery, Sendai City Medical Center 

[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. The aim of this study 

is to assess the clinical outcome of the laparoscopic colorectal 

cancer surgery in our hospital. [Patients and Methods] During 

June 1999 and Aug. 2004, we operated more than 700 cases of 

colorectal cancer patients. Of those 205 patients underwent 

laparoscopic colorectal surgery. We assessed an operative 

time, estimated blood loss, postoperative complications, duration 

of hospitalization, and clinical outcome, retrospectively. 

[Results] Male female ratio was 118:87, and mean age of these 

patients was 64.6 year-old. Among these cases, 71 tumors 

were located in the cecum or ascending colon, 20 in the transverse 

colon, 7 in the descending colon, 55 in the sigmoid 

colon, and 52 in the rectum. Among 52 cases of rectal cancer, 

17 cases were localized in Rs, which is rectosigmoid region, 30 

in Ra, which is rectum above the peritoneal reflection, and 5 in 


Rb, which is rectum below the peritoneal reflection according 

to the Japanese classification of colorectal cancer. Histological 

T numbers of the tumor according to the UICC classification 

were as follows; 113 cases of T1, 43 cases of T2, 33 of T3, and 

11 of T4. Forty nine cases (23.9%) of them were node-positive. 

Mean operative time was 178 min., and mean estimated blood 

loss was 62 ml. Twelve cases (5.9%) were converted to conventional 

surgery because of the severe adhesion. 

Postoperative complications were identified in 16 cases (7.8%), 

of those 6 cases represented an anastomotic leakage, and 5 of 

them required further operation. Two cases were complicated 

with postoperative hemorrhage which required reoperation. 

No operative mortality was observed in these patients. Mean 

postoperative hospitalization was 16 days. Mean follow-up 

time was 23 months. Five patients have tumor recurrence; 1 

case with local recurrence, 2 with liver metastasis, 1 with lung 

metastasis, and 1 with peritoneal carcinomatosis. Only one 

patient with local recurrence died of cancer 2 years after initial 

surgery, so far. [Conclusion] Although further evaluation is 

mandatory, laparoscopic colorectal cancer surgery is safe and 

would be oncologically adequate procedure. 


LAPAROSCOPIC SURGERY FOR DIVERTICULAR DISEASE 

COMPLICATED BY ENTERIC FISTULAS, Scott Q Nguyen MD, 

Celia M Divino MD,Anthony Vine MD,Mark Reiner MD,Lester B 

Katz MD,Barry Salky MD, Mount Sinai Medical Center 

Introduction. Enteric fistulas complicate diverticular disease in 

up to 20% of cases. Elective laparoscopic surgery for uncomplicated 

diverticular disease is considered safe and effective, 

however little data exists for disease complicated by fistulas. 

This study describes a series of patients who underwent 

laparoscopic assisted sigmoid resection for diverticulitis complicated 

by fistulas. 

Methods. A retrospective chart review was performed of 

patients who underwent laparoscopic treatment of enteric fistulas 

complicating diverticular disease by four surgeons specializing 

in minimally invasive surgery at the Mount Sinai 

Medical Center. 

Results. During a 10-year period (1994-2004), 14 patients 

underwent elective laparosopically assisted sigmoid resections 

for diverticular disease complicated by enteric fistulas. The 

average age was 62 and the male/female ratio was 10:4. 

Twenty nine percent of patients had previous abdominal surgery 

and 21% had multiple fistulas. There were 8 colovesical, 5 

enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous 

fistulas. 100% patients successfully underwent sigmoid 

resection and 2/14 (14%) required additional bowel resections. 

No cases were proximally diverted. Thirty-six percent of cases 

were converted to open, all due to dense adhesions and 

severe inflammation resulting in difficult dissection. The mean 

operative time was 209 minutes and the mean blood loss was 

326 ml. There were two (14%) postoperative complications, 

including one self-limiting anastamotic bleed and one prolonged 

ileus. No anastamotic leaks occurred and there were 

no mortalities. The mean postoperative stay was six days. 

Conclusions. Laparoscopic management of diverticular disease 

complicated by fistulas can be performed effectively and safely 

with minimal morbidity and mortality. The conversion rate is 

higher than in uncomplicated cases of diverticulitis and is 

associated with severe adhesions and inflammation interfering 

with safe laparoscopic dissection. 


LESS INVASIVE SURGERY ON THE PATIENTS WITH SEVERE 

CONSTIPATION, Hirotsugu Ohara MD, Yasuhiko Masuda 

MD,Toshiyuki Hirai MD, Department of surgery , Fujieda Heisei 

Memorial Hospital , Fujieda , Sizuoka , Japan 

INTRODUCTION : Until now, operation for severe constipation 

have seldom been performed, because severe constipation 

was most common in the elderly or the institutionalized 

patients, and in patients with a variety neurologic disorders. 

Recently, we have been able to perform less invasive surgery 

on the the patients with severe constipation. In all cases we 

achieved good results by our own unique method. This 

method, including the indication to operate, will be discussed. 

METHODS AND PROCEDURES : At first, these diseases are


divided to two major categories, the Mega-colon involving 

only the sigmoid colon (sigmoid colon volvulus) and the 

extended Mega-colon involving all proximal colon. On the 

patients with sigmoid colon volvulus(Type??), we have performed 

sigmoidectomy through a 4 cm incision (with a laparoscope 

as a bach-up ). On the patients with the extended Megacolon 

involving all proximal colon (Type ? ), we have performed 

subtotal colectomy using gasless HALS with our 

unique lifting bar that consists of a bent, stainless steel rod 

5mm in diameter. We have performed these methods on 11 

patients consisting of 9 Type I patients and 2 Type? patients, 

after enough bowel preparation. 

RESULTS : There are neither major complications nor conversions 

to conventional open surgery. All of the patients had 

more than one bowel movement a day with a low dose of laxatives. 

CONCLUSIONS : On the patients with Type??, the sigmoid 

colon was not attached to retroperitoneal tissue, therefore the 

elongationed sigmoid colon could be easily removed from the 

abdominal cavity and operated on extracoroporeally. On the 

patient with Type? , by performing the operation not only 

under laparoscopy, but also via the small incision, the operation 

time can be shortened and the operation procedure is 

simplified. This combined technique is an advantage of gassless 

surgery. 


A CASE OF PERITONEAL DISSEMINATION ACCOMPANIED BY 

PORT SITE METASTASIS EIGHT MONTHS AFTER INITIAL 

LAPAROSCOPIC RESECTION OF SIGMOID COLON CANCER., 

Mitsuyoshi Ota MD, Shigeki Yamaguchi MD,Hirofumi Morita 

MD,Masayuki Ishii MD, Shizuoka Cancer Center 

A sixty-one year old woman who developed sigmoid colon 

cancer, underwent sigmoidectomy at our institution on 

October second, 2003. Inraoperative peritoneal lavage cytology 

was negative. We had difficulty with dissection of the firm 

adhesion of the greater omentum in the lower peritoneal cavity. 

After high ligation of IMA and mobilization, we made a 

transverse incision in the lower abdominal region, 6cm in 

diameter, attached a wound protecter, extracted the intestine, 

cut the proximal and distal side of the intestine, and anastomosed 

the intestine using functional end-to-end anastomosis. 

During the course of this procedure, the mesocolon was widely 

damaged. Pathological finding confirmed that the tumor 

was resected curatively and the staging was pT4 N1 M0. Eight 

months after the initial operation, multiple disseminated tumor 

was detected in CT scan and Positron Emission Tomography, 

accompanied by a port site recurrence which recognized at the 

assistant?fs port site of right lower abdomen. 


LAPAROSCOPIC COLON RESECTION PERFORMED IN A COM- 

MUNITY-BASED TEACHING HOSPITAL, D J Reichenbach MD, 

A D Tackett MD,A Stiles BS,J Harris MD, New Hanover 

Regional Medical Center 

PURPOSE: The purpose of this study was to review the first 50 

laparoscopic colon resections performed by two surgeons at a 

community-based teaching hospital. METHODS: A retrospective 

chart review was conducted of the first 50 patients undergoing 

laparoscopic colon resection at New Hanover Regional 

Medical Center from January 2002 to May 2003. Conversions 

to open resections were included in the data collection and 

analysis. RESULTS: The majority of the patients were 

Caucasian and female (92% and 68% respectively). Sixty-two 

percent had undergone previous abdominal surgery. The 

mean age of patients undergoing resection was 64 ± 13.5 

years, and the mean BMI was 28.6 ± 5.3 kg/m2. The most common 

indications for surgery were diverticulitis (44%) and 

polyps (32%). Twenty percent of resections were undertaken 

with a pre-operative diagnosis of malignancy. The majority of 

procedures performed were sigmoid colectomies (56%), followed 

by right hemicolectomy (34%), and transverse colectomy 

(10%). Sixty-four percent were totally laparoscopic procedures, 

10% were lap-assisted, and 14% were hand-assisted. 

The conversion to open rate was 12%. Mean operating time 

was 161 ± 41 minutes. The overall complication rate was low, 

with 5 (10%) wound infections, 1 (2%) wound dehiscence, 3 

(6%) small bowel obstructions, and 2 (4%) instances of perioperative 

bleeding requiring transfusion. The 30-day mortality 

rate was zero. The mean length of stay for the entire study 

group was 5.0 ± 4.1 days. CONCLUSIONS: Laparoscopic colon 

resection offers several advantages to the traditional open 

technique. Laparoscopic colon resection can be performed 

safely in the community hospital setting provided that the surgeon 

possesses advanced laparoscopic skills. A learning curve 

exists, and the transition from open to laparoscopic resection 

can be bridged by the use of hand-assist devices. 


LAPAROSCOPIC VERSUS OPEN COLOSTOMY REVERSAL: A 

COMPARATIVE ANALYSIS, Michael J Rosen MD, William S 

Cobb MD,Kent W Kercher MD,Andy G Harrell MD,Yuri W 

Novitsky MD,Ron F Sing DO,B Todd Heniford MD, Carolinas 


Purpose: Open colostomy reversal carries significant rates of 

anastomotic leak, wound infection, and incisional hernia often 

limiting its acceptance. We hypothesized that the laparoscopic 

approach to the restoration of intestinal continuity may result 

in lower perioperative morbidity and faster postoperative 

recovery. 

Methods: 22 cases of laparoscopic colostomy reversals performed 

at a single institution were identified and compared to 

22 randomly selected open colostomy closures performed during 

the same time period. Patients were compared based on 

demographics, previous indications for colostomy procedures, 

and perioperative outcomes. 

Results: A total of 150 patients underwent reversal of left sided 

colostomies during the study period. The laparoscopic 

approach was successful in 20 of 22 cases; there were 2 conversions 

to open (10%) secondary to inability to localize the 

rectal stump. The laparoscopic and open groups were comparable 

based on mean age (54 years v 49 years; p=0.23), BMI 

(26kg/m2 v 27kg/m2; p=0.66), Sex (9%males v 13%; p=0.23), 

ASA (2.6 v 2.3; p=0.07), and history of previous intra-abdominal 

sepsis (17 v 16 cases). Operative times were similar (158 

min v 189 min; p=0.16), and EBL was significantly less in the 

laparoscopic group (113cc v 270cc; p=0.01). No intraoperative 

complications occurred in the laparoscopic group and two 

enterotomies occurred in the open group. The laparoscopic 

group had earlier passage of flatus (3.5d v 5.0d; p=0.001) and 

shorter hospitalization (4.2d v 7.3d; p=0.001). Perioperative 

complications occurred in 3 (14%) laparoscopic and 13 (59%) 

open cases (p=0.01). There was no mortality in this series. 

Conclusions: The laparoscopic approach can be safely 

employed in the restoration of intestinal continuity. It results in 

a decreased perioperative morbidity and faster recovery. It 

offers distinct advantages over the open approach to colostomy 

reversal. 


SHORT AND LONG TERM RESULTS IN 306 LAPAROSCOPIC 

COLORECTAL PROCEDURES, Danny Rosin MD, Oded Amora 

MD,Aviad Hoffman MD,Marat Khaikin MD,Barak Bar Zakai 

MD,Yaron Munz MD,Moshe Shabtai MD,Amram Ayalon MD, 

Sheba Medical Center, Tel Hashomer, Sackler Scool of 

Medicine, Tel Aviv, Israel 

Background : Laparoscopic surgery has recently gained wide 

acceptance in the treatment of colorectal pathologies, including 

cancer. Long term outcome however requires further 

assessment. The aim of this study is to evaluate short and 

long term outcomes after 8 years of performing laparoscopic 

colon and rectal surgery. 

Methods: Data relative to all patients who underwent laparoscopic 

colon and rectal surgery in our department was 

prospectively recorded. Demographics, operative procedure, 

post operative course, oncologic treatment and follow-up data 

were reviewed in this study. Survival was calculated for 

patients with cancer who completed at least 3 years of followup. 

Results: 306 procedures were performed over a period of 8 

years, 184 (60%) for malignancy and 122 (40%) for benign conditions. 

The number of procedures stabilized at around 50 per 

year, and included right colectomy (81), sigmoidectomy (80), 

Anterior resection (55) and left colectomy (34), and other pro- 



159



cedures (56). 

Mean operating time was 243 minutes, and conversion rate 

was 14.7%. 

Post operative complications included wound infection in 

16.9% and anastomotic leak in 5.2% of the cases. Re-operation 

was required in 9.1%, and overall post-operative mortality, 

including emergency procedures, was 3.2%. 

For the group operated for cancer until 2001, actual 3-year survival 

for all stages was 71%. Node positive patients had 73% 3- 

year survival rate. 

Conclusions: Laparoscopic colorectal surgery allows for 

acceptable short term and oncologic outcome, comparable to 

that achieved by open surgery. 


TOTALLY LAPAROSCOPIC COLON RESECTION WITH INTRA- 

CORPOREAL ANASTOMOSIS FOR BENIGN AND MALIGNANT 

DISEASE, Bethany Sacks MD, S G Mattar MD,G Eid MD,L Velcu 

MD,T Rogula MD,P Thodiyil MD,J Collins MD,F Qureshi MD,P 

Yenumula MD,B Lane MD,R C Ramanathan MD,P R Schauer 

MD, Magee-Womens Hospital, University of Pittsburgh Medical 

Center 

Introduction/Objective: The advantages of intracorporeal anastomotic 

principles include optimal exposure, reduced bowel 

manipulation, and superior anastomotic integrity in patients 

with shortened mesentery or thick abdominal wall. We report 

our experience with colon resections for both benign and 

malignant disease using a totally laparoscopic approach utilizing 

an intracorporeal anastomosis. 

Methods: 57 patients underwent laparoscopic colon resections 

with an intracorporeal bowel anastomosis from August 1996 to 

July 2004. Information on the following were collected for each 

patient: age, sex, indication for surgery, procedure performed, 

concurrent procedures, complications, length of stay, pathology, 

number of nodes, and length of disease-free follow-up. 

Results: Of the 57 patients, 30 were female (53%), with an age 

range of 25-88 years (median 69). Indications for surgery 

included polyps (52.6%), adenocarcinoma (21.1%), diverticular 

disease (17.5%), and other benign indications (8.8%). Of the 

colonic polyps, 11 contained adenocarcinoma, 7 contained 

dysplasia, and 9 were unresectable endoscopically. The most 

common procedures performed were right hemicolectomy 

(46%), sigmoidectomy (26%), left hemicolectomy (9%) and low 

anterior resection (9%). When operating for malignancy, the 

average number of lymph nodes removed was 10.8 (range 1- 

39). The median length of stay was 4.0 days (range 2-18). 

There were three intraoperative complications and no major 

complications. Long-term complications included five extraction 

site hernias (8.8%) and four patients had small bowel 

obstruction. There were three intraabdominal recurrences 

(5.3%), but no port site or wound recurrences. 

Conclusions: Laparoscopic colon resection with intracorporeal 

anastomosis is a safe and effective treatment for both benign 

and malignant disease. 


THE LEARNING CURVE OF 100 LAPAROSCOPIC COLORECTAL 

RESECTIONS: TWO COMMUNITY SURGEONS? EXPERIENCE, 

Herawaty Sebajang MD, Laurent Biertho MD,Mehran Anvari 

PhD,Susan Hegge MD,Craig McKinley MD, Centre for Minimal 

Access Surgery, McMaster University Hamilton Ontario 

Canada; North Bay District Hospital, North Bay Ontario Canada 

PURPOSE: The learning curve for laparoscopic colorectal surgery 

has been questioned. The purpose of this article is to 

assess the learning curve and steps taken by two community 

surgeons who have created a laparoscopic colorectal surgery 

program in their local hospital. 

METHODS: Between October 2000 and December 2003, 100 

laparoscopic colorectal resections were performed for benign 

and malignant disease at the North Bay District Hospital, a 200 

bed community hospital located 400 km away from the nearest 

tertiary care center. All cases were performed by two community 

surgeons with no formal advanced laparoscopic fellowship. 

We have evaluated the changes in patient outcome during 

the two surgeons? learning curve. 

RESULTS: During the initial 50 cases, the indication for laparoscopic 

colorectal surgery was mostly benign disease and the 

primary surgeon was assisted by another general surgeon. 

Initially, both surgeons attended laparoscopic colorectal surgery 

courses. During the last 50 cases, a wider range of procedures 

was performed and telementoring or telerobotic assistance 

was used selectively. The learning curve had an impact 

on the operating time as well as the conversion rate. 

CONCLUSION: A laparoscopic colorectal surgery program can 

be safely developed in a community hospital. Laparoscopic 

work courses, telementoring, telerobotic assistance, dedicated 

nursing staff and appropriate instrument acquisition are 

important factors that minimize complications during the 

learning curve. 


A SURVEY OF LAPAROSCOPIC SURGERY FOR COLORECTAL 

CANCER IN JAPAN, Mitsugu Sekimoto MD, Hirofumi 

Yamamoto MD,Masataka Ikeda MD,Ichiro Takemasa MD,Rei 

Suzuki MD,Shuji Takiguchi MD,Morito Monden MD,Tetsuichiro 

Muto MD, Department of Surgery and Clinical Oncology, 

Osaka University, Japanese Society for Cancer of the Colon 

and Rectum 

Aim) Increasing laparoscopic resections of colorectal cancer 

(LC) are performing in Japan. Results of survey of LC in Japan 

were reported. Method and Result) The survey was performed 

on the home page of the organizer of 60th Japanese Society 

for Cancer of the Colon and Rectum(JSCCR) meeting in 

January, 2004. The questionnaires referred to the experiences 

and points of view on LC of Japanese colorectal surgeons. A 

total of 110 colorectal surgeons completed the questionnaire. 

Ninety one of them had experiences of LC, and 19 did not. 

Most surgeons performing LC indicated LC for curative resection 

of advanced cancer. Eighty one thought that LC was less 

invasive than open surgery. Fifty nine thought that LC had 

some insufficient points regarding the accuracy of the procedures, 

such as insufficient lymph node dissection and/ or 

resection margin. Fifty three surgeons answered that LC did 

give no merits to the hospitals. Income increased only in 16 

hospitals. Most of the nineteen surgeons who did not perform 

LC, answered that they would start performing LC when they 

got an evidence of the superiority of LC over conventional surgery. 

Conclusion) Many Japanese colorectal surgeons indicated 

LC for advanced cancer. Although most surgeons agreed 

regarding the less invasiveness of LC, more than half of them 

had doubts about the accuracy of the operation. 


LAPAROSCOPIC APPENDECTOMY: LOOP LIGATION OR ENDO- 

SCOPIC STAPLING? A COMPARISON OF TWO TECHNIQUES, 

Thomas P Stites MD, Jon C Gould MD,Charles P Heise MD, 

University of Wisconsin, Madison 

Introduction: Several methods of laparoscopic appendectomy 

have been described, yet few studies compare the outcome of 

different techniques. Two methods predominate at our institution: 

1) endoscopic stapling of the appendix and mesoappendix 

and 2) ultrasonic division of the mesoappendix with endoscopic 

loop ligation of the appendix. It is not known whether 

the technique utilized contributes to post-operative abscess 

formation. 

Methods: We hypothesized that endoscopic loop ligation is 

associated with an increased rate of post-operative, intraabdominal 

abscess formation. This is a retrospective review of 

consecutive laparoscopic appendectomies performed over the 

last 4 years for presumed acute appendicitis at a single hospital 

by attending surgeons with junior level assistants. The primary 

outcome measured was post-operative, intra-abdominal 

abscess formation. Outcomes were stratified by operative findings 

and comparisons made by the Fisher?s exact test. 

Results: This review identified 724 laparoscopic appendec- 



tomies during this time period. The following table summarizes 

the incidence of intra-abdominal abscess formation 

based on surgical technique. 

Conclusion: The two common methods of laparoscopic appendectomy 

evaluated in this study are associated with similar 

rates of post-operative intra-abdominal abscess formation. Use 

of endoscopic loop ligation may be associated with an 

increased rate of abscess formation in cases of gangrenous 

appendicitis, though further confirmation based on 

histopathology is required. 


CLINICAL AND EXPERIMENTAL STUDY ON ENDOSCOPIC 

HEMOSTASIS BY LOCAL INJECTION OF FIBRIN GLUE- 

HISTOPATHOLOGICAL OBSERVATION OF ITS HEMOSTATIC 

AND WOUND HEALING EFFECTS, Hiroyasu Suga MD, Takao 

Nakagawa MD,Yukihiro Soga MD,Haruki Takahashi 

MD,Yoshizumi Deguchi MD,Takahiro Terada MD,Masatake 

Ishikawa* MD,Tadashi Suzuki* MD,Yoshiaki Imamura** 

MD,Masaru Fukuda** MD, Department of Emergency 

Medicine, Tokyo Women’s Medical University Daini 

Hospital.*Department of Emergency Medicine,Tokyo Women’s 

Medical University.**Department of Surgical Pathology, 

University Hospital, Faculty of Medicine, University of Fukui 

[Introduction] Since October 2000, a fibrin glue has been used 

for endoscopic hemostasis on 37 cases of hemorrhagic ulcer, 

polypectomy, and control of hemorrhage in the EMR, and 

found to be effective. In addition, the histological effect of a 

local injection of fibrin glue was observed in rats. It was found 

that, compared with a local injection of ethanol, a fibrin injection 

results in less tissue trauma; and when compared to HSE, 

its hemostatic effect was more reliable and longer lasting. In 

the current study, dogs were used to evaluate the tissue regenerating 

effect of a local injection of fibrin glue. The results are 

introduced below. 

[Methods] Under Nembutal anesthesia, mongrels were subjected 

to a laparotomy and a hemorrhagic ulcer was mechanically 

created in the pyloric vestibule.After prepared ulcers, the 

lesion was treated with a local injection of fibrin glue (FG), 

ethanol (ET), hypertonic saline-epinephrine (HSE), or physiologic 

saline (sham). Then the wound was closed. The animals 

were fed liquid feed on day 1 after surgery, then placed on a 

normal diet and received postoperative care. On the 5th day 

following surgery, the animals were subjected to a second 

laparotomy and gastrectomy on the pyloric side (where the 

ulcer had been created) to compare and evaluate the hemostatic 

effects of the 4 agents. 

[Results] The development of the regenerative epithelium was 

most satisfactory in the FG group. The local injection did not 

cause tissue damage but hemorrhage into the mucous membrane 

and submucosal area was noted in the sham group. In 

the former group, some tissue damage was recognized but fibrin 

remained in the submucosal region until the 5th day, indicating 

that the procedure had a sustained hemostatic effect. 

The development of a regenerative epithelium was recognized 

in the ET group. Although there was no hemorrhage, infiltration 

by inflammatory cells was accentuated in this group. The 

tissue damage was slight in the HSE group, but the development 

of a regenerative epithelium was poor. 

[Conclusion] Because fibrin persisted for a long period in the 

area where it was injected, it was believed that a local injection 

of fibrin glue has a sustained hemostatic effect. Compared 

with the hemostatic agents that have been in use (such as 

ethanol and HSE), the development of a regenerative epithelium 

was good. Fibrin glue appears to be promising as a hemostatic 

agent, as well as an agent to promote wound-healing. 


EFFECTIVENESS OF ELECTROTHERMAL BIPOLAR VESSEL 

SEALER IN LAPAROSCOPIC COLECTOMY, Moriatsu Takada 

MD, Takao Ichihara MD,Yoshikazu Kuroda MD, Department of 

Gastroenterological Surgery, Graduate School of Medical 

Sciences, Kobe University 

INTRODUCTION: Lymphadenectomy at the origin of the middle 

colic artery is sometimes difficult in laparoscopic transverse 

colectomy (LTC). Recently, an electrothermal bipolar vessel 

sealer (EBVS) has been inovated. We have developed the 

affordable extended lymphadenectomy in LTC using EBVS. 

METHODS AND PROCEDURES: From August 2001 through 

July 2004, thirty-five consecutive patients with transverse 

colon cancer underwent laparoscopic colectomy using non-clip 

technique in Kobe University Hospital. Median patient age was 

69.4 years. After the isolation of transverse colon, all vessels 

were isolated and divided using EBVS except the main artery. 

The transverse colon is rotated by centering at the base of 

meso-colon and the anal side of the colon is pulled up vertically. 

The middle colic artery was divided at the root with the dissection 

of lymph nodes around the base of meso-colon. The 

origin of main artery was then divided using EBVS. All other 

surgical procedures were performed after the manner of standard 

laparoscopic colectomy. 

RESULTS : All procedures were performed successfully without 

any kind of troubles. The average blood loss was 86.2 ?} 

22.6 mL. The average operation time was 186.4 ?} 26.2 min. 

Successful lymphadenectomy of the lymph node along the origin 

of middle colic artery have been performed. There was no 

postoperative death. 

CONCLUSION:The method using EBVS may contribute to the 

easy and safe LTC by improving the limited view of laparoscope 

and raise a possibility for the laparoscopic resection of 

advanced colon cancer. We convince that this rotation technique 

and use of EBVS contribute to the easier and safe LTC. 


SURGERY OF RECTAL CANCER : LAPAROSCOPY DECREASE 

THE LONG TERM MORTALITY BY CANCER., ERIC VIBERT, 

CHRISTINE DENET MD,THIERRY PERNICENI MD,HUGUES 

LEVARD MD,CHRISTOPHE VINDEVOGEL MD,BRICE GAYET 

MD, INSTITUT MUTUALISTE MONTSOURIS, PARIS 

Introduction:Laparoscopy in cancer remains discussed. This 

study compared the long-term results of the treatment of the 

rectal cancer by coelioscopy (C) and laparotomy (L). 

Methods: Monocentric retrospective study of 245 patients 

operated curatively (C=124 group and L=121 group) between 

1994 and 2004. Groups were comparable (p>0,05) for the sex, 

the age, the ASA score, the preoperative radiotherapy, the T 

stage, the N stage, The M stage, the localization supra or infra 

peritoneal of tumour, the type of resection, the distal margin 

and the post-operative chemotherapy. Even if the rate of morbidity 

and the length of hospitalization was comparable 

between the two groups, the rate of post-operative reintervention 

was higher in coelioscopy (p=0,04). The follow-up of the 

groups were different: C=46 months/L=59 month (p=0,002). 

The conversion rate was 13,2%. The role of the laparoscopy 

(analyzes in intent-to-treat) was evaluated by a univariate 

analysis then multivariate of the long-term results. 

Results: In univariate analysis, the laparoscopy increased specific 

survival (SS) (mortality by cancer) but not influence global 

survival (GS) and survival without recurrence (SWR). In multivariate 

analysis, the laparoscopy increased specific survival 

(RR=0,355(0,126-0,995),p=0,04) like T1-T2 stage 

(RR=0,121(0,160-0,943), p=0,04) and contrary to the age 

(RR=1,06(1,01-1,11), p=0,007). At 36 months, the SS was 95.8% 

after laparoscopy (68 patients at risk on 124) versus 88% after 

laparotomy (84 patients at risk on 121) (p=0,005). At 36 months 

GS, 93%(C) versus 83%(L), and SWR, 82%(C) versus 72%(L) 

were not statistically influenced by the laparoscopy. 

Conclusions: This study suggests that the laparoscopic treatment 

of rectal cancer decrease the long term mortality by cancer. 


LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER: EXPE- 

RIENCE IN 500 SUCCESSFUL CASES, HM WANG MD, JB 

CHEN MD, Division of Colorectal Surgery, Department of 

Surgery, Taichung Veterans General Hospital 



161



AIM: Controversial issues surrounding the use of laparoscopic 

surgery (LAP) for colorectal cancer include high 

conversion¡Bhigh complication rate¡Bport site recurrence and 

poor outcome than open surgery (OPEN) previously reported. 

The purpose of this single center, prospective study was to 

assess the oncological outcomes achieved after curative LAP 

for cancer. 

MATERIALS & METHODS: We enrolled 514 consecutive 

patients with colorectal cancer undergoing LAP between July 

1998 and May 2004. The data were including patient 

profile¡Boperative complication ¡Bpathology and oncological 

outcome. We compared the oncologic outcomes achieved 

using LAP and OPEN during period from July 1998 to June 

2001. Patient follow-up ranged from 36 to 72 months. The follow-up 

rate was 95%. We recorded the final status of all cancer 

patients as of June 30, 2004. 

RESULTS: We attempted to perform LAP in 514 patients and 

14 patients (2.7%) needed conversion to open surgery. The 

LAP was successfully in 500 patients with 308 males and 192 

females, age from 26 to 96 years, av. 64.2 years. Of the 500 

LAP patients, 85 (17.0%) experienced complications & 42 

(8.4%) patients had major complications that required further 

surgery. Major complication of LAP for rectal cancer was higher 

than colon cancer: 11.4% (34/298) vs. 4.0% (8/202). There 

were three (0.6%) operative mortality due to sepsis, CVA and 

hepatic failure. We examined the oncologic results achieved in 

185 patients who had curative LAP between July 1998 and 

June 2001. The 3Y-DFS between LAP and OPEN were no difference 

in stage I (94.2% vs. 93.9%), stage II (79.7% vs. 73.4%), 

stage III (57.2% vs. 56.7%) and over-all (75.8% vs. 70.3%). 

There were two (0.4%) port site recurrence found in LAP 

patients. 

Conclusion: The LAP for cancer was feasible for the acceptable 

morbidity rate & operation time. The oncological results are 

encouraging and equal to OPEN. 


LAPAROSCOPIC COLORECTAL SURGERY: EARLY AND LATER 

EXPERIENCE, David A Vivas MD,Seong-Yeop You MD,Dan Ruiz 

MD,Jonathan Efron MD,Eric Weiss MD,Juan J Nogeras 

MD,Dana Sands MD,Anthony Vernava MD, Steven Wexner 

MD, Department of Colorectal Surgery, Cleveland Clinic 

Florida, Weston ,FL 

Background: The aim of this study was to compare early and 

more recent results of laparoscopic colorectal surgery to 

assess any differences in indications or procedures and any 

changes in results. Methods: After IRB approval, the medical 

records of all patients who underwent elective laparoscopic 

colorectal surgery between August 1991 and April 2004 were 

reviewed. Group I included patients operated upon between 

August 1991 and December 1995 (53 months), Group II included 

patients who were operated between January 1996 to 

September 1999 (45 months) and Group III included patients 

who underwent laparoscopic colorectal surgery between 

October 1999 and April 2004 (55 months). Results: 644 

patients underwent elective laparoscopic colorectal surgery 

during this period, including 175 patients in Group I, 199 

patients in Group II and 270 patients in Group III. While there 

were no differences among Group I, Group II and Group III relative 

to gender (p=NS), patients in Group II were significantly 

older than those of Group I [50.2 (range 15-88) versus 58.3 

(range 15-89); (p = 0.05)]; there was no difference between 

Group II and Group III (p=NS) respect to age. Significantly 

more patients underwent sigmoid colectomy in Group III than 

in Groups I and II (24% versus 13.7% and 15.6%, respectively; 

p = 0.05). Interventions for diverticular disease increased significantly 

during this period from 10.9% in Group I, to 14.1% in 

Group II to 24.8% in Group III (p= 0.05). Right hemicolectomy 

was one of the most common procedures performed, representing 

24.6%, 39.7% and 22.2% for Groups I, II and III, respectivelyç 

11 procedures in Group III were ileocolic resections for 

Crohn’s disease. Intraoperative complications decreased significantly 

from Group I to Group II (16.0% versus 4.5%, respectively; 

p = 0.05) but remained unchanged between Group II 

and Group III (4.5% versus 6.66%, respectively; NS). Although 

the operative time decreased significantly between Group I 


and II (180.5 min versus 146.0 min, respectively; p = 0.05), it 

increased between Group II and Group III (146.0 min versus 

170.02 min, respectively; p = 0.05). 

Conclusion: Increasing experience in laparoscopic colorectal 

surgery may lead to better results as attested to by the 

decrease in morbidity. However, the selection of more challenging 

cases like sigmoid diverticulitis and ileal Crohn’s disease 

may be the reason for the increase in operative time. 


SHORT TIME RESULTS OF LAPAROSCOPIC COLORECTAL 

RESECTION BY DIFFERENT SURGEONS, Shigeki Yamaguchi 

PhD, Ota Mitsuyoshi MD,Masayuki Ishii MD,Hirofumi Morita 

MD, Shizuoka Cancer Center 

Purpose: The purpose of this study is to assess short term 

results of laparoscopic colorectal cancer resection and to clarify 

the difference between surgeons. 

Patients: One hundred thirteen colorectal cancer resection 

were included since 2002 September to 2004 April by surgeons. 

Surgeon A was tutor, B had some experience, and C, D 

were beginner. When B, C, D did operator, A assisted them in 

80% cases. Number of patients was A: 59, B: 20, C: 22, D: 12, 

respectively. 

Results: Each tumor location was as right colon/ left colon/ rectum, 

A: 11/ 29/ 19, B: 7/ 9/ 4, C: 7/ 12/ 3, D: 5/ 4/ 3. Lymph node 

dissection was as D1/ D2/ D3, A: 2/ 16/ 41, B: 2/ 5/ 13, C: 0/ 9/ 

13, D: 2/ 4/ 6. Mean BMI was A: 23.1, B: 23.6, C: 23.2, D: 22.6. 

Mean operating time was A: 238 minutes(128?`459), B: 

227(135?`485), C: 209(136?`300), D: 204(136?`279). Each operating 

time of the first half and second half were A: 240?¨234 min. 

B: 273?¨180, C: 240?¨179, D: 234?¨174. B, C, D had shortened 

operating time except A. Mean blood loss count was A: 65??, 

B: 74, C: 45, D: 29, and no patient received blood transfusion. 

Three patients in group A were converted to open surgery 

because of blood supply insufficiency, mesorectal inflammation, 

and obesity. Median postoperative hospital stay was 8.0 

in all groups. Postoperative complications were 1) anastomotic 

leakage A: 3, B: 0, C: 0, D: 0, 2) ileus A: 2, B: 1, C: 0, D:1, 3) 

wound infection A: 1, B: 1, C: 1, D:0. 

Conclusion: Because of making operating team and assisting 

beginner surgeon, operating time and blood loss were no difference 

between all surgeons. 


LAPAROSCOPIC APPROACH TO A JEJUNAL STROMAL 

TUMOR., Nihat Yavuz MD, Abdullah As MD,Fatih Aydogan 

MD,Sabri Erguney MD,Osman Tortum MD, Istanbul 

University,Cerrahpasa Medical School,General Surgery 

Department 

Introduction: 

Small bowel tumors are rarely seen and are difficult to diagnose.As 

other small bowell tumors,they lead to either obstruction 

or haemorrhage.In recent years with the introduction of 

capsule endoscopy procedure,their preoperative recognation 

has become possible. 

Materyal-Method: 

We report here a 61 years old woman with a jejunal tumor 

which led to an acute lower gastrointestinal haemorrhage. She 

had two more episodes of bleeding in the last year. All investigations 

including upper and lower gastrointestinal endoscopies, 

abdominal CT scan and enteroclysis performed in this 

period could not detect any source of bleeding. Following the 

last haemorrhage a capsule endoscopy was realized,which evidenced 

a 3 cm ulcerated polypoid mass in the proximal 

jejunum. In 

laparoscopic exploration,the tumor was seen in the jejunum,20 

cm distal to Treitz ligament. Laparoscopic assisted segmentary 

jejunal resection was performed. The corresponding mesentary 

was dissected with the use of LigaSure Vessel Sealing 

System(LVSS) intracorporally,the specimen was exteriorized 

through a small insicion of 4 cm length and the jejunal anastomosis 

was performed extracorporally. 

Results: 

The operation time was 120 minutes.The oral intake was 

begun on the 3th postoperative day and patient was discharged 

the day after.No any postoperative complication was 

seen.Histopathological exam revealed a malignant stromal


tumor. 

Discussion: 

Gastrointestinal stromal tumors represent a considerable part 

of small bowel tumors. Total resection of the tumor with clean 

surgical margins is adequate surgical treatment. This procedure 

can be performed with laparoscopic assistance,and may 

be an alternative to its open counterpart . 

P146–Education/Outcomes 

TASK DECONSTRUCTION FOR TRAINING ON A LAPARO- 

SCOPIC VIRTUAL REALITY SIMULATOR, R Aggarwal MD, J 

Hance MD,S Saso,A Tully,A Darzi MD, Department of Surgical 

Oncology & Technology, Imperial College London, UK. 

Introduction: Virtual reality simulation has been shown to be 

beneficial for training in basic and advanced laparoscopic 

skills. One of the proposed benefits of training on a VR simulator 

is the ability to deconstruct a procedure into a series of 

component tasks and skills. This study aims to establish the 

level of deconstruction that delivers the optimal task-based 

approach to achieve proficiency in laparoscopic suturing. 

Methods: 30 laparoscopic novices trained on a laparoscopic 

VR simulator (MIST-VR) in a stepwise approach commencing 

with a previously validated basic skills curriculum. They were 

then randomised into three groups to train over five half-hour 

sessions on the VR laparoscopic suturing module of MIST-VR. 

The simulator breaks down training into a series of 12 tasks, 

the last two enabling practice at performing a complete 

laparoscopic suture. Group A performed all 10 constituent 

tasks, Group B the three most complex constituent tasks, and 

Group C practiced laparoscopic suturing without task breakdown. 

Assessments of laparoscopic suturing skill were carried 

out at the beginning and end of each subject’s training period, 

using a synthetic bowel model placed in a video trainer. Each 

subject’s performance was scored objectively using a validated 

motion analysis system, together with blinded checklist scoring 

of videos of each procedure. Data analysis used non-parametric 

tests, p




EXPERIENCE WITH THE OPTICAL ACCESS TROCAR FOR SAFE 

AND RAPID ENTRY IN PERFORMING THE LAPAROSCOPIC 

GASTRIC BYPASS, Barry R Berch MD, Rami Lutfi MD,Alfonso 

Torquati MD,William O Richards MD, Vanderbilt University 


BACKGROUND: In laparoscopic surgery, serious complications 

caused by the blind insertion of trocars and the Veress needle 

are well known. The open technique is compromised by the 

leakage of carbon dioxide and can also be time consuming, 

especially in the obese population. Our aim is to determine 

whether the optical access trocar can be used to establish a 

safe and rapid entry during laparoscopic gastric bypass. 

METHODS: The data on a single Surgeons experience with 

over 350 laparoscopic gastric bypass procedures during a 4 

year period was reviewed. The Optiview (Ethicon 

Endosurgery) trocar was used on all but the initial 21 patients. 

The entry time for the optical trocar was measured in 10 

patients. RESULTS: Of the 350 patients undergoing laparoscopic 

gastric bypass from 11/2000 to 9/2004, the initial 21 

were performed using the standard Veress needle to create the 

pneumoperitoneum. The next 22 were performed using the 

Veress needle to create the pneumoperitoneum followed by 

the optical access trocar in the left upper quadrant as the initial 

trocar inserted. From this point to present, the optical 

access trocar has been inserted without the use of a Veress 

needle. There have been no trocar related bowel or vascular 

injuries in the entire series. Mean optical trocar insertion times 

were 28 ± 1.26 seconds. CONCLUSIONS: This is the first 

laparoscopic gastric bypass series to report the results of its 

experience with the optical access trocar. This device provides 

a safe and rapid technique for the initial trocar placement in 

the laparoscopic gastric bypass. Insertion of the optical trocar 

with a 10mm laparoscope into the left upper quadrant is our 

procedure of choice for obtaining the pneumoperitoneum in 

this patient population. 


TELEMENTORING VERSUS ON-SITE MENTORING IN SIMULA- 

TION TRAINING, Lucian Panait MD, Alfredo M Carbonell DO, 

Victor Tomulescu MD,Azhar Rafiq MD,Cosmin Boanca BS,Irinel 

Popescu MD,Ronald C Merrell MD, Virginia Commonwealth 

University Medical Center, Richmond, VA & Fundeni Clinical 

Institute, Bucharest, Romania 

Telementoring could be an adjunct tool to surgical training 

using virtual reality (VR) surgical simulation. The hypothesis of 

this study was that telementoring is just as effective as proximal 

mentoring for acquisition of surgical skills in simulation. 

Twenty Romanian medical students, with no previous 

laparoscopy experience, were randomly assigned to two 

groups that trained with a VR surgical simulator (LapSim, 

Surgical Science) under supervision of a telementor or a proximal 

mentor, respectively. The telementor, located in the US, 

interacted with the students by videoconferencing, coaching 

both vocally and demonstrating on another VR simulator. The 

simulator screen and two other room cameras were integrated 

into a videoconferencing unit with audio for Internet broadband 

transmission. All students watched an instructional module 

at the beginning of the exercise. Skill assessment before 

and after the training sessions involved measurement of path 

length and time for completing four basic laparoscopic tasks: 

grasping, cutting, clip applying, and suturing. Student t-test 

statistical analysis was used to compare the results within 

each group at the beginning and end of study. 

The combined use of instructional media and practice session 

with mentoring prior to testing resulted in similar a level of 

performance between proximal and telementored groups. 

After adjusting for other covariates, right and left hand path 

length and time decreased significantly within each group 

from the initial to the final evaluation (p


to avoid dissemination of the cystic contents or a anaphylactic 

shock. 

Cystectomy and pericystic resection, (by open surgery) as 

extensive as possible, is the adequate treatment that gives 

successful results in most cases. 

note: I wish to present this clinical case in the form of poster. 


A PRIMARY HYDATID CYST OF THE GLUTEAL MUSCLE : A 

CASE REPORT, Adel Chokki MD, Youssef Harrath MD,Soufiene 

Nouira MD,Jalel Kdous MD,Chedly Dziri MD,Mohamed Tahar 

Khalfallah MD, Service de chirurgie Hopital de Siliana. Siliana. 

Tunisie 

hydatidosis remains an endemic surgical problem in many 

Mediterranean countries like Tunisia. the hydatid cyst can 

touch all the organs of the human body. 

The muscular localization of the hydatid cyst is uncommon 

(0.5 to 5.4%) and it is usually secondary to hepatic or pulmonary 

disease. 

A 59 year old woman presented with a mass of the left buttock 

witch appeared two years before and increased size gradually. 

Clinical examination, noted the presence of two masses of the 

left buttock 

Ultrasonography revealed that the masses were a hydatid cystic 

classified stage III (Garbi’s classification). 

Serology was positive. 

Thoracic radiography and abdominal Ultrasonography were 

normal and did not revealed another localisation of the 

hydatid cyst. 

At surgical exploration, three hydatid cyst were found. 

Two cyst were totally removed and the third cyst was treated 

by pericystic resection. 

Follow up : four years later, there was no recurrence. 

An isolated hydatid cyst can be the unique manifestation of 

hydatid disease. Preoperative diagnosis is desirable for the 

selection of a surgical approach and prevention of allergic 

reactions and operative spillage. 

The purpose of this work is to call attention to this atypical 

localization of the disease, which should be taken into account 

in the practice of surgery. 

In the light of this case, we discuss the epidemiological, diagnostic 

and therapeutic aspects of muscle hydatidosis. 


CHARACTERIZING THE LEARNING CURVE FOR A BASIC 

LAPAROSCOPIC DRILL., Shannon A Fraser MD, Liane S 

Feldman MD,Donna Stanbridge RN,Gerald M Fried, Steinberg- 

Bernstein Center for Minimally Invasive Surgery, McGill 

University 

CHARACTERIZING THE LEARNING CURVE FOR A BASIC 

LAPAROSCOPIC DRILL 

Shannon A. Fraser MD, Liane S. Feldman MD, Donna 

Stanbridge RN, Gerald M. Fried MD Steinberg-Bernstein 

Centre for Minimally Invasive Surgery, McGill University, 

Montreal, Canada. 

Background: Psychomotor challenges inherent in laparoscopic 

surgery are evident by the steep procedural ?learning curves? 

documented throughout the literature. Few methods have 

been described to evaluate learning curves. The cumulative 

summation (CUSUM) method is a criterion-based evaluation 

of the learning process. The purpose of this study is to 

describe the CUSUM learning curves for a simple task for individuals 

and for a group of novice laparoscopists. Methods: 16 

medical students did 40 repetitions of MISTELS laparoscopic 

peg transfers. Performance was recorded for each trial. 

CUSUM learning curves were constructed based on the goal 

of achieving mean scores for senior, intermediate or junior 

laparoscopists >95% time. Results: Based on senior criteria, 1 

student achieved the goal by the 40th trial; based on intermediate 

criteria, 3 achieved the goal by the 40th trial (trials 21, 

36), and for junior criteria, 10 achieved the acceptable success 

rate by the 40th trial (range = 26-40). 

Conclusion: CUSUM analysis suggests criterion-based practice 

is useful for novice laparoscopists. It allows educators to track 

an individuals progress toward specific performance 

goals for each MISTELS task, to more logically allocate the 

required time for training and set attainable goals, to objectively 

evaluate trainee acquisition of basic laparoscopic skills, 

and to identify trainees who need remediation. 


OBJECTIVE ASSESSMENT OF LAPAROSCOPIC SKILLS USING 

A VIRTUAL REALITY SIMULATOR ? CORREALTION WITH PER- 

FORMANCE IN THE OPERATING ROOM, Teodor P Grantcharov 

PhD, J Ravn Eriksen MD,PF Caushaj MD,P Funch Jensen MD, 

Department of Surgery, Copenhagen University, Glostrup 

Hospital, Denmark, Department of Surgery, Aarhus University, 

Kommunehospitalet, Denmark, The Western Pennsylvania 

Hospital, Pittsburgh, USA 

BACKGROUND 

The study was carried out to validate the role of virtual reality 

computer simulation as a method for assessment of psychomotor 

skills in laparoscopic surgery. We aimed to investigate 

whether performance in the OR, assessed using a modified 

OSATS correlated with the performance parameters, registered 

by LapSim during simulated laparoscopic tasks. 

MATERIALS AND METHODS 

Ten surgical residents with similar, limited experience in 

laparoscopic surgery (median 5 (range 1-16) laparoscopic 

cholecystectomies) were included in the study. All participants 

performed 3 repetitions of all 7 tasks on the LapSim trainer 

and one laparoscopic cholecystectomy in the OR. The OR procedure 

was video recorded and blindly assessed by 2 independent 

observers using a modified OSATS rating scale. 

Assessment in the OR was based on 3 parameters: time used, 

error score and economy of motion score. During the tasks on 

LapSim, time, error- (tissue damage, mm tissue damage (tasks 

2-6) and error score (task 7)) and economy of movement 

parameters (path length, angular path) were registered. Data 

was analysed using Spearman?s test. 

RESULTS 

Significant correlations were demonstrated between time used 

to complete the OR procedure and task 7 (p=0.015). Error score 

demonstrated during the laparoscopic cholecystectomy correlated 

well with tissue damage (task 4 (p=0.04), task 5 (p=0.05) 

and task 6 (p=0.01)); mm tissue damage (task 3 (p=0.001), task 

6 (p=0.028)); and error score in task 7 (p=0.034). Furthermore, 

statistically significant correlations were observed between 

economy of motion score from the operative procedure and 

LapSim?s economy parameters ? path length (task 1 (p=0.028), 

task 2 (p=0.006), task 3 (p=0.004), task 4 (p=0.001), task 5 

(p


MD,Mark L Wulkan MD,Evan R Kokoska MD,Thom E Lobe 

MD,Douglas C Barnhart MD,Tara J Loux BA, University of 

Alabama Medical Center, Cincinnati Children’s Hospital, 

University of Pittsburgh Medical Center, Emory University 

School of Medicine, University of Arkansas Medical Center, 

University of Tennessee Health Science Center 

Background: Laparoscopic suturing and knot tying skills are 

critical to performing advanced pediatric laparoscopic operations. 

The value of advanced laparoscopic training courses 

which include animate models, has been reported to be beneficial 

in improving laparoscopic suturing and knot tying skills 

for general surgery residents. However, no specific information 

is available regarding the value of advanced training 

courses for pediatric surgical residents. The purpose of this 

study was to assess whether training courses resulted in 

improved advanced skills in surgeons who have recently completed 

general surgery residencies. 

Methods: Twenty-three pediatric surgery residents (PGY-6 

through PGY-9) participated in an advanced laparoscopic skills 

course, which included a didactic session followed by an animate 

surgical session using a pig model and performing a 

Roux-en-Y gastric bypass. At the onset of the operative procedure, 

each pediatric surgery resident was timed during laparoscopic 

placement of a simple silk suture in the intestinal wall 

and tying of four knots. After completion of the five-hour operative 

session, the residents were again timed in the suturing 

and knot tying skill to evaluate any change in performance. 

Data are presented as time (seconds ± SD) and statistical 

analysis was performed using repeated measures t-test. 

Results: Of the 23 participants, 20 had faster recorded suturing 

and knot tying times after the training session as compared to 

those times recorded before the session. Mean pre-session 

suturing and tying time was 173.8 ± 71.4 s, and mean post-session 

time was 98.4 ± 32.3 s. Suturing and tying time from preto 

post-session significantly decreased by a mean of 75.4 ± 

74.2 s (95% CI 43.3 ? 107.5 s, p


sure of a gastric perforation (using two suture ligatures), and 

3) laparoscopic cholecystectomy. The students alternately 

worked as operators or cameramen, and endoscopic surgeons 

with more than 10 years of experience were their assistants. 

Their performance was assessed from the time required for 

each procedure and the error score. There were no significant 

differences between the three groups in the total operating 

time for the three procedures, the operating time for LC, and 

the error score. However, there was a significant difference in 

the time required for suturing the gastric perforation between 

the VR group and the control group (p=0.0002), as well as 

between the TB group and the control group (p=0.0012). The 

time for the second suture comparing for the first suture was 

significantly reduced in the VR group compared with the TB 

group (p=0.0181). In the TB group, the time required for suture 

ligatures by three students who were given instructions by the 

trainers watching the procedure was shorter than that required 

by students who received instructions from the trainers not 

watching the procedure (p=0.0495). Based on these findings, 

both the virtual simulator and the training box were useful in 

training for placement of suture ligatures, but were not useful 

in training for overall operation. The virtual simulator was also 

useful for shortening the learning curve, while the training box 

became more useful if instructions were given by a trainer 

who was viewing the surgical procedures. 


VALIDITY AND RELIABILITY OF A VIDEOTRAINER LAPARO- 

SCOPIC CAMERA NAVIGATION SIMULATOR, J R Korndorffer 

Jr. MD, D Stefanidis MD,R Sierra MD,J L Clayton PhD,C L 

Touchard BS,J B Dunne PhD,D J Scott MD, Tulane University 

Health Sciences Center, Department of Surgery 

The videotrainer laparoscopic camera navigation (LCN) simulator 

has previously been shown to develop skills which translate 

to the OR. The purpose of this study was to determine the 

construct and face validity and the reliability of the LCN simulator. 

Subjects (n=31) including novices (R1, n=20), intermediates 

(R2-5, n=7), and experts (>200 lap cases, n=4) were enrolled in 

an IRB-approved protocol. Each subject performed 3 repetitions 

on the 0° and 30° simulators and was scored (accuracy 

and time) by direct observation. To evaluate construct validity, 

scores were compared between groups using ANOVA and 

with LCN experience using Pearson Correlation. To evaluate 

face validity, intermediate and expert subjects rated the simulators 

using a 10-point Likert scale. To evaluate reliability, 

scores were analyzed by Pearson Correlation (test-retest) and 

Cronbach alpha (internal consistency). 

For the 0° simulator, no significant difference was 

detected between groups and LCN experience did not correlate 

with performance (r=0.26, p<0.16). For the 30° 

simulator, a significant difference was detected between all 

groups and LCN experience correlated significantly with performance 

(r= 0.72, p<0.001). Face validity ratings were; 8.7 

for "simulates movements required for LCN," 8.2 

for "relevance to actual LCN," and 8.2 for 

"usefulness for training." Test-retest reliability was 

0.8 (p<0.001) for both the 0° and 30° simulators 

and Cronbach alpha was 0.6 (0°) and 0.9 

(30°).Although a trend was noted in the 0° simulator 

scores, statistical significance was not reached due to the 

easy level of difficulty and limited group sizes (further accrual 

is underway). However, the more difficult 30° simulator 

was able to discriminate between groups and clearly demonstrated 

construct validity. Both simulators showed excellent 

face validity and moderate to high reliability. These data further 

support the use of the LCN simulator for training and possibly 

assessment purposes. 


PROFICIENCY-BASED TRAINING FOR LAPAROSCOPIC SUTUR- 

ING: VR, VT, OR BOTH?, J R Korndorffer, Jr MD, J B Dunne 

PhD,D Stefanidis MD,R Sierra MD,C L Touchard BS,D J Scott 

MD, Tulane University Health Sciences Center 

The purpose of this study was to compare the effectiveness of 

laparoscopic suturing curricula using videotrainer (VT) and virtual 

reality (VR) simulators, and to examine the role of VR 

training as a cost effective adjunct to VT training. 

Medical students (MS4, n=8) with no laparoscopic suturing 

experience were enrolled in an IRB-approved, randomized, 

controlled protocol. Subjects were pre-tested on a live porcine 

laparoscopic Nissen fundoplication model, stratified according 

to pre-test scores and randomized into three groups. The VT 

group (n=3) practiced on a VT suturing model and the VR 

group (n=3) practiced on the MIST-VR suturing module (stitch 

and square-knot tasks) until predetermined proficiency scores 

were achieved. The control group (n=2) received no training. 

All groups were post-tested. The VR group then crossed over 

to train on VT. Analysis was by ANOVA and paired t-test (mean 

± sd, p



BSP used or perceptions of the relative safety of LS. 

Conclusion: Occupational exposures among surgical residents 

are less common in LS as compared with open surgery. 

Operating laparoscopically did not influence the BSP used by 

surgical trainees during surgery, even though the majority of 

surgical residents feel LS is safer. 


EARLY VERSUS DELAYED INTERVAL LAPAROSCOPIC CHOLE- 

CYSTECTOMY FOR ACUTE CHOLECYSTITIS: A META-ANALY- 

SIS, Hung Lau MD, University of Hong Kong Medical Center, 

Tung Wah Hospital, Sheung Wan, Hong Kong 

Background: Early laparoscopic cholecystectomy has been 

advocated for the management of acute cholecystitis but little 

data exists to support the superiority of this approach over 

delayed interval operation. The present systematic review was 

undertaken to compare the outcomes and efficacy of early and 

delayed interval laparoscopic cholecystectomy for acute cholecystitis 

in an evidence-based approach using meta-analytical 

techniques. 

Methods: A search of electronic databases, including MEDLINE 

and EMBASE, was conducted to identify relevant articles published 

between January 1988 and June 2004. Only randomized 

or quasi-randomized prospective clinical trials in English language 

comparing the outcomes of early and delayed interval 

laparoscopic cholecystectomy for acute cholecystitis were 

recruited. All papers were critically appraised with respect to 

their methodology and outcome. Both qualitative and quantitative 

statistical analyses were carried out. The effect size of 

outcome parameters was estimated by odds ratio and weight 

mean difference where feasible and appropriate. 

Results: A total of 4 clinical trials comprising 504 patients met 

the inclusion criteria. Failure of conservative treatment requiring 

emergency cholecystectomy occurred in 42 patients in the 

delayed group. Meta-analyses demonstrated a significant 

shortening in the total length of hospital stay in the early 

group (weighted mean difference = - 1.12, 95% CI = -1.42 to 

¡V0.99, P < 0.001). Pooled estimates of operative time, conversion 

rate, overall complication rate, bile leakage and intraabdominal 

collection showed no significant differences between 

two approaches. 

Conclusions: The safety and efficacy of early and delayed 

interval laparoscopic cholecystectomy for acute cholecystitis 

were comparable. Evidence suggested that early laparoscopic 

cholecystectomy conferred a significant shortening in the total 

length of hospital stay. Early cholecystectomy is therefore a 

cost-effective approach and reduces the risk of recurrent acute 

cholecystitis or development of other biliary complications. 


TELESURGERY ENHANCES EDUCATION OF MEDICAL STU- 

DENTS, Thomas P McIntyre MD, Leonardo Villegas 

MD,Jennifer Doyle BA,Daniel B Jones, Beth Israel Deaconess 

Medical Center, Harvard University 

INTRODUCTION: Telesurgery (TS) may improve the learning 

environment for third year medical students. Our aim was to 

evaluate the TS environment vs. the traditional Operating 

Room (OR) in two aspects: student satisfaction and studentfaculty 

interaction. METHODS: Typical OR learning during the 

third year medical student surgery clerkship was supplemented 

with two TS sessions to which all students (n=11) were 

invited. Faculty-student interaction was evaluated by an independent 

observer in both settings. Surgeons and students 

were blinded to the study. Students also completed a questionnaire 

evaluating each setting. (scale: 1=not at all; 5=completely). 

Analysis was performed using a T-Test. RESULTS: The 

average time allotted to sessions were; TS=77.5 min; OR=76 

min. A total of 12 observations were conducted (TS=2; OR=10), 

and 29 evaluations were returned (TS=19; OR=10). 

Observations revealed that nearly 4 times as many teaching 

points were made in TS sessions: students asked 5 times more 

questions; and faculty asked 3 times more questions of students. 

In addition teaching points made in TS sessions were 

broader than anatomy and surgical technique. [See Table] 

Student evaluations of the TS sessions were more positive: 

they felt freer to ask questions, reported leaving TS sessions 


with fewer unanswered questions and more felt TS sessions 

were a good use of their time. 

CONCLUSIONS: This study suggests that TS sessions provide 

a positive learning environment for third year students, 

enabling greater student-faculty interaction. TS sessions allow 

the scope of clerkship teaching to expand beyond anatomy 

and surgical technique. 


VIRTUAL REALITY TESTING ON THE EFFECTS OF SLEEP 

DEPRIVATION, Benjamin E Schneider MD, Louis C Rivera BS, 

Leonardo Villegas MD,Daniel B Jones MD, Beth Israel 

Deaconess Hospital, Harvard Medical School 

Background: Sleep deprivation has been shown to increase 

technical errors in a virtual reality simulated environment 

among surgical residents averaging 2 hours of sleep on call. 

Recent adoption of resident work hour restrictions may obviate 

the impact of sleep deprivation. 

Aim: The purpose of this study was to objectively mesure the 

performance of residents when rested and when sleep 

deprived. 

Methods: Volunteer surgical residents (N=18) were enrolled 

prospectively. Residents underwent pre-test instruction, randomization, 

and served as their own controls. Questionnaires 

assessed sleep, caffeine intake, and subjective measure of 

?tiredness.? Testing was directly observed, although actual 

assessment was computer-generated using the Minimally 

Invasive Surgery Trainer, Virtual Reality (MIST-VR) with a 

series of six tasks designed to simulate simple laparoscopic 

procedures. Outcomes included speed, error, economy of 

motion, and economy of diathermy. 

Results: Rested residents reported an average of 6.45 hours 

(range 1-13) since last period of sleep compared to an average 

of 18.76 hours (range 5.8-33.5) for sleep-deprived residents. 

Rested residents reported the length of their last sleep period 

to be an average of 5.89 hours (range 4.5-8) while sleepdeprived 

residents reported their last sleep as an average of 

4.83 hours (range 1.75-7). 

Conclusion: In the era of shortened workweek, while residents 

report fatigue, resident performance in a simulated learning 

environment does not seem to be adversely affected due to 

sleep deprivation. 


THE IMPACT OF HAPTIC EXPECTATIONS ON INITIAL LAPSIM® 

PERFORMANCE: PRIOR LAPAROSCOPIC EXPERIENCE DOES 

NOT PREDICT PERFORMANCE, Charles Y Ro MD, Joseph J 

DeRose MD,Robert C Ashton MD,Tony Jebara PhD,Avinash 

Burra MS,Seung H Shin MD,Haroon L Chughtai MD,George J 

Todd MD,James J McGinty MD, St. Luke’s-Roosevelt Hospital 

Center, Columbia University 

Experts and novices may have different expectations when 

confronted with a novel simulated environment. The LapSim® 

is a computer-based virtual reality laparoscopic trainer. We 

sought to analyze the performance of experienced basic 

laparoscopists and novices during their first exposure to the 

LapSim® Basic Skill set and Dissection module. 

Experienced basic laparoscopists (n=16) were defined as 

attending surgeons and chief residents who performed > 30 

laparoscopic cholecystectomies. Novices (n=13) were surgical 

residents with minimal laparoscopic experience. None of the


subjects had used a computer generated laparoscopic simulator 

in the past. Subjects were given one practice session on 

the LapSim® tutorial and dissection module and were supervised 

throughout the testing. Instrument motion, time, and 

errors were recorded by the LapSim®. A Performance Score 

(PS) was calculated using the sum of total errors and time to 

task completion. A Relative Efficiency Score (RES) was calculated 

using the sum of the path lengths and angular path 

lengths for each hand expressed as a ratio of the subject?s 

score to the worst score achieved among the subjects. Thus, a 

lower PS and RES indicated better performance. All groups 

were compared using the Kruskal-Wallis and Mann-Whitney U- 

test. 

Novices achieved better PS and/or RES in Instrument 

Navigation, Suturing, and Dissection (p250 

procedures) consultant surgeons were asked to complete the 

task breakdown pre-operatively, regarding the tools used and 

method employed, for tasks in an ?ideal? procedure. The selfassessment 

was then compared with the surgeons? actual 

operations, which had been recorded onto DVD after the task 

analysis was done, and analyzed for tool use and method 

used, by 2 independent observers. 

Results 

All patients were between ASA 1-2, BMI < 30 and had clinicopathological 

grade 1-2 gallbladders. Inter-rater reliability task 

analysis was kappa = 0.77. The concordance between surgeons? 

perceived and actual styles varied from 73-91%. The 

majority of discordance occurred in non-technical tasks, as 

opposed to technical actions. Surgeons were unable to 

describe the manner in which they used some specific tools. 

Conclusions 

Surgeon self-evaluation is accurate for technical skills aspects 

of the procedure, but is not sufficiently detailed to allow selfevaluation 

of technical styles. Surgeon self-evaluation is poor 

in non-technical aspects of the procedure. This study demonstrates 

that self-appraisal using hierarchical task analysis is 

feasible, accurate and practical. We aim to increase the numbers 

in our study and recruit also resident surgeons. 


CONSTRUCT VALIDITY OF ASSESSORS OF STRUCTURED 

SURGICAL TECHNICAL SKILLS ASSESSMENT IN LAPARO- 

SCOPIC SURGERY, Sudip K Sarker MD, Avril Chang 

MD,Charles Vincent PhD,Ara W Darzi MD, Department of 

Surgical Oncology & Technology, Imperial College London, UK 

Objectives 

Objective structured assessment of technical skills in live operations 

removes subjectivity and bias. To date these assessments 

have been done blindly and independently, but require 

experienced surgeons and are time consuming. We aim in this 

present to evaluate novice assessors, with and without surgical 

experience, can assess technical skills in live laparoscopic 

surgery. 

Methods 

Two full length versions of laparoscopic cholecystectomies 

(LC) performed by two attending/consultant surgeons were 

digitally recorded and converted to DVD. A Likert scale for 

generic and procedure specific technical skill aspects of LC 

were devised. LC were assessed by two experienced surgeons 

and then assessed by two groups of 15 clinical medical students 

and 15 junior surgical residents respectively. The two 

groups assessed the LC without specific instruction but only 

using the Likert scales devised. 

Results 

Inter-rater reliability between the 2 experienced surgeons was 

kappa = 0.93, p< 0.05. Kappa coefficient between the 2 experienced 

surgical assessors and the medical students collectively 

was k = 0.37, p> 0.05 and for the surgical residents collectively 

was k = 0.62, p> 0.05. Mann-Whitney test for construct validity 

was significant p < 0.05 for the groups (experience surgeons, 

junior residents, medical students). 

Conclusions 

Our study shows that novice technical skills assessors with or 

without any surgical experience can not assess live laparoscopic 

operations. We aim in the future to assess if surgeons, 

with varying surgical experience and specified training in technical 

skills assessment can assess technical skills in live open 

and laparoscopic surgery. 


DEVELOPMENT OF A STRUCTURED GLOBAL TECHNICAL 

SKILLS ASSESSMENT TOOL IN OPEN & LAPAROSCOPIC 

SURGERY, Sudip K Sarker MD, Avril Chang MD,Charles 

Vincent PhD,Ara W Darzi MD, Department of Surgical 

Oncology & Technology, Imperial College London, UK 

Objectives 

Assessing live surgery using objective and structured methodology 

is still in its infancy. Assessing live operations in such a 

way removes bias and subjectivity and is a fairer assessment 

of technical performance of surgeons. We assess a global 

assessment tool for technical skills in open and laparoscopic 

surgery performed by attending/consultant surgeons and 

trainees. 

Methods 

A global assessment for primary inguinal hernia repair (IH) 

and laparoscopic cholecystectomy (LC) using generic and procedure 

specific scales for each operation were devised. All 

operations were recorded in their entirety and converted to 

DVD. Two experienced surgeons assessed the full length operations 

on DVD blindly and independently. 

Results 

All patients were between ASA 1-2, BMI < 30, < 75 years old. 

They were all discharged the same or next day. There were no 

post-operative complications. 

All IH were primary repairs and LC were grade 1-2. 60 live procedures 

were assessed (30 IH and 30 LC). 19/30 IH were performed 

by consultants, 11/30 performed by trainees. 22/30 LC 

were performed by consultants, 8/30 performed by trainees. 

Using Mann-Whitney comparing the generic and procedure 

specific scores for IH between consultants and trainees was 

significant, p = < 0.05, and for LC generic and procedure specific 

scores was also significant, p = < 0.05. 

Conclusions 



169



Our study shows that this global assessment tool for live surgery 

has construct validity and is able to differentiate from 

generic surgical technical skills and procedure specific skills. 

We aim to recruit more surgeons to our study and develop a 

parallel technical skills error scoring system. Also we aim to 

assess other common open and laparoscopic operations. 


ANALYSIS OF PSYCHOMOTOR SKILLS USED IN LEARNING 

TEP, Scott Ellner DO,David Easter MD, Michelle K Savu MD, 

UCSD, VA San Diego Healthcare System, San Diego, CA 

Introduction:Acquisition of advanced laparoscopic skills is necessary 

for continued learning of new emerging laparoscopic 

procedures. Which skills are essential for rapid and safe learning 

have yet to be defined. By using a standardized technique 

for dissection of hernias by TEP, we compared two groups of 

residents, one more novice (PGY-3) and one more experienced 

(PGY4-5) to assess the learning ability and skills necessary for 

acquisition of this technique. 

Methods: During a period from October 2003 until August 

2004, 31 patients underwent 55 hernia repairs, the majority of 

patients had bilateral hernias (23 patients) while the remaining 

9 had recurrent hernia repairs. All participating residents had 

seen or performed less than 1 TEP before starting in this 

study. Each resident was proctored by the same attending 

using a standardized approach to the TEP procedure. All procedures 

were recorded and analyzed according to psychomotor 

skills performed and at which frequency. Skills included 

use of 2 hands for grasping, dissection, counter traction, cutting, 

manipulation of mesh, and ability to staple at fixation 

point with accuracy (i.e. lack of slippage from intended insertion 

point). 

Results: The average age of the patient was 58 (31-81) years 

old. Three of 31 patients (5 hernias) were converted to open 

technique for inability to identify anatomy (2) or bleeding (1). 

Group 1 (PGY-3) performed 20 hernia repairs while group2 

(PGY 4-5) performed 30 repairs by the TEP method. The average 

operating time for Group 1 vs. 2 was 64 vs. 52 minutes 

(p


(CS2) tasks, and 5 validated VT tasks. Participants were then 

stratified according to pre-test composite score (sum of each 

task mean), and randomized into two groups. All subjects 

trained during one-hour weekly sessions over a 1-year period. 

In Group I (n=10) training continued until previously reported 

proficiency levels were achieved on each task (maximum 

attempts - 80); in Group II (n=11), training continued until 30 

repetitions where performed on each task. Statistical analysis 

was performed using t-tests, and chi-square. 

RESULTS: At pre-test there was no significant difference 

between scores of the two groups. During the study period all 

subjects completed the assigned training on all 17 tasks. Upon 

curriculum completion, proficiency was demonstrated for 98% 

of tasks by Group I compared to 72% of tasks for Group II 

(p<0.001). Compared to Group II, Group I achieved a significant 

better final score after fewer repetitions, which suggest 

that goal directed criteria might have enhanced motivation and 

maximized learning. Additionally, a non-significant trend 

towards a shorter training duration was noted for Group 

I.CONCLUSIONS: These data indicate that proficiency-based 

training results in superior performance and is more efficient 

compared to repetition-based endpoints. Future simulator 

training should incorporate predetermined proficiency scores 

as training goals and repetition-based training should be abandoned. 


THE ROLE OF OBSERVATION IN THE ACQUISITION OF 

LAPAROSCOPIC TECHNICAL SKILLS, Donna D Stanbridge RN, 

Melina C Vassiliou MD,Liane S Feldman MD,Simon Bergman 

MD,Gerald M Fried MD, Steinberg-Bernstein Centre for 

Minimally Invasive Surgery, McGill University, Montreal, QC 

Introduction: The observation of a motor task can activate cognitive 

processes similar to those seen during actual performance 

of that task. The technical challenges inherent to laparoscopic 

surgery have created a growing interest in how these 

skills are acquired. Research in surgery and motor learning 

has focused primarily on hands-on practice of skills, either in 

the operating room or in a simulation laboratory. The purpose 

of this study was to examine the relationship between repeated 

observation during MIS surgery without hands-on experience 

and the acquisition of laparoscopic technical skills in a 

physical simulator. 

Methods: After demonstration and explanation, 12 perioperative 

nurses (6 MIS-trained and 6 non-MIS trained) were scored 

during 2 iterations of the peg transfer task in the MISTELS 

(McGill Inanimate System for Training and Evaluation of 

Laparoscopic Skills) physical simulator. Scores and baseline 

characteristics (age, gender, handedness, years of OR experience) 

were compared between the MIS-trained group (n=6) 

and the non-MIS group (n=6). Fisher?s Exact test was used to 

analyze proportions and the Students t-test was used for continuous 

data. 

Results: There were no differences in baseline characteristics 

between the MIS and non-MIS trained nurses. The mean score 

in the peg transfer task (average of both iterations) for the MIS 

group was 71.5 (95% CI 61.1-81,9) compared to 44.6 (36.2-52.9, 

p=0.0025) for the non-MIS group. 

Conclusions: Active observation and participation in a MIS surgical 

team may contribute to the acquisition of laparoscopic 

technical skills. The role of observation in the training and 

evaluation of laparoscopic skills merits further study. 


INTEGRATING BASIC SKILLS IS COST-EFFECTIVE FOR TEACH- 

ING LAPAROSCOPIC SUTURING, Dimitrios Stefanidis MD, 

Sarah Markley MS,Rafael Sierra MD,James R Korndorffer Jr 

MD,Bruce J Dunne PhD,Daniel J Scott MD, Tulane University 

Health Sciences Center 

BACKGROUND: Laparoscopic suturing is an advanced skill 

that requires specialized training and is difficult to acquire. We 

hypothesize that mastering basic skills first may enhance skill 

acquisition and reduce resource requirements for a videotrainer 

(VT) suturing curriculum. 

METHODS: Medical students (n=18) with no previous VT experience 

were enrolled in an IRB-approved protocol, pre-tested 

on a validated suturing model, and randomized into two 

groups. Group I (n=9) trained (unsupervised) until proficiency 

levels were achieved on 5 basic tasks, whereas Group II (n=9) 

received no basic training. Both groups then trained (supervised) 

on the suturing model (1hr every other day) until previously 

reported proficiency levels were achieved. Scores (based 

on time and errors), training parameters, instruction requirements 

(interventions), and cost (material and personnel) were 

compared between groups using t-test. 

RESULTS: Pretest scores were similar for both groups and all 

subjects achieved the proficiency levels. The overall time 

required to finish the curriculum was similar for both groups 

(Group I 353 ± 58 vs. Group II 310 ± 98 min, NS). The Group I 

training strategy was more cost-effective with a savings of 

$147 per trainee. Group I required less active instruction (3 ±1 

interventions) compared to Group II (7 ± 4), p



able weightings contributing to score. We feel that the number 

and type of errors in laparoscopic training are more significant 

than either time or economy. MIST-VR variable weightings 

contributing to score should be modified according to training 

purposes. 


PREVENTING COMMON BILE DUCT INJURIES IN LAPARO- 

SCOPIC CHOLECYSTECTOMY - A TEACHING INSTITUTE 

EXPERIENCE, Abhay N Dalvi MS, Pinky M Thapar MS, Aparna 

A Deshpande MS,Sameer A Rege MS, Seth G S Medical 

College & King Edward VII Memorial Hospital 

Common bile duct (CBD) injuries after laparoscopic cholecystectomy 

(LC) have faulted the learning curve or experienced 

surgeons. Conversion rates range from 4.3 to 19%.(1-3) 

Teaching institutes are reported to have higher incidence of 

complications (0.65% to 0.3%)(4-6). In our Institute, starting the 

LC in 1994, we had a policy of converting the LC to open as 

soon as the operating surgeon or the supervising surgeon 

realized that it could cause CBD injury. A record was kept of all 

surgeons in training that varied on time scale. The aim was to 

convert before CBD injury. Factors were analyzed as to the 

causes of conversion. The results of the study on varying factors 

that influenced the reason for conversion are presented. 

From 1994 to 1996 while the faculty was under training, we 

analyzed the factors responsible for conversion. Nineteen factors 

were analyzed and a computer generated multivariate 

analysis was done. Of the 276 patients subjected to LC, conversion 

was in 22 (7.97%) with CBD injury in 2 (0.72%). Age 

greater than 65 years, prior upper abdominal surgery, ERC, 

palpable lump, wall thickness more than 4 mm, shrunken GB 

were the cause for conversion. From 1997 onwards, we had 

trained teachers; and resident doctors under training. Keeping 

the same principle of ?convert before CBD injury?, we kept on 

performing LC under supervision and being taken over by a 

senior as required. We have performed a total of 1260 LC with 

a conversion rate of 7.85% (n = 99). While the conversion rate 

was comparable, analysis of the cause of conversions was different. 

Contracted gall bladder (44.52%), pericholecystic collection 

(18.75%), adhesions (13.02%) and anatomical cause 

(13.23%) were the cause of conversions. The CBD injury rate in 

1260 cases done was 3 (0.23%) comparable to literature. 

Literature review suggests that visual perception illusion(7-9) 

and adhesions are commonest cause of CBD injuries. A common 

aim in a teaching institute can bring down the morbidity 

of CBD injury in LC. Constant supervision and vigilance can 

stem down the rate of CBD injuries. 

1.Sikora WJS 1995 

2.Woods Am J Surg 1994 

3.Roslyn Ann Surg 1993 

4.Fletcher Ann Surg 1994 

5.Gouma J Am Coll Surg 1994 

6.Woods Surg Endosc 1995 

7.Bingener Arch Surg 2003 

8.Krahenbuhl WJS 2001 

9.Way Ann Surg 2003 


OPERATIVE END-PRODUCT QUALITY AND PROCEDURE 

EFFECTIVENESS COMPARING ROBOTIC CAMERA HOLDER TO 

HUMAN CAMERA HOLDER IN A LAPAROSCOPIC INANIMATE 

SIMULATOR, Miro Uchal MD, Chris Haughn MD,Sam Rossi 

MD,Yannis Raftopoulos MD,Marc Torpey,Roberto Bergamaschi 

PhD, Dept. og Research and Develop., Forde Health System, 

Bergen University, Forde, Norway and Minimally Invasive 

Surgery Center, Allegheny General Hospital, Pittsburgh, PA 

Some reports suggested that robotic camera holders (RCH) 

may be superior to a human camera holder (HCH) in terms of 

motion efficiency, and rate of surgical error. This study aims to 

compare RCH to HCH with regard to operative end-product 

quality (OEPQ) and procedure effectiveness (PE) of suturing a 

perforated ulcer in a laparoscopic simulator. 

This was a prospective randomized crossover trial including 

voluntary post-graduate year (PGY) residents. Block randomization 

generated RCH - HCH or HCH - RCH sequence allocation. 

Tasks were suturing a perforated ulcer in a foam stomach 

and intracorporeally tying a surgeon?s knot in a inanimate 

physical simulator. The same voice-controlled robot and the 

same person operated the camera during all tasks. OEPQ was 

measured by accuracy error (AE), tissue damage (TD), sliding 

knot (SK) and leak rates. PE was measured by operating time 

(OT), non-goal directed actions (NGDA), and dangerous movements 

(DM). 44 subjects were needed to declare significant a 

1-min difference in operating time at the alpha=0.05 with 90% 

power. Data were presented as median (range). McNemar, 

Wilcoxon matched pair rank sum, and t-test were used for 

binary (SK, leak), ordinal (AE, TD, NGDA, DM), and continuous 

variables (OT), respectively. Kendall?s coefficient tau_b was 

used for concordance of 2 raters? evaluation to assess interrater 

reliability (IRR). 

44 subjects performed tasks as allocated. There were 15 PGY1, 

8 PGY2, 5 PGY3, 4 PGY4, 6 PGY5, 6 PGY6. All variables were 

not significantly different comparing 1st to 2nd task ignoring 

camera holder type. There was no evidence of unequal carryover 

effect when comparison was stratified by RCH - HCH or 

HCH - RCH sequence. Comparing RCH to HCH, leak rates 

(15.9% vs 34% p=0.001) and operating time (139 vs 159 p0.80) except for DM (tau_b=0.72, p=0.08). 

RCH compared to HCH led to decreased leak rate and operating 

time in suturing a perforated ulcer in a simulator. 


LARGE-SCALE ASSESSMENT OF LAPAROSCOPIC SKILLS 

USING SIMULATION: ANALYSIS FROM THE 2004 SAGES 

LEARNING CENTER MIST-VR STUDY, Kent R Van Sickle MD, 

Anthony G Gallagher PhD,E. Matt Ritter MD,David A McClusky 

MD,Andrew Ledermen MD,Mercedeh Baghai MD,C. Daniel 

Smith MD, Emory Endosurgery Unit, Emory University School 

of Medicine, Atlanta GA 

Background: The MIST-VR (Mentice, Gothenberg, Sweden) 

simulator has been validated as a training and assessment 

tool for technical skills in laparoscopy. The purpose of this 

study was to assess performance on the MIST-VR using a 

large number of experienced laparoscopic surgeons. Methods: 

Surgeons attending the SAGES 2004 Annual Meeting who had 

performed more than 100 laparoscopic procedures volunteered 

to participate and were tested in the SAGES Learning 

Center. All subjects performed two consecutive trials of the 

MIST-VR Core Skills 1 Program (acquire place, transfer place, 

traversal, withdrawal insert, diathermy task, manipulate 

diathermy). Trial 1 was considered a ?warm-up? and Trial 2 

functioned as the test trial proper. The mean performance 

results were analyzed for differences from Trial 1 to Trial 2 

using a paired t-test. Correlations between simulator performance 

and demographic information (i.e. age, experience, etc.) 

were made using a Pearson?s Correlation Coefficient r. 

Results: 57 surgeons participated in the study, 42 of which had 

complete data for both Trials. Average age was 42±8 years, 

average laparoscopic surgery experience was 8.5±5 years and 

1160±1250 cases, and 16 surgeons (38%) had prior MIST-VR 

experience. 

The strongest predictors of performance were previous MIST- 

VR experience (r= -0.63, p<0.0001), and younger age (r=0.36, 

p<0.02). No correlations were seen between MIST scores 

and years of laparoscopic experience (r=0.19, p=0.23) or number 

of laparoscopic procedures (r=-0.07, p=0.64), but greatest 

improvements in scores from Trial 1 to Trial 2 were seen in 

surgeons with no prior MIST-VR experience. Conclusions: 

Large-scale assessment of surgeons laparoscopic skills 

is possible using MIST-VR. There is a learning curve associated 

with the simulator, and should be taken into account when 

establishing performance criteria. Performance appears to be 

independent of laparoscopic experience and correlates well 

with prior MISTexperience 




CANNULATION: A POTENTIAL ADDITION TO THE FLS PRO- 

GRAM, Melina C Vassiliou MD, Donna D Stanbridge RN,Liane 

S Feldman MD,Gerald M Fried MD, Steinberg-Bernstein Centre 

for Minimally Invasive Surgery, McGill University, Montreal, 

Canada. 

In developing the simulator component of the SAGES FLS 

(Fundamentals of Laparoscopic Surgery) curriculum, cannulation 

was one of 3 deficiencies identified by a panel of experts. 

The purpose of this study was to create a cannulation task and 

evaluate its reliability, validity and internal consistency. 

Methods: Intravenous tubing with a premade defect is suspended 

in the endotrainer box. After viewing an instructional 

video, the operator uses 2 curved forceps to introduce a 

cholangiogram catheter into the box, threads it into the tubing 

up to a marked length and then removes it. The score is based 

on a cut-off time and normalized using the best performance 

of the sample. Participants (n=38) at all levels of training were 

timed and video-taped (n= 34) during 2 sequential iterations of 

the task by one of 2 examiners. Participants (n=30) were also 

tested in the FLS tasks. Inter-rater reliability was assessed by 

having the other examiner score the taped performances (intraclass 

correlation coefficient, ICC). Internal consistency was 

estimated using Cronbach?s alpha. Construct validity was 

evaluated by comparing novice (medical student ? PGY2, n= 

22) to experienced (PGY3 ? attending, n=16) operators (t-test) 

and concurrent validity was ascertained by correlating cannulation 

scores to total FLS score (manual component). Results: 

The inter-rater reliability for the mean score (both iterations) 

between examiners was 0.99 (ICC). Cronbach?s alpha with the 

addition of the cannulation task to the other tasks was 0.91 

and was not improved with deletion of the new task. The 

mean score for novices was 37 (95% CI 24-50) and for experienced 

operators was 86.2 (80.5 ? 91.9, p



they had further training in endoscopy prior to starting practice 

as opposed to 46% (p< 0.05) of non-rural surgeons. 

Rural surgeons perform flexible endoscopy at a much higher 

rate than their non-rural counterparts. The majority of rural 

surgeons feel they would have benefited from additional flexible 

endoscopy training prior to entering practice. 

P184–Hepatobiliary/Pancreatic 

Surgery 

TO DETERMINE THE VALUE OF DIAGNOSTIC LAPAROSCOPY 

IN PATIENTS WITH POTENTIALLY RESECTABLE ADENOCARCI- 

NOMA OF PANCREAS, Syed I Ahmed MD, Dmitry Oleynikov 

MD,Brian K Zebrowski MD,Arron Sasson MD, University of 

Nebraska medical center, Omaha 

Introduction: 

Minimally invasive surgical techniques especially staging 

laparoscopy can determine resectability of pancreatic adenocarcinoma. 

This may spare unnecessary laparotomy and its 

associated morbidity to non resectable patients with advanced 

disease. Therefore the aim of this study is to identify patients 

at our institution with unresectable pancreatic adenocarcinoma 

prior to non therapeutic laparotomy. 

Method: 

The records of patients undergoing pancreatic surgery were 

reviewed from 2001 to 2004 from a prospectively maintained 

data base. Inclusion criteria consisted of patients with adenocarcinoma 

of pancreas whereas non pancreatic peri-ampullary 

carcinomas, cystic neoplasm, and endocrine tumors were 

excluded. All patients were staged with a high resolution computed 

tomography (CT) scan prior to surgical intervention. 

Results: 

Fifty four patients meeting the above criteria were included in 

the study. These patients were identified and deemed 

resectable by routine preoperative staging. Thirty five patients 

underwent exploratory laparoscopy (Group I). Nineteen proceeded 

directly to laparotomy (Group II). In Group I, 10 

patients (28.6%) had obvious detectable metastatic disease at 

laparoscopy and were deemed unresectable. An additional 6 

patients were deemed locally unresectable radiographically 

and had staging laparoscopy only. The remaining 19 patients 

(Group I) proceeded to resection with curative intent but 2 

were found to have metastatic disease at laparotomy (false 

negative rate of 10.5%). 2 had locally advanced but non 

metastatic disease and were deemed unresectable. The combination 

of these 2 false negative patients and the 10 patients 

identified as having metastatic disease (true positive) represent 

34.2% of patient that were not resectable and would have 

ultimately benefited from laparoscopic staging. The reason for 

not performing laparoscopy in group II included need for biliary 

decompression, and extensive abdominal adhesions. 

Conclusion: 

In this series, laparoscopy altered the management in 28.6% of 

the patient undergoing resection for pancreatic malignancy. 

The morbidity and hospital stay was reduced significantly by 

not having to proceed to laparotomy in non resectable cases. 

Potentially up to 10.5% patients could have avoided laparotomy 

if all false negatives were detected. This false negative 

could be decreased by adding intraoperative laparoscopic 

ultrasound in future. 


Surgery 

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH SPLENIC 

PRESERVATION FOR SEROUS CYSTADENOMA OF THE PAN- 

CREAS: A CASE REPORT AND LITERATURE REVIEW, 

Kanayochukwu J Aluka MD, Cynthia Long MD,Terrence M 

Fullum MD, Providence Hospital 

Introduction: A minimally invasive approach can be beneficial 

in spleen preserving distal pancreatectomy. We present a 71 

year old female in which laparoscopy was used for resection 

of an incidental 4cm x 3cm x 2cm serous cystadenoma of the 

pancreas. 

Method: A 71 year old female who presented to her internist 

with HTN and persistent hypokalemia had an MRI to rule out 

an adrenal mass. The MRI revealed a lesion of the distal pancreas 

and normal adrenal glands. She was referred to the 


General Surgery Service for resection of the distal pancreatic 

lesion. A laparoscopic spleen preserving distal pancreatectomy 

was performed using the EndoGIA? linear cutter stapler with 

PeriStrips?. 

Results: The pathology report revealed a completely excised 

cystic lesion with a diagnosis of serous cystadenoma with 

focal fibrosis and atrophic acini. Postoperatively the advantages 

of the laparoscopic approach were exemplified with the 

patient?s early return of bowel function, minimal narcotic 

requirements and early resumption of normal activities. 

Conclusion: This case illustrates the advantages of minimally 

invasive surgery in the performance of a spleen preserving 

distal pancreatectomy. 


Surgery 

THE EFFECTS OF PRE-OPERATIVE ROFECOXIB, METOCLO- 

PRAMIDE HYDROCHLORIDE DEXAMETHASONE, AND 

ONDANSETRON ON POST OPERATIVE PAIN AND NAUSEA IN 

PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTO- 

MY, Marc C Antonetti MD, Phiet Bui, Orlando Kirton 

MD,Richard Lilly MD, University of Connecticut 

Improvements in the safety and efficiency of laparoscopic 

cholecystectomy (LC) have transformed this operation into an 

outpatient procedure. Postoperative pain and nausea are 

deterrents to eventual same day discharge. No trial to date has 

evaluated the combined effect of pre-operative Rofecoxib, 

Metoclopramide, Dexamethasone, and Ondansetron on postoperative 

pain and nausea in patients undergoing LC. 

A prospective randomized double-blinded placebo controlled 

trial was conducted on patients undergoing elective LC at a 

single tertiary referral center from January 2002 until June 

2004. The patients in the intervention group received 

Rofecoxib 25 mg PO during the admission process. All 

patients were given a standard anesthetic regimen. 

Additionally the study group received Metoclopramide 10 mg 

IV and Dexamethasone 4 mg IV after induction; and 

Ondansetron 4 mg just prior to closure. Local anesthetic was 

administered to all wounds at the conclusion of the procedure. 

A 0-10 box scale was used to rate pain and nausea pre-operatively, 

on arrival at PACU, 0.5, 1.5, 3, 6 and 9 hours after 

arrival, at discharge, and at 24 hour follow-up. 

Of the 249 patients consented, 44 were excluded for a final 

study sample of 205. There were 97 patients in the control 

group, and 108 received intervention. 16% of the patients were 

male; 84% were female. The intervention and control groups 

were compatible on most demographic and health characteristics. 

The intervention group had a significantly smaller proportion 

of men than control group (10% vs. 23%; p


laparoscopic equipment with very reduced diameter, which 

has led to “state of the art” of 2mm instruments, also known 

as mini or needle instruments. 

OBJECTIVE: To present modifications to mini-laparascopic 

technique which may make it possible to conduct minilaparascopic 

procedures safely and effectively, thereby reducing 

considerably the cost of this type of surgery. 

PATIENTS: Patients suffering from chronic lithiasic cholecystitis 

at various stages of the disease were submitted to procedures 

fully performed by mini-laparascopy, including acute 

cholecystitis and per-operative cholangiography. 

METHOD: After performing the pneumoperitoneum in the 

umbilical site, four trocars are inserted; two of 2mm (support 

trocars), one of 3mm (work trocar) and one of 10mm, through 

which a 10 mm 30 degrees laparoscope is inserted. Neither 

the 3mm laparoscope nor clips are used, the cystic artery is 

safely sealed by eletrocautery, near the gallbladder and the 

cystic duct is sealed with surgical knots. Removal of the gallbladder 

is carried out, in a bag made with a glove wrist, 

through the 10mm umbilical site. 

CONCLUSION: Mini-laparascopic cholecystectomy is a safe 

and effective procedure which results in a better esthetic effect 

for the patients, when compared to conventional laparascopy. 

The technique described above allows a considerable reduction 

in the costs associated with the original mini-laparascopic 

procedure, since neither clips, endobags, nor mini-loops are 

used. Neither is any use made of 3mm laparoscope which is 

the most expensive component among mini-laparascopic 

instruments. 


Surgery 

LAPAROSCOPIC CBD EXPLORATION WITHOUT T-TUBE, In 

Seok Choi PhD, Ji Hoon Park MD,Won Jun Choi PhD,Dae 

Gyoung Go MD,Dae Sung Yoon MD, Dept. of Surgery, 

Konyang University Hospital, Konyang University College of 

medicine, Daejeon, Korea 

(Objective) Laparoscopic common bile duct 

exploration(LCBDE) is feasible and becoming popular. LCBDE 

has traditionally been accompanied by T-tube drainage which 

has a 4.7-17.5% morbidity rate and increases hospital stay. 

Avoidance of T-tube drainage therefore should advantageously 

contribute to the ideal approach for LCBDE. The authors report 

a prospective evaluation of LCBDE without T-tube drainage. 

(Methods and Procedures) Between March 2001 and August 

2004, 30 patients with common bile duct(CBD) stones underwent 

this approach. We adopted internal endobiliary stent in 

11 patients and performed primary closure for choledochotomy. 

Other 19 patients who had external drainage such as, 

endoscopic nasobiliary drain(ENBD), percutaneous transhepatic 

biliary drain(PTBD), were treated by LCBDE with primary 

closure. 

(Results) Open conversion, because of impacted large CBD 

stones, was 1 case (3.5%). The mean operative time of LCBDE 

was 134 minutes, postoperative hospital stay was 8.5 days. 

Complication rate was 13.8%( 4/30 cases, 2 cases : migration 

of endobiliary stent in CBD, 1case : subhepatic biloma, 1case: 

retained stone) and no mortality. The rate of successful stone 

removal was 96.6%. Biliary stents were eliminated spontaneously 

via the gastrointestinal tract among 4 patients, and for 

6 patients, the stents had to be removed endoscopically. The 

other 1 patient underwent laparotomy for stent removal. 

(Conclusions) LCBDE without T-tube was safe and feasible 

technique. Further study and assessment of internal biliary 

stent should be warranted. 


Surgery 

LAPAROSCOPIC LIVER RESECTION IN PORCINE: DEVELOP- 

MENT OF AN EXPERIMENTAL MODEL, Alex Escalona MD, 

Felipe Bellolio MD,Nicolás Jarufe MD,Luis Ibáñez MD,Gustavo 

Pérez MD,Matías Guajardo MS, Pontificia Universidad Católica 

de Chile 

Introduction: The development of the laparoscopic surgery has 

permitted to incorporate this technology to the surgical treatment 

of different pathologies. The left lateral segmentectomy 

(LLS) (segments II and III of Couinaud) is the more frequently 

carried out laparoscopic liver resection. The objective of this 

study is to evaluate the feasibility to carry out laparoscopic 

LLS in porcine model and to compare the results with the 

open technique. Material and Methods: Ten animals of similar 

age, weight and size were undergone to LLS. In 4 cases the 

procedure was performed by open technique (group 1) and in 

6 cases by laparoscopy (group 2). The operative time, bleeding 

and weight of the resected liver segment was registered in a 

prospective database. Autopsy was carried out at seventh 

postoperative day. Results: The operative time was 77 ± 19 

minutes in the group 1 and 52 ± 38 minutes in the group 2 (p = 

0,21). Intraoperative bleeding was of 185 ± 67 and 70 ± 52 ml. 

in the group 1 and 2 respectively (p = 0,01). The weight of the 

extracted segment was of 128 ± 27 and of 128 ± 16 grams in 

groups 1 and 2 respectively (p = NS). One animal operated by 

open technique presented a wound infection. There were no 

other complications or deaths. Conclusions: Laparoscopic LLS 

in porcine model is a feasible procedure. In this series a less 

intraoperative bleeding was observed in the animals operated 

by laparoscopic technique. The operative time and weight of 

the specimen is comparable in both techniques. The implementation 

of this procedure in an animal model could be useful 

in the development of research, acquisition of laparoscopic 

skills in liver surgery and implementation of the technique in 

humans. 


Surgery 

IMPROVEMENT IN GASTROINTESTINAL SYMPTOMS AND 

QUALITY OF LIFE FOLLOWING CHOLECYSTECTOMY, Kelly R 

Finan MD, Leeth R Ruth MPH,Brian M Whitley MPH,Joshua C 

Klapow PhD,Mary T Hawn MD, University of Alabama at 

Birmingham 

Background: Laparoscopic cholecystectomy (LC) is the accepted 

treatment for symptomatic gallstone disease, but has been 

criticized as an over-utilized procedure. The aim of this study is 

to assess the effectiveness of LC on reduction of specific gastrointestinal 

(GI) symptoms and the impact on quality of life 

(QOL). Methods: A prospective cohort of consecutive subjects 

evaluated for gallstone disease between 8/2001 and 7/2004 

were given the SF-36 QOL survey and a gallbladder symptom 

survey. The latter was developed to assess symptom frequency, 

severity and distressfulness for 16 related GI symptoms. 

Postoperative surveys were sent to all subjects who underwent 

LC. A chart abstraction was performed to collect demographic 

information and operative details. The surveys were 

scored and evaluated using paired t-tests. Results: 100 patients 

were mailed postoperative surveys with a 61% response rate 

at a mean follow up of 17.5 months (2-31). Preoperative indications 

were biliary colic (64%), cholecystitis (15%), biliary pancreatitis/cholodocholithiasis 

(11%) and biliary dyskinesia (8%). 

Preoperative QOL scores measured by the SF-36 were significantly 

below normative values in 6 of 8 categories (p





Surgery 

MINIMALLY INVASIVE INCISION FOR CYSTGASTROSTOMY IN 

LARGE PANCREATIC PSEUDOCYSTS, S Dissanaike MD, B 

Barragan MD,J A Griswold DO,E E Frezza MD, Texas Tech 

University Health Sciences Center 

There are many approaches to the treatment of pancreatic 

pseudocysts, including laparoscopic, endoscopic and open 

surgical drainage. We have previously described the merits of 

the posterior approach to laparoscopic cystgastrostomy (LCG). 

We describe a minimally invasive approach to open drainage 

in patients with very large pseudocysts and compare this to 

our previous experience with both laparoscopic and open cystgastrostomy. 

METHODS 

Seven patients underwent LCG, two patients underwent open 

CG via standard incision and two patients underwent open CG 

(OCG) with a small (less than 10cm) left subcostal incision. The 

laparoscopic group consisted of both anterior and posterior 

approaches. The open group consisted of those with a midline 

incision. The minimally invasive open group had a left subcostal 

incision placed approximately 3-4 cm below the costal 

margin for direct approach to the pseudocyst. 

RESULTS 

All of the patients developed pancreatitis and pseudocyst secondary 

to gallstones. Three patients had LCG via the anterior 

approach; four via the posterior approach. Two patients had 

OCG via the midline incision, and two via the smaller subcostal 

incision. 

The open group had larger pseudocysts (21 +/- 3cm diameter) 

than the laparoscopic group (10 +/- 3cm). Most of the patients 

in the open group also had previous major abdominal operations 

(n=3).The combination of large cysts and previous operations 

made these patients less suitable for the LCG approach 

and at a higher risk of conversion. The patients with the minimal 

subcostal incision had pseudocysts of 22 and 24 cm, 

respectively. The post-operative analgesic requirements, time 

to return of bowel function and length of stay was shorter in 

the laparoscopic (4 +/- 2 days) and minimally invasive open 

groups (5 +/- 2 days), compared to the midline approach (10 

+/- 2 days). 

CONCLUSION 

We have previously reported that LCG is usually associated 

with less post-operative pain and quicker return to function 

than the open operation. However, patients with a very large 

pseudocyst may not be suitable candidates for safe LCG. In 

these patients, we found that we were able to successfully perform 

an OCG using a minimal subcostal incision. This enabled 

an earlier return to function and less post-operative pain when 

compared to the open midline approach, with a mean hospital 

stay similar to patients with LCG. 


Surgery 

LAPAROSCOPIC　PANCREATIC CYSTGASTOROSTOMY, 

Kazunori Furuta PhD, Hiroki Hoshino MD,Masamichi Katori 

PhD,Kouichi Itabashi PhD,Tsuyoshi Takahashi PhD,Muneki 

Yoshida PhD,Masahiko Watanabe PhD, Kitasato University 

Internal drainage of acute pancreatic pseudocysts is indicated 

that have no reduced 8 weeks after the first occurrence of 

pseudocysts. 

Pancreatic pseudocysts are best drainage by pseudocystgastrostomy, 

when they are located in adhere closely with the 

posterior wall of the stomach. Pseudocystgastrostomy can be 

completed using of intraorgan surgical technique.We present 

the case of laparoscopic pancreatic cystgastrostomy. 

Using a technique of percutaneous endoscopic gastrostomy, 

under gastroendoscopic observation, three intragastric ports 

are placed through the abdominal walls and the anterior gastric 

walls. 

One port for a telescope and the other two ports for bi-hand 

instruments are established. 

After the location of the pseudocysts is confirmed, the posterior 

gastric wall and cyst wall can be incised and drainage orifice 

is made by electrocautery and Harmonic Scalpel (Ethicon 

Endo-Surgery). After a sufficient orifice is made, the cyst contents 

are discharged into the stomach completely. After the 

intragastric ports are removed, the defect of the anterior gastric 

walls are closed with sutures in laparoscopically.This 

approach is less invasive than the conventional procedure and 

a safe procedure for cyst drainage. However, in the treatment 

for pancreatic pseudocysts, there are many options that convention 

surgery, catheter drainage of cysts , using interventional 

radiology technique and endoscopic interventions. 

Laparoscopic pancreatic cystgastrostomy is one of the treatment 

options. 

?@This procedure should be the one of the method of choice 

when the interventional methods are not effective. 


Surgery 

QUALITY OF LIFE AFTER LAPAROSCOPIC AND OPEN CHOLE- 

CYSTECTOMY-A COMPUTER BASED ANALYSIS USING THE 

GASTROINTESTINAL QALITY OF LIFE (GIQLI ) INDEX, Istvan 

Gal PhD, Lorand Nagy, Department of Univ.Teaching Surgery 

Bugat Pal Hospital, Gyöngyös Hungary 

Qality of life is a multifactorial construction of several dimensions: 

emotional or psychological well being, physical function, 

social relations and symptoms of diseases as well as 

results of treatment. For assesment of these dimensions tha 

Gastrointestinal Qality of Life Index (GIQLI) developed by 

Eypasch et al. was used. The GIQLI is a questionnaire containing 

36 questions each with five response categories. These 

data were analysed with a computer program ( SPSS for 

Windows) 

Inthe present study the GIQLI was tested in 240 patients who 

were randomised for laparoscopic (LC)-120pts- or open (OC)- 

120 pts- cholecystectomy. The obtained data were compared 

to data of healthy volunteers ( 168). The questionnaires were 

filled by the operated patients under the control of a physician 

at the follow-up visits at 1 to 5 years after surgery. 

There was significant ( p less 0.05) difference between the 

mean score of the LC group( 115,00 plus- minus 18,98 GIQLI 

points) and that of the patients underwent OC ( 108 plus-minus 

22.48 GIQLI points). The mean value of healthy volunters 

group ( 124, 8 plus-minus 13 GIQLI points) was not significantly 

higher than that LC group , while it was significantly higher ( 

p less 0.01) than that of the OC group. The mean values measured 

at different time points following the operations ( within 1 

year 107.65 OC vs. 112.94 LC, in the 5th year 111.76 OC vs 

119.39 LC) were similar, and they did not show signifivant differences 

( p less 0.05) comparing the starting values. 

In cinclusion, the quality of life can be a measurable parameter 

for the clinical practice. The computer program SPSS for 

Windows seems to be usefol for statistical analysis of quality 

of life data. The GIQLI scores demonstrated that quality of life 

following LC does not differ significantly from that of healthy 

volunteers, while after the OC a significantly poorer quality of 

life was registered. 


Surgery 

ENDOSCOPIC ULTRASOUND EVALUATION DIRECTS LAPARO- 

SCOPIC RESECTION OF PANCREATIC NEOPLASMS, T C 

Gamblin MD, N Jani MD,K McGrath MD,K K Lee MD, Divisions 

of Surgical Oncology and Gastroenterology, Hepatology, and 

Nutrition, University of Pittsburgh, Pittsburgh, PA., USA 

Introduction: Although laparoscopic resection of the distal 

pancreas is technically feasible and safe, its oncologic appropriateness 

for the treatment of invasive pancreatic cancer 

remains undetermined. Endoscopic ultrasound (EUS) provides 

detailed imaging of pancreatic abnormalities and can guide 

fine needle aspiration (FNA) of these abnormalities. We 

describe in two patients the use of EUS with FNA to establish 

the low malignant potential of solid pancreatic masses and 

their subsequent treatment by means of laparoscopic distal 

pancreatectomy. 

Methods/Procedures: Two patients were found on abdominal 

CT to have solitary solid masses in the body of the pancreas. 

EUS demonstrated the masses to be hypoechoic with well-


defined borders, and with no signs of invasion into the splenic 

artery or vein. EUS-guided FNA in both patients confirmed the 

diagnosis of a pancreatic solid pseudopapillary tumor (SPT), 

an uncommon tumor of the pancreas possessing low malignant 

potential and usually cured by surgical resection alone. 

Based upon this definitive preoperative diagnosis, complete 

resection of both masses was accomplished by means of a 

laparoscopic distal pancreatectomy. Final pathologic evaluation 

of both resected specimens confirmed the diagnosis of 

SPT. 

Conclusions: Until laparoscopic treatment of pancreatic cancer 

is proven to be comparable to open treatment, laparoscopic 

resection should be limited to abnormalities that are benign, 

premalignant, or of low malignant potential. These two cases 

demonstrate the utility of a management algorithm that combines 

preoperative evaluation by means of EUS with FNA, followed 

either by laparoscopic or open resection as directed by 

the EUS and FNA results. 


Surgery 

MIRIZZI SYNDROME AFTER LAPAROSCOPIC ROUX-EN-Y 

GASTRIC BYPASS, Giselle G Hamad MD, Kenneth K.W. Lee 

MD,Ryan Levy MD,Adam Slivka MD, University of Pittsburgh 


Mirizzi syndrome is an uncommon disorder characterized by 

benign extrinsic compression of the extrahepatic bile duct by a 

gallstone impacted in the cystic duct. Following Roux-en-Y 

gastric bypass, performance of ERCP to establish the diagnosis 

of Mirizzi syndrome is challenging because the distal stomach 

and duodenum are excluded. A 46 year-old female who underwent 

laparoscopic Roux-en-Y gastric bypass 30 months ago 

presented with right upper quadrant pain and nausea. 

Laboratory data revealed conjugated bilirubin 0, total bilirubin 

0.5, alkaline phosphatase 975, AST 155, ALT 191. Amylase and 

lipase were elevated at 193 and 785, respectively. Right upper 

quadrant ultrasound demonstrated a 1.7 cm gallstone and 

dilatation of the common bile duct and right hepatic duct. The 

patient underwent an attempted laparoscopic cholecystectomy. 

Because a calculus was impacted in the cystic duct, intraoperative 

cholangiography was not possible. Intraoperative 

ERCP was performed through a gastrotomy created in the 

excluded distal stomach and established the diagnosis of 

Mirizzi syndrome. The proximal common bile duct was dilated 

and was compressed by a 2 cm stone impacted in the cystic 

duct that was eroding through the distal cystic duct wall, causing 

ductal necrosis. An additional 2 cm stone was identified 

within the common bile duct. Endoscopic stone extraction and 

lithotripsy were attempted but were unsuccessful. The procedure 

was then converted to an open cholecystectomy and 

common bile duct exploration. Intraoperative cholangiography 

confirmed clearance of the common bile duct. The patient 

recovered uneventfully. Mirizzi syndrome after Roux-en-Y gastric 

bypass presents a unique challenge for both diagnosis and 

surgical management. ERCP through the excluded stomach is 

valuable in establishing the diagnosis. 


Surgery 

TOTALLY LAPAROSCOPIC RIGHT POSTERIOR SECTIONECTO- 

MY (SEGMENTS VI-VII) FOR HEPATOCELLULAR CARCINOMA, 

Ho-Seong Han MD, Yoo-Seok Yoon MD,Yoo Shin Choi 

MD,Sang Il Lee MD,Jin-Young Jang MD,Sun-Whe Kim 

MD,Yong-Hyun Park MD, Department of Surgery, Seoul 

National University College of Medicine, Seoul, Korea 

Introduction: Localization of lesions is considered as a major 

determinant for the indication of laparoscopic liver resection. 

Until now, reports on laparoscopic liver resections mainly 

involved the antero-lateral segments (Couinaud segments II- 

VI). We report on a totally laparoscopic right posterior sectionectomy 

for hepatocellular carcinoma. To our knowledge, 

this is the first reported case in terms that it was totally performed 

laparoscopically. 

Methods and Procedures: A 57-year-old man known as a HBs 

Ag carrier presented with a liver mass detected in the physical 

checkup. Abdominal USG and CT revealed a 5cm sized single 

nodular hepatoma located in S6-7, multi-septated cystic tumor 

presumed to originate from the liver. Preoperative liver function 

was Child A. A totally laparoscopic right posterior sectionectomy 

was performed. Five trocars were inserted at the 

proper position. After cholecystectomy, the ligaments around 

the liver and right triangular ligament were dissected. Liver 

was dissected from the IVC and short hepatic veins met during 

dissection were controlled with double application of endoclips. 

After full mobilization of the right liver, major Glissonian 

cord to right post section was dissected and transected with 

endo-GIA. The hepatic parenchyma was dissected with 

Harmonic scalpel and Ligasure along the ischemic line. The 

small branches of hepatic veins were controlled with endoclips 

and large branches were transected with endo-GIA. The hepatic 

veins were transected with endo-GIA. The epigastric trocar 

site was extensionally incised for the removal of the specimen. 

Results: The operative time was 540 minutes. The estimated 

intraoperative blood loss was about 1450 cc, and 3 units of red 

blood cells were transfused. The patient was discharged on 

postoperative day 13 without postoperative complications. 

Postoperative pathology confirmed a hepatocellular carcinoma 

with 1 cm free resection margin. He remains alive without the 

evidence of recurrence after follow-up of 12 months 

Conclusion: This case confirms that totally laparoscopic liver 

resection is a possible operative procedure in the patient with 

the lesion in the right posterior section of the liver. However, 

the technical problems such as long operation time and large 

amount of blood loss should be resolved in order that this procedure 

can be more safely accomplished. 


Surgery 

LAPAROSCOPIC MANAGEMENT OF INSULINOMAS, Jorge 

Montalvo MD,Paulina Bezaury MD,Manuel Tielve MD,Juan A 

Rull MD,Juan P Pantoja MD, Miguel F Herrera MD, Department 

of Surgery, INCMNSZ, Mexico City, Mexico. 

Background. Laparoscopic resection of Insulinomas has been 

reported with increasing frequency. Preoperative localization 

and intraoperative evaluation by ultrasound have been extensively 

recommended. 

Patients and methods. In a 10 year period, 13 patients (pts) 

with biochemical diagnosis of organic hypoglycemia were 

referred for surgical treatment. In all pts laparoscopic management 

was attempted. Preoperative clinical, biochemical and 

radiological characteristics, surgical findings and procedures, 

and postoperative outcome were reviewed and analyzed. 

Results. There were 9 females and 4 males with a mean age of 

37 ± 15 years. All pts presented with symptoms of neuroglycopenia. 

Fasting serum glucose was low in all pts (mean value 

38 ± 8.2 mg/dL). In 7 of 11 pts basal serum insulin was elevated. 

C Peptide was measured in 8 pts and was abnormal in 6. 

Plasma insulin/glucose ratio was abnormal in 91% pts. The 

tumor was preoperatively situated by image studies in 10 pts 

(76.9%). Of the 11 pts who underwent CT, the tumor was correctly 

localized in 7, also in 2 of the 4 pts who underwent MRI 

and in 9 of the 12 pts in whom angiography was performed. 

Using the selective arterial stimulation image test the tumor 

was regionalized in 5 of 6 pts. Surgical procedures included 

Lap enucleation in 3 pts, and Lap distal pancreatectomy in 7, 

of these, Lap splenectomy was necessary in 3 pts. In all these 

cases the tumor was situated in the body or tail of the pancreas. 

Conversion to open surgery was necessary in 3 pts. In 2 

pts the tumor was located in the head, and in one case no 

tumor was found and an open subtotal pancreatectomy was 

performed. Intraoperative US was used in 10 pts. In 9 pts US 

correctly localized the tumor. There were no intraoperative 

complications. Two pts developed postoperative complications 

(a pancreatic pseudocyst in one, and a pancreatic fistula with 

an abscess that required drainage in one pt that had a conversion). 

Mean tumor size was 2.2 cm ± 0.9 cm. 

Postoperative glucose levels became normal in all pts. In a 

mean follow-up of 21 ± 15 months, no recurrences have been 

observed. 

Conclusion. Laparoscopic resection of Insulinomas can be efficiently 

performed in most tumors located in the body and the 

tail of the pancreas. 



177




Surgery 

SURGICAL TREATMENT OF BILE DUCT INJURIES FOLLOWING 

LAPAROSCOPIC CHOLECYSTECTOMY, Faton T Hoxha, 

University Clinical Center, Surgery Clinic, Hepato-biliary 

Service, Medical Faculty of Prishtina, Kosovo 

Background: Bile duct injuries remain one of the most devastating 

injuries during Laparoscopic cholecystectomy. In a retrospective 

study, we analyses the clinical presentation, diagnostic, 

therapeutic treatment and results of ten patients with bile 

duct injuries. 

Methods: Retrospective analysis of patients requiring biliary 

reconstruction with bile duct injuries during Laparoscopic 

cholecystectomy at our Center and other Regional Centers 

between 2000-2003. 

Results: Three patients presented with circumferential bile 

duct injuries( one with wall defect); two tangential lesions, one 

bile stricture after suture of the lesion; Less severe injuries ( 

four were bile leaks from Luschka canals). According to the 

Strasberg classification are 2 patients - E1; 1-E2; 1-E4; 2-D, and 

4-A injuries. According to Stewart-Way Classification of 

Laparoscopic bile duct injuries are 2 patients -I Class; 1-II; 2-III 

and 1- IV class. All of them were treated surgically. Suture at 4 

patients with Luschka canals, and suture with T drainage at 

tangential lesions at two patients and one with thermal lesion ; 

Hepatico-duodenostomy with good mobilization of duodenum 

at one patient with T drain, and two R-Y hepatico ?jejunostomy. 

Patients were dismissed from Hospital after a median of 

24 days after operation. Signs of cholangitis presents at three 

patients . 

Conclusions : High morbidity, prolonged hospitalization is 

present at Bile duct injured patients. Early recognition of injury 

and early referral to more experienced center is then main 

determinant of the success. 


Surgery 

LAPAROSCOPIC HEPATECTOMY FOR METASTATIC LIVER 

TUMOR AFTER LAPAROSCOPIC COLECTOMY - REPORT OF 2 

CASES., Hitoshi Inagaki MD, Tsuyoshi Kurokawa MD,Hiroshi 

Nagata MD,Katsuhiro Kotake MD,Yoshihiro Owa MD,Ichiro 

Horikoshi MD,Mari Tsubamoto MD,Takashi Arikawa 

MD,Toshiaki Nonami MD, Department of Surgery, Aichi 

Medical University 

From December 1997 to August 2004, we performed in a total 

of 54 laparoscopic hepatectomies. Among them were 7 

patients with metastatic liver tumor. Two of these cases had a 

past history of laparoscopic colectomy for primary disease. 

The first patient was a 60-year-old man who was diagnosed 

with a metastatic liver tumor located in segment 6 after right 

colectomy for the ascending colon cancer. The second patient 

was a 73-year-old man with a metastatic liver tumor located in 

segment 5 after sigmoidectomy for the sigmoid colon cancer. 

The operative therapy for primary disease was pathologically 

curative. Both liver tumors were solitary. 

There was little adhesion to the abdominal wall in both 

patients, and no recurrence in the port sites. In the first patient 

we used hand-assisted laparoscopic surgery (HALS), and we 

made a small incision for HALS to confirm the existence of 

adhesion. In the second patient we did not use HALS. Both 

patients began to walk at post operative day 1. Their hospital 

stay after operation was 11 days and 14 days, respectively. 

Although the indications for laparoscopic hepatic resection are 

determined, we believe that laparoscopic hepatectomy is also 

one useful strategy for metastatic liver tumor, especially after 

laparoscopic colectomy for primary tumor. 


Surgery 

TOTALLY LAPAROSCOPIC MANAGEMENT OF CHOLEDOCHAL 

CYST USING 4 HOLES METHODS, JY Jang MD, SW Kim 

MD,HS Han MD,YS Yoon MD,MG Choi MD,YH Park MD, 

Department of Surgery, Seoul National University College of 

Medicine, Seoul, Korea 


Objectives: Choledochal cyst is a rare benign disease in a biliary 

tract. However it must be excised with gallbladder (GB) 

due to the risk of cancer development in biliary tree including 

GB. Here we introduce new surgical technique for totally 

laparoscopic excision of choledochal cyst and hepaticojejunostomy 

using 4 holes methods. 

Methods: Between October 2003 and September 2004, we performed 

totally laparoscopic choledochal cyst excision in seven 

patients. All were female with mean age 32.5 (range:19-46) 

years old. According to the Todani classification, four were 

type Ia, one type Ic and two type IV. Choledochal cyst excision 

and Roux-en-Y hepaticojejunostomy was entirely performed 

laparoscopically using 4 port technique. 

Results: The mean operation time was 272 (200~330) minutes. 

There was no operative or postoperative transfusion. An oral 

diet was started on the 3rd operative day. The average length 

of hospital stay was 5.5 days. There was no morbidity associated 

with anastomosis leakage or obstruction. All patients 

have showed no specific symptoms or laboratory abnormalities 

during 5~9 months follow-up periods. 

Conclusions: Considering that choledochal cyst is common in 

young ages and females, who are especially interested in cosmetic 

results as well as cure of disease, laparoscopic management 

of choledochal cyst can be an attractive treatment 

option. 


Surgery 

CALCULOUS CHOLECYSTITIS AFTER LIVER TRAUMA IN A 

CHILD, Jin Kim PhD, Min Young Cho PhD,Chong Suk Kim 

PhD,Young Chul Kim PhD,Cheung Wung Whang PhD,Sung 

Ock Suh PhD, Korea University Hospital 

Gallbladder disease is quite uncommon during childhood and 

adolescence. Cholelithiasis is not often given serious consideration 

in differential diagnosis of abdominal pain. We report the 

development of calculous cholecystitis after hepatic injury in a 

4 year-old child. He got hepatic grade III injury in a traffic accident. 

After a period of conservative treatment, the patient 

complained of abdominal pain. Follow-up computed tomography 

of abdomen showed multiple stones in gallbladder which 

had not been shown in the initial study. He was successfully 

treated with laparoscopic cholecystectomy. A review of the literature 

indicates that calculous cholecystitis is associated with 

hemobilia and parenteral nutrition in children . 


Surgery 

NEEDLESCOPIC CHOLECYSTECTOMY, Fumito Kuranishi PhD, 

Yoshinori Kuroda PhD,Yuzou Okamoto PhD,Masahiro 

Nakahara PhD,Shuuichi Wada PhD,Mizukami Taketomo 

MD,Toshikatu Fukuda PhD,Masataka Banshoudani MD,Manabu 

Shimomura MD,Junnko Nanbu MD, Onomichi General 

Hospital 

?yINTRODUCTION?zWe have introduced laparoscopic cholecystectomy(LC) 

from 1992,and performed it 800 

cases.?@According to the development of peripheral equipment 

we have started needlescopic cholecystectomy(NC) from 

1997. Conventional laparoscopic cholecystectomy has done by 

four trocar method(12,12,5,5:Group A), needlescopic cholecystectomy(NC) 

has done by four trocar method(12,3,3,3:Group 

B).?@First trocar was inserted ?@infraumbilically,another 

three was inserted by rotation.We compared conventional 

laparoscopic cholecystectomy (Group A) and needlescopic 

cholecystectomy(NC:Group B) in several aspects.We report the 

detail about it. 

?yOBJECT?zFrom 1997, we have done 328 cases of 

LC.?@Exclusion criteria was combined 

operation(25cases:Modified radical mastectomy etc),open conversion(29cases),complication(3cases). 

Therefore we estimated 

271cases of LC(Group A 223 cases,Group B 48cases). 

?yRESULT?zAbout first walking, first flatus, intestinal murmur, 

first stool and laboratory data(WBC,CRP) there was no significant 

difference. 

But post opearative analgesics(Group A 2.6?}1.8 

times,?@Group B 1.9 ?}1.7 

times, p =0.02),oral intake (Group A 1.2?}0.5 days,?@Group


B1.1?}0.3days, 

p =0.02),post opeartive hospital stay (Group A 4.5?}2.7 

days,?@Group B 3.9?} 

2.2days, p =0.01) there was significant difference. 

?yCONCLUSION?z This is a not randomized but historical 

study.?@Needlescopic cholecystectomy contributed to shorten 

the post opeartive hospital stay. The main reason of shorter 

hospital stay was faster recovery due to less pain and faster 

oral intake. 


Surgery 

POST LAPAROSCOPIC CHOLECYSTECTOMY BODY TEMPERA- 

TURE, Fumito Kuranishi PhD, Yoshinori Kuroda PhD,Yuuzou 

Okamoto PhD,Masahiro Nakahara PhD,Toshikatsu Fukuda 

PhD,Hideichi Wada PhD,Manabu Shimomura,Masataka 

BAnshoudani,Junnko Nanbu,Taketomo Mizukami, Onomichi 

General Hospital 

?yINTRODUCTION?zWe have introduced laparoscopic cholecystectomy(LC) 

from 1992,and performed it 800 cases. At the 

beginning, we have adopted peumoperitoneum(8 mmHg,8 

liter/min), we have started combined method(peumoperitoneum 

: 4 mmHg,4 liter/min and abdominal wall lifting 

method) from 1993. Combined method ?@enables to perform 

LC by low pressure. From the standpoint of body temperature(BT) 

we report the effect of combined method. 

?yOBJECT&METHOD ?zExclusion criteria was combined operation(28cases:Modified 

radical mastectomy etc),open conversion(52cases),complication(18cases). 

We could?ft confirm the 

BTabout 22 cases. Therefore we estimated 680?@?@cases 

.?@According to the chart of anesthesia, we classfied these 

680 cases into three categories depending on the change of 

BT. Group A (162 case) showed increased BT post-operatively. 

Group B (448cases) showed decreased BT. Group C(70 cases 

)showed no change. 

?yRESULT?zBetween three groups(A,B &C) there was no significant 

difference about first walking, first flatus, intestinal 

murmur, first stool, laboratory data(WBC,CRP), pain killer 

usage and post operative hospital stay. There was no significant 

difference between Group A & B about oral intake. In the 

Group A combined method (0.33?}0.25 ??) showed higher BT 

than pneumoperitoneum method (0.25?}0.15??)?iP=0.053?j. In 

the Group B the degree of BT decrease showed significant difference 

between pneumoperitoneum method (0.56?}0.33 ??) 

and combined method(0.44?}0.29??)?iP??0.01?j. 

?yCONCLUSION?zNo remarkable effect of post operative BT 

change was seen. Combined method method showed more 

high BT 

tendency. Physiologically speaking post operative high BT may 

be better, so far as these data the merit of high BT is unknown. 


Surgery 

INTRAOPERATIVE MAGNETIC RESONANCE IMAGING ABLA- 

TION OF HEPATIC TUMORS, R Martin BA, S Hushek BA,K 

McMasters BA, University of Louisville Department of Surgery 

and The Center for Advanced Surgical Technology 

Background: The utilization of hepatic ablation of tumors for 

both primary and secondary cancers has continued to rise at a 

significant rate. The most significant rise in the utilization of 

hepatic ablation has come from image guided techniques with 

both computer tomography and ultrasound. The limitations of 

targeting hepatic lesions by these techniques remain morbid 

obesity, abnormal hepatic parenchyma and inability to visualize 

lesions without the utilization of intravenous contrast. 

Magnetic Resonance Imaging (MRI) on the other hand, has 

continued to provide a high contrast of soft tissue to lesion 

conspicuity without the need of IV dye. The recent development 

of an open configuration magnetic resonance scanners, 

which have allowed improved patient access, near real time 

imaging, and more available MR compatible equipment, has 

opened up an entire new area of image guided surgical and 

interventional procedures. Thus the aim of this study was to 

evaluate the use of iMRI ablation of hepatic tumors performed 

by surgeons. 

Method: iMRI hepatic ablation was performed on 10 patients 

from 1/2003 to 4/2004 for control of either primary or secondary 

hepatic disease. These lesions were defined as inaccessible 

by computer tomography and thus were ablated using 

real-time intraoperative MRI guidance. 

Results: Hepatic ablation was performed on 5 women and 5 

men with a median age of 71 (range 51-81) years. Eighteen 

hepatic lesions were ablated were successfully ablated, with a 

majority of lesions being located in segments 6 and 7. Median 

hospital stay was 1 day, with complications occurring in 2 

patients. 

Conclusions: Image guided hepatic ablations represent a useful 

technique in managing hepatic tumors. Intra-operative MRI 

(iMRI) represents a new technique with initial success that has 

been limited to European centers. Further evaluation in U.S. 

centers has demonstrated iMRI to be useful for certain hepatic 

tumors that cannot be adequately visualized by ultrasound or 

computer tomography. This study demonstrates the importance 

of a multi-disciplinary approach involving a surgical 

oncologist and interventional radiologist to the integral short 

and long-term success of image guided ablations. 


Surgery 

LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH 

SEVERE CARDIAC DISEASE, Meghna Misra MD, Jeffrey Schiff 

BS,Gonzalo Rendon MD,Janice Rothschild MD,Steven 

Schwaitzberg MD, Tufts-New England Medical Center 

Objective: 

Cardiac disease is frequently a co-morbidity of patients undergoing 

cholecystectomies (CCYs). However, congestive heart 

failure (CHF) is often considered a contraindication to laparoscopic 

cholecystectomy (LC). As LC is considered the standard 

of care for removal of the gallbladder, this reviews the outcome 

of LC in this high-risk population. 

Methods: 

This study is a retrospective review of medical records of 1285 

consecutive CCY patients operated from 7/1996-6/2003 in a tertiary 

care medical center. 

Results: 

100 patients in this population had cardiac disease (7.8% of 

total population). 86 patients had coronary artery disease 

(CAD). 44 of the CAD patients underwent LC. The remaining 

patients had open CCYs, or conversions to open surgery. 14 

(1.1%) patients in this study had congestive heart failure. 12 of 

these patients underwent LC. Pre-operative left ventricular 

ejection fraction (LVEF) of the LC CHF patients ranged from 

15% to 65%. 8 of the 12 CHF patients had heart transplants. 7 

of 8 transplant patients had LC. Indications for surgery for 

these patients included biliary colic (n=4), acute cholecystitis 

(n=2), and chronic cholecystitis (n=1). The one transplant 

patient with an open CCY had acute gangrenous cholecystitis 

with hydrops. 3 of the transplant patients had their transplant 

before their CCY ? the time period between transplant and 

CCY ranged from 1 to 13 years. 5 of the transplant patients 

had their CCY before their transplant. Time periods between 

transplant and CCY in these patients ranged from 1 to 3 years. 

Acute complications of transplant patients included 2 patients 

with post-op electrolyte abnormalities, 1 patient with post-op 

pneumonia, and 1 patient with retained gallstones. There were 

no deaths in the cardiac population. There were no conversions 

because of inability to tolerate pneumoperitoneum. 

Conclusions: 

The severity of gallstone disease in cardiac populations is 

greater compared to that of the general population. 

Laparoscopy does not increase the risk of intra-operative or 

post-operative complications in patients with even severe CHF 

compared to the general population. Asymptomatic patients 

(from a biliary standpoint) awaiting cardiac transplant can 

undergo LC following transplantation with good results. LC is 

a safe procedure for gallbladder resection in high-risk populations. 


Surgery 

CRYOABLATION OF HEPATIC TUMORS: A COMPARATIVE 

STUDY BETWEEN TWO INSTRUMENTS., Alessandro Maria 



179



Paganini MD, Mario Guerrieri MD,Jlenia Sarnari MD,Giancarlo 

D’Ambrosio MD,Luigi Solinas MD,Emanuele Lezoche MD, 

Department of General Surgery, University of Ancona, Ancona, 

Italy; *II Clinica Chirurgica , Università La Sapienza, Rome, 

Italy. 

Aim: to compare the results of Cryosurgical Ablation (CSA) of 

hepatic tumors in two consecutive series of patients (pts) treated 

with two different instruments both using liquid nitrogen. 

Methods: between February 1996 and August 2004, 86 pts (41 

males, 45 females, mean age 57.3 years, range 30-79) were 

treated with the CMS AccuProbe System (Rockville, MD, USA) 

using 5-8 mm probes (laparoscopically 29%, open surgery 

71%) (group A); 7 pts (3 males, 4 females, mean age 57,1, 

range 38-73) were treated with the Cryo 6 Erbe (Tuebingen, 

Germany) using 3 mm probes (open surgery). 

ResultsGroup AGroup B 

Intra operative Transfusions, pts47 (55%)1 (14%) 

Post operative Transfusions, pts36 (42%)0 

Major Complications21 (24%) 0 

Minor Complications44 (51%)0 

Local recurrence 0 0 

Mortality 4 (6%)0 

Group B pts were then matched with 7 group A patients based 

on age, sex, type of tumor, number of lesions, liver segments, 

Child/ASA classification. 

ResultsGroup AGroup B 

Intra operative Transfusions, pts 3 (43%)1 (14%) 

Post operative Transfusions, pts 4 (57%)0 

Major Complications 2 (29%)0 

Minor Complications 4 (57%) 0 

Local recurrence 00 

Mortality 0 0 

Conclusions:the Cryo 6 Erbe instrument was equally effective 

as compared to the CMS AccuProbe System but with less intra 

or postoperative bleeding, lesser need for blood transfusions 

and lower morbidity. 


Surgery 

ACUTE ACALCULOUS CHOLECYSTITIS: INCIDENCE, TREAT- 

MENT OPTIONS AND EVENTUAL OUTCOME, Brian J Schmidt 

MD, Heidi K Chua MD, Mayo Clinic Jacksonville 

ACUTE ACALCULOUS CHOLECYSTITIS: INCIDENCE, TREAT- 

MENT OPTIONS AND EVENTUAL OUTCOME. 

Brian J. Schmidt, M.D., Heidi K. Chua, M.D. 

Department of Surgery, Mayo Clinic Jacksonville 

Jacksonville, FL 32224 

Introduction: 

Percutaneous cholecystostomy is a reasonable treatment alternative 

in patients with acute acalculous cholecystitis. Our 

objective was to determine if percutaneous cholecystostomy 

was a reasonable treatment option for these patients and if so, 

what percentage ultimately required cholecystectomy, either 

open or laparoscopically. 

Methods and Procedures: 

We examined all patients at our institution over an eleven-year 

period with the diagnosis of acute acalculous cholecystitis to 

evaluate the demographics, optimal therapeutic sequence and 

outcomes in patients with the diagnosis of acute acalculous 

cholecystitis. We identified 18 patients with this diagnosis. Of 

these, 83% were male and 33% occurred in patients who had 

recently undergone non-biliary tract surgery. We examined the 

patients in regards to initial therapy (percutaneous cholecystostomy 

vs. surgery), eventual outcome and whether or not 

the interval cholecystectomy could be completed laparoscopically. 

Results: 

Preoperative laboratory testing was non-specific, while presenting 

signs or symptoms ranged from abdominal pain to 

sepsis in the critically ill. Eighty-nine percent of patients whose 

initial therapy was percutaneous cholecystostomy tube placement 

did not require interval cholecystectomy. Many of these 

patients had severe systemic illness, which limited their survival. 

Of the patients who required early surgical intervention, 

78% underwent laparoscopic cholecystectomy. The in-hospital 

mortality rate was 22%. 

Conclusions: 

We conclude that percutaneous cholecystostomy is a reasonable 

treatment alternative in patients too ill to undergo surgical 

therapy. The majority of these patients will not require surgical 

therapy after resolution of the presenting comorbid illnesses. 

In those who undergo early surgical therapy, a majority 

of these cases can be completed laparoscopically. 


Surgery 

LAPAROSCOPIC ENUCLEATION OF PANCREATIC INSULINO- 

MAS, Alberto Goldenberg MD,Jose Francisco de Matos Farah 

MD, Vladimir Schraibman MD, Edson J Lobo MD, Discipline of 

Gastric Surgery, Federal University of Sao Paulo, Brazil 

Insulinomas are rare endocrine pancreatic tumors. It´s incidence 

is increasing in the last years due to early detection by 

clinical and tomographic (CT) findings. The classical treatment 

consists of open surgical resection that is associated to relative 

morbidity and mortality. 

The objective of this work is to present 4 patients diagnosed 

with pancreatic insulinomas that were treated by laparoscopic 

resection. 

Four patients, ranging from 14 to 45 years-old, presenting classical 

Whipple Triad had lesions ranging from 1,5 to 2,5 cm by 

CT (body and tail of the pancreas) diagnosed as insulinomas. 

Eco-endoscopy showed no combined lesions. They were treated 

by laparoscopic resection, using four trocars (2 of 10 mm 

and 2 of 5 mm), 10mm 30º optic and ultrasonic scalpel. 

Surgery consisted of opening of the greater omentum, identification 

of the superficial lesions and dissection using ultrasonic 

scalpel, without complementary suture. Abdominal drainage 

was made using JP drain. Glicemic levels were controlled during 

surgery with expected glucose raise. All patients had an 

uneventfull recovery. Mean follow-up is 10 months (2 to 24 

months) 

Laparoscopic resection of pancreatic insulinomas using just 

ultrasonic scalpel is reliable in superficial lesions in the body 

and tail of the pancreas. 


Surgery 

INFLUENCE FOR HEMODINAMICS OF THE HEPATIC ARTERIAL 

BLOOD CIRCURATION BY PNEUMOPERITONEUM IN LAPARO- 

SCOPIC CHOLECYSTECTOMY., Masamori Shimabuku MD, 

Toshiomi Kusano PhD,Kazuyuki Tachibana MD,Hiroyuki 

Yuzawa MD,Masahiro Kamachi MD, Department of Surgery, 

Digestive Disease Center, Tenjin-kai Koga Hospital, Kurume, 

Japan 

The influence due to pneumoperitoneum on respiratory and 

circulatory kinetic during laparoscopic cholecystectomy (LC) 

has been was reported thus far. However, there were few 

reports regarding the hepatic arterial circulation. The purpose 

of this study was to investigate the influence due to pneumoperitoneum 

on the hepatic blood flow during LC. The subjects 

were 32 cases undergoing LC for 6 months. In this study, 

an arterial keton body ratio (AKBR) which was proportional to 

the hepatic arterial blood flow. Furthermore a partial pressure 

of carbon dioxide (PaCO2) were measured. During surgery, 

under anesthesia with neuroleptic analgesia, a muscle relaxant 

was administered at a sufficient dose; quantitative ventilation 

was performed at a laughing gas-oxygen ratio of 2:1. Average 

operation time was 1 hour and 47 minutes. Influence with the 

pneumoperitoneum included the temporarily lowered AKBR 

just after the pneumoperitoneum under anesthesia. However, 

when AKBR could be kept at a pressure of 10 mmHg or lower, 

AKBR remained in the safety range. PaCO2 stayed around 30 

mmHg until 180 minutes, when the pressure due to pneumoperitoneum 

was maintained low, but it is measured at over 

14mmHg, at 120 minutes later PaCO2 exceeded 40 mmHg. 

In conclusion, if maneuvered at a low pneumoperitoneum 

pressure, LC is a safe operative procedure with a slight negative 

general influence. 




Surgery 

GALLSTONES: BEST SERVED HOT, Tarun Singhal MS, 

Santosh Balakrishnan MS,S El-Hasani,Starlene Grandy-Smith, 

Princess Royal University Hospital, Kent, U. K. 

Background: 

Acute gallstone related diseases have traditionally been managed 

conservatively. Endoscopic extraction of common bile 

duct stones is attempted in a small percentage of patients. The 

gall bladder is usually left in-situ for interval cholecystectomy 

after 4 to 6 weeks when the acute inflammatory changes have 

subsided. This places the patient at increased risk of recurrent 

pancreatitis or other complications of cholelithiasis. 

Method: 

Patients who presented with acute gallstone related disease 

were investigated for Common Bile Duct (CBD) stones and 

underwent Laparoscopic cholecystectomy (LC) in the same 

admission according to a pre-determined treatment protocol 

(Table 1). 

Results: 

All 119 patients who were treated according to the study treatment 

protocol had good results with no mortality and no biliary 

tract injuries. One patient had bleeding from cystic artery, 

and six patients required conversion to open surgery. 

Discussion: 

The traditionally quoted rationales for interval cholecystectomies 

were the increased risk of causing damage to adjoining 

structures, primarily extra-hepatic biliary tree and cystic artery, 

while dissecting oedematous and inflamed tissues with distorted 

anatomy. Further, failure to complete the operation 

laparoscopically due to technical difficulties often left the 

patient with a large laparotomy scar. However, it has long 

been recognised that this results in significant increase in risk 

of intercurrent attacks of gallstone related diseases [1,2,3,4]. 

Introduction of laparoscopic cholecystectomy (LC) and steadily 

increasing expertise has made it possible for surgeons to perform 

cholecystectomies in the presence of acute gallstone 

related disease without having to commit oneself to a major 

laparotomy [2,5,6,7,8,9]. Our experience of managing gallstone 

disease with prompt cholecystectomy in the index admission 

after evaluation of common bile duct (CBD) showed that this 

approach is not only safe but also economical. 


Surgery 

NEEDLESCOPIC CHOLECYSTECTOMY VS NEEDLESCOPE- 

ASSISTED LAPAROSCOPIC CHOLECYSTECTOMY, Nobumi 

Tagaya PhD, Norio Suzuki MD,Kyu Rokkaku MD,Keiichi Kubota 

PhD, Second Department of Surgery, Dokkyo University 

School of Medicine, Tochigi, Japan 

Background: Laparoscopic cholecystectomy with needlescopic 

instruments has been progressed. However, this refinement 

has several limitations to perform surgical procedure. We performed 

a prospective study to evaluate the feasibility of 

needlescope and needlescopic instruments. 

Materials and Methods: Needlescopic or needlescope-assisted 

cholecystectomy was performed in 40 cases of cholecystolithiasis 

or gallbladder polyp. They were 12 men and 28 women 

with mean age of 51.8 years (range: 27-79). After creation of 

pneumoperitoneum, the port sites consisted of three 2-mm 

ports at the right upper quadrant and one 12-mm port at the 

umbilicus. In needlescopic cholecystectomy group (NC), the 

operator manipulated dissecting forceps or electrocautery in 

the left hand and 2-mm needlescope in the right hand during 

all procedures. The assistant manipulated two grasping forceps 

form the right subcostal ports. In needlescope-assisted 

cholecystectomy group (NAC), the operator manipulated two 

dissecting or grasping forceps under 10-mm laparoscope. The 

assistant manipulated grasping forceps from the right subcostal 

port and 10-mm laparoscope from the umbilical port. 

When we perform clipping or cutting of cystic duct and artery, 

intraoperative cholangiography and removal of gallbladder, 2- 

mm needlescope is moved from the umbilical port to the epigastric 

port. To evaluate the feasibility and safety of needlescope, 

we compared the each segments of operation time of 

NC with those of NAC. Operation time were divided into skin 

incision to insertion of ports, insertion of ports to intraoperative 

cholangiography (IOC), time of IOC, IOC to dissection of 

gallbladder (GB), dissection to removal of GB, removal of GB 

to skin closure, insertion of ports to cut of cystic duct in non- 

IOC case and total operation time. 

Results: IOC was performed in each 10 cases of NC and NAC. 

Respective mean times of NC vs NAC were 5.3 vs 5.3 min, 32. 

1 vs 34.3 min, 18.5 vs 20.0 min, 18.8 vs 19.6 min, 2.9 vs 3.0 

min, 10.0 vs 10.2 min, 50.6 vs 54.3 min and 78.5 vs 81.7 min. 

There were no significant differences between the two groups. 

IOC occupied 24% of all operation time of each group. There 

were no perioperative complications. 

Conclusion: The use of needlescope and needlescopic instruments 

was feasible and safe to perform laparoscopic cholecystectomies. 


Surgery 

NEW ASPECTS IN LAPAROSCOPIC CHOLECYSTECTOMY, 

Mohammad m Talebpour PhD, Moosa m Zargar PhD, 

Laparoscopic surgical ward, Sina Hospital, Tehran University 

Aim: Increasing the safety of laparoscopic cholecystectomy 

technique 

Method: In this prospective study on 230 cases, four important 

points used as a new technique to increase the safety of operation; 

including: 

* Choosing the place of trocars based on ergonomic law of 

120 degree angle between telescope and two hands with at 

least 7 to 10 cm distance and 15 to 20 cm distance between 

telescope trocar and end point (Different points in different 

cases). 

* Starting dissection from Hartman Pouch at first and after 

encircling Hartman Pouch, continuing it to cystic duct and cystic 

artery in this aim to decrease unavoidable risk of ductal 

iatrogenic trauma. 

* Ligating cystic duct and cystic artery by intracorporeal suturing 

to decrease the risk of bile leak, ductal trauma, cystic 

artery bleeding or inversion of clips into duct. 

* Removing gallbladder from umbilical trocar to reserve size 

of trocars in three 5mm and one 10 mm. 

Result: 18 out of 150 cases were impossible to use one or 

some of above points due to short cystic duct, acute cholecystitis, 

bleeding during dissection and so on. Cystic duct knot 

were loose in 7 cases and resuturing performed. Mean time of 

operation was 48 min (sem= 9min) but ductal trauma and leak 

of bile was zero even in acute cases. Cosmetic results for 

patient are excellent because there is not any sub xyphoid 10 

mm trocar in this method. 

Conclusion: Using above points is effective to decrease risk of 

ductal trauma or bile leak, better cosmetic results but longer 

time and more hard operation. 


Surgery 

LCBDE USING THE MULTI-CHANNEL INSTRUMENT GUIDE, 

Donald E Wenner MD, Paul R Whitwam MD,David M Turner 

MD,Syed Hashmi MD, Eastern New Mexico Medical Center 

Introduction: LCBDE is the safest and most cost effective way 

to treat choledocholithiasis in patients with an intact gallbladder. 

A single stage approach to remove the gall bladder and 

clear the bile duct is possible. This approach avoids ERCP and 

its associated risk of pancreatitis. LCBDE techniques and 

instrumentation continue to evolve. Our experience using the 

MIG (multi-channel instrument guide) and techniques from 

urologic surgery adapted for LCBDE is presented. 

Method: A consecutive case study that includes all patients 

with choledocholithiasis that underwent LCBDE using the MIG 

is reviewed. Choledocholithiasis was identified by DFIOC 

(dynamic fluoroscopic intra-operative cholangiography) during 

laparoscopic cholecystectomy. Both trans-cystic duct and 

choledochotomy techniques were employed. A staged procedural 

algorithm was applied based on operative and DFIOC 

findings. 79% of these patients had difficult stone features, 

including large stones over 8mm, multiple stones, hepatic duct 



181



stones, impacted stones or fibrin embedded stones. 

Choledochoscopy was employed in all patients. Simple choledocholithiasis 

cases that were resolved using trans-cystic duct 

flushing, glucagon and passage of a catheter were excluded 

from analysis. 

Results: A total of 43 patients met study inclusion criterion. 

Total bile duct clearance was achieved in 98% of these 

patients. 9% of these LCBDE cases were completed via the cystic 

duct and 91% using choledochotomy techniques. No cases 

of pancreatitis resulted from LCBDE in this study. 

Conclusion: LCBDE using the MIG, choledochoscope, stone 

baskets and lithotripter is safe and effective. A 98% success 

rate was achieved in this series of patients. Trans-cystic duct 

techniques and choledochotomy techniques are complementary, 

and laparoscopic biliary tract surgeons need to be familiar 

with both of these procedural methodologies. Urologic surgery 

has developed effective methods to deal with ureteral 

stones that can be adapted for cases of choledocholithiasis 

with great efficacy. The necessary instrumentation for LCBDE 

is available, relatively inexpensive, and can be cross utilized 

with urologic surgery. 


Surgery 

LAPAROSCOPIC ANATOMICAL LIVER RESECTION IN A PADI- 

ATRIC PATIENT WITH BENIGN CYSTIC LESION, Ho-Seong Han 

MD, Yoo-Seok Yoon MD, Yoo Shin Choi MD,Sang Il Lee 

MD,Jin-Young Jang MD,Sun-Whe Kim MD,Yong-Hyun Park 

MD, Department of Surgery, Seoul National University College 

of Medicine, Seoul, Korea 

Introduction: Despite recently increasing numbers of reports 

on laparoscopic liver resection, cases performed in pediatrics 

have been rarely documented. We report on a totally laparoscopic 

left lateral sectionectomy in a pediatric patient with 

benign cystic lesion. To our knowledge, this is the first reported 

case of laparoscopic anatomical liver resection in a pediatric 

patient. 

Methods and Procedures: A 5-year-old girl presented with a 1- 

month history of right upper quadrant pain. Abdominal CT 

revealed a large (10 x 10 cm), multi-septated cystic tumor presumed 

to originate from the liver. At the inspection via laparoscope, 

an exophytic tumor originating from the left lateral section 

was identified, and so a totally laparoscopic left lateral 

sectionectomy was performed. Three 10 mm and one 12 mm 

trocars were placed, and a 30¡Æ laparoscope was used. 

Intraabdominal pressure was maintained below 10 mmHg. 

After complete mobilization of the left lateral section by dissection 

of the falciform and triangular ligaments, the liver 

parenchyma was superficially dissected with Harmonic scalpel. 

Then the Glisson¡¯s pedicles to the lateral section and left 

hepatic vein with the overlying remnant liver parenchyma 

were completely divided using two Endo-vascular GIAs. The 

specimen was extracted through a small incision of about 4.5 

cm, created by extending the epigastric port. 

Results: The operative time was 150 minutes. The estimated 

blood loss was about 100 cc, and no intraoperative transfusion 

was needed. The patient was discharged on postoperative day 

11 without postoperative complications. Postoperative pathology 

confirmed a mesenchyal hamartoma of the liver with a 

free resection margin. 

Conclusion: This case shows that laparoscopic liver resection 

can be a safe and feasible operative procedure in the pediatric 

patient with liver disease. Thus we believe that laparoscopic 

liver resection can be a promising surgical technique in selected 

pediatric patients. 


Surgery 

THE USEFULNESS OF CUSA DURING LAPAROSCOPIC LIVER 

RESECTION, Yoo-Seok Yoon MD, Ho-Seong Han MD,Yoo Shin 

Choi MD,Sang Il Lee MD,Jin-Young Jang MD,Sun-Whe Kim 

MD,Yong-Hyun Park MD, Departement of Surgery, Seoul 

National University College of Medicine, Seoul, Korea 

Introduction: The major problem of laparoscopic liver resection 

is bleeding during liver parenchymal transection, which is 


difficult to control laparoscopically and may increase postoperative 

complications. Although Harmonic scalpel, Ligasure, and 

endo-vascular GIA etc are being widely employed in parenchymal 

dissection, these have a possibility of incomplete vascular 

control due to somewhat blind application. We experienced 

reduced intraoperative blood loss after adoption of CUSA 

(Cavitron Ultrasonic Surgical Aspirator). In this study, we evaluated 

the usefulness of CUSA in laparoscopic liver resection 

by analyzing our experiences. 

Methods and Procedures: Between May 2003 and August 

2004, a total of 21 cases of laparoscopic liver resection (11 left 

lateral sectionectomy, 5 left hepatectomy, 4 tumorectomy, 1 

right posterior sectionectomy) were performed by one surgeon 

(Dr. Han HS). Of total cases, we selected the cases of leftsided 

liver resections (left: 5 cases, left lateral: 11 cases) and 

compared the clinical results between 10 cases before use of 

CUSA (Harmonica scalpel or Ligasure was used) (group A) and 

6 cases after use of CUSA (group B) for of total cases. 

Results: The patients comprised 8 men and 8 women, ranging 

from 5 to 74 years with a mean age of 55.9 years. Indications 

for this procedure included 10 cases of localized IHD stones 

and 6 cases of tumor (3 benign tumor, 3 hepatocellular carcinoma). 

No significant differences between two groups were 

observed in sex, age, and indications between two groups. 

Group B showed improved results compared to group A in 

operation time (group A vs. group B: 382.3¡_175.4 vs. 

250.0¡_87.5 minutes), blood transfusion amount (2.1¡_2.9 vs. 0 

units), postoperative hospital stay (15.8¡_6.6 vs. 9.3¡_3.3 days), 

postoperative complications (30% vs. 0%), although statistical 

analysis was not done due to a small number of cases. Three 

cases of postoperative complications (sepsis, biliary fistula, 

intraabdominal fluid collection) were present in group A, and 

postoperative mortality occurred in one patient due to sepsis. 

However, there was no postoperative complication and mortality 

in group B. 

Conclusions: Our experiences, although limited, indicate that 

CUSA enables more precise resection of the liver parenchyma 

in a dry field, and eventually can lead to reduction of blood 

loss, shorter operator time, and decreased postoperative complications. 


Surgery 

CLINICAL OUTCOMES AFTER LAPAROSCOPIC CBD EXPLO- 

RATION, Yoo-Seok Yoon MD, Ho-Seong Han MD,Seog Ki Min* 

MD,Hyeon-Kook Lee* MD,Yoo Shin Choi MD,Sang Il Lee 

MD,Jin-Young Jang MD,Sun-Whe Kim MD,Yong-Hyun Park 

BA, *Department of Surgery, Ewha Women?s University 

College of Medicine, 

Introduction: Recently, one stage operation with laparoscopic 

common bile duct exploration (LCBDE) is being widely used 

for the treatment of CBD stone disease. The aim of this study 

is to evaluate the long term-results of LCBDE. 

Methods and Procedures: From March 1997 to February 2004, 

a total of 110 cases of LCBDE for choledocholithiasis was performed 

at Ewha Women University Mokdong Hospital and 

Seoul National University Bundang Hospital. Excluding 19 

cases with combined intrahepatic duct stones, 91 patients who 

underwent the LCBDE for choledocholithiasis confined to CBD 

were retrospectively analyzed by reviewing the medical 

records. 

Results: The patients were composed of 51 men (56%) and 40 

women (44%), with a mean age of 67.4?2.7 years. Endoscopic 

sphincterotomy (ES) was performed in 32 cases (35.2%) during 

preoperative period. The mean operation time was 218?0 minutes, 

and the open conversion rate was 2.2% (2 cases). The 

mean postoperative hospital stay was 13.6?.7 days. 

Postoperative complications occurred in 9 cases (11%), all of 

which responded to the conservative medical management. 

There was no postoperative mortality. Excluding 15 cases of 

follow-up loss, recurred CBD stones were detected in 5 cases 

(6.6%) after a mean follow up period of 35 months. Among the 

recurred cases, 2 cases were treated with ES and lithotripsy, 

and the remaining 3 cases were not managed due to asymptomatic 

small stones. 

Conclusions: LCBDE is a safe and effective method in clearing 

of CBD stones.


P218–Basic Science 


NORMAL INTRA-ABDOMINAL PRESSURE IN HEALTHY 

ADULTS William S Cobb MD, Justin M Burns MD, Kent W 

Kercher MD, B Todd Heniford MD, Carolinas Medical Center 

Purpose: The goal of this study is to measure the normal 

range of intra-abdominal pressure in healthy, non-obese adults 

and correlate this with sex and body mass index (BMI). 

Methods: After Institutional Review Board approval, healthy 

young adults with no prior history of abdominal surgery were 

enrolled. Intra-abdominal pressure readings were obtained 

through a transurethral bladder (Foley) catheter. Each subject 

performed 13 different tasks including standing, sitting, bending 

at the waist, bending at the knees, performing abdominal 

crunches, jumping, climbing stairs, bench pressing 25 pounds, 

arm curling 10 pounds, and performing a Valsalva and coughing 

both while sitting and standing. Three separate readings 

were taken during each maneuver. Data were analyzed by 

Student t-test and Pearson’s correlation coefficients 

Results: Measurements were taken in 10 male and 10 female 

subjects. Mean age of the study group was 22.7 years (range; 

18 - 30 years), and BMI averaged 24.6 kg/m2 (range; 18.4 - 31.9 

kg/m2). The mean pressures were not different between males 

and females for each maneuver. There was a significant correlation 

between higher BMI and increased intra-abdominal 

pressure in 5 of 13 exercises. The mean maximum pressures 

and their correlation coefficients with BMI for these maneuvers 

is shown below. 

Conclusion: Normal intra-abdominal pressure correlates with 

BMI, but does not vary based on sex. The highest intraabdominal 

pressures in healthy patients are generated during 

coughing and jumping. Patients with higher BMI and chronic 

cough appear to generate significant elevation in intra-abdominal 

pressure and may potentially be at increased risk for 

abdominal wall hernia formation. 

P219–Basic Science 


CARBON DIOXIDE PNEUMOPERITONEUM POSTTREATMENT 

ATTENUATES IL-6 PRODUCTION, Joseph M Fuentes MD, Eric 

J Hanly MD,Alexander R Aurora MD,Antonio De Maio 

PhD,Michael R Marohn MD,Mark A Talamini MD, Johns 

Hopkins University School of Medicine 

CO2 pneumoperitoneum is known to have beneficial immune 

effects in laparoscopic surgery. We have recently shown that 

CO2-pneumoperitoneum posttreatment increases survival. The 

purpose of this study was to determine if CO2 pneumoperitoneum 

posttreatment would reduce the cytokine response to 

lipopolysaccharide (LPS) sepsis. Forty rats (n=10) were randomized 

into four groups: CO2 pneumoperitoneum, helium 

pneumoperitoneum, anesthesia control, and laparotomy control. 

In all groups a laparotomy was performed. 

Simultaneously, all animals received intraperitoneal 

Escherichia coli LPS (1mg/kg). Immediatley after all animals 

were closed, the first three groups received their respective 

posttreatment for 30 minutes. Blood samples for serum 

cytokine assays were collected via cardiac puncture 2 hours 

following LPS injection. Compared to laparotomy/LPS only 

control, plasma levels of IL-6 were depressed 54.6% by anesthesia 

posttreatment, 77% by He-pneumoperitoneum posttreatment, 

and 74.1% by CO2-pneumoperitoneum posttreatment 

(*P



plantation. Parameters before and after transplant are 

expressed as group median values +- 1st and 3rd quartile deviations. 

RESULTS: To date, 4 dogs have been studied. All animals tolerated 

the surgery (100% survival 9 months post-transplant.) 

They maintained their body weight after transplant and there 

were no pre/post differences in activity level. All four parameters 

that make up the 24-h pH monitoring increased after 

transplant: total number of reflux episodes were 7 (5,13) 

before versus 12 (4,28) after; the number of reflux episodes 

longer that 5 min were 0 (0,1) before versus 1 (0,3) after; the 

longest reflux episode was 3.5 (1.8,8.0) min before versus 8.0 

(1.0,20.0) min after; and the total time esophageal pH


P225–Complications of Surgery 

PITFALLS AND COMPLICATIONS OF LAPAROSCOPIC NISSEN 

FUNDOPLICATION, Mohey El-Banna, Mahmoud El- 

Meteini,Osama Fouad, Department of General Surgery, Ain 

Shams University 

Background: Since the introduction of laparoscopic Nissen 

fundoplication by Dallmagne 1991, its importance increased 

dramatically. In this study, the lessons learned from 60 consecutive 

laparoscopic Antireflux procedures (LAP) procedures are 

analyzed. 

Methods: Between March 2001 and March 2004, 60 cases were 

subjected to LAP for gastroesophageal reflux disease (GERD). 

The preoperative decision depended on 

Esophagogastroduodenoscopy (EGD) and Esophageal 

Manometry (EM) to record the lower esophageal sphincter 

pressure and length and the esophageal body motility pattern. 

Barium study was done for hiatus hernia. The operative details 

were recorded, as well as the postoperative outcome and complications. 

The postoperative study included a standardized 

questionnaire, EGD and EM. 

Results: Of the sixty cases studied, 6 cases were converted to 

open fundoplication due to gastric perforation, equipment failure 

and procedural difficulties. Four patients underwent 

Laparoscopic Toupet Fundoplication (LTF). Except three 

patients, all demonstrated subjective and objective improvement 

or cure of GERD. 

Conclusion: We concluded that LAP is a safe and effective 

approach for the management of GERD. However, the success 

of LAP depends on the ability of the surgeon to take into consideration 

the possible intra-operative complications and factors 

contributing to dissatisfaction with the functional outcome. 


BLADELESS TROCAR HERNIA RATE IN UNCLOSED FASCIAL 

DEFECTS IN BARIATRIC PATIENTS, Alison M Fecher MD, Ross 

L McMahon MD,John P Grant MD,Aurora D Pryor MD, Duke 

University Medical Center 

Objective 

Utilization of the bladeless step trocar system has the perceived 

advantage of minimal trocar related hernias in patients 

undergoing laparoscopic Roux en Y Gastric Bypass surgery 

(RYGB). We propose a retrospective review of hernias in these 

patients and a review of the literature. 

Methods & Procedures 

A retrospective chart review was performed on 591 patients 

who underwent RYGB at Duke University Weight Loss Surgery 

Center from July 2002 through June 2004. A total of 2955 

bladeless trocar sites were used. Step trocars were used in all 

cases. The configuration of ports included one Hasson port, 

two 12-mm and three 5-mm ports . The Hasson port was 

closed with a figure of eight number 1 Polysorb. All other trocar 

sites did not have fascial closure. The gastrojejunal anastomosis 

was created with a linear stapler in all of the laparoscopic 

cases with hand suturing of the residual enterotomy. 

The charts were reviewed for fascial defect, subsequent surgeries 

and intra-operative findings. 

Results 

There were no hernias seen at any of the unclosed bladeless 

trocar sites for a 0% incidence. There were four ventral hernias 

at the Hasson port site which required re-operation for repair 

for a 0.68% incidence. 

Conclusion 

There were no hernias from the unclosed bladeless trocar site 

with radial expanders out of a total of 1182 12-mm ports. Four 

hernias occurred at the Hasson port site. In the bariatric RYGB 

population the routine closure of radially expanding step trocars 

does not appear to be necessary due to the extremely low 

rate of subsequent hernia. 


DELAYED PRESENTATION OF SPLENIC RUPTURE AFTER 

COLONOSCOPY, Richard Fortunato DO, Daniel Gagné 

MD,Pavlos Papasavas MD,Philip Caushaj MD, The Western 

Pennsylvania Hospital, Temple University Medical School 

Clinical Campus 

Splenic rupture after a colonoscopy is a rare but potentially 

fatal complication. Patients typically present with signs of 

abdominal pain and hemorrhagic shock within minutes to 

days after the procedure. 

We present a case of a 59 year-old woman with a past history 

of Hodgkin?s disease and gastric bypass who developed 

increasing abdominal pain three weeks after a routine 

colonoscopy and polypectomy. The patient presented with 

hypotension and underwent aggressive resuscitation with IVF 

and IV pressors. CT scan demonstrated a large subcapsular 

hematoma of the spleen. Angiography did not reveal active 

bleeding. Due to the patient?s continued clinical deterioration, 

she was taken emergently to the operating room for an 

exploratory laparotomy, which demonstrated a full splenic 

capsular avulsion and hemorrhage. The patient underwent 

splenectomy and had an uneventful recovery. 

Though usually presenting hours to a few days after 

colonoscopy, severe splenic injury can have an insidious onset 

weeks from the original insult. This is the most delayed presentation 

of such an injury after colonoscopy to date. 


INCIDENCE OF INTERNAL HERNIA FOLLOWING LAPARO- 

SCOPIC RETROCOLIC RETROGASTRIC ROUX-EN-Y GASTRIC 

BYPASS, Giselle G Hamad MD, Gina M Kozak, PA-C, University 

of Pittsburgh 

The optimal route of the Roux limb in the laparoscopic Rouxen-Y 

gastric bypass remains controversial. The retrogastricretrocolic 

approach to Roux-en-Y gastric bypass has been criticized 

for the incidence of internal hernias at Petersen?s defect 

and the transverse mesocolon window. The postoperative 

weight loss coupled with the reduction in postoperative adhesions 

associated with the laparoscopic approach may contribute 

to a higher incidence of internal hernias. Internal herniation 

may lead to a closed loop obstruction and necessitates 

early surgical intervention. The purpose of this study was to 

determine the incidence of internal hernias among patients 

who underwent a retrocolic-retrogastric Roux-en-Y gastric 

bypass. Between 2001 and 2004, 520 patients underwent a 

retrocolic-retrogastric Roux-en-Y gastric bypass with continuous 

sutured closure of Petersen?s, transmesenteric, and small 

bowel mesenteric defects. Three patients were converted to 

open procedure (0.6%). There were 500 females and 20 males. 

Mean age was 40 years (range 18-65) and mean preoperative 

body mass index was 46.4 kg/m2 (range 36-68). Mean followup 

for all patients was 11 months and mean excess weight 

loss at 18 months was 70%. One patient (0.19%) who had lost 

57% of excess weight three months after laparoscopic gastric 

bypass developed a high-grade small bowel obstruction and 

was diagnosed with an internal hernia by CT scan. An 

exploratory laparotomy was performed for reduction and 

repair of Petersen?s defect and the patient recovered uneventfully. 

Internal herniation is an infrequent complication following 

retrocolic-retrogastric laparoscopic Roux-en-Y gastric 

bypass. Meticulous continuous suture closure of the potential 

hernia defects is essential to reduce the incidence of this 

dreaded complication. 


INCIDENCE OF STOMAL STENOSIS FOLLOWING LAPARO- 

SCOPIC RETROCOLIC-RETROGASTRIC ROUX-EN-Y GASTRIC 

BYPASS, Giselle G Hamad MD, Gina M Kozak PA-C, University 

of Pittsburgh 

Stomal stenosis is a complication reported in 3 to 37% of 

patients following Roux-en-Y gastric bypass. Contributing factors 

include tension of the Roux limb, ischemia, preserved acid 

secretion in the gastric pouch, NSAID use, and smoking. The 

optimal route of the Roux limb in the laparoscopic Roux-en-Y 

gastric bypass remains controversial. The retrocolic-retrogastric 

route has been said to subject the Roux limb to less tension 

on the gastrojejunal anastomosis than the antecolic-antegastric 

approach. The purpose of this study was to determine 

the incidence of stomal stenosis among patients who underwent 

a retrocolic-retrogastric Roux-en-Y gastric bypass. 

Between 2001 and 2004, 520 patients underwent a retrocolicretrogastric 

Roux-en-Y gastric bypass with gastric pouch size 

of 15 mL and Roux limb lengths of 75 or 150 cm. The gastroje- 



185



junostomy was created using a combined linear stapled and 

handsewn technique. Three patients were converted to open 

procedure (0.6%). There were 500 females and 20 males. Mean 

age was 40 years (range 18-65) and mean preoperative body 

mass index was 46.4 kg/m2 (range 36-68). Mean follow-up for 

all patients was 11 months and mean excess weight loss at 18 

months was 70%. None of the patients presented stomal 

stenosis postoperatively. Eleven (2.1%) were diagnosed with 

marginal ulceration by upper endoscopy. Stomal stenosis is an 

infrequent complication following retrocolic-retrogastric 

laparoscopic Roux-en-Y gastric bypass with combined linear 

stapled and handsewn gastrojejunostomy. A reduction in Roux 

limb tension with the retrocolic-retrogastric approach may play 

a role in reducing the incidence of this complication. 


LATE GASTRIC PERFORATIONS AFTER LAPAROSCOPIC FUN- 

DOPLICATION, K L Huguet MD, T Berland,R A Hinder, Mayo 

Clinic Jacksonville 

Introduction: Late complications are rarely encountered after 

laparoscopic Nissen fundoplication (LNF). We report a series of 

delayed gastric perforations complicating LNF and review the 

potential etiologies. 

Methods: In the authors? series of 1600 laparoscopic antireflux 

procedures performed between July 1991 and March 2002, we 

report a new finding of six delayed gastric fundal perforations 

in three patients 1, 41, 48, 51, 60, and 64 months after surgery. 

All had been taking celecoxib. 

Patient # 1: 71 yo WM presented 3 years after LNF with pneumoperitoneum 

while on celecoxib. Exploratory laparotomy 

revealed a gastric perforation on the gastric fundus, which was 

oversewn. Several months later the patient again presented 

with pneumoperitoneum and exploratory laparotomy revealed 

a gastric perforation at the same site, which was oversewn. 

Patient # 2: 58 yo WF presented 1 month after LNF with pneumoperitoneum 


revealed a gastric perforation on the anterior surface of the 

fundus. This was oversewn without complications. 

Patient #3: 67 yo WM presented 4 years after a LNF with pneumoperitoneum 


revealed no source. One year later the patient again presented 

with pneumoperitoneum and exploratory laparotomy revealed 

a gastric perforation on the anterior surface of the fundoplication, 

which was oversewn. Several months later the patient 

again presented with pneumoperitoneum. He recovered well 

after percutaneous aspiration and medical management. 

All patients had minimal peritoneal contamination leading to 

the conservative management of patient # 3. 

Conclusion: This series of late gastric fundal perforations in 

0.2% of patients after laparoscopic fundoplication could potentially 

have been caused by celecoxib, gastric stasis, ischemia, 

or foreign body such as a stitch or pledget. Patients after 

laparoscopic fundoplication should be advised to avoid the use 

of non-steroidal anti-inflammatory drugs, which may cause 

acute gastric ulceration with perforation. 


PANCREATIC COMPLICATIONS AFTER LAPAROSCOPIC 

SPLENECTOMY, Kotaro Kitani MD, Masataka Ikeda 

PhD,Mitsugu Sekimoto PhD,Masayuki Ohue PhD,Hirofumi 

Yamamoto PhD,Masakazu Ikenaga PhD,Ichiro Takemasa 

PhD,Shuji Takiguchi MD,Masayoshi Yasui MD,Taishi Hata 

MD,Tatsushi Shingai MD,Morito Monden PhD, Department of 

Surgery and Clinical Oncology, Graduate School of Medicine, 

Osaka University 

Background: Laparoscopic splenectomy (LS) has been accepted 

as a standard operational procedure for hematological diseases. 

Pancreatic complication is one of major complications 

associated with this procedure. We reviewed pancreatic complications 

following LS to find out the incidence of pancreatic 

injury and its impact on postoperative management. 

Methods: Case log analysis of hospital charts were reviewed. 

85 patients in a variety of hematological disorders underwent 

LS (including Hand-Assisted LS) between May 1996 and March 

2004. We selected to perform Hand-Assisted LS (HALS) for 


patients with splenomegaly. We measured postoperative 

serum amylase level (S-AMY) and amylase concentration of 

peritoneal fluid (D-AMY). Pancreatic fistula was defined as 

infected drainage with high D-AMY 

Results: Two patients (2.4%) had pancreatic fistula and one 

patient had concomitant pancreatitis. Their D-AMY was 

extremely high level (66600 and 4458 IU/L), while their S-AMY 

was almost within normal range (91 and 171). Their surgical 

drains were removed on 15 and 8 postoperative days, respectively. 

For the rest of other patients, drains were removed 

within three days of operation. In the first patient, HALS was 

employed, and operative time was 245 and 315 minutes, blood 

loss was 100 and 120ml, resected splenic weight was 2315 and 

1100g, respectively. Fifteen patients (20%) had asymptomatic 

hyperamylasemia, and recovered uneventfully. Eleven patients 

(11%) developed high D-AMY level without any symptoms. 

Mean splenic weight of these patients was 654g and statistical 

analysis showed a significant relationship between D-AMY and 

resected splenic weight. 

Conclusions: We report two cases of postoperative pancreatic 

fistula which required long drainage. Patients with 

splenomegaly need special attention for postoperative pancreatic 



PORTAL VEIN THROMBOSIS AFTER LAPAROSCOPIC 

SPLENECTOMY FOR SYSTEMIC MASTOCYTOSIS, Majed 

Maalouf MD, Daniel Gagné MD,Pavlos Papasavas MD,David 

Goitein MD,Philip Caushaj MD, The Western Pennsylvania 

Hospital, Temple University Medical School Clinical Campus 

Laparoscopic splenectomy has become the surgical technique 

of choice for various diseases of the spleen. Portal vein thrombosis 

(PVT) following splenectomy occurs in 0.5-22% of 

patients. Symptoms are non-specific and include fever, 

abdominal pain, and epigastric distress. Risk factors for PVT 

following splenectomy include underlying hematological disorders, 

massive splenomegaly (>1kg), thrombocytosis (>106) 

and other hypercoagulable states. 

We describe a case of PVT in a woman who underwent laparoscopic 

splenectomy for symptomatic splenomegaly secondary 

to systemic mastocytosis. The patient was discharged from the 

hospital without anticoagulation and experienced nonspecific 

symptoms beginning 10 days postoperatively. Diagnosis of 

PVT was made by contrast enhanced abdominal computed 

tomography. The patient had no underlying risk factors. 

Anticoagulation treatment facilitated recanalization of the portal 

vein and this was verified by Doppler ultrasound at followup. 

PVT following laparoscopic splenectomy is not uncommon. 

Signs and symptoms are vague and require a high index of 

suspicion for timely diagnosis. Anticoagulation is the treatment 

of choice and allows recanalization of the portal system 

in the majority of cases. 


DOES LAPAROSCOPIC APPENDECTOMY INCREASE THE RISK 

OF INTRAABDOMINAL ABSCESS, J M Saxe MD, D Tong MD,K 

Kralovich, Henry Ford Hospital 

The laparoscopic approach to appendectomy has been gaining 

in popularity. Some reports have indicated however an 

increased incidence of post operative abscess formation in 

complex appendicitis treated by laparoscopy. 

Recommendations have favored open procedures when 

abscess was known preoperatively. Perforation and infected 

fluid is not always able to be determined preoperatively. Our 

hypothesis is that postoperative intra-abdominal abscess formation 

is not higher after laparoscopic appendectomy when 

compared to open appendectomy for appendicitis. 

Methods: A retrospective study of all patients who underwent 

an appendectomy at our single institution between January 

2002 and March 2003. Exclusion criteria included patients 

under 18 years of age and incidental appendectomy. Charts 

were reviewed for age, gender, intraoperative diagnosis, operative 

procedure, postoperative complications, and length of 

stay. Operations were classified as laparoscopic(LA), lap. converted 

to open (CO), and open appendectomy (OA). Diagnosis 

was classified as normal, acute appendicitis, gangrenous and


perforated. 

Results: A total of 302 patients underwent appendectomy during 

the study time. 203 patients were studied. LA was performed 

in 77 patients, 115 underwent OA, and 11 patients 

were converted. Complications in LA included abscess(3), Ileus 

(3), and wound infection (2). OA complications include wound 

infection (12), ileus (11), Abscess (7), enterocutaneous fistula 

(1), cardiac (1), and hernia (1). Wound infection differences 

were statistically significant. 

Conclusion: LA does not appear to increase the incidence of 

intra abdominal abscess formation. Furthermore, overall complications 

seem to be less with LA than those seen in OA. 

Prospective studies of OA vs. LA are necessary to validate 

these findings. 


CASE REPROT OF DELAYED SMALL BOWEL OBSTRUCTION 

FOLLOWING LAPARASCOPIC-ASSISTED HEMICOLECTOMY, 

David J Swierzewski MD, Robert J Hyde MS,Christian Galvez- 

Padilla MD,Robert D Fanelli MD,Eugene L Curletti MD, 

Berkshire Medical Surgery, Department of Surgery; University 

of Massachusetts Medical School 

This is a case report of Richter?s hernia through 5-mm port 

after laparoscopic-assisted hemicolectomy. 

The patient is an 84-year-old woman with PMHx of HTN, CHF, 

Type 2 DM and COPD (on prednisone 5mg TID) who initially 

underwent screening colonoscopy and had multiple polyps 

removed. The patient underwent laparoscopic-assisted right 

hemicolectomy to remove a sessile polyp in the cecum. Three 

5-mm incisions were made in the umbilicus, suprapubic region 

and the left lower quadrant using bladed trocars. A fourth incision 

was made in the right lower quadrant through which the 

right colon and ileum were delivered and resected. At the end 

of the case, the three 5-mm incisions were closed with 4-0 

Vicryl suture in a subcuticular fashion. The right lower quadrant 

incision was closed with #1 PDS sutures in two layers for 

the anterior and posterior sheath, and staples for the skin. 

Postoperatively, the patient did not have any flatus or bowel 

movement. On POD #7, the patient became nauseous and 

vomited. A nasogastric tube was inserted for decompression. 

By POD #10, the patient remained without bowel function. It 

was decided to bring the patient back to the OR for exploratory 

laparotomy. The decision not to attempt a laparoscopic 

exploration was based on the amount of small bowel distention 

and concern regarding safe peritoneal access. After 

abdominal access was achieved through an infraumbilical 

midline incision, collapsed loops of small bowel were visualized. 

In addition, the entire jejunum was distended. At approximately 

the midpoint of the jejunum, a portion of the antimesenteric 

border was herniated through a defect in the 

abdominal wall. This defect was identified and correlated with 

the left lower quadrant skin incision at the 5-mm port site. The 

fascial defect was closed with a running simple stitch using 2-0 

Prolene. 

Richter?s hernia is an infrequently encountered hernia that 

involves incomplete protrusion of bowel wall through a defect. 

Standard practice is to routinely close the fascia of port sites 

>10 mm in adults, and >5 mm in children, to prevent such herniation. 

Our case of a hernia through a 5-mm port site in an 84 

year-old patient is further evidence that other factors such as 

patient age, past medical history, pharmacotherapeutics (i.e. 

steroids) and other factors should be considered when deciding 

whether or not to close port sites < 10 mm. Additionally, 

the use of non-bladed trocars may be of benefit in this subset 

of patients. 


LAPAROSCOPIC SPLENECTOMY FOR THE TREATMENT OF 

SPLENIC AND HEMATOLOGIC DISORDERS. -A RISK OF 

ENLARGED OR MASSIVE SPLENOMEGALY-, M Yasui MD, M 

Sekimoto PhD,M Ikeda PhD,S Takiguchi MD,I Takemasa PhD,H 

Yamamoto PhD,T Hata MD,T Shingai MD,M Ikenaga PhD,M 

Ohue PhD,M Monden PhD, Department of surgery and clinical 

oncology, Graduated school of medicine, Osaka University 

Laparoscopic splenectomy (LS) is the surgical approach of 

choice for patients with disorders requiring splenectomy. We 

performed LS with patients who have normal to enlarged 

spleens for the treatment of splenic and hematologic disorders. 

This study was performed to evaluate a risk of splenomegaly 

for perioperative complications (hemorrhage, operative time, 

and more) of LS. 

86 consecutive patients who admitted our hospital from 1995 

to May/2004 underwent LS(or hand-assisted laparoscopic 

splenectomy, HALS) for various indications. We reviewed the 

perioperative outcomes and various clinical factor in the 

patients. Patients were divided into three groups-normal 

spleen group (splenic weight



ent screws, to adjust the friction of the ball, giving the angle of 

the instrument and a second screw for defining the length of 

optical instruments inside the abdomen. The ball has to be in 

close contact with the abdominal wall. The ball is held by a 

metal clamp, which is attached to a mechanical retractor, 

which connects the system with the operating table. 

After adjusting the friction to the needs of the operation and 

allowing a change of the position by using one hand without 

opening the screws the optic is focused upon the operative 

field. The operation is performed with the use of a curved 

grasper for the left hand, which allows that both instruments 

for the surgeons are located on the right side of the optic, e.g. 

in gallbladder surgery. Therefore, there is no conflict between 

operative instruments and retractors given. If the position of 

the optic or the retracting instrument has to be changed, it can 

be performed with the move of one hand in a very short time 

(no more than a second). 

Results: We have operated with the use of solo-surgery 50 

patients with chronic cholecystitis and gallbladder-stones and 

5 patients with acute cholecystitis. It takes 0.9 minutes to 

establish the retracting technology, to break down the system 

0.5 minutes in the average. 

All procedures went smooth without any complications. We 

observed that less movements of the camera have been performed 

compared to the assisted procedure and that the position 

of the optic was clearly more stabile than the assisted procedure. 

We perform today routinely solo-surgery for resection 

of the gallbladder in chronic cholecystolithiasis, except in educational 

tasks. One ball trocar is routinely used for retraction of 

the liver in fundoplication, so that a third assistant is never 

necessary. 

P238–Ergonomics/Instrumentation 

OBJECTIVE ASSESSMENT OF KNOT QUALITY SCORE, Daniel 

L Howell MD, Huang Ih-Ping MD,E A Goldenberg MD,C D 

Smith MD, Endosurgery Unit, Department of Surgery, Emory 

University 

Surgical skills in laparoscopy are difficult to acquire and 

assess. Knot Quality Scores (KQS) have been used by some to 

assess the quality of laparoscopically tied knots as a measure 

of the difficult task of laparoscopic suturing and knot tying. 

KQS is calculated by the following formula, 

We have found that KQS has a large amount of variability for 

knots that slip. This study compared tensile strength of tied 

suture to that of untied suture utilizing a measure of elasticity 

known as Youngs modulus (YM). 100 four throw, slip 

square knots were tied laparoscopically in a box trainer using 

USS 2-0 silk suture. Knot quality was assessed using an In- 

Spec 2200 Benchtop tensiometer and the KQS was calculated 

using the previously described formula. Mean breaking force 

was determined for tied and untied suture along with the distraction 

of the suture in mm. Knots with a plateau of the curve 

extending beyond 6.5mm were designated as slipped. From 

the maximum breaking strain and distance of distraction in 

mm the YM was calculated in Pascals.Mean breaking force 

was 20.04 for slipped knots and 20.66 in knots that did not slip. 

The mean distraction in slipped knots was 7.8 mm with a KQS 

of 0.31 compared to 5.73mm and KQS of 0.34 in knots, which 

did not slip p < 0.05. Mean YM in untied suture was 3.40x10- 

3 Pascals in slipped knots the YM was 2.39x10-3 Pascals and 

3.30x10-3 Pascals in knots that did not slip p< 0.05. While 

KQS provides a benchmark for knot quality knots which slip 

may result in a falsely high KQS. Calculating YM for the knotted 

ligature reveals that in tight knots force is distributed as 

the suture elongates due to its elastic properties. When knots 

slip the measure of elasticity is much lower implying most of 

the force is distributed as the knot tightens despite similar 

KQS between the two populations. This will be important as 

skills assessment strategies are implemented in General 

Surgery Residencies and in the Credentialing of surgeons. 



DEVELOPMENT OF A NEW FLAT NEEDLE AND TIGHTER 

THREAD FOR ENDOSCOPIC SUTURING, Soji Ozawa MD, 

Yasuhide Morikawa MD,Toshiharu Furukawa MD,Junya 

Oguma MD,Hironori Asada MD,Masaki Kitajima MD, 

Department of Surgery and Department of Obstetrics & 

Gynecology, School of Medicine, Keio University, Tokyo, Japan 

As a means of facilitating intracorporeal suturing, we made 1/3 

of the body of a curved needle flat to allow it to be grasped 

easily, and we reduced the surface coating of the thread as 

much as possible to prevent the knots from loosening. The 

new needle and the thread were evaluated in this study. 

Ten surgeons manipulated a needle 

driver and an assistant grasper to grasp the new flat needle 

(70% oblateness, F needle; 25 mm, 1/2 circ., AZWELL, Japan) 

and a regular round needle (R needle) ten times each with a 

Lap Coacher training system (Hakko, Japan). The time 

between needle insertion and grasping as correctly as possible 

was measured. The tip of the needle driver and the needle 

were photographed from two directions, and the error in angle 

between 90 degrees and the actually measured angle was analyzed. 

A multiple overhand knot was made on the sponge with 

99.75% reduced silicone-coated thread (Reduced thread; 3-0, 

polyester, braided, AZWELL) and regular silicone-coated 

thread (Regular thread). The minimum number of multiple of 

overhand knot required to hold the knot when the surgeon’s 

hand was removed was counted. The time in the F- 

needle group (12.6 +/- 4.3 sec) was shorter than in the R-needle 

group (18.1 +/- 9.2 sec) (p < 0.01). The error in pitch angle 

was 7.4 +/- 7.3 degrees in the F-needle group and 9.3 +/- 8.1 

degrees in the R-needle group (p = 0.08), and the error in yaw 

angle in the F-needle group (4.7 +/- 5.1) was smaller than in 

the R-needle group (10.2 +/- 8.9 degrees) (p < 0.01). The product 

of time and the number of degrees of error in the pitch 

angle and the yaw angle with the F needle were significantly 

smaller than with the R needle in 20% and 60% of the surgeons, 

respectively. The product of time and the sum of the 

error in the pitch and yaw angles with the F needle was significantly 

smaller than with the R needle in 30% of the surgeons. 

The minimum number of multiple of overhand knot made with 

dry Reduced thread and dry Regular thread were 3 and 5, 

respectively, versus 2 and 5, respectively, with wet Reduced 

thread and wet Regular thread. The results 

demonstrated that the new flat needle is grasped more correctly 

and quickly than conventional round needles, and that 

the thread with reduced surface coating is less likely to loosen. 

It was, therefore, concluded that the combination of the new 

flat needle and thread with reduced surface coating is useful 

for endoscopic suturing. 


FAILURE MODE AND EFFECTS ANALYSIS ON THE LAPARO- 

SCOPIC CHOLECYSTECTOMY, Kazuhiko Shinohara MD, School 

of Bionics,Tokyo Univesity of Technology 

Failure Mode and Effects Analysis (FMEA) on the procedure of 

laparoscopic cholecystectomy was performed for the purpose 

of medical safety. The procedure of laparoscopic cholecystectomy 

was classified into 12 steps by the method of Indutrial 

Enginnering. Incidents and troubles were analysed in each 

step and their influences were classified into 4 classes in the 

manner of FMEA (1:catastrophic,2:critical,3:marginal,4:negligible). 

49 cases of the incidents and troubles were extracted and 

all of them were classified in 1 or 2. 76% of the incidents and 

troubles were caused by the factors of medical electric devices 

and surgical instruments. 55% were caused by both human 

and machine factors ,25% were caused by human factors. 43% 

of the incidents and troubles were peculiar to the laparoscopic 

surgery. One of the safety problems cleared from this study 

was that most of the incidents and troubles could be detected 

only by the human and the lack of the integrated monitoring 

system for the total operational environments. 


ASSESSING ENDOSCOPIC CUTTING PERFORMANCE WITH 

AND WITHOUT THE TARGET BEING HELD WITH THE NON- 

PREFERRED HAND, Bin Zheng PhD, Stephen Obradovich,Alan


J Lomax MD,Christine L MacKenzie PhD, Simon Fraser 

University, BC, Canada 

In performing a complex endoscopic task, surgeons tend to 

work with the two hands, stabilizing the target with an instrument 

in the nonpreferred hand and manipulating the target 

using the preferred hand. The benefits of bimanual collaboration 

in the endoscopic cutting task were quantified using video 

analysis technology. 

Twelve participants were required to perform three pseudoendoscopic 

tasks in counterbalanced order, reaching and cutting 

a 1 cm thread using endoscopic scissors in the preferred 

hand, with and without having the thread held by a grasper in 

the nonpreferred hand, and simply reaching and grasping the 

thread with an endoscopic grasper in the preferred hand. The 

image of the work plane was displayed vertically or superimposed 

over the work plane. In half the conditions, the camera 

was rotated 45 degrees, causing misalignment between the 

actual and displayed work plane. Movements were videotaped 

and decomposed into subtasks. Durations of subtasks performed 

by the preferred hand were analyzed using 3 (task) X 2 

(display) X 2 (camera rotation) within subject MANOVA. 

Cutting with the thread being held by the nonpreferred hand 

had shorter total time (6.6 s) than when the thread was not 

stabilized by the nonpreferred hand (7.6 s). However, due to 

the individual difference, the difference was not significant. 

Rather, reaching and grasping the thread with the preferred 

hand was preformed in 5.4 s, significantly shorter than the two 

cutting tasks above. Rotation of the camera degraded task performances 

over all movement phases. The superimposed 

image display shortened the total execution time (5.8) compared 

to the vertical image display (7.3 s). This addressed the 

benefits of superimposing the display on the workspace to 

facilitate endoscopic task performance. 

P242–Esophageal/Gastric Surgery 

LAPAROSCOPIC RESECTION OF GASTRIC GISTS: NOT ALL 

TUMORS ARE CREATED EQUAL, Eric Bedard MD, Christopher 

M Schlachta MD,Joseph Mamazza MD, The Centre for 

Minimally Invasive Surgery, St. Michael’s Hospital, University 

of Toronto, Toronto, Ontario, Canada 

INTRODUCTION: Laparoscopic resection has become an 

accepted approach to gastric GIST tumors with acceptable 

early results published in the literature. Long term recurrence 

rates, however, are still unclear and the management of 

tumors in challenging locations requires exploration. 

METHODS: A retrospective analysis of all patients undergoing 

a laparoscopic resection of gastric GIST in our institution 

between November 1997 and July 2004 was performed. 

RESULTS: A total of 12 patients (13 tumors) were evaluated: 5 

tumors were located high on the lesser curve, 7 on the fundus/greater 

curve and 1 in the distal antrum. The mean patient 

age was 62+/-14 years. Symptoms at initial presentation, in 

order of frequency, were dyspepsia, upper GI hemorrhage and 

early satiety. All patients had an attempted laparoscopic 

approach with the following procedures performed: stapled 

wedge excision (8), excision and manual sewing technique (4) 

and distal gastrectomy (1). Overall, there was a 15% (2) conversion 

rate. As reported by others, lesions found in the fundus/greater 

curvature area were easily resected via simple stapled 

wedge excision. High lesser curve tumors, on the other 

hand, were more difficult to manage and required a combination 

of modalities for complete excision and preservation of 

the GE junction. These included: intra-operative resection margin 

localization via gastroscopy (4/5, 80%), excision and manual 

sewing technique (4/5, 80%) and reconstruction over an 

esophageal bougie (5/5, 100%). One patient with a high lesser 

curve GIST required conversion due to size and proximity to 

the GE junction, as did one patient with a lesion adjacent to 

the pylorus. Overall, the mean tumor diameter was 3.9 +/- 2.7 

cm with 75% spindle and 17% epithelioid types. There were no 

post-operative complications and length of stay was 4.8 +/- 2.1 

days. At median follow-up of 48 months (mean 37.1+/- 25 

months) one patient has suffered a recurrence (18 months 

post-op) with eventual disease-related death. 

CONCLUSION: The laparoscopic approach to gastric GIST 

tumors is safe and associated with acceptable short and intermediate 

term results. High lesser curve GISTs can be safely 

approached laparoscopically by utilizing various techniques to 

ensure an adequate resection margin without compromising 

the GE junction. 


THE INFLUENCE OF PSYCHOLOGICAL DISORDERS ON THE 

OUTCOMES OF LAPAROSCOPIC NISSEN FUNDOPLICATION: 

PRELIMINARY RESULTS, Laurent Biertho MD, Sanjeev Dutta 

MD,Herawaty Sebajang MD,Martin Antony PhD,Mehran Anvari 

PhD, St. Joseph’s Healthcare, McMaster University, Hamilton, 

Ontario, Canada 

Background: Psychological disorders have been associated 

with functional dysfunction of the digestive system. The aim of 

this study was to evaluate the influence of psychological factors 

on the outcomes of Laparoscopic Nissen Fundoplication 

(LNF) for documented GastroEsophageal Reflux Disease 

(GERD). 

Methods: This is a prospective, single Institution, controlled 

trial. 17 patients (13 females and 4 males) with documented 

GERD underwent psychological testing before LNF, 3 months 

and 6 months after surgery (LNF Group). The results were 

compared with 10 patients (9 females and 1 male) who underwent 

a Laparoscopic Cholecystectomy (Control Group). 

Psychological assessment was performed using the Symptom 

CheckList-90 (SCL-90), the Depression Anxiety Stress Scale, 

Anxiety screening test, Illness attitude testing and Beck 

Depression Inventory II. GERD symptoms were evaluated 

using a specific scoring system based on 5 major GERD symptoms 

(score 0 to 60). 

Results: 7 patients in the LNF Group had ongoing reflux symptoms 

with GERD Symptom Score >12 at 6 months after surgery. 

In comparison to the remaining LNF patients with excellent 

outcome (minimal or no GERD symptoms) and to the 

Laparoscopic Cholecystectomy patients, this group had significantly 

higher preoperative SCL-90 scores (p




LAPAROSCOPIC TREATMENT OF POST-DILATION ESOPHAGIC 

ENDOSCOPIC PERFORATION IN A PATIENT WITH IDIOPATHIC 

ACHALASIA BY THAL ESOPHAGOGASTROPLASTY WITH DOR 

ANTIREFLUX VALVE, Gustavo L Carvalho PhD, Gildo O Passos 

Jr,Frederico P Santos,Frederico W Silva MD,Carlos H Ramos 

MD,Gilvan Loureiro MD,Carlos T Brandt PhD, Clínica Cirúrgica 

Videolaparoscópica Gustavo Carvalho, UPE - Universidade de 

Pernambuco, UFPE - Universidade Federal de Pernambuco, 

Recife ? BRAZIL 

BACKGROUND: The most serious complication of forced dilation 

of the esophagus is rupture of the thoracic esophagus 

with mediastinitis. This leads to a surgical emergency and usually 

requires a thoractomy or laparatomy approach, or both, 

for it to be repaired and possibly to the need for a cervicotomy 

to re-route the esophageal passage. There has been a recent 

report of the repair of these lesions by laparoscopy through 

suture of the lesion. However, the repair of this severe injury 

using Thal´s esophagogastroplasty with Dor?s anterior fundoplication 

(Thal-Dor) fully performed by laparoscopy has not 

previously been reported. 

OBJECTIVE: To report the case of a female patient with idiopathic 

achalasia who suffered post-dilation endoscopic rupture 

of the esophagus and received treatment exclusively by 

laparascopic means using Thal-Dor Procedure. 

PATIENT: A 52 year-old female patient suffering from idiopathic 

achalasia, with strong symptoms, suffered an approximately 

6cm rupture in the distal esophagus while undergoing endoscopic 

balloon dilation. The lesion was identified immediately 

and the patient referred for emergency surgical treatment by 

laparoscopy. 

METHOD: After performing the pneumoperitoneum, a phrenotomy 

was undertaken on the anterior part of the diaphragmatic 

hiatus which allowed a better view of the mediastinum and 

complete identification of the esophageal injury. By using 

ultrasonic scissors 4 cm of the stomach adjacent to the lesion 

were sectioned longitudinally from the cardia. 

Esophagogastroplasty was carried out using transverse suture 

to repair the injury. After testing with instilation of methylene 

blue, an antireflux Dor valve was made to cover up the gastroesophageal 

suture. 

RESULTS: An esophagogram taken on the 1st POD showed no 

leakages and the esophageal passage without abnormalities, 

with the patient being fed in sequence. Three weeks after surgery, 

endoscopy showed the esophagogastric region without 

signs of esophagitis or stenosis; and from a rear view, the 

antireflux valve well adjusted to the endoscope. The patient 

was satisfied with the procedure and to date has not mentioned 

any eating restrictions. 

CONCLUSION: It is being increasingly demonstrated that the 

resources of minimally invasive surgery are safe and effective 

in conducting complex procedures, even in emergency situations, 

as long as patient clinical adequacy, level of technical 

skill of the surgical team and availability of instruments are 

respected. 


LAPARASCOPIC RE-FUNDOPLICATION IN THE TREATMENT OF 

GERD - AN ANALYSIS OF 18 CASES., Gustavo L Carvalho PhD, 

Marco Antônio C Melo MD,Frederico P Santos,Gildo O Passos 

Jr.,Gilvan Loureiro MD,Frederico W Silva MD,Roberto Pabst 

MD, Clínica Cirúrgica Videolaparoscópica Gustavo Carvalho, 

UFPE-Universidade Federal de Pernambuco, UPE - 

Universidade de Pernambuco, Recife - BRAZIL 

BACKGROUND: Antireflux surgeries have a low rate of reoperations, 

varying from 2 to 10%. Nevertheless, when this is 

necessary, it is common to opt for open surgery under the 

belief that this will be safer. However, various centers have 

observed the efficiency of re-operations by laparascopic 

means in antireflux surgeries, so demonstrating that the rate 

of complications is small, apart from the good long-term 

results. 

OBJECTIVE: To assess the effectiveness and safety of laparascopic 

re-fundoplication in a series of 18 patients. 

PATIENTS: In the period from 1992 to 2004, a study was made 

of 18 patients (11 men and 7 women; whose average age was 


46 years old) who underwent antireflux surgery by the Nissen 

procedure and who needed a second fundoplication. In all of 

them, endoscopy was carried out, from which 11 patients were 

shown to have esophagitis of varying degrees, 9 presented 

accessory gastric chamber due to migration of the valve, 8 

presented other problems in the valve whether associated with 

migration or not (3 incomplete, 2 twisted, 2 tightened and 1 

partially undone) and in 2 patients it was associated with 

Barrett´s esophagus. The main indications of the second operation 

were migration (9), undoing (4), tightening (3) and torsion 

(2) of the valve. 

METHOD: In one patient, the surgery consisted of removing a 

stitch which was tightening the lower esophagus. In the other 

cases, fundoplication was again carried out and was associated 

with a new hiatoplastia in 13 of these. The patients were 

later assessed by endoscopy and biopsy. 

RESULTS: There was no conversion to open surgery. The average 

hospital stay was 3.37 ±5,36 days. One female patient presented 

sudden thoracic pain on the 12th POD and needed 

another laparascopic operation in which a perforation of the 

valve was diagnosed and treated. One male patient had postoperative 

discomfort for some time. There were no other complications 

from the operations and 15 patients have shown 

themselves to be asymptomatic since then. An endoscopy for 

control was carried out on the 30th and 60th post-operative 

days from which it was shown that 15 patients remained free 

of esophagitis and GERD. 

CONCLUSION: Laparoscopic re-fundoplication are not only 

technically feasible but also clinically effective with low rates 

of complications and conversions. 


LAPAROSCOPIC RESECTION OF A TUBULOVILLOUS ADENO- 

MA ARISING IN THE DUODENAL BULB, Kuo-Hsin Chen MD, 

Shih-Horng Huang PhD, Department of Surgery, Far-Eastern 

Memorial Hopital, Taipei,Taiwan 

LAPAROSCOPIC RESECTION OF A TUBULOVILLOUS ADENO- 

MA ARISING IN THE DUODENAL BULB 

Kuo-Hsin Chen MD, Shih-Horng Huang PhD, Department of 

Surgery, Far-Eastern Memorial Hospital, Taipei, Taiwan 

Tubulovillous adenoma arising in the duodenum is rare. Most 

of the lesions are found during endoscopic examination and 

removed by endoscopic cauterization. 

We report a 74 y/o male patient with a tubulovillous adenoma 

of the duodenum bulb, which caused duodenal obstruction 

and intermittent bleeding. The patient had a history of previous 

laparotomy for cholecystectomy, vagotomy and pyloroplasty 

6 years before this admission. Endoscopic polypectomy 

was attempted but failed to remove it completely due to the 

large size. 

Laparoscopic duodenotomy is performed under CO2 pneumoperitoneam. 

The pedunculated lesion is exposed and lifted 

with an Endoloop. An EndoGIA is applied and the lesion is 

removed completely. The duodenotomy is closed by interrupted 

intracorporeal sutures. 

The postoperative course is uneventful. The patient remained 

symptoms free 22 months after the surgery. 

The laparoscopic resection of the duodenal bulb tubulovillous 

adenoma is feasible. To hold the lesion with an Endoloop 

helps to avoid tissue trauma during surgery. Any bleeding 

from the base of the lesion could be checked and controlled 

through laparoscopic approach. The patient recovered faster 

when compared with traditional open resection. 


LAPAROSCOPIC NISSEN FUNDOPLICATION AFTER FAILED 

STRETTA PROCEDURE, S S Davis MD, M I Goldblatt MD,D J 

Mikami MD,W S Melvin MD, The Ohio State University 

Medical Center, Center for Minimally Invasive Surgery 

OBJECTIVE: Radiofrequency energy delivery to the GE junction 

(the Stretta procedure) has been shown to be a safe and 

effective short-term treatment for GERD. Studies show 

improvements in GERD symptom scores, patient satisfaction 

and distal esophageal acid exposure. Laparoscopic Nissen 

Fundoplication may still be required for symptom control in 

patients who do not respond to Stretta. No literature exists 

describing the feasibility or efficacy of LF after failed Stretta.


METHODS: A database of 52 patients undergoing Stretta was 

retrospectively reviewed and four patients were identified who 

went on to require fundoplication. All had 24-hour pH studies, 

manometry and endoscopy to document the presence of 

reflux before the Stretta procedure. The decision to proceed 

with fundoplication was based on recurrence of reflux symptoms. 

Data for operative time, length of stay, and postoperative 

complications were collected from chart review, and compared 

to a cohort of patients undergoing routine fundoplication. 

Pre- and post-operative symptom surveys were completed 

by the patients to evaluate outcome. 

RESULTS: Operative times were similar in both groups (98 vs. 

97 minutes). The surgeon did not note a difficult dissection in 

any of the cases. There were no perioperative complications. 

Three of four patients were discharged home on postoperative 

day one. Most patients completed symptom surveys at the last 

postoperative visit and all reported excellent results. 

CONCLUSIONS: Laparoscopic Nissen fundoplication after previous 

Stretta procedure is safe, and the outcomes are similar 

to those having fundoplication as an initial procedure. The use 

of Stretta as a first line procedure in patients with uncomplicated 

GERD does not preclude later performance of laparoscopic 

fundoplication in those with continued reflux symptoms. 


EVOLUTION OF THE EPTFE SOFT BELT NONINFLATABLE 

LAPAROSCOPY GASTRIC BANDING (SBNLGB), MULTICEN- 

TERS 10 YEARS COMPARATIVE EVOLUTION STUDY, Moshe 

Dudai MD, Martin Fried MD,Gregorio Jermian MD,David 

Edelman MD, Jerusalem, Prague, Buenos-Aires, Miami 

Aim: To examine the influence of the along time (10 years) 

changing in the surgical technique and the characters of the 

ePTFE Noninflatable bands, on the results of the SBNLGB. 

Methods: Four centers taking part in a prospective and retrospective 

study: Prague(P), Jerusalem(J), Buenos-Arias(B) and 

Miami(M). Six parameters were changed along the time; 3 for 

the surgical technique: size of the pouch, place of the retrogastric 

canulation and number of over-band placations; and 3 for 

the bands: type of the ePTFE, shape of the band and method 

of its fixation. The length of experience of each center was 

divided into tree main periods reflecting the changes in surgical 

technique and bands: Early experimental (EE P93-6, J97, 

B98-9, M00-1), Late experimental (LE P97-98, J98, B00-2, M01- 

2) and Stabilized Plato (SP P99-04, J99-04, B03-4) periods. At 

EE the pouch size was 25-50cc and reduced gradually to 10cc 

at SP. Lesser-sac canulation changed to very high perigastric 

or Pars-Placida at SP. Multiples over-band placations changed 

to minimal over-band placations at SP. The band material 

changed from vascular PTFE or simple ePTFE at EE to Dual 

Mesh at SP and the shape from loop or wrap band that was 

fixed to itself or to the stomach, to Soft Belt that fixed only to 

itself. 

Results: Were compares between the centers, for each period: 

Numbers of patients/Early PO complications/Bands 

Migration/De-Rebanding. For EE period: P-300/4/3/8 J-90/4/2/6 

B27/4/1/4 M-30/2/1/2, for LE period: P-200/2/2/5 J-150/2/1/5 B- 

100/2/1/3 M-30/1/1/1, for SP period: P-400/0/0/3 J-360/0/0/3 B- 

43/0/0/0.There is similarity of the results between the centers 

at the same period examined as well as the pattern of improving 

the results along the evolution of the surgical technique 

and bands. Sever PO complications were prevented at the SP 

period as well as band migration, will late Debanding were 

reduced from 7% at EE and 3% at LE to 0.75% at SP period 

(800 patients over 5years of follow-up). 

Conclusion: Experience of 4 centers over 10 years with evolution 

of the surgical technique and bands, lead the SBNLGB to 

achieved very low late band complications. Thus results create 

a doubt on the need for the inflatable mechanism, that its benefit 

never was evidence base proved. 


LAPAROSCOPIC RESECTION OF GASTROINTESTINAL STRO- 

MAL TUMORS, Melanie A Edwards MD, Jonathan Critchlow 

MD,Benjamin Schneider MD, Beth Israel Deaconess Medical 

Center 

Objective/Introduction: Laparoscopic wedge resection is suitable 

for gastrointestinal stromal tumors located in the stomach. 

We present our experience with gastrointestinal stromal 

tumors (GIST) 

Methods and Procedures: We reviewed the charts of 30 

patients operated on for GISTs between 1994 and 2004. All 

laparoscopic procedures were gastric resections, while open 

procedures included gastric, small bowel, and large bowel 

resections, as well as a partial hepatectomy for metastatic disease. 

Presenting symptoms, completeness of resection, tumor 

size and location, operating times and length of hospital stay 

are presented. 

Results: There were 17 open, 11 laparoscopic and 2 handassisted 

resections performed for 35 tumors. In the laparoscopic 

and hand-assisted group, mean patient age was 63. 

Abdominal pain, gastrointestinal bleeding and anemia were 

the most common presenting symptoms. Other tumors were 

asymptomatic and discovered on evaluation for other conditions. 

38% of lap resections were performed for anterior gastric 

tumors with size ranging from 0.7-5.5cm. Mean operating 

time was 168 minutes in the lap group and 191 mins for the 

open procedures. There was one liver laceration in the lap 

group, and no intraop complications for open procedures. 

There were 3 conversions to an open procedure in the laparoscopic 

group, 2 because of inability to achieve clear margins 

due to tumor location, and 1 because of an adherent stomach. 

Hospital stay was shorter in the lap group, mean 4.4 vs. 7.1 

days and there were fewer postop complications. There were 

no recurrences during the follow up period in the lap group 

and 5 in the open group. 

Conclusions: Gastric GISTs that are small are well suited for 

laparoscopic resection. The low malignant potential associated 

with smaller tumors makes this a feasible alternative to open 

resection. 


POSTOPERATIVE ACHALASIA, AS AN ANTIREFLUX SURGERY 

COMPLICATION, Edgardo Suarez MD, Hiosadhara E Fernandez 

MD, Jose J Herrera MD, Hospital Español de México GI motility 

unit and gastroenterology department. 

Gastro esophageal reflux disease (GERD) is the most common 

esophageal disease in USA. Classic symptoms that suggest 

GERD are heartburn and regurgitation. Nissen fundoplication 

remains as the surgical gold standard technique in selected 

patients. Fifty percent of patients with moderate to severe 

esophagitis have peristaltic dysfunction usually characterized 

by decreased wave amplitude; this amplitude finding is directly 

proportional to GERD severity. Nissen fundoplication in 

patients with peristaltic dysfunction remains controversial 

because of postoperative dysphagia but there have been 

recent reports that suggest esophageal improved motor function 

after fundoplication. 

Aim: To identify most common esophageal motility dysfunction 

in patients with GERD. To identify most common 

esophageal motility dysfunction in patients with postoperative 

dysphagia 

Methods: In a three years retrospective, transverse, observational 

and descriptive study we analyzed preoperative (Nissen) 

manometric evaluations in patients with GERD and postoperative 

manometric evaluations in those cases with postoperative 

dysphagia. We excluded patients with preoperative diagnosis 

of achalasia and those patients with postoperative motility disorder 

but without previous manometric evaluation. Results: 

From March 2000 to April 2003 we reviewed 430 esophageal 

manometric preoperative (Nissen) evaluations, with GERD preoperative 

diagnosis. In 95.11% (n=409) patients we observed 

esophageal ineffective motility (EIM). 7.17% (n=31) of patients 

had postoperative dysphagia; 5.78% (n=25) were referred for 

postoperative manometric evaluation for early dysphagia and 

1.15% (n=5) with late dysphagia. 6/31 patients (18.61%) 

showed a manometric pattern compatible with achalasia. 

Conclusion: Nissen fundoplication remains as the gold standard 

surgical technique for GERD. Dysphagia remains also as 

the principal postoperative complication with an expected rate 

from 10 to 40% for early dysphagia and 10% for late dysphagia. 

There are only few previous papers that make reference to 

achalasia as a complication of Nissen fundoplication. The 



191



pathophysiology of this phenomenon remains unclear and it 

will require further research to establish it. Preoperative manometric 

evaluation for fundoplication is a controversial issue 

but it is also the gold standard to recognize esophageal motor 

disorders. It also helps identify esophageal motor disorders 

whether they were, or not present preoperatively for legal purpose. 


THE ROLE OF SELECTIVE VAGOTOMY DURING NISSEN FUN- 

DOPLICATION, S Dissanaike MD, K O Shebani MD,E E Frezza 

MD, Texas Tech University Health Sciences Center 

After Laparoscopic Nissen fundoplication, some patients continued 

to experience symptoms related to high acid output. To 

alleviate this problem, we decided to perform selective vagotomy 

on those patients who complained of epigastric pain, a 

pain consistent with peptic ulcer disease, or who have had a 

history of peptic ulcer disease. 

METHODS We prospectively studied all patients who came to 

see us with gastroesophageal reflux disease GERD, a history 

of peptic ulcer disease or associated gastritis. The patients 

were assigned to two treatment groups: 1) Nissen fundoplication 

(NF) only and 2) NF with highly selective vagotomy (HSV). 

Patients were selected for HSV based on: 1) high acid output, 

2) pre-prandial pain, 3) history of peptic ulcer, 4) high dose 

protein pump inhibitor therapy and 5) failure of anti-acid therapy 

after 6 months. Prior to the operation, an upper endoscopy 

was performed to rule out acute peptic ulcer or gastritis. A 24 

hour pH study and manometry were also performed. 

RESULTS Three patients in each group were considered in our 

initial series. The mean age was 41 +/- 8 in the first group and 

44 +/- 9 in the second. Patients were on anti-acid therapy for 

an average of 12 +/- 4 months in the first group and 10 +/- 3 

months in the second group. There were no active peptic 

ulcers or active gastritis in either group. Esophagitis was present 

in both groups. Manometry was normal. The DeMeester 

score was slightly higher in the second group. Operative time 

was 90 +/- 20 minutes for group 1 and 110 +/- 15 minutes for 

group 2. None of the patients complained of reflux. In group 1, 

2 out of 3 patients were re-started on anti-acid therapy, with 

some relief of symptoms. In group 2, no patients complained 

of stomach pain or required anti-acid therapy. 

CONCLUSION Adding HSV to the Nissen fundoplication 

decreased the symptomatology of high acid production. More 

studies are needed before a final conclusion can be drawn. 

From our preliminary data, we feel that performing HSV can 

be advantageous to the patient, adding only 15 to 20 minutes 

to the procedure. 


LAPAROSCOPIC GASTRIC BYPASS ? AN EFFECTIVE TREAT- 

MENT FOR COMPLICATED GERD. A CASE REPORT., Piotr 

Gorecki MD, Kevin Cho MD,Katherine Martone MD,Leslie Wise 

MD, Department of Surgery, New York Methodist Hospital, 

Brooklyn, NY 

Introduction: Surgical treatment of severe complicated gastroesophageal 

reflux disease (GERD) associated with a large 

hiatal hernia remains a challenging problem. High incidence of 

symptoms recurrence has been reported after laparoscopic 

repair. 

Case report: A 29 year- old morbidly obese female suffering 

from severe heartburn, regurgitation and dysphagia presented 

for evaluation for weight reduction surgery. Her weight was 

234 lbs and BMI was 40 kg/m2. Her quality of life was significantly 

impaired because of her symptoms. Her preoperative 

evaluation revealed esophagitis with a 6 cm hiatal hernia and 

stricture of the distal esophagus. A 24-h pH testing revealed a 

significant acid exposure of the distal esophagus with 

DeMeester score of 177. Esophageal manometry revealed 

hypotensive low esophageal sphincter (LES) with LES pressure 

of 1 mm Hg. The patient underwent endoscopic balloon dilatation 

of the esophageal stricture followed by a course of 

aggressive treatment of esophagitis with proton pump 

inhibitors for three months. Her dysphagia improved. She 

underwent a laparoscopic reduction of a large hiatal hernia 

with high mediastinal dissection to establish intraabdominal 


segment of the short esophagus and a Roux-en Y gastric 

bypass. Her recovery was uneventful and she was discharged 

home on a fourth postoperative day. At four-month follow up 

visit she reported complete resolution of her reflux and dysphagia 

symptoms and no need for acid suppresion medications. 

She enjoyed weight loss of 47 lbs and her quality of life 

improved from not acceptable to excellent. Radiograms and 

endoscopy photographs will be presented. 

Conclusion: Aggressive treatment of esophagitis and preoperative 

balloon dilatation of peptic stricture followed by laparoscopic 

repair of hiatal hernia and Roux Y gastric bypass is feasible 

and may be considered as the most definite surgical 

treatment of severe GERD complicated by esophageal stricture. 


LESSONS LEARNED FROM LAPAROSCOPIC TREATMENT OF 

ESOPHAGEAL AND GASTRIC SPINDLE CELL TUMORS, Steven 

R Granger MD, Michael D Rollins MD,Sean J Mulvihill 

MD,Robert E Glasgow MD, Department of Surgery, University 

of Utah Medical Center, Salt Lake City, Utah, USA 

Introduction: Gastric and esophageal spindle cell tumors are 

rare neoplasms that have been traditionally resected for negative 

margins through an open approach. The aim of this study 

was to evaluate the efficacy and lessons learned from laparoscopic 

resection of gastric and esophageal spindle cell tumors. 

Methods and Procedures: This was a retrospective review of 

all patients who underwent laparoscopic resection of gastric or 

esophageal spindle cell tumors at a tertiary referral center 

between December 2002 and August 2004. Medical records 

were reviewed with regard to patient demographics, preoperative 

evaluation, operative approach, tumor location and 

pathology, length of operation, complications, and length of 

hospital stay. 

Results: Ten consecutive patients (6 men and 4 women) with a 

mean±SEM age of 51±6.2 years (range, 21-72) were treated. 

Preoperative endoscopic ultrasound (EUS) was performed in 

all patients with a diagnostic accuracy of 100% for predicting 

spindle cell neoplasm, while EUS-guided FNA had a diagnostic 

accuracy of 55% in correctly predicting the final pathology. R0 

laparoscopic resection was achieved in all patients. Four 

patients with symptomatic distal esophageal leiomyomas were 

treated with enucleation and Nissen fundoplication. Six 

patients were treated with laparoscopic wedge resection of 

gastric lesions which included leiomyoma (1), GIST (3), and 

heterotopic pancreas (2). Intraoperative endoscopy was performed 

in 4 patients and was associated with shorter operative 

times (161±21.7 versus 196±24.2 without intraoperative 

endoscopy). Operative time for this whole series was 182±17 

minutes, 197±28 minutes for the first 5 cases and 167±19 minutes 

for the last 5 cases. The mean length of hospital stay was 

2.1±0.25 days. One patient with esophageal leiomyoma had 

persistent dysphagia at 12 month follow-up. There were no 

other complications and no deaths in this series of patients. 

Conclusions: Laparoscopic resection of esophageal and gastric 

spindle cell tumors may be performed safely with low patient 

morbidity. This approach can accomplish adequate surgical 

margins and lead to short hospital stays. Improvements in 

technique have led to shorter operative times. 


SYMPTOMATIC OUTCOMES AFTER LAPAROSCOPIC MODI- 

FIED HELLER MYOTOMY AND DOR FUNDOPLICATION 

(MHMDF) FOLLOWING FAILED MEDICAL MANAGEMENT OF 

ACHALASIA., Mohammad K Jamal MD, Eric J DeMaria 

MD,Alfredo M Carbonell DO,Jason M Johnson DO,Brennan J 

Carmody MD, Department of Surgery, Virginia Commonwealth 

University, Richmond, Virginia. 

Patients with failed non-operative management of achalasia 

may have suboptimal outcomes after MHMDF. We report a single 

surgeon experience in 30 patients with achalasia who 

underwent a MHMDF between 1998 and 2004. The aim of the 

study was to determine the impact of pre-operative treatment 

on a detailed symptom assessment. Pre- and post-operative 

symptom scoring (SS) was obtained using a standard questionnaire. 

Patients were asked to quantitate their symptoms in 

6 categories on a scale of 0 to 3 (0=none, 1=mild, 2=moderate,


3=severe). A total SS was calculated as the sum of scores in all 

6 categories. 

The male:female ratio was 1.14:1 and mean age of 46 years. 

The mean duration of symptoms was 48 months and during 

this time 80% of patients failed non-operative treatments 

including botox (n=1), dilatation (n=12) or combined treatment 

(n=11). Three patients had sigmoid esophagus on contrast 

study. Only 6 patients did not receive any pre-operative treatment 

and underwent MHMDF as a first line therapy. Some 

form of pre-operative testing was carried out in all patients 

and included manometry (n=17), upper gastro-intestinal series 

(n=28) and upper endoscopy (n=29). Post-operative contrast 

studies were performed in all patients. 

MHMDF was completed laparoscopically in 29/30 patients. 

There was one esophageal perforation necessitating an open 

conversion and no mortality in the group. All patients regardless 

of pre-operative therapy showed improvement in their 

post-operative dysphagia scores. The total SS decreased significantly 

from pre- to post-operatively in patients without previous 

treatment (8.3 ± 3.8 vs. 1.3 ± 1.2, p



their weight after effective treatment with Heller myotomy. 

Heller myotomy with simultaneous duodenal switch has been 

described as one treatment option. However, reflux and pathological 

malabsorbtion are potential complications that may 

limit the effectiveness of this procedure. Although it has never 

been reported, LRYGB with combined Heller myotomy is 

another feasible therapeutic option. However, the effect of a 

restrictive procedure (LRYGB) in the setting of esophageal dysmotility 

is unclear. Our short term results indicate that LRYGB 

can yield typical weight loss results of gastric bypass surgery 

with resolution of dysphagia. Creating a larger gastro-jejunostomy 

(2.5cm) may reduce the risk of postoperative dysphagia. 

Finally, because the gastric pouch has minimal acid production, 

the risk of pathological acid reflux is reduced. 


OUTCOMES OF LAPAROSCOPIC PARAESOPHAGEAL HERNIA 

REPAIR: 49 CONSECUTIVE CASES IN A RURAL CENTER, 

Vittorio Lombardo MD, Carly Stell BS,Yaron Perry MD,Salman 

Malik MD,Craig Wood BS,Anthony T Petrick MD, Geisinger 


INTRO: Patient referrals for laparoscopic paraesophageal hernia 

repair (LPHR) have recently increased in our center.. Recent 

series have advocated the laparoscopic approach. No large 

studies of LPHR have been reported in a rural population. Our 

objective is to analyze the outcomes of our initial experience 

with LPHR. METHODS: Retrospective data was obtained 

through a GERD/dysphagia questionnaire, review of UGI and 

electronic medical records. Statistical significance was calculated 

using student?s t-test. RESULTS: The mean age of 49 

consecutive patients was 67.1±14.8 with a 1:2.5 M:F ratio. 

Preop UGI and EGD demonstrated a PEH in 95% and 92% of 

patients respectively. Collis gastroplasty and Nissen were performed 

in 86% and only Nissen in 14%. Crural repair was performed 

in all patients. Median LOS was 3.5 days (range 2- 9 

days). 98% completed at least one postop questionnaire at a 

mean of 12.7 months and 80% had an UGI at least 3 mo 

postop (mean=12.2mo). UGI was normal 90% and 10% had 

recurrence of paraesophageal hernia. Major complications 

occurred in 12%. Mortality was 2.0%(n=1). Results were reported 

as excellent in 41%, good in 43%, fair in 10% and poor in 

6%. 

Outcomes of LPHR 

Symptoms Preop Postop 

Heartburn 80% (n=39) 6.1% (n=3)* 

Regurg/Emesis 71% (n=35) 6.1% (n=3)* 

Dysphagia 41% (n=20) 12% (n=6))* 

Epigastic pain 33% (n=16) 2.0% (n=1)* 

PPI's 76% (n=38) 18% (n=9)* 

* = p


silluminated the anterior abdominal wall, and secured the 

stomach to the anterior abdominal wall with T-bar fasteners. 

Using a modified Seldinger technique, we placed a gastrostomy 

tube through the center of the T-bars. 

Forty-seven children (mean age, 6.4 years), including 15 

infants aged less that 1 year, underwent the procedure. 

Indications for long-term enteral access included failure to 

thrive (n=11), feeding disorder secondary to neurologic dysfunction 

(n=31), gastroparesis (n=1), and dysphagia (n=4). 

Forty procedures were performed in the operating room, three 

in the neonatal intensive care unit and four in the pediatric 

intesive care unit. Operative time averaged 23 minutes (range 

12 to 45). One late complication occurred (gastrocolonic fistula). 

The one minor complication was early dislodgement of the 

gastrostomy tube, which required replacement. In this study, 

the technique was found to be safe and effective for placing 

gastrostomy tubes in infants and children. 


DIVISION OF THE SHORT GASTRIC VESSELS DURING 

LAPAROSCOPIC NISSEN FUNDOPLICATION, S Mehta MD, A 

Hindmarsh MD,R Lowndes,M Rhodes MD, Department of 

Upper Gastrointestinal Surgery, Norfolk and Norwich 

University Hospital, Norwich, UK 

Introduction 

Division of the Short Gastric Vessels (SGV) during 

Laparoscopic Nissen Fundoplication may be an important step 

in reducing the prevalence of post-operative dysphagia. 

Clinical outcome measures have been used in the past to 

assess the relative importance of this technique. This study 

prospectively evaluates both clinical outcome and physiological 

measurements in patients with or without division of the 

SGV. 

Methods 

204 patients underwent Laparoscopic Nissen Fundoplication 

after 24 hr pH testing and manometry. Post-operatively they 

were invited to have repeat physiology measurements at 4 

months and symptom assessment at 6 months. 

Results 

110 patients had division of the SGV (Group 1), whilst 94 did 

not (Group 2). Age and severity of reflux disease were similar 

in the 2 groups. Mean DeMeester score improved from 38 to 8 

in Group 1 and from 45 to 7 in Group 2(no significant difference 

between groups). Mean lower oesophageal sphincter 

pressure improved from 6.1 to 17.7 mmHg in Group 1 and 

from 5.4 to 17.3 mmHg in Group 2 (no significant difference 

between groups). Mean operating time was significantly 

longer in those having division of the SGV (65 vs. 54 mins 

p



cation rate for SN was 100% (32/32), and the mean number of 

SN was 5.2?}3.8 (1~13 SN). Five of the 32 patients had lymph 

node metastasis. The sensitivity (5/5) and diagnostic accuracy 

(32/32) were both 100%. CONCLUSION: By the use of IRLS 

observation in laparoscopic surgery, the same sensitivity was 

obtained in SN identification as with infrared ray electronic 

endoscopy; it was not necessary to darken the operating 

room, and the operation of the IRLS as well as observation 

with IRLS were easier than those in open surgery. The IRLS 

seems to be a useful tool for laparoscopic identification of SN 

for early gastric cancer. 


LAPAROSCOPY- ASSISTED TOTAL GASTRECTOMY FOR GAS- 

TRIC CANCER, Kazuyuki Okada MD, Syuji Takiguchi 

MD,Mitsugu Sekimoto MD,Hiroshi Miyata MD,Yoshiyuki 

Fujiwara MD,Takushi Yasuda MD,Yuichiro Doki MD,Morito 

Monden MD, Department surgery and clinical oncology, 

Graduate school of medicine, Osaka university 

[Purpose] With the development of related instruments and 

techniques, laparoscopic gastrectomy which include partial 

gastrectomy and distal gastrectomy, has come to be applied to 

the treatment of?@gastric cancer as a minimally invasive surgery. 

However, laparoscopy- assisted total and proximal gastrectomy 

are not so common, and they are also considered as 

the challenging procedures. It is the most major reasons that 

esophagojejunostomy and esophagogastrostomy under the 

laparoscopy have technical difficulties. So, we will report 

about our technique of laparoscopy- assisted total gastrectomy, 

especially about esophagojejunostomy by using semi 

automatic suturing device?iEndostitch?j. [Method] From 

September 2001 to March 2004, laparoscopy- assisted total 

gastrectomy with lymph node dissection was performed on 14 

patients in our hospital. They were also divided into two 

groups by the extent of lymph node dissection based on the 

preoperative clinical stage. One was laparoscopic D1+ beta 

lymph node dissection for 11 patients with T1N0, the other 

was hand- assisted laparoscopic D2 lymph node dissection for 

3 patients with T1N1 or T2N0. Hand- assisted method was performed 

for splenectomy and the dissection of NO.10 and 

NO.11d lymph nodes. The way of laparoscopic anvil- head fixation 

on esophagojejunostomy is as follows. Firstly, the tip of 

the suture of Endostitch was brought outside the body using 

the Endoclose instrument. After about ten encircling pursestring 

sutures were performed by Endostitch, an anvil-head 

was placed laparoscopically with supporting the esophageal 

wall at three points. When the intracorporeal ligation using 

Endostitch was performed, it was possible to get ligation with 

a sufficient degree of tension by pulling the suture placed 

through the abdominal wall extracorporeally. [Result] The 

mean operating time and blood loss on the cases of laparoscopic 

D1+ beta lymph node dissection were 287 minutes and 

155.4 ml. On the other hand, those were 364 minutes and 

583.3 ml respectively on the cases of hand- assisted laparoscopic 

D2 lymph node dissection. There was no major postoperative 

complication and no recurrent cases in both procedures. 

It was indicated that our technique of esophagojejunostomy 

was suitable and laparoscopy- assisted total gastrectomy 

was a feasible procedure for gastric cancer. 


LAPAROSCOPIC WEDGE GASTRECTOMY ESOPHAGEAL 

LENGTHENING PROCEDURE: CLINICAL AND PHYSIOLOGICAL 

FOLLOW-UP, Allan Okrainec MD, Cliff Sample MD,Herawaty 

Sebajang MD,Mehran Anvari PhD, Centre for Minimal Access 

Surgery, McMaster University, Hamilton Ontario Canada 

Background: Various methods of Collis gastroplasty have been 

described to lengthen the esophagus. In this series of 8 

patients, we describe early outcomes following a laparoscopic 

wedge gastrectomy (LWG) esophageal lengthening procedure. 

Methods: Between January 2004 and August 2004, patients 

with PEH were assessed pre-operatively with symptom scores 

(SF-36, GERD score), upper endoscopy, barium swallow, 24-hr 

pH monitoring, and esophageal manometry. Intra-operatively, 

after reduction of the PEH and mobilization of the esophagus, 

patients with less than 2 cm of intraabdominal esophagus, 

underwent LWG. A 52 French bougie was advanced and the 


wedge gastrectomy was performed using a 45mm endo-GIA 

linear-cutting stapler. 

Results: Eight patients (5M:3F) with a mean age of 66.9 ± 11.6 

years underwent LWG. Six patients (75%) had GERD; seven 

patients (87.5%) had PEH (6 type III, 1 type IV); six (75%) had 

organoaxial volvulus of the stomach; two patients (25%) had 

previously failed fundoplications; three patients (37.5%) had 

Barrett?s esophagus. Mean O.R. time was 188.1 ± 51.9 min. 

Mean LOS was 3.9 ± 2.0 days. Mean time to start of oral diet 

was 1.25 ± 0.7 days. All patients had a gastrograffin swallow 

on POD one. All were normal except one which showed a 

small stricture at the level of the diaphragm. The only minor 

complication was post-op dysphagia in this same patient. This 

resolved without dilatation. There were no major complications. 

Objective evaluation with upper endoscopy, 24-h. pH 

recording and manometry is planned for our patients at 6 

months. 

Conclusion: LWG esophageal lengthening procedure is a safe 

technique for dealing with a shortened esophagus. Long term 

clinical and physiological follow-up are still needed. Our six 

month follow-up data will be available at the time of presentation. 


LAPAROSCOPIC INTRAGASTRIC SURGERY UNDER CARBON 

DIOXIDE PNEUMOSTOMACH, Takeshi Omori MD, Kiyokazu 

Nakajima PhD,Toshirou Nishida PhD,Syunnji Endo MD,Eiji 

Taniguchi* PhD,Shuichi Ohashi* PhD,Toshinori Ito PhD,Hikaru 

Matsuda PhD, Department of Surgery, Osaka University 

Graduate School of Medicine. Osaka, Japan *Department of 

Surgery, Osaka Central Hospital, Osaka, Japan 

Background: Laparoscopic intragastric surgery (LIGS) requires 

pneumostomach to maintain exposure and working space in 

the stomach. The pneumostomach is originally created by 

atmospheric air insufflation through flexible gastrointestinal 

endoscopy. The insufflated air, however, often migrates downwards 

without duodenal clamping and causes excessive and 

prolonged bowel distention. The distention of downstream 

bowel complicates visualization of conclusion laparoscopy in 

LIGS, and may further lead to postoperative abdominal pain 

and bloating. Carbon dioxide (CO2), with its faster absorption 

than air, can attenuate downstream bowel distention when 

used to establish pneumostomach. The objectives of this study 

were to evaluate feasibility, safety and effectiveness of CO2 

pneumostomach in LIGS. To our knowledge, this is the first 

clinical series of CO2 pneumostomach. Methods: We have performed 

15 LIGSs under CO2 pneumostomach (01/1997 to 

08/2004): 8 males, 7 females; mean age of 60.9 years. The 

stomach was insufflated with CO2 via automatic surgical insufflator 

up to 8 mmHg of intraluminal pressure. No duodenal 

clamping was employed prior to insufflation. Cardiopulmonary 

parameters e.g. heart rate, body temperature, end tidal CO2, 

were prospectively registered and retrospectively analyzed. 

Minute volume was positively adjusted when indicated. The 

degree and extent of bowel distention was assessed by conclusion 

laparoscopy and the amount of intestinal gas was evaluated 

by postoperative plain abdominal radiograph. Results: 

LIGS was completed in all 15 cases with mean intragastric 

insufflation time of 100 minutes. CO2 pneumostomach provided 

good and constant surgical exposure with sufficient working 

space. No adverse effect of intragastric CO2 insufflation 

was observed on cardiopulmonary function, with minimal 

hyperventilation (i.e. 20% increase of minute volume). Even 

without duodenal clamping, the insufflated small bowel loops 

already shrank at the time of conclusion laparoscopy. Fair 

residual gas was documented radiologically in 2 cases, whereas 

only faint in remaining 13 cases. No patients showed 

abdominal pain/bloating postoperatively and no consequences 

related to CO2 pneumostomach were encountered in the 

series. Conclusions: CO2 pneumostomach is feasible and safe 

alternative and potentially effective for LIGS, by eliminating 

need for prior duodenal clamping and minimizing bowel distention. 


LAPROSCOPIC ASSISTED TOTAL GASTRECTOMY, Shailesh P 

Puntambekar MD, Rajendra S Jathar MD,Suresh M Ranka MD, 

King Edward Memorial


Introduction 

Radical total gastrectomy is a technically difficult 

procedure.Since the anastomosis is to the abdominal esophagus 

a lot of retraction is needed in open sugery.The magnification 

offered by laparoscopy facilitates the dissection as well as 

the anstomosis.The abdominal incision is considerably small 

and so is the morbidity. 

Methods 

We have done 15 total gastrectomies laparoscopically in the 

last 15 months.A total of five ports are used.The port placement 

is the same as in fundoplication except the camera port 

which is below the umbilicus in the midline.The complete 

stomach along with omentum is dissected.All the vessels are 

ligated at the origin and nodal clearance is achieved..The duodenum 

is transected with stapler.An additional 2-0 vicryl 

suture is taken on the duodenal stump.A purse string suture 

with 1-0 proline is taken on the lower end of esophagus and 

the anvil of stapler is inserted.A loop of jejunum is delivered 

through the transverse mesocolon..A small abdominal incision 

is taken and the specimen is removed.The EEA stapler is then 

fired through the jejunum. 

Results 

The average time taken is 180 minutes.The average blood loss 

is 100 ml.None of our patients had anastomotic leak.No conversion 

to open surgery was needed.There was no 

mortality.The average hospitalisation was 6 days.3 patients 

have completed one year follow up. 

Conclusion. 

Total gastrectomy with esophagojejunostomy can be done 

laparoscopically.The oncological clearance is the same as in 

open surgery but there is a definate decrease in the morbidity 

and hospitalisation. 


EVALUATION OF LAPAROSCOPIC ANTI-REFLUX SURGERY 

WITHOUT A BOUGIE USING A POSTOPERATIVE VALIDATED 

SYMPTOM SCORE, K Ramkumar, M Deakin,C V N Cheruvu, 

University Hospital of North Staffordshire, Stoke-on-Trent, UK 

Introduction 

Traditionally Laparoscopic Anti-reflux Surgery (LARS) was performed 

with the insertion of a bougie blindly through the gastro 

oesophageal junction to prevent a tight fundoplication. The 

bougie insertion is associated with oesophageal and gastric 

perforations. The aim of this study is to assess whether LARS 

without a bougie is safe and effective documenting the postoperative 

symptom of dysphagia, recurrent reflux and gas 

bloat as the main outcome measures. 

Methods 

Data was collected prospectively in 68 consecutive patients 

who underwent LARS without a bougie between January 2000 

and July 2004 in a tertiary care university hospital. 8 patients 

were excluded due to additional procedures. All these patients 

had preoperative 24hr pH studies, manometry and upper GI 

endoscopy. Patients were seen for follow-up at six weeks then 

at four months interval upto one year. A validated Modified 

Visick Symptom Score (MVSS) questionnaire to assess recurrent 

reflux, dysphagia and gas bloat was sent by post and 

results were collected by post / telephone interview. 

Results 

Of the 60 patients, 43 were male and the mean age was 39.7 

yrs (range 15 ? 61 yrs). 42 (70%) patients had a floppy 360 fundoplication 

and 18 (30%) patients had partial fundoplication. 3 

(5%) patients had an open conversion. Median length of hospital 

stay was two days. There was no mortality and postoperative 

morbidity was seen in 4 (6.7%) patients, of whom two had 

chest infections, one developed acute pulmonary oedema and 

one had acute gas bloat with a prolonged hospital stay. Longterm 

follow up assessment was achieved in 55 (91.6%) 

patients with a mean follow-up of 16.35 months. Modified 

Visick Symptom Score (MVSS) for heartburn and regurgitation 

was good and excellent (Visick 1 or 2) in 96.6% of patients. 

Similarly MVSS for dysphagia and gas bloat was good and 

excellent (Visick 1 or 2) in 95% and 91.6% of patients respectively. 

We had a 91.6% patient satisfaction and all said that 

they would recommend surgery to others. Long-term side 

effects occurred in 8 (13%) patients of whom five patients had 

gas bloat, two had recurrent reflux and one patient had dysphagia. 

Conclusions 

These results demonstrate that Laparoscopic Anti-reflux 

Surgery without a bougie is a safe and effective therapy for 

Gastro oesophageal reflux disease avoiding the risks of 

oesophageal and gastric injury. 


USE OF A LEFT HEMIDIAPHRAGM RELAXING INCISION FOR A 

TENSION FREE CRURAL CLOSURE IN THE REPAIR OF LARGE 

HIATAL HERNIAS., Patrick R Reardon MD, Wiljon Beltre 

MD,Ajay K Chopra MD,Michael J Reardon MD, Department of 

Surgery, University of Texas Health Sciences Center at 

Houston, The Methodist Hospital. Houston, Texas. 

Introduction: Repair of a large hiatal or paraesophageal hernia 

with simple cruroplasty is associated with a high recurrence 

rate. The tension on the suture line renders it prone to disruption. 

To achieve a tension free repair, prosthetic materials have 

been utilized as bridging materials for the repair of the large 

hiatus. We report the use of a relaxing incision in the central 

tendon in the left hemidiaphragm to achieve a tension free 

crural closure. 

Methods: From July 1995 to August 2004, a total of 123 

patients underwent laparoscopic repair of a hiatal hernia with 

or without fundoplication in a single surgeon?s practice. Six of 

them presented with large symptomatic hernias (five type III/IV 

and one large type II hiatal hernia). There were 3 males and 3 

females in this group. The average age was 65.3 years (range 

42-84 years). The average BMI was 30.94 (range 27.4-38.4). The 

size of the hiatal defect ranged from 8 to 9 cm. Attempt at closure 

of such a large defect resulted in undue tension. 

Therefore, a vertical relaxing incision was made in the central 

tendon of the left hemidiaphragm. The hiatus was then closed 

with Teflon pledgeted Dacron sutures. The resulting defect in 

the left diaphragm was patched with Gore-Tex Dual Mesh 

using 0 braided Dacron sutures utilizing the Endo Stitch 

device. The mean duration for the procedure was 348 minutes 

(range 325-365 minutes). Patients have been followed up from 

7 to 44 months (average 31.5 months). All patients are asymptomatic 

and recent contrast studies obtained in 3 of the 

patients are normal. 

Conclusion: A relaxing incision in the left hemidiaphragm 

achieves an effective and tension free repair of a large hiatal 

hernia. There are no adverse effects noted with this technique. 

Longer follow-up is needed regarding recurrence rates. 


MIDTERM FOLLOW UP AFTER LAPAROSCOPIC HELLER 

MYOTOMY ALONE VERSUS TOUPET, DOR AND MODIFIED 

DOR FUNDOPLICATION, William S Richardson MD, Colleen I 

Kennedy MD,John S Bolton MD, Ochsner Clinic Foundation, 

New Orleans, LA, USA 

Our aim was to compare outcomes of Heller myotomy alone 

(H) and with different partial fundoplications. 

We retrospectively reviewed our experience of 69 laparoscopic 

Heller myotomies. 80% were performed with partial fundoplication 

(20 Toupet (T), 18 Dor (D), and 17 modified Dor (MD) 

where the fundoplication is sutured to both sides of the crura 

and not the myotomy). 

Age was 69 (range 15-80) years. There were 4 mucosal perforations 

repaired intraoperatively. There was one small bowel 

fistula at an area of open hernia repair distant from the myotomy. 

There was one death from pneumonia in a patient with 

severe COPD. Phone follow-up was achieved in 68% (7-H, 12-T, 

12-D, 13-MD) of cases at a mean of 37 (range2-97) months. 

Results are in %. D=Dysphagia. 

In addition, there were two patients with reflux strictures 

requiring annual dilation (T, D), one redo Heller myotomy (D), 

and one esophageal replacement (T). 

Heller myotomy provides excellent relief of dysphagia with 



197



and without fundoplication. Heartburn is a significant problem 

in a minority of patients. In our hands, T had the worst results 

and MD was more protective for heartburn. 


BMI IMPACTS PRESENTING SYMPTOMS OF ACHALASIA AND 

OUTCOME AFTER HELLER MYOTOMY, Alexander S 

Rosemurgy MD, Desiree V Villadolid BS,Candace M Kalipersad 

BS,Donald P Thometz BA,Steven S Rakita MD, Department of 

Surgery, University of South Florida College of Medicine, 

Tampa General Hospital 

Introduction: The impact of obesity on health is increasingly 

recognized. The impact of obesity on presenting symptoms of 

achalasia and on outcome after Heller myotomy is not established. 

This study was undertaken to determine the impact of 

Body Mass Index (BMI) on the presenting symptoms of achalasia 

and outcome after laparoscopic Heller myotomy. 

Methods: Since 1992, 254 patients, 137 men and 117 women, 

of median age 47 years (49 years ± 17.9), and of median BMI 

24 (25 ± 4.9), have undergone laparoscopic Heller myotomy 

and have been followed through a prospectively maintained 

registry. With median follow-up at 26 months (32 months ± 

28.6), patients scored their symptoms after myotomy using a 

Likert scale (0=never/not bothersome to 5=every time I 

eat/very bothersome). Data are presented as median, mean ± 

SD, when appropriate. 

Results: Patient scores improved with myotomy (p


and GERD symptom scale scores are presented. 

RESULTS: The table bellow presents the early surgical outcomes: 

Outcomes n=100 

OR time (min) 104 (60-235) 

30 d mortality 1% 

Morbidity 7% 

Mean LOS 

1.87 days 

Conversion rate 0% 

Outcomes n=100 OR time (min) 104 (60-235) 30 d mortality 

1% Morbidity 7% Mean LOS 1.87 days Conversion rate 0% 

Six patients presented with dysphagia following the surgery 

and were treated conservatively (two patients required dilatation). 

The median follow-up for this series is 22.6 months with 

a mean satisfaction score of 10 ± 2.98 on a visual scale of 0 to 

10. Eighty five percent of patients would undergo the surgery 

again and 86% estimated that surgery had improved their 

quality of life. 

CONCLUSION: Community surgeons can safely develop a 

laparoscopic Nissen fundoplication practice in their local hospital 

with outcomes similar to larger tertiary centers. 


THE LEARNING CURVE OF LAPAROSCOPIC NISSEN FUNDO- 

PLICATIONS PERFORMED BY A COMMUNITY SURGEON, 

Herawaty Sebajang MD, Laurent Biertho MD,Mehran Anvari 

PhD,Craig McKinley MD, Centre for Minimal Access Surgery, 

McMaster University Hamilton Ontario Canada; North Bay 

District Hospital, North Bay Ontario Canada 

PURPOSE: The learning curve of laparoscopic Nissen fundoplications 

performed by academic surgeons is reported to be 20 

to 50 cases. The aim of this study was to assess a community 

surgeon?s learning curve with this procedure. 

METHODS: Between January 2001 and June 2003, data was 

collected prospectively on the initial fifty laparoscopic Nissen 

fundoplications performed in a community hospital by a single 

surgeon with no fellowship training in advanced laparoscopic 

surgery. 

RESULTS: 

There was no symptom recurrence noted in all 50 patients at a 

mean follow-up of 25 months. At 6 weeks postoperative, four 

patients (8%) had dysphagia and were managed conservatively. 

The community surgeon involved in this series attended 

laparoscopic courses early in the learning curve and after the 

17th case received mentoring, telementoring and telerobotic 

assistance. 

CONCLUSION: There is a significant drop in morbidity, mortality 

and operating time after the first 20 cases. A number of factors 

including mentoring, telementoring, telerobotic assistance 

and dedicated operating room nursing staff may have impacted 

on reducing this learning curve. 


A NOVEL CONCEPTUAL MODEL OF THE CURRENT SURGICAL 

CLASSIFICATION OF PARAESOPHAGEAL HERNIAS USING 

DYNAMIC THREE-DIMENSIONAL RECONSTRUCTION, Ross D 

Segan MD, Stephen M Kavic MD,Ivan M George,Patricia L 

Turner MD,Adrian E Park MD, University of Maryland 

Baltimore 

The existing classification system of hiatal and paraesophageal 

hernias has been described throughout the literature. 

Currently, there is no satisfactory comprehensive graphic representation 

of this system for the surgeon. Multiple modalities 

have been used to illustrate these hernias, most relying on 

artists? renderings or 2-dimensional radiographic studies. The 

ambiguity of existing illustrations, along with a lack of a current 

standard, promotes miscommunication among clinicians. 

Polygonal mesh surface modeling techniques were utilized to 

render dynamic 3-dimensional CT-based models of the four 

recognized types of paraesophageal hernias. The resulting 

images allow near-real time navigation by the surgeon in an 

intuitive and clinically relevant fashion. 

This model should clarify the existing classification system 

and will ultimately improve management of paraesophageal 

hernias. 


LAPAROSCOPIC HAND-ASSISTED NISSEN FUNDOPLICATION, 

Kazuyuki Shimomura MD, Tatsuo Yamakawa MD, Dept. of 

Surgery, Mizonokuchi Hospital, Teikyo-University 

Although laparoscopic surgery is being widely accepted by 

surgeons, some drawbacks of this procedure, mainly from that 

laparoscopic procedures are 2-D remote surgery without tactile 

sensation, are being recognisied. Hand-assited laparosopic 

surgery (HALS), which started in recent years to improve these 

situations, provides surgeon tactile sensation and good organ 

handlings. Usually the indications of HALS are supposed to be 

associated with large resected specimen like colectomy, 

gasterectomy, and nephrectomy. However in selected cases 

like in complicated or high risk patients, HALS is also useful in 

functional diseases like GERD (gastro-esophageal reflux disease) 

even without surgical specimen. We would demonstrate 

the procedures and usefulness of Hand-assisted Laparoscopic 

Nissen Fundoplication (HALS Nissen) for GERD. The procedures 

of HALS Nissen is almost similar to pure laparoscopic 

access, but these procedures can be performed by the surgeon’s 

finger guide. The advantages of HALS Nissen are mainly 

in the phase of blunt dissection around lower esophagus 

with surrounded adhesion by severe esophagitis. And it also 

contributes for the better results in avoiding intraoperative 

injury in the area of esophago-gastric junction. As for the procedure 

of suture for fundoplication, HALS is useful to build the 

wrapping around fundus with appropriate pressure to fundus 

by finger knotting. We performed 3 cases of HALS Nissen so 

far, and the operation time is around 1 hour 30 min. All the 

patients discharged in 3 to 7 post portative days without complications 

or recurrence. HALS Nissen procedure is considered 

to be a safe and useful option to GERD to promote surgical 

safety. 


HAND-ASSISTED LAPAROSCOPIC SURGERY FOR A HUGE 

GASTROINTESTINAL STROMAL TUMOR OF THE 

STOMACH:REPORT OF TWO CASES, Hitotoshi Takemoto MD, 

Hiroshi Yano MD,Takushi Monden MD, Department of 

Surgery,NTT West Osaka Hospital 

Gastrointestinal stromal tumor (GIST) of the stomach is difficult 

to diagnose preoperatively no matter whether it is malignant 

or benign. Although recent advances in imaging techniques, 

such as US, CT, and MRI have aided in the identification 

of space-occupying lesions of the stomach, these techniques 

do not permit preoperative diagnosis of these lesions. 

Therefore, the resection of the tumor is generally necessary 

from both diagnostic and also therapeutic aspects in patients 

with GIST of the stomach. There are variable operative 

approaches, and most surgeons expect that the laparoscopic 

procedure will be better than open surgery because it carries 

low complications, faster recovery, less pain and better cosmetics. 

We report two cases of a huge GIST of the stomach 



199




that were successfully treated by hand-assisted laparoscopic 

surgery (HALS). Two patients, a 56-year-old woman and a 60- 

year-old man, were admitted to our department for the treatment 

of a huge submucosal tumor of the stomach. After gastrointestinal 

endoscopy, US, CT, and MRI, we suspected that 

the masses measuring 7.0 cm and 8.0 cm in diameter, respectively, 

were GISTs in the stomach. However, we preoperatively 

could not rule out the possibility of a malignant neoplasm 

because they had been bleeding or gradually growing. Handassisted 

laparoscopic wedge resection was safely performed 

for the diagnosis and treatment of the submucosal tumor of 

the stomach. The duration of surgery was 85 minutes and 91 

minutes, respectively. The intraoperative blood loss was 

insignificant. Intra- and postoperative course was uneventful. 

An immunohistological diagnosis was GIST with low-grade 

malignancy of the stomach. Two patients remain well with no 

sign of recurrence of GIST. HALS may be a good indication for 

huge GISTs of the stomach that are difficult to diagnose preoperatively 

whether they are malignant or benign. 


LAPAROSCOPIC GASTRIC RESECTION: THE RESULTS OF 

NINETEEN CONSECUTIVE CASES, Laurent Layani MD, Craig j 

taylor MD, Robert Winn MD,michael ghusn MD, John Flynn 

Gold Coast Hospital, Queensland Australia 

INTRODUCTION. Whilst the benefits of the laparoscopic surgery 

in the management many intra-abdominal pathologies 

such as cholelithiasis are well established, the benefit and feasibility 

of laparoscopic gastrectomy, particularly for gastric 

malignancy, remain uncertain. We sought to investigate this 

by reporting our experience with totally intracorporeal gastric 

resection (LGR) 

METHODS. All lap gastric resections performed by a single 

surgeon were retrospectively analysed. 

RESULTS. Between March 2000 and August 2004, 19 patients 

(median age 74 years) underwent LGR. Pathologies included 

11 adenocarcinomas, 2 malignant GIST tumours, 4 benign 

GIST tumours, 1 incomplete dysplastic polypectomy, and 1 

gastroparesis. Seven of 13 patients with malignancy were 

treated with curative intent. Two total gastrectomies, 8 subtotal 

gastrectomies, and 9 wedge resections were performed. 

Median operative time was 154 minutes. There were no conversions 

to laparotomy and no postoperative deaths. A median 

of 25 lymph nodes were retrieved in curative malignant 

resections. Fluid and solid food intake was recommenced at a 

median of 16 hours and 3 days respectively. Median length of 

hospitalisation was 4.5 days. (range 3-15) The median return 

to usual preoperative activities was 17 days. One radiological 

anastomotic leak occurred and was successfully managed conservatively. 

There was no major morbidity. No port site recurrences 

occurred. Two patients (10%) underwent reoperation 

for laparoscopic re-resection of microscopically involved margins. 

One patient with locally advanced adenocarcinoma died 

17 months post resection. The remaining 12 patients with gastric 

malignancy were still alive at a median of 15 months. 

CONCLUSION. Totally laparoscopic gastric resection is technically 

feasible and confers the established benefits of minimal 

access surgery, particularly low postoperative morbidity and 

short convalescence and is set to become the procedure of 

choice for benign and palliative gastric pathology. Whilst large 

randomised trials are needed to confirm its safety in potentially 

curative gastric malignancy, our results indicate that an 

oncologically sound resection can be achieved. 


IDENTIFICATION OF A LARGE SYMPATHETIC NERVE AT THE 

GASTROESOPHAGEAL JUNCTION DURING LAPAROSCOPIC 

NISSEN FUNDOPLICATION., Cyrus Vakili MD, Departments of 

Surgery, University of Massachusetts Affiliated Hospitals, 

Gardner MA, and Leominster MA 

Functional symptoms such as gas bloat, flatulence, early satiety, 

inability to belch, epigastric fullness, and dysphagia frequently 

occur following Nissen fundoplication. The cause of 

these symptoms in the majority of cases has not been determined. 

This author has performed 449 laparoscopic Nissen 

fundoplications between January 1993 and June 2004. A relatively 

large sympathetic nerve supplying the gastroesophageal 

junction (GEJ) was observed during video laparoscopy. This 

nerve is a branch of the left greater splanchnic nerve. It exits 

through the left true crus, and enters the most distal part of 

the esophagus, just above the angle of His. At first glance it 

looks as a fibrovascular structure. Upon biopsy on multiple 

occasions, its histology and identity was verified. The diameter 

of the nerve varies from 0.8 mm to 1.4 mm. There is no contralateral 

sympathetic innervation from the right side. 

Interestingly, this sympathetic nerve to the GEJ has not been 

depicted or described in surgical literature. There are also a 

couple of smaller sympathetic nerves, parallel but more cephalad 

to the GEJ nerve, which exit through the true left crus and 

enter the distal esophagus. Classically, the sympathetic innervation 

of the distal esophagus and the stomach has been 

described as fine nerve fibers traveling along large arteries 

such as the left gastric artery. Compared to the parasympathetic 

nerves, less information is available regarding the function 

of the sympathetic system on the lower esophageal 

sphincter and the fundus of the stomach. During Nissen procedure, 

these sympathetic nerves are often transected to facilitate 

mobilization of the distal esophagus, and to develop a 

window behind the esophagus for fundoplication. In my experience, 

preservation of these sympathetic nerves did not 

change the rate of gas bloat, or flatulence. However, its preservation 

seems to have shortened the period of post operative 

dysphagia. Considering the relative large size of the GEJ 

nerve, and its anatomic location, investigation into its function 

is warranted, particularly when the parasympathetic nerves 

are preserved. 


FEASIBILITY OF LAPAROSCOPIC FUNDOPLICATION AFTER 

FAILED ENDOSCOPIC ANTIREFLUX THERAPY, YKS Viswanath 

RN, P Cann MD,P Davis MS,PP Vassallo,K Subramanian, 

Department of Surgery and Medicine, James Cook University 

Hospital 

Background and aims: The intraoperative difficulties and post 

operative outcome after failed endoscopic Enteryx polymer 

injection therapy (EEPIT) to improve the reflux symptoms is 

unclear .We assessed the feasibility and safety of undertaking 

the Laparoscopic Nissen-Rossetti fundoplication (LNRF) after 

failed EEPIT. 

Methods: Eleven among a total of 22 patients failed to respond 

to EEPIT. Hitherto 6 among 11 patients had undergone LNRF. 

All patients had Upper GI endoscopy, oesophageal manometry 

and pH profiles prior to EEPIT. At surgery care was taken to 

identify any distortion in the normal anatomy and to identify 

any areas of fibrosis and abnormal foreign material. 

Results: All patients underwent successful LNRF. In five 

patients there were dense perioesophageal adhesions and two 

of them had foreign body granulomata anterior to the gastrooesophageal 

junction obliterating the left sub hepatic space. 

The remaining 1 had no significant adhesions. Median hospital 

stay 1.5 days. The procedures were event free and all had 

excellent control of reflux symptoms in a median follow up of 

5 months. 

Conclusion: Laparoscopic fundoplication following failed EEPIT 

injection is feasible and is not associated with increased postoperative 

morbidity. 


LAPAROSCOPIC IVOR LEWIS ESOPHAGECTOMY IN THREE 

PATIENTS WITH ABERRENT RIGHT SUBCLAVIAN ARTERIES, 

Tracey L Weigel MD, Anna Ibele MD,Joseph Bobadilla 

MD,Loay F Kabbani MD,Niloo M Edwards MD, University of 

Wisconsin 

Introduction: An aberrent right subclavian artery is a common 

anomaly often referred to as “dysphagia lusoria” if symptomatic. 

In patients with a resectable gastroesophageal junction 

carcinoma, an aberrent right subclavian that courses posterior 

to the esophagus, even if an incidental finding on chest CT, 

poses a challenge to safe resection and reconstruction. 

Methods: Three patients with gastroesophageal junction carcinomas 

were found to have an aberrent right subclavian artery 

on preoperative chest CT and were approached with a laparoscopic 

Ivor Lewis esophagectomy. Diagnostic laparoscopy was


performed followed by division of the gastrohepatic ligament 

and short gastrics with the harmonic scapel. The left gastric 

artery was divided at its origin with an EndoGIA vascular stapler 

and the nodal tissue resected with the specimen. A 

Compat 7Fr. feeding jejunostomy was placed using the 

Seldinger technique. The patient was then reintubated with a 

double lumen ETT and a vertical, mini (9cm) muscle-sparing 

thoracotomy was then performed. The esophagus was mobilized 

to the level of the aberrent subclavian artery and the azygous 

was divided. Levels #4,7,8,and 9 mediastinal lymph 

nodes were dissected. Finally, an end to side, handsewn 

esophagogastric anastomosis was fashioned 3-4 cm caudal to 

the aberrent right subclavian artery coursing posterior to the 

upper thoracic esophagus. 

Results:Three patients with esophageal carcinoma were 

approached with a laparoscopic Ivor Lewis esophagectomy. 

Two patients had Siewert Type II T3N1 lesions, one had 

Barrett’s with carcinoma in situ. One patient had neoadjuvant 

chemoradiation therapy. Median age was 63 yo and median 

LOS was 9 days. One patient had a barium obstipation treated 

succesfully with enemas, there were no deaths. No patient had 

dysphagia postoperatively secondary to the aberrent posterior 

right subclavian that was left in its native position. 

Conclusion: A laparoscopic Ivor lewis esophagectomy is feasible 

with acceptable morbidity and LOS. In patients with gastroesophageal 

junction carcinomas and an incidental aberrent 

right subclavian artery posterior to the thoracic esophagus, a 

laparoscopic Ivor Lewis esophagectomy appears to be a safe 

approach that affords good postoperative swallowing function. 


LAPAROSCOPIC NISSEN FUNDOPLICATION IN INFANTS LESS 

THAN 10KG, Robert J Wilmoth MD, Michael E Harned 

MD,David T Schindel MD,Konstantinos G Papadakis MD, East 

Tenessee Children’s Hospital and The University of Tennessee 

Medical Center at Knoxville, Tennessee 

Introduction: Laparoscopic Nissen fundoplication is an effective 

means for treating gastroesophageal reflux disease 

(GERD). As it gains popularity in the pediatric population, its 

widespread utility is still being defined. We present a group of 

patients in whom laparoscopic Nissen fundoplication was performed 

successfully in infants weighing less than 10 kg. Our 

purpose is to illustrate that laparoscopic Nissen fundoplication 

is a safe and effective means for treating GERD in this patient 

population. 

Patients and Methods: Patients undergoing an anti-reflux procedure 

between June, 2001 and July, 2004 were identified. 

Retrospective review was performed of both the patients? 

medical record and office chart. Data was recorded with 

respect to: age, weight, indications, operative time, concurrent 

procedures, time to initiate feeding, post-operative length of 

stay, and complications. 

Results: 22 laparoscopic Nissen fundoplications were performed 

in patients weighing less than 10kg. Most common 

indications included GERD (N=22), associated with failure to 

thrive (N=10) or respiratory symptoms (N=7). Gastrostomy 

was performed in 17 patients. Pyloromyotomy was performed 

concurrently for delayed gastric emptying in three patients. 

Mean patient weight was 6.3kg (range 3.0 to 9.5kg). Mean 

operating time was 2 hrs 50min. Mean post-operative hospital 

stay of all patients was 7.2 days. There were no conversions to 

an open procedure. There were no complications or recurrences 

during a mean follow-up of one year. 

Conclusions: Laparoscopic Nissen fundoplication is an effective 

means for treating GERD in the infant population. Our 

data specifically illustrates its safety and efficacy in patients 

who weigh less than 10kg. As experience with this procedure 

continues to evolve, its role within other populations will further 

be defined. 


EXPERIENCE WITH DEVELOPMENT AND CLINICAL USE OF A 

SMALL OPENER FOR LAPAROSCOPIC ASSISTED GASTRIC 

SURGERY, Hideo Yamada PhD, Juri Kondo MD,Eiji Kanehira 

PhD,Masahiko Sato PhD,Kouich Nakajima PhD,Takahiro 

Kinoshita PhD,Shigetaka Suzuki MD, Endoscopic Surgery 

Center , Toho University Sakura Hospital 

?yObjective?zOrgan extraction and anastomosis in the event of 

laparoscopic assisted gastric surgery is performed in direct 

view from a small opening; an instrument is needed to reinsufflate 

the peritoneal cavity and perform laparoscopy again 

after anastomosis is complete. Various instruments are currently 

being developed, although the current situation is one 

in which there are no instruments with which a sufficient 

opening and laparoscopic manipulation afterwards can be 

smoothly performed. Thus, the authors developed a small 

opener for laparoscopically assisted surgery (Multi Flap Gate : 

afterwards, MFG) intended for protection and effective opening 

of the peritoneal wound and simple re-insufflation in 

laparoscopic assisted gastric surgery . ?ySubjects and 

Methods?zThe specifications of the MFG have been indicated. 

There are four aspects: a surface ring (approx. dimensions 

?Ó140 mm, height 13 mm, opening ?Ó110 mm), an intraperitoneal 

ring (ext. dia. ?Ó125 mm, int. dia. ?Ó105 mm, thickness 

5 mm), a draft protection sheet (length 100 mm), and a tension 

belt (width 35 mm, thickness 1.5 mm); the site is opened further 

by pulling the latter. Re-insufflation can be performed by 

attachment of a converter (approx. dimensions ?Ó140 mm, 

?Ó70 mm) to the ring. In addition, there is a small hole in the 

center and it can be used as a port through insertion of a cannula 

here. The MFG was used in 60 cases of laparoscopic 

assisted gastric surgery March 1999 to August 2004. The 

length of the skin incision was 5-9 cm. 

?yResults?zThe MFG was easily attached in all cases and 

retraction strength was favorable. Damage to the MFG during 

surgical handling and trouble with regard to manipulation was 

not seen. The shape of the opening was almost square; extraction 

of organs and surgical manipulation in direct view were 

favorable. Gas leaks were also not noted during re-insufflation. 

In addition, no cases of postoperative wound infection or portsite 

recurrence were noted. We can do stomach resection , 

anastomosis and lymph node dissection easily using MFG. 

?yConclusion?zThe MFG has exceptional opening strength and 

is an optimal instrument for laparoscopic assisted gastric surgery 

that allows re-insufflation. A favorable surgical field was 

ensured by this instrument and laparoscopic assisted gastric 

surgery can be performed; it was also useful for prevention of 

wound infection and cancer cell implantation. 


PERFORATED PYLORODUODENAL ULCERS, A.A. Gulyaev, P.A. 

Yartsev, G.V. Pahomova, Gastroenterology department. 

Scientific research institute of emergency help named after 

N.V.Sklifosovskiy. Moscow. Russia. 

Methods:346 patients were treated with perforated gastroduodenal 

ulcers during the period of 1999 to 2004. 

Results:All patients had to take polyposition X-ray test of a 

belly cavity. In case of free gas absence (50%) in a belly cavity 

and a doubtful clinical picture of perforated ulcer, the gastroscopy 

was the next stage in the diagnostic program. 

Repeated X-ray test of a belly cavity after gastroscopy allowed 

to reveal free gas in 91 % of the patients who had not have 

endoscopic indications of perforated ulcer (53%). Laparoscopy 

is the most effective diagnostic method in complicated cases. 

At Sklifosovskiy hospital operation of a choice for patients 

with perforated pyloroduodenal ulcer, without accompanying 

complications of ulcer disease (a stenosis, a bleeding), is simple 

closing perforation. The perforation on forward wall of 

duodenal, the sizes less then 0.5sm, without expressed inflammation 

and no widespread peritonitis were direct indications 

for laparoscopic operation. Major cause of refusal from laparoscopic 

interventions was the widespread peritonitis, a combination 

of perforation and a bleeding, the big sizes of perforation 

(more than 1,0sm). Closing perforated ulcer is directed at 

treating complication of an ulcer disease, but does not result 

in complete quire of it. In this connection these patients 

require therapy of ulcer disease, since the first hours after 

operation. The long term results of 67 patients have been 

investigated (in terms after operation from 5 months till 3 

years). To get the precise assessment of the received results 

the patients have been split in two groups. Group “ A “ included 

the patients observing main principles of an ulcer disease 

treatment, in group “ B “ the patients who were not. The 



201



cumulative estimation of the remote results does not differ 

from well-known and makes 47 % of a ulcer relapses. 

However, after studying patients in view of their division into 

the groups it becomes obvious, that the most part of relapses 

directly connected to inadequacy of an ulcer disease treatment. 

In group “ A “ good and satisfactory results are marked 

in 81 %, bad results in 19 %. In group “ B “ good and satisfactory 

results are marked in 38 % of patients, bad in 62 %. 

Conclusions:We can state that treatment of patients with perforated 

ulcer must consist of combinated surgical and therapy 

treatment. It allows in most cases to perform operation of simple 

closer of perforation, on the indications laparoscopy is preferred. 


LAPAROSCOPIC REDO NISSEN FUNDOPLICATION, 

Constantine T Frantzides MD, Tallal M Zeni MD, John G 

Zografakis MD,Mark A Carlson MD, Evanston Northwestern 

Hospital 

Objective: To evaluate the mechanisms of failure after laparoscopic 

fundoplication, and the operative techniques necessary 

to reduce failure. 

Methods and Procedure: A retrospective review of 42 patients 

with failed laparoscopic fundoplication was done. Pre- and 

postoperative symptoms and testing (endoscopic, radiologic 

and manometric) were analyzed. Operative techniques to correct 

the etiologies of failure were documented. 

Results: Hearburn (69%) and dysphagia (12%) were the most 

common presenting symptoms; both symptoms were present 

in 10% of patients. Preoperative testing revealed the presence 

of reflux (76%), esophagitis (67%), hiatal hernia (45%), stenosis 

(14%), and dysmotility (5%). The most common intraoperative 

finding was a combination of ?slipped? fundoplication and 

hiatal hernia (24%). Other intraoperative findings included isolated 

slippage or malpositioning (17% each); combined malpositioning 

with hiatal hernia (12)%; isolated hiatal hernia or tight 

fundoplication (10% each); loose fundoplication (7%); and tight 

cruroplasty (5%). Redo fundoplication alone was performed in 

45% of patients, and another 45% underwent redo fundoplication 

with hiatal hernia repair; 68% of the hiatal hernia repairs 

were done with mesh. Suture removal from a tight cruroplasty 

(5%) and additional suture placement on a loose fundoplication 

(5%) occasionally were employed. Complications included 

four gastric perforations, which were all recognized and 

repaired during the redo procedure. Open conversion occurred 

in one patient. Length of stay was 3.5 +/- 1.0 days. Long-term 

failure occurred in 7/42 patients (17%). Four of these patients 

had a recurrent hiatal hernia, while three had a failed fundoplication. 

Conclusion: Redo fundoplication can be successfully accomplished 

laparoscopically in nearly all patients. Hiatal hernia 

repair (with mesh reinforcement) and secure anchorage of the 

fundoplication appear to be essential components of longterm 

success. The recurrence rate following reoperation is 

higher than after primary fundoplication. 

P290–Flexible Diagnostic & 

Therapeutic Endoscopy 

ENDOSCOPE DIAGNOSIS AND TREATMENT OF SEVERAL 

PEDIATRIC GASTROINTESTINAL DISEASES :A SINGLE CEN- 

TER EXPERIENCE, Merab Buadze MD, Ramaz Kutubidze 

MD,George Adamashvili MD,Zaza Chagelishvili MD,Levan 

Labauri MD, Dept. of Gastrointestinal Endoscope Surgery of 

Pediatric Clinic. Tbilisi State Medical University.Georgia. 

Introduction: Endoscopy is a common procedure for diagnosis 

and treatment of various gastrointestinal and colonic disorders 

in children. 

Methods: We report our experience 1985 ? 2003 of 14911 

(11504 diagnostic and 3407 therapeutic) upper and lower 

endoscopies in children from newborn to 16 years. There were 

used concisions sedations with repeated doses of midazolam 

(0.025mg/kg) up to summary dose (0.4 mg/kg). The surgical 

endoscopies were performed under general anesthesia. 

Results: 

1.Peptic Ulcer Disease ? 685; Doudenal ulcer ? 598 (87%), 

Gastric ulcer ? 87 (13%). Study of speciments was done by 


PCR to evaluate H.pylori specific CagA and VacA genes in 24 

patients. 

2.Endoscope treatment of gastroduodenal bleeding of ulcerous 

genesis 296 cases, among them DU ? 244 (82%), GU ? 52 

(18%). Bleeding due to esophageal varices ? 27 cases, sclerotherapy 

? 12. 

3.Endoscope polypectomy of single (84%) or multiple (16%) 

colon polyps ?2250 cases. 91% of the polyps were juvenile. 

4.Removal of foreign bodies from upper GI ? 570 cases 

(esophageal ? 392, gastric ? 160, duodenal ? 18). 

5.Endoscope treatment of accidental chemical burns of esophagus 

with repeated endoscope control and dilatation ? 180 

cases. 

6.Endoscope diagnosis and successful dissolution of gastric 

phytobezoars using white turnip ? 87 cases. 

7.Endoscope investigations among the new-born such diseases 

as congenital hypertrophic pyloric stenosis?239. 

8.Endoscope balloon dilatation of esophageal stenosis ? in 26 

patients: among them after esophageal atresia-9. 

9.Eosinophilic esophagitis ? 25, treatment with Kromolin- 

Natrium and corticosteroidis. 

10.Endoscope diagnosis and treatment by colonoileoscopy of 

ileocolic intussusception in children under 2 years ? 73 cases. 

Endoscope treatment was done totally in 68 from 73 (93,1%) 

cases. The valve of Baugin and 10-15 cm in length terminal 

ileum were observed usually after endoscope pneumatic 

reduction. 

Conclusions: Hence in some surgical diseases of intestinal 

tract in children the use of endoscope treatment is primary 

safe method. Also it decreases the number of laparatomies 

and complications. 

P291––Flexible Diagnostic & 


THE USEFULNESS OF INTRAOPERATIVE ENDOSCOPY, John 

M Cosgrove MD, George Denoto MD,Jeremy Goverman MD, 

North Shore University Hospital/North Shore-Long Island 

Jewish Health Care System 

The usefulness of intraoperative endoscopy as an adjunct to 

general surgery procedures cannot be overstated. The performance 

of upper endoscopy, colonoscopy and sigmoidoscopy 

can be accomplished with minimal setup and preparation, 

little difficulty and essentially no morbidity. Also, the 

procedure can be performed without adding much time to the 

operative case. The experience of one surgical endoscopist 

and a busy laparoscopic surgeon at a large academic medical 

center is chronicled. A two-year period(September 2002- 

September 2004) was chosen for review. All intraoperative 

endoscopies, colonoscopies and sigmoidoscopies were included. 

Those procedures performed outside the operating 

room(i.e.; endoscopy suite and SICU) were excluded. 

There were 95 intraoperative endoscopies performed during 

the study period. There were 23 endoscopies to evaluate open 

gastric bypass(RYGBP), 14 colonoscopies for evaluation of 

colonic anastomoses, 16 colonoscopies for evaluation of rectal 

stumps or lower gastrointestinal hemorrhage, 5 endoscopies 

for upper gastrointestinal hemorrhage or small bowel obstruction, 

9 tracheostomies/PEGs, 13 sigmoidoscopies, 6 endoscopies 

for laparoscopic assisted myotomies, 4 colonoscopies 

for laparoscopic assisted colectomies, 3 endoscopies for 

laparoscopic assisted partial gastrectomies and 3 endoscopies 

for therapeutic reasons status post gastric bypass procedures. 

The endoscopies were therapeutic in 5 cases(3RYGBP, 2 foreign 

bodies). Furthermore, our policy of intraoperative 

endoscopy picked up three anastomotic defects(1RYGBP, 2 colorectal 

anastomoses) that were easily corrected at the same 

setting. The endoscopic procedures have an excellent predictive 

value as there were no postoperative leaks. The average 

time for each endoscopy was less than two minutes. 

The performance of intraoperative endoscopy is an invaluable 

adjunct to the surgical armamentarium. It can be performed 

easily and safely and the information obtained is very useful 

and therapy will be altered in a subgroup of patients. The 

endoscopy allows the entire team to visualize the anastomosis 

on the monitor and photographs can be taken for inclusion in 

the medical record. We advocate the widespread application of


this practice by the general surgeon who performs gastrointestinal 

procedures. 



ULTRASOUND GUIDED PRE-OPERATIVE LOCALIZATION OF 

THE THYROID GLAND AS A TOOL FOR ENDOSCOPIC AXIL- 

LARY THYROID AND PARATHYROIDECTOMY, Titus D Duncan, 

MD, FACS, Atlanta Medical Center and Morehouse School of 

Medicine 

Minimally invasive surgical techniques have become common 

place in the treatment of surgical diseases processes once 

necessitating major incisions. Improved cosmesis, less pain 

and faster return to normal activity have been the driving force 

behind innovative surgical procedures now seen as common 

place. Improved surgical visualization with superior optics has 

also spawned claims of some procedures being safer than 

their open counterparts. Minimal access thyroid and parathyroid 

surgery has been shown to offer superior cosmetic results 

with improved patient satisfaction over its open counterpart. 

Furthermore, recent results have espoused superior visualization 

inferring improved safety for patients undergoing thyroid 

and parathyroid surgery. However, disadvantages of such 

techniques have prohibited them from enjoying much of the 

popularity as other minimally invasive techniques. Such disadvantages 

include increased costs, prolonged surgical times 

and a steep learning curve. We recently reviewed our series of 

patients undergoing minimal access surgery to the thyroid and 

parathyroid gland. We compared our results of patients undergoing 

surgery with pre-operative ultrasound guided localization 

of the thyroid with patients who did not have pre-op ultrasound 

localization. 

Our theory was that pre-operative localization could reduce the 

operative time of the surgical procedure. We concluded that 

pre-operative ultrasound localization significantly reduced the 

overall operative time of the minimal access procedure as well 

as reduced the learning curve for surgeons learning the procedure. 

We present our data in support of the above conclusions. 



ENDOSCOPIC PARATHYROIDECTOMY AND THYROIDECTOMY 

USING AN AXILLARY APPROACH: A VIABLE ALTERNATIVE TO 

THE OPEN APPROACH, Titus D Duncan, MD, FACS, Ijeoma 

Acholonu Ejeh MD, Department of Minimally Invasive Surgery 

Morehouse School of Medicine and Atlanta Medical Center, 

Atlanta, Georgia 

A permanent transverse scar in the neck is the usual endpoint 

for conventional surgical treatment for thyroid and parathyroid 

diseases despite that the majority of these procedures are performed 

for benign disease. The introduction of laparoscopic 

surgery in the 1980?s ushered in an era of minimal access 

techniques for many surgical fields. Endoscopic surgery can 

be performed in anatomic regions with limited space unlike 

the thoracic and abdominal cavities. The global acceptance of 

minimal access surgery has been primarily due to the advantages 

the procedures hold for the patient. Some of these 

advantages include less pain, faster return to activity, shorter 

hospital stay and improved cosmesis. However, it is well 

known that there are similar advantages for the surgeon performing 

surgery through minimally invasive approach. Better 

view of the anatomy, perhaps leading to safer dissection, has 

been one of the main advantages to this particular approach. 

Unlike laparoscopic surgery where reports of less pain, faster 

return to activity and shorter hospital stays have prevailed, 

few reports espouse similar advantages using an endoscopic 

technique over the open approach in thyroid and parathyroid 

surgery. Therefore, advantages to such an approach appear to 

be one of cosmesis for the patient and improved visualization 

and safer dissection for the surgeon. We reviewed our series 

of endoscopic thyroid and parathyroidectomies in a single 

institution to assess whether such advantages outweigh the 

difficult learning curve. We examined the technical aspects of 

the procedure and the surgeons visualization of vital structures 

as well as subjective patient scar analysis and cosmetic satisfaction. 

Our results show that the axillary approach to the thyroid 

and parathyroid can be performed safely with minimal 

complications. It is expected as is seen in other series, that the 

operative time will diminish as the plateau of the learning 

curve is reached. Though the advantages commonly seen in 

most minimally invasive procedures (i.e., less pain, faster 

recovery, shorter hospital stay, etc.) are not evident using this 

technique, the superior cosmetic outcome and patient satisfaction 

from such an approach appear to outweigh the technical 

obstacles in hands of experienced minimally invasive surgeons. 

Improved visualization, that allows safer dissection for 

the surgeon, may make this a viable alternative to the open 

technique in select patients requiring these surgeries. 



THE CASE FOR PREOPERATIVE ESOPHAGOGASTRODUO- 

DENOSCOPY IN BARIATRIC PATIENTS, D Francis MD, N 

Fearing MD,M Bozuk MD,R Altieri MD,P Leggett MD,T 

Scarborough MD,E Wilson, Department of Surgery, University 

of Texas Medical School at Houston 

Introduction: There currently is no standard preoperative workup 

for the morbidly obese patient undergoing gastric bypass 

(GB) surgery. Once the stomach is divided it is difficult to evaluate 

for pathology that may have been present prior to bypass 

surgery. We reviewed the results of the preoperative workup 

for GB in our patients to determine whether esophagogastroduodenoscopy 

(EGD) is warranted. 

Methods: We reviewed a prospectively compiled database of 

findings in patients undergoing preoperative EGD in their 

workup for GB surgery. We have been performing routine EGD 

for over two years with routine biopsies on these 

patients. Data collected included, age, body mass index, clinical 

findings, pathological findings, and presence of H. pylori 

and treatment. 

Results: Over a two-year period, 240 patients underwent preoperative 

EGD. Only 22 had normal findings and thus, no biopsy 

was performed. A total of 451 abnormal findings were 

noted on clinical exam. They included findings such as gastritis, 

esophagitis, and hiatal hernias. Pathology results in those 

that were biopsied showed abnormalities in 206 specimens. 

Gastritis was most often noted clinically in 189 patients (79% 

of all the EGD?s). Pathological evaluation of biopsies revealed 

gastritis in 120 patients(63%). Reflux esophagitis was found on 

EGD in 107 patients(45%). However, on pathological evalution, 

74 of those 107 patients (69%) had some grade of esophagitis. 

Interestingly, 7 of the patients with esophagitis were thought 

to have Barrett?s metaplasia and pathologically it was found in 

10 of 218 (4.5%) patients biopsied. These patients had previously 

undiagnosed disease. One patient had severe high-grade 

dysplasia. Hiatal hernias were seen in 31% of patients. Other 

findings included gastric polyps, duodenitis, ulcerations, 

Schatzki?s rings and gastroesophageal strictures. Most 

patients were tested for H. pylori, which was seen in 18% of 

those biopsied for the bacteria. 

Discussion: The distal remnant created with GB surgery leaves 

a potential diagnostic challenge for the bariatric surgeon. 

Based on these results, EGD prior 

to surgical isolation of this remnant is warranted to rule out 

pathology that may become a source for problems in the 

future. In addition, our findings led to medical treatment in a 

significant number of patients and will help improve our surveillance 

of those patients with Barrett?s esophagus. 



INTERFACE OF ENDOSCOPY X ADJUSTABLE GASTRIC BAND 

(AGB). 356 ENDOSCOPIES IN 1111 BANDS, Manoel P Galvao 

Neto MD, Almino C Ramos MD,Manoela S Galvao MD,Andrey 

Carlo MD,Edwin Canseco MD,Thiago Secchi MD, Gastro 

Obeso Center ? São Paulo ? Brazil 

BACKGROUND: The Adjustable Gastric Band (AGB) is one of 

the approved options in terms of bariatric surgery witch is less 

invasive with lower mortality rates, but the reports inform 

more complications and re-operation rates that the so-called 



203



golden standard in bariatric surgery, the gastric bypass. 

Endoscopic evaluation and surveillance on the follow-up of 

AGB band is an important tool witch its interface will be 

described. AIM: Evaluate upper endoscopies and endoscopic 

procedures in a series patients submitted to laparoscopic AGB 

in a 4 year period. CASUISTIC: Between December of 1999 and 

July of 2004, 1111 patients were submitted to AGB under NIH 

indications for bariatric surgery. Among those AGB patients, 

356 were submitted to upper endoscopies and procedures by 

endoscopists of reefer centers with proper training in dealing 

with endoscopy in AGB. 217 were female (61%) with a followup 

between 45d e 4y (M=20months) and had their data retrospectively 

analyzed. METHODS: The endoscopic evaluation of 

the AGB consists in analyze the esophagus looking for dilatations 

and esophagitis. In the gastric pouch, the endoscopists 

had to look for its extension, mucosal damage, contents, centralization 

and shape. The stoma was evaluated in terms of its 

axis and if it is easy to pass trough. In the stomach the band 

fundoplication was analyzed by its shape and integrity. The 

rest of the stomach and duodenum were analyzed on routine 

manner. RESULTS: From 356 (32% of 1111 AGB) patients submitted 

to endoscopies in this AGB series, 259 (72,7%) were 

considered as normal (compatible with the endoscopic expectations 

of AGB), with a gastric pouch in between 5cm (M = 

2cm), stoma centered and easy to pass and a compatible fundoplication 

on u-turn maneuver. 53 (14,8% of endoscopies) 

presents with any grade of erosive esophagitis . Esophageal 

dilatation - acalasia like occurred in 2 (0,56%), Food impactation 

in 1(0,28%). The main complications found on the AGB 

endoscopies were; slippage in 31 (8,7% ) and band migration 

in 10 (2,8%) patients .The patients with esophageal dilatation 

had their band deflated, the food impactation was removed, 

patients with slippage had their band repositioned by 

laparoscopy and 5 of the migrated bands were removed by 

endoscopy. CONCLUSION: By the numbers presented above it 

is clear that the interface between AGB and endoscopy plays 

an important rule on the follow-up of AGB patients and suold 

be stimulated 



1000 COLONOSCOPIES IN OCTOGENARIEANS, JP Gonzalvo 

DO, J E Efron MD,A M Vernava MD,D M Jones MD,M E Avalos 

MD,M A Liberman MD, Cleveland Clinic Florida-Naples 

Objectives: To evaluate the endoscopic and pathologic findings 

in colonoscopy performed in 1000 patients greater than 80 

years of age at a single institution. 

Methods: We retrospectively queried the endoscopic database 

for patients greater than 80 years of age that under went 

colonoscopy at the Cleveland Clinic Florida-Naples from May 

24, 1999 to September 15, 2004. We analyzed the indications, 

findings, complications, and pathology of those patients. 

Results: Indications for colonoscopy included screening (174), 

follow up of polyp (171), bright red bleeding (133), anemia 

(114), abdominal pain (73), diarrhea (57), follow-up cancer (54), 

surveillance (52), constipation (51), change in bowel habit (46), 

hemocult positive stools (41), family history of colon cancer 

(39), melenic bleeding (23), hematochezia (21), weight loss 

(21), and other diagnoses. Our endoscopic findings were 

polyps in 545 patients, diverticular disease in 716, mass in 26, 

AV malformations in 21, inadequate bowel prep or incomplete 

colonoscopy in 8, ulcer in 6, stricture in 6, and a normal colon 

was found in 94 patients. The pathology of biopsied lesions 

showed a total of 19 adenocarcinomas, 8 high-grade dysplastic 

lesions or carcinoma in-situ, 37 tubulovillous adenomas, 303 

pts. with tubular adenoma, and 275 pts. with hyperplastic 

polyp. The total number of complications in this patient group 

was 5, this included 1 perforation, and 1 bleeding episode after 

polypectomy. 

Conclusion: Colonoscopy can be safely performed in octogenarians. 

The bowel preparation is well tolerated and the procedure 

can be performed to completion in >99% of the patients. 

A majority of octogenarians will require therapeutic colonoscopies 

and therefore it is the procedure of choice in examining 

the colon. 




PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN THE COM- 

PLICATED OBESE PATIENT CAN BE PERFORMED SAFELY, 

James L Guzzo MD, Grant V Bochicchio MD,James Haan 

MD,Steven B Johnson MD,Adrian Park MD,Thomas Scalea 

MD, University of Maryland Medical Center and the R. Adams 

Cowley Shock Trauma Center 

Introduction: Percutaneous endoscopic gastrostomy (PEG) has 

become a commonly performed procedure with an acceptable 

complication rate. There is an absence of data reporting the 

success and complication rates of PEG placement in the obese 

and morbidly obese (MO) patient. 

Methods: Prospective data was collected from January 2001 to 

June 2004 evaluating the safety of our experience with PEG in 

obese and MO patients. In addition to BMI, patients were stratified 

by no previous abdominal surgery (NPAS) and previous 

abdominal surgery (PAS). Complication rates were evaluated 

by number of successful attempts, wound complications, 

bleeding, and tube dislodgement. 

Results: 103 patients underwent attempted PEG placement 

over the 3 _ year study period. Mean age of the study group 

was 55 ± 13 years, 73% were male, and 80% were trauma 

patients. The most common indication for PEG was dysphagia 

2° to chronic respiratory failure following traumatic brain 

injury. The overall success rate of PEG was 94% with a complication 

rate of 9.7%. There was no significant difference in the 

complication rates between NPAS and PAS patients. 

BMI (kg/m2) 30-40 41-70 >70 

Successful PEG 83/89 17/17 3/3 

Wound 5/83 2/14 0 

Bleeding 1/83 0 0 

Dislodgement 2/83 0 0 

Conclusions: PEG can be safely performed in this challenging 

patient population. Lessons learned from treating obese and 

morbidly obese patients will help push the already expanding 

frontiers of endoscopic and laparoscopic surgery. 



IS THERE ALWAYS AN HIPERTONIC LOWER ESOPHAGEAL 

SPHINCTER IN ACHALASIA, Edgardo Suarez MD, Jose J 

Herrera MD, Jesus A Insunza MD,Maria E Lopez 

MD,Hiosadhara E Fernandez MD,Jose A Palacios MD, Hospital 

Español de México GI motility and endoscopy unit. Hospital 

General ?Dr. Manuel Gea González?, GI motility unit and general 

surgery division. 

Achalasia is an esophageal motor disorder characterized for 

the absence of primary progressive peristalsis in the esophagus; 

abnormalities in the lower esophageal sphincter (LES) 

have been described. This disease was first described by Sir 

Thomas Willis in 1674. It is the best known esophageal motility 

disorder. There are 0.03-1.1 cases every 100,000 persons per 

year. The name derivates from Greek, meaning ?lack of relaxation? 

and regards to the LES. The recent manometric studies 

have suggested that these LES abnormalities are not always 

present and the diagnostic criteria for achalasia have been 

changed. The absence of peristalsis is the mandatory manometric 

finding for achalasia diagnosis. Other manometric findings 

of the esophageal body, the LES and upper esophageal 

sphincter (UES) are not always present and are not required 

for diagnosis. 

AIM: To know LES and esophageal body manometric findings 

in achalasia patients. 

We reviewed clinical presentation and manometric findings of 

patients with achalasia diagnosis between April, 1998 and 

July, 2004. Manometric study was done with solid state 

Konigsberg-Castell We used stationary and pull through technique 

according to Castell protocol. 

RESULTS: One hundred thirty six patients were included. 

Average age was 42.5+-SD 16.5 years. There were 54.4% 

female (n=74) and 45.6% male (n=62). Dysphagia was present 

in 88.1% of cases, regurgitation in 62.7%, and chest pain in 

50.8%, weight lost in 45.7% and heartburn in 35.5%.


Esophageal aperistalsis and simultaneous contractions waves 

were observed in all cases. LES resting pressure was normal 

in 79.5% of patients, hypertonic in 16.9% and hypotonic in 

3.6%. LES segment was from 3 to 5 cms. in 66.1%, and shorter 

in 33% of cases. We observed LES lack of relaxation in 2.5% of 

patients, relaxation was incomplete in 87.5% and total in only 

10%. 

Manometric criteria in achalasia diagnosis have changed. 

Despite Achalasia means lack of relaxation regarding the LES. 

And that historically it was considered that LES should be 

hypertonic in this disease. We found these criteria to be not 

constant. Nowadays there are mandatory manometric criteria 

for the diagnosis of achalasia (ESOPHAGEAL PRIMARY PERI- 

STALSIS REPLACEMENT BY SIMULTANEUS WAVES 

?ESOPHAGEAL APERISTALSIS?) since it is found constantly. 

And there are non obligated manometric criteria for diagnosis 

of this disease as the LES findings. 



ESOPHAGEAL DIFFUSE SPASM. A MOTOR PATTERN THAT 

PRECEDE ACHALASIA, Jose J Herrera MD, Edgardo Suarez 

MD,Maria E Lopez MD,Hiosadhara E Fernandez MD,Jose A 

Palacios MD, Hospital Español de México gastrointestinal 

motility and endoscopy unit. Hospital General ?Dr. Manuel Gea 

González?, gastrointestinal motility and general surgery division. 

Esophageal diffuse spasm is a rare motor disorder characterized 

for chest pain, dysphagia and segmentarial wave contractions. 

Pathophysiology and natural history remains unclear 

and it has been suggested that it could precede achalasia. In 

both entities the proposed pathophysiology is a Nitric oxide 

neuromuscular defect. Manometric findings for diffuse 

esophageal spasm are simultaneous wave contractions over 

30mmHg amplitude in more than 10% of swallows and for 

achalasia the absence of peristalsis is the mandatory manometric 

finding. 

Aim: To present a patient whom has an initial diagnosis of diffuse 

esophageal spasm who in further evaluation had a vigorous 

esophageal achalasia. 

Case report: We present a 41 years female who came in 2003 

with last 3 months progressive dysphagia, heartburn, 5kgs 

weight lost, chest pain and hiccups. On first evaluation the 

barium esophagogastric evaluation showed esophageal dilation 

with bird peak distal segment. EGD revealed dilated 

esophagus with remanent food in the esophagus. The manometric 

findings were compatible with diffuse esophageal 

spasm. Patient was discharged with medical treatment but 7 

months alter she came in again because of continuous vomiting, 

severe dysphagia, and 12 kgs weight lost. In this new 

evaluation the EGD revealed no organic obstruction, dilated 

esophagus, and remanent food in it. The manometric pattern 

in this new evaluation was compatible with esophageal vigorous 

achalasia. The patient went under Heller miotomy with 

partial fundoplication. 

Manometric findings: First manometric study showed effective 

primary peristalsis replacement with simultaneous waves in 

40% of swallows. Second manometric study showed effective 

primary peristalsis replacement with simultaneous waves in 

100% of swallows, with amplitude waves greater than 

30mmHg. 

Conclusion: Pathophysiology and natural history of 

esophageal diffuse spasm remains unclear. Hypersensitivity to 

cholinergic stimulus as in achalasia has been observed. It has 

been suggested that progression from esophageal diffuse 

spasm could precede achalasia in 2 to 5% of cases. 



EFFICACY OF ENDOLUMINAL GASTROPLICATION FOR GAS- 

TROESOPHAGEAL REFLUX DEVELOPED AFTER LYMPH 

NODES DISSECTION ALONG THE LESSER CURVATURE OF 

THE STOMACH, Hitoshi Idani MD, Takashi Ishikawa 

MD,Takayuki Iwamoto MD,Masahiko Muro MD,Tatsuaki Ishii 

MD,Masahiko Maruyama MD,Shinichiro Kubo MD,Hiroki 

Nojima MD,Shinichiro Watanabe MD,Hitoshi Kin MD, 

Fukuyama City Hospital, Department of Surgery 

Introduction: Endoluminal gastroplication (ELGP) is one of the 

newly developed endoscopic treatments for gastroesophageal 

reflux disease (GERD). However, its efficacy has been demonstrated 

only for primary GERD and there have been no reports 

on ELGP for post-surgical GERD. In this paper, we report a 

case of GERD developed after perigastric lymph nodes dissection 

successfully treated by ELGP. 

Case report: 75 year-old man presented with heart burn, regurgitation 

and dysphagia which had appeared after dissection of 

involved lymph nodes along the lesser curvature of the stomach 

performed with lateral segmentectomy for liver metastases 

from rectal cancer. Esophagogastrofiberscopy showed 

grade B esophagitis and small hiatal hernia. Since the symptom 

had not been controlled by medical therapy and Nissen 

fundoplication could not be indicated in such a post surgical 

state, ELGP was performed. Using BARD endoscopic suturing 

system (EndoCinchTM), two plications were placed at the 

esophagogastric junction (EGJ). The procedure time was 

55min. There were no adverse events without a slight chest 

pain which disappeared within few days. The symptoms associated 

with GER markedly reduced after the treatment. Acid 

exposure time and bile reflux time were improved after the 

procedure (pH



model. Material and Methods: Overall 58 sutures were placed 

in the cardia of 10 complete exenterative cadaver model) at 

three different suction levels, 0,4-0,6-0,8 bar using the suturing 

machine EndoCinch® (BARD). After preparation of the cardia 

from its anatomical bed, all sutures were fixed in formalin and 

stained with HE for histological examination. Results: Absolute 

and relative distribution of suction pressure and suture depth 

is listed in the following table 

0.4 bar 0.6 bar 0.8 bar 

Mucosa 0 (0%) 1 (1,7%) 0 (0%) 

Submucosa 6 (10,3%) 4 (6,9%) 1 (1,7%) 

cir. M. propria 4 (6,9%) 2 (3,4%) 4 (6,9%) 

lon. M. propria 5 (8,6%) 6 (10,3%) 4 (6,9%) 

extramural 5 (8,6%) 6 (10,3%) 10 (17,2%) 

Absolut and relativ distribution of suture depth 

Conclusions: Most of the sutures were placed in the longitudinal 

M.propria or were placed transmural. A submucosal placement 

may lead to bunked sutures. 



SYMPTOMATIC MESOCOLIC STRICTURE AFTER RETROCOLIC 

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS: TREATMENT 

BY ENDOSCOPIC DILATION, Brian Lane MD, Samer Mattar 

MD,Amy Biedenbach MS,Faisal Qureshi MD,Joy Collins 

MD,Paul Thodiyil MD,Tomasz Rogula MD,Pandu Yenumula 

MD,Laura Velcu MD,Giselle Hamad MD,George Eid 

MD,Ramesh Ramanathan MD,Philip Schauer MD, Department 

of MIS Surgery, University of Pittsburgh Medical Center 

INTRODUCTION: Internal hernias at the mesocolic defect after 

retrocolic laparoscopic roux-en-Y gastric bypass have been 

demonstrated to be a potential site for small bowel obstruction. 

Many have emphasized complete and secure closure of 

all potential internal hernia defects when performing LRNYGB. 

Conversely, isolated cases of obstruction at the mesocolic 

defect have been reported. We report two cases of stricture at 

the mesocolic opening in retrocolic, antegastric LRNYGB diagnosed 

at endoscopy and treated by balloon dilation. 

METHODS AND RESULTS: Two patients, ages 26 and 53, with 

BMI of 46 and 42 kgm2 respectively, underwent uncomplicated 

retrocolic antegastric LRNYGB. In both cases, the mesocolic 

and Petersen defects were closed with a running 2-0 silk 

endostitch on the medial and lateral aspects of the mesentery. 

Both patients had an uneventful postoperative course. One 

patient presented five weeks postop with complaints of vomiting 

to solid foods. The second patient presented ten weeks 

postop with complaints of progressive dysphagia to solid and 

soft foods. Both initial UGI studies were initially felt to be unremarkable. 

Both patients underwent esophagogastroscopy. The 

gastrojejunal anastomoses were 9-10 mm in diameter, and the 

endoscope could pass easily. Further investigation revealed a 

tight narrowing of the jejunum at the location where the jejunal 

roux limb would pass through the retrocolic space. This 

narrowed area was dilated with a 16 mm balloon to 5 atm. 

Subsequently the endoscope was able to be passed easily 

through the jejunal stricture. Both patients had prompt resolution 

of symptoms which continued through six months follow 

up. Retrospective review of the pre-endoscopy UGI study 

showed a focal narrowing consistent with a partial obstruction 

at the mesocolic defect. 

CONCLUSION: Stricture of the jejunum at the point where the 

roux limb passes through the mesocolic defect in retrocolic 

LRNYGB may be a cause for partial obstruction symptoms 

similar to those seen with gastrojejunal stricture. Gastrojejunal 

stricture is the more commonly described finding with solid 

food dysphagia after LRNYGB. When this is not found, endoscopic 

exam more distally should be considered to assess and 

treat a jejunal stricture. 



ACUTE CHOLECYSTITIS FOLLOWING COLONOSCOPY: TWO 

CASE REPORTS AND LITERATURE REVIEW, Faizal Aziz 

MD,Perry Milman MD, John McNelis MD, Long Island Jewish 

Medical Center, New Hyde Park NY 

INTRODUCTION: Sporadic reports of acute cholecystitis following 

colonoscopy have previously been described. Two 

cases are presented and the relatively sparse medical literature 

on this subject is reviewed. 

MATERIALS AND METHODS: The medical and surgical records 

of two cases were reviewed retrospectively. Data acquired 

included demographic, medical, surgical, and outcomes. The 

available literature was then reviewed and all reported cases 

were summarized. 

RESULTS: CASE 1: A 63-year-old female who presented to ER 

with severe epigastric pain 24 hours post colonoscopy with 

polypectomy. After a diagnosis of acute cholecystitis was 

made, the patient underwent uneventful laparoscopic cholecystyectomy. 

The gall bladder was found to be distended, 

tense and gangrenous. 

CASE 2: 60 year old male who 72 hours post colonoscopy and 

polypectomy, presented to the ER with acute cholecystitis. The 

patient underwent uneventful cholecystectomy. Pathology 

revealed acute and chronic cholecystitis with extensive hemorrhage 

and reactive epithelial atypia. 

DISCUSSION: Possible etiologies of our observations include 

dehydration following purgative preperation or elaboration of 

local inflammatory mediators inducing acute cholecystitis. 

While it is entirely possible that the reported observations are 

incidental, the authors? observations argue for the inclusion of 

acute cholecystitis in the differential diagnosis of post 

colonoscopy abdominal pain. 



ENDOSCOPIC FINDINGS ON COMPLICATIONS AFTER GAS- 

TRIC BAND, J A Palacios-Ruiz MD, J J Herrera-Esquivel MD,G 

A López-Toledo MD,L E González-Monroy, General Hospital Dr. 

Manuel Gea Gonzalez 

Introduction: Nowadays obesity represents a World Health 

concern, in Mexico 60% of population is overweight. Surgery 

is considered last frontier in treatment. There are several 

options described for surgical treatment, one of the most popular 

due to low mortality and morbidity is laparoscopically 

placed gastric band. 

Matherial and methods: We performed endoscopies on postoperative 

patients after laparoscopically placed gastric band. 

The first cause of reference was disfagia followed by emesis. 

Results: Most frequent findings were esophagitis, esophagic 

diverticulae, gastric band migration, pseudoachalasia within 

others. 

Summary: Complications after gastric band placing are relatively 

unknown, being band migration the most frequent; however 

after times goes by and more experience is accumulated, 

there are other adverse events that are presenting. 



ENDOSCOPIC IDENTIFICATION OF THE JEJUNUM FACILI- 

TATES MINIMALLY INVASIVE JEJUNOSTOMY TUBE INSER- 

TION IN SELECTED CASES., NIAZY M SELIM MD, University of 

Arkansas for Medical Sciences 

Background: Percutaneous endoscopic gastrostomy tube, 

Direct percutaneous endoscopic jejunostomy and laparoscopic 

feeding tube insertion are established techniques for feeding 

tube insertion. However, these techniques may be difficult or 

contraindicated after previous gastric or upper abdominal surgery. 

Methods: In one year, eight cases underwent minimally 

invasive jejunostomy tube insertion via endoscopic identification 

of the jejunum. Indications of the procedure were dysphagia, 

poor nutritional status and prolonged ICU admission. 

Seven patients had previous upper abdominal surgeries and 



were rejected for either percutaneous Endoscopic gastrostomy 

(PEG) or direct percutansous jejunostomy. Under general 

anesthesia, EGD was performed. The jejunum was identified 

and intubated. A small abdominal incision (1 inch) was done. 

The proximal jejunum was identified easily by the light of the 

endoscope and the digital palpation of the endoscope. The 

jejunum was delivered in the wound and the Jejunosotmy 

tube was inserted using Witzel technique. The wound was 

closed. Results: All of the patients tolerated the procedure 

well. The mean time for the procedure was 20 minutes. There 

were no mortality related to the procedure. There were no 

complications. Feeding started in the next dayConclusions: 

The use of intraoperative endoscopy facilitated the identification 

of the Jejunum. It saved the patient a formal laparotomy 

and extensive manipulation. It is easy, safe and quick.. 



ENDOSCOPIC APPEARANCE OF A SURVIVAL PORCINE 

MODEL OF THE POST GASTRIC BYPASS STATE, Matthew 

Sheppard MD, Steven P Bowers MD, Wilford Hall Medical 

Center 

Background: The porcine foregut anatomy closely resembles 

the human, making it the ideal model for development of new 

surgical and endoscopic procedures. The author sought to 

develop a porcine gastric bypass model for training and development 

of endoscopic procedures in the post-gastric bypass 

state. 

Methods: Eight healthy pigs (sus domestica) weighing 80 to 

120 pounds were subjected to open Roux en Y gastric bypass 

with hand-sewn gastrojejunostomy of a 50 mL proximal gastric 

pouch to a 60 cm Roux limb. Animals were returned to soft 

gruel diet 24 hours after operation, were weighed weekly, and 

underwent endoscopy prior to euthanasia and necropsy. 

Gastrojejunostomy anastamotic circumference was measured 

at operation and at necropsy done between three and ninety 

days postoperatively. 

Results: The endoscopic anatomy of the post-gastric bypass 

state closely resembled that of human patients. The inclusion 

of the gastric fundus in the proximal gastric pouch did not 

affect the endoscopic appearance of the model, and was associated 

with a trend towards improved complication free survival 

(p=0.1, Fisher?s exact test). Four animals were euthanized 

due to clinical deterioration on postoperative days 3,11, 17 and 

33. Two of these had perforated ulcers of the proximal gastric 

pouch. Another animal had anastamotic dehiscence and the 

fourth had anastamotic abscess without perforation. All animals 

had rapid spontaneous dilatation of the gastrojejunostomy 

anastamosis with an mean increase in anastamotic circumference 

of 4.8 cm, despite a limited diet that induced average 

weight loss of 3.4 pounds per week. Anastamotic dilatation 

was accelerated in animals with postoperative complication. 

Conclusions: The porcine gastric bypass model closely approximates 

the endoscopic appearance of human anatomy in the 

post-gastric bypass state, but measures of weight loss and 

anastamotic size are not meaningful outcomes and long-term 

studies are prohibited by excess weight loss. 



THE ROLE OF EARLY ERCP IN BLUNT HEPATIC INJURY WITH 

BILIARY FISTULA: A CASE SERIES AND REVIEW OF THE LIT- 

ERATURE, William R Silliman MD, Kimberly A Lieber MD,Nitin 

Rangnekar MD, Department of Surgery - University of 

Missouri-Columbia 

Background: 

The liver is one of the most common organs injured from 

blunt abdominal trauma. Historically, treatment of severe liver 

injuries required an exploratory laparotomy. The objectives of 

the operation were: 1. control hemorrhage, 2. debride necrotic 

tissue and 3. drain the right upper quadrant. Today, nonoperative 

therapy for hepatic injuries is being utilized with increasing 

frequency. Instead of a laparotomy, patients will undergo 

angiography, which is often successful at controlling hemorrhage. 

However, biliary injury associated with blunt liver trauma, 

if left untreated may result in bile leak, abscess formation, 

or hemobilia. To the author?s knowledge, no studies have 

established a role for early endoscopic retrograde cholangiography 

(ERCP) in patients with severe liver injury after blunt 

abdominal trauma. 

Methods: 

We report a case series of three patients who underwent ERCP 

to treat biliary injuries secondary to blunt abdominal trauma. 

All patients had biliary injury confirmed radiographically or 

clinically prior to the performance of the ERCP. The patients? 

clinical course, morbidity and mortality will be reviewed. 

Results: 

All three patients underwent successful ERCP with sphincterotomy. 

Two of the three had stent placement at the initial procedure. 

The patient who underwent ERCP with sphincterotomy 

alone had a recurrent biloma which required repeat ERCP with 

stent placement. There were no mortalities associated with the 

procedures. 

Conclusion: 

ERCP allows both diagnostic and therapeutic goals to be 

achieved in a single intervention. It appears ERCP with sphincterotomy 

and stenting is safe and may be utilized to treat 

patients with biliary injury after blunt abdominal trauma. 

However, more studies are needed to establish a role for early 

ERCP in patients with severe liver injury after blunt abdominal 

trauma. 



POSTER: IS ITRAOPERATIVE ENDOSCOPY STILL IMPORTANT 

FOR THE MANAGEMENT OF OBSCURE INTESTINAL BLEED- 

ING?, S Truong, J Nutzmann,O Schumacher,R Schwab,V 

Schumpelick, Chirurgische Klinik und Poliklinik der Rheinisch 

Westfälischen Technischen Hochschule Aachen 

Background: In a retrospective study we tested the importance 

of intraoperative endoscopy in 19 patients, 4 patients with 

occult bleeding, 15 patients with a haemoglobin relevant massive 

haemorrhage. Method: All 19 patients underwent laparotomy 

under general anaesthetic. After solving adhesions we 

either used a gastroscope inducted over an enterostomy or a 

colonoscope inducted orally. Advancing the endoscope in the 

small intestine was done by the surgeon by slipping the small 

intestine slowly over the endoscope. Results: A complete evaluation 

of the small intestine was possible in all 19 patients. 

The cause for bleeding was found in 15 patients. 5 patients 

showed angiodysplasia, 3 patients ulcera, 2 patients had 

haemorrhage from a diverticulum, 1 patient had Peutz- 

Jeghers-Syndrome, 1 patient had Crohn` s disease, 1 patient 

suffered from radiation induced enteritis, 1 patient had variceal 

bleeding and 1 patient had bleeding from a carcinoma. 12 

patients underwent a segmentresection of the small intestine, 

in 2 cases segmentresection and ulcera excision and in 1 case 

segmentresection and endoscopic treatment with clips and fibrin 

injection was done. In 4 patients only laparotomy was performed 

as no reason for haemorrhage was found. 3 patients 

had a recurrence bleeding, 1 had to undergo surgery a second 

time. In 14 of 15 cases of massive bleeding the diagnosis and 

location could be found correctly. Therefore the cause for massive 

bleeding can be correctly identified in 93% through intraoperative 

endoscopy, whereas in only 25% of cases of occult 

bleeding identification can be achieved. Conclusions: Correct 

diagnosis and location of a massive bleeding can be achieved 

in 78% by intraoperative endoscopy and is still a major advice 

to find the correct diagnosis and location of obscure intestinal 

bleeding. Keywords: intraoperative endoscopy, obscure intestinal 

bleeding, small intestine 



207





ENDOSCOPIC REMOVAL OF SIGMOID COLON FOREIGN 

BODY: WHAT TO DO WITH A TRAPPED BREAD BAG CLIP?, K J 

Wirsing MD, D E Scheeres, M.D., FACS, Grand Rapids General 

Surgery Residency Program, Grand Rapids, MI 

Introduction: Ingestion of plastic bread bag clips is a rare but 

potentially life threatening cause of bowel obstruction or perforation. 

At least 25 cases of ingestion of this foreign body 

have been reported in the medical literature. We present a 

patient who presented with rectal pain and bleeding after she 

unknowingly swallowed a plastic bread bag clip, and review 

the literature on this topic as well as the relevant anatomy. 

Case: A 59 year-old female presented with intermittent hematochezia. 

Colonoscopy revealed a foreign body 35 cm from the 

anal verge, which was identified as a plastic bread bag clip. Its 

two teeth had encircled a haustral fold and eroded through its 

base, creating a colo-colonic fistula which trapped the clip in 

the colonic mucosa. Attempts to forcibly remove the bag clip 

using a polypectomy snare, endoscopic scissors, and toothed 

forceps failed. 

Following a mechanical and antibiotic bowel prep, a flexible 

sigmoidoscopy was performed. An endoscopic sphincterotomy 

catheter was passed under the haustal fold through the fistula, 

and the opening was enlarged by cutting the haustral 

band with the wire directed towards the colonic lumen. After 

this, the tip of a snare device was used to incise the top of the 

haustrum in a longitudinal fashion to reduce the size of the 

fold trapping the bread bag clip. The clip was then grasped 

with rat-tooth forceps and manipulated until it disengaged 

from the haustrum. The foreign body was removed with no 

radiographic evidence of bowel perforation and an uneventful 

observation overnight in the hospital. 

Conclusion: Bread bag clips that become entrapped on mucosal 

surfaces can be difficult to remove. Use of an endoscopic 

sphincterotomy catheter and a polypectomy snare to cut the 

mucosal fold has not been described in the literature, and is a 

safe method to remove this foreign body from the colon. 

P311–Hernia Surgery 

COMPARATIVE STUDY OF INCIDENCE OF WOUND INFEC- 

TION, PAIN AND QUALITY OF LIFE IN PATIENTS UNDERGO- 

ING INGUINAL HERNIA MESH REPAIR BY LAPAROSCOPY 

AND OPEN METHOD, Sandeep Aggarwal MD, Arvind Kumar 

MD,Madhusudan MD,Rajinder Parshad MD,Sandeep Guleria 

MD,Hemraj Pal* MD, Department of Surgical Disciplines and 

Psychiatry* All India Institute of Medical Sciences, Ansari 

Nagar, New Delhi 110029, India 

ABSTRACT 

TITLE: Comparative Study of incidence of wound infection, 

pain and quality of life in patients undergoing inguinal hernia 

mesh repair by laparoscopy and open method 

BACKGROUND 

Laparoscopic surgery for inguinal hernia is gaining increasing 

popularity, both among the patients as well as surgeons. The 

main reported benefits of the laparoscopic approach to unilateral 

inguinal hernia repair are decreased postoperative pain 

and decreased wound infection rate. In recent years, the outcomes 

of different health care interventions have been 

assessed in terms of quality of life. Therefore we did a 

prospective non-randomized study to compare the incidence 

of wound infection, pain and quality of life in patients undergoing 

inguinal hernia repair by laparoscopic and open methods. 

Methods 

Between January 2002 and November 2003, 90 patients above 

15 years of age with a clinical diagnosis of uncomplicated unilateral 

inguinal hernia were assigned to open method of hernia 

repair by Lichtenstein technique (Group A, n=60) and 

laparoscopic hernia repair (Group B, n=30). 

RESULTS 

There was no significant difference in wound infection rate 

between the two groups. The pain scores were higher in the 

open group in the early postoperative period. At the end of 

three months following surgery, the pain scores were similar 

in the two groups. However, there was no difference in the 

quality of life in the two groups at any time in the postoperative 

period ( at the end of one week, 1 month and 3 months). 

CONCLUSIONS 

Laparoscopic repair of unilateral inguinal hernia offers no 

advantage over open repair in terms of improved quality of 

life. However the pain scores are lower in the early postoperative 

period in the laparoscopy group allowing early mobilisation 

and possible early return to work. 


MINILAPAROSCOPIC INGUINAL HERNIA REPAIR, Ferdinando 

Agresta (1) MD, Emanuele Santoro (2) MD,Luigi Francesco 

Ciardo (1) MD,Giacco Mulieri (2) MD,Natalino Bedin (1) 

MD,Massimo Mulieri (2) MD, (1) Dept. of General Surgery, Civil 

Hospital, Vittorio Veneto (TV); (2) Dept. of General Surgery 

?Nuovo Regina Margherita? Hospital, Rome - Italy. 

INTRODUCTION: Laparoscopy has recently been characterised 

by an increasing development of smaller laparoscopes, trocars 

and operative instruments, thus in order to minimise more 

nerve and muscle damage and to optimise aesthetical results. 

As a consequence minilaparoscopy has been gradually 

employed in the treatment of several pathologies. 

Minilaparoscopic surgery has recently commenced in the 

treatment of inguinal hernias, similar to its ?major sister? 

laparoscopy. The indications for latter are well defined (bilateral 

or recurrent hernias or patients desiring or requiring a fast 

recovery to resume normal activities), however not completely 

clear is the feasibility of the minilaparoscopic technique. The 

aim of this study is to evaluate retrospectively the last three 

years of patients who underwent minilaparoscopic transabdominal 

inguinal hernia repair (miniTAPP) at Our Institutions. 

Materials and Methods: Between February 2000 and December 

2003 a total of 303 patients (mean age 45 years) underwent a 

miniTAPP procedure. Amongst them, 213 (70.2%) were operated 

on for a bilateral diseases and 90 (28.7%) for a monolateral 

defect, with a total of 516 hernia defects repaired. 

Results: No conversion to laparoscopy or anterior open 

approach was registered. Major complications were nil whilst 

minor occurance ranged as high as 0.3%. Hospital stay was 

the same as a laparoscopic approach with a faster recovery to 

a normal activity and less analgesic requirement 

CONCLUSIONS: On the basis of our initial experience minilaparoscopic 

preperitoneal transabdominal hernioplasty is feasible, 

effective and easy to perform (without any increase in 

technique difficulties) in experienced hands. MiniTAPP provides 

positive and comparable results concerning the operative 

time, the post op. morbidity and hospitalisation as the 

classical LAP. Sparing patients a wider skin incision in the trocars 

site might reduce postoperative pain, increase prompt 

recovery of gastrointestinal functions, shorten hospitalisation, 

help contain health-care costs and increases cosmesis. This 

approach appears to play a crucial role in the laparoscopic 

approach of all kind of hernias in patients not previously having 

had abdominal surgery. 


LAPAROSCOPIC VS. OPEN INCISIONAL HERNIA REPAIR: A 

COMPARATIVE STUDY., C G Andrew MD, L S Feldman MD,W 

Hanna,S Bergman MD,M Vassiliou MD,S Demyttenaere MD,D 

Stanbridge RN,G M Fried MD, Steinberg-Bernstein Centre for 

Minimally Invasive Surgery, McGill University, Montreal, 

Canada. 

Introduction: Laparoscopic incisional hernia repair (LIHR) has 

been shown to be safe and feasible. However, comparative 

studies have had conflicting results. Our goal was to compare 

short-term outcomes and recurrence rates after laparoscopic 

vs. open incisional hernia repair (OIHR). 

Methods: Charts were reviewed of all patients who had elective 

mesh repair of incisional hernia at a single institution over 

a two year period. Patients were contacted by telephone and 

subsequently examined in clinic. Using an intention-to-treat 

analysis, LIHR (n=42) and OIHR (n=97) data were compared 

using Student?s T, Chi Square, and rank sum tests. 

Results: Both groups were similar with respect to age, gender 

and ASA. There were more morbidly obese patients in the 



LIHR group (27.5% vs. 10.3%, p=0.01) and more patients with 

previous incisional hernia repair (48.8% vs. 27.8%, p=0.01). 

Mean operative time was greater in the LIHR group (129+/-19 

minutes vs.105+/-12 minutes, p=0.04); however, median hospital 

stay was shorter (1.0, range 0.5-24 days vs. 3.0, range 0.5- 

53 days, p0.05, histiocyte 

p>0.05, gaint cell p>0.05, p>0.05, vascular proliferation 

p>0.05, fibroblast proliferation p>0.05, collagen p>0.05). There 

was a significant difference between 3 groups regarding to 

adhesion formation (X2: 7,287, SD:2, p:0,026). The difference 

was coming from the PM group. PM group was significantly 

adhesive than the other groups. There wasn?t a significant difference 

between SM and PM+IC groups (p>0.05). There was a 

significant difference between these 3 groups regarding to dissection 

difficulty (X2:13,322 SD:2, p:0,001). The significant difference 

occurred due to the PM group. There wasn?t a significant 

difference between SM and PM+IC groups (p>0.05). 

Conclusion: SM and PM+YC adhesion barrier can be safely 

used in incisional hernia repair to prevent intraabdominal 

adhesions. As a surgical technique the SM application is much 

easier than PM+IC, however; PM+IC application is much 

cheaper than the SM application. 



209





10 YEARS CONTROLLED STUDYCOMPARING LAPAROSCOPIC 

TRANSABDOMINAL PREPERITONEAL TO LICHTENSTEIN 

INGUINAL HERNIA REPAIR, O. Avrutis MD, M Dudai, V. 

Michalevsky MD,O Sibirsky MD,J. Meshoulam MD,A. Durst 

MD, Bikur Cholim Hospital , Jerusalem , Israel 

Background: Lichtenstein tension free mesh repair (LTFMR) is 

a time - tested, simple, safe and well - understood procedure 

with a high success rate. Laparoscopic transabdominal 

preperitoneal inguinal hernia repair ( TAPP) is the first established 

laparoscopic technique. Few studies have compared 

hernia mesh repair of TAPP with LTFMR. 

Aim: To compare operative time, complications, postoperative 

pain, length of hospital stay, reccurency rate, and time until 

return to normal daily activity on long term between LTFMR 

and TAPP. 

Methods: A prospective study investigated 947 male patients 

who underwent LTFMR (n = 449) or TAPP ( n = 498 ) from 

February 1992 to December 2001. Four hundred twenty one 

patient (93.8 %) in LTFMR group and 466 patients (93.6 %) in 

TAPP group still followed ?up until July 2002 with the range of 

follow- up from 6 to 125 months. 

Results: The mean operative time of LTFMR for unilateral and 

for bilateral repair was significantly shorter than in the TAPP 

group : 43.3 min vs. 64.4 min and 77.6 min vs. 105 min, 

respectively (p = 0.005). There were 23 complications ( 5.5%) in 

LTFMR group and 21 complications ( 4.2%) in TAPP group ( p = 

NS). The mean postoperative hospital stay after LTFMR and 

TAPP was similar: 1.36 day and 1.79 day. There were three 

recurrences in the both groups (0.7%/0.6% respectevly, for 

TAPP only at the first year). There were not significant differences 

in the mean postoperative pain scores, analgesic doses, 

and the time until return to the normal daily activity between 

compared groups. 

Conclusion: This results suggest that TAPP inguinal hernia 

repair is comparable with Lichtenstein repair regarding postoperative 

pain, complications, reccurrence and time until 

return to normal daily activity. Operative time of LTFMR is significantly 

shorter than TAPP only at the early experience period. 


OUTCOMES OF LAPAROSCOPIC VENTRAL HERNIA REPAIR IN 

A TEACHING INSTITUTION, Tamara L Ellis BA, Juliane 

Bingener MD,Wayne H Schwesinger MD,Melanie L Richards 

MD,Kenneth R Sirinek MD, Dept of Surgery, UTHSCSA 

Background and Clinical Significance: Ventral incisional hernia 

repairs constitute one of the most frequently performed surgical 

procedures in the United States. Recently laparoscopic VIH 

repair as been added to the armamentarium of surgical techniques. 

Reports of follow up from several specialized centers 

are available, however few data about the patient outcome in 

the teaching environment. The primary aim of this study is to 

retrospectively evaluate the patient outcome after laparoscopic 

ventral incisional hernia repair in a teaching hospital. 

Secondary aim is to identify potential risk factors for hernia 

recurrence. 

Study design and methods: Data from patients who underwent 

a laparoscopic ventral incisional hernia repair since 1999 were 

prospectively collected in a data base and retrospectively 

reviewed. Additional data were corroborated through chart 

review. Data regarding demographics, co-morbidities, procedure 

specific data and outcome variables were collected. 

Results: From 1999 to 2004 104 patients underwent laparoscopic 

ventral incisional hernia repair; 19 men (18%) and 85 

women (82%). The mean age was 51 years, (range 21-71). 

Average mesh size was 310 cm2. The majority of the patients 

were obese. The VIH repair was assisted by a resident in PGY 

year 1 in 2 patients, in PGY year 2 in 13 patients, PGY 3 in 20 

patients, PGY 4 in 1 patient and PGY 5 in 68 patients. There 

were 10 recurrences (10%). The recurrence rate for patients 

who underwent lap VIH repair with the assistance of a junior 

resident was 11.5%, for a senior resident it was 8.6% (NS). The 

mean estimated blood loss was 33 cc (range 10-300 cc). 27 

Patients had complications (25 %). 2 patients (2%) required reoperation. 

24 (92%) of the complications were grade 1 (seroma, 

urinary retention). No mortality or disabling morbidity was 

noted. The complication rate for senior residents was 30%, for 

junior residents 17%.The mean follow-up ranged from 1-59 

months. 

Conclusion: Laparoscopic ventral incisional hernia repair in a 

teaching environment is feasible and safe. In selected patients 

this advanced laparoscopic procedure can be performed by 

junior residents with similar outcomes as their senior colleagues. 


COMPOSIX SEPARATION: A REPORT OF THREE CASES, 

Andrew G Harrell MD, Kent W Kercher MD,William S Cobb 

MD,B. Todd Heniford MD, Carolinas Medical Center 

Background: Standard laparoscopic ventral hernia repair 

requires the use of a prosthetic mesh. Many of the biomaterials 

used in this procedure were developed to allow tissue ingrowth 

on the abdominal wall side of the mesh while limiting 

adhesions on the intestinal side. A popular concept has been 

to combine two materials to form a ?composite? mesh for the 

desired effects. Composix mesh combines polypropylene and 

expanded polytetrafluoroethylene (ePTFE). Unfortunately, 

delamination of the mesh?s components can occur with a subsequent 

intra-mesh fluid collection and infection, which 

requires surgical resection. 

Methods: Patients with Composix mesh infections where the 

mesh separated, developed a fluid collection and became 

infected were reviewed. 

Results: Three patients referred from outside institutions were 

identified. They included 1 male and 2 female patients age 52, 

39, and 89. Each patient had a laparoscopic ventral hernia 

repaired with intraperitoneal placement of the Composix 

mesh. The patients presented with abdominal pain and redness 

of the abdominal wall at 3 months, 11 months, and 16 

months after original implantation. CT imaging demonstrated 

the mesh components had separated and the intra-mesh space 

contained enhancing fluid collections. All patients required 

mesh removal with primary abdominal wall closure. 

Staphylococcus aureus was grown from the infected fluid collection 

in each case. Subsequent hernia recurrence was noted 

in 2 of the 3 patients, and one of the patients has undergone 

successful laparoscopic repair. 

Conclusion: Despite the improvement in mesh prosthetics, 

some complications will occur. This series of patients 

describes an unusual and rare event. Prior descriptions of 

mesh separation are limited. Successful management of this 

problem requires mesh removal, primary closure with possible 

recurrent hernia repair in the future. 


LAPAROSCOPIC TOTALLY EXTRAPERITONEAL (TEP) REPAIR 

OF RECURRENT HERNIA WITH PREVIOUS MESH AND PLUG 

REPAIR, Kyung Yul Hur MD, Koo Yong Hahn MD,Jae Young 

Jung MD,Sang Hwa Yu MD,Seung Han Kim MD,Yong Geul Joh 

MD,Seon Han Kim MD,Dong Keun Lee MD, Laparoscopic 

Surgery Center, Department of surgery, Hansol Hospital, 

Seoul, Korea 

Introduction: We report our experiences of laparoscopic totally 

extraperitoneal (TEP) repair for recurrent hernia with previous 

mesh and plug repair. Laparoscopic herniorrhaphy is effective 

especially for the recurrent hernia that have previously been 

repaired using a conventional anterior technique. But in case 

of recurrent hernia with previous mesh and plug repair can be 

troublesome because of dense scar at the site of the plug with 

peritoneum and entire abdominal wall. 

Methods: Between December 2000 and July 2004, 221 laparoscopic 

hernia repairs were performed. Among them, three 

cases of recurrent hernias with previous mesh and plug repair 

were managed by laparoscopic TEP repair. Balloon dissector 

was not used to avoid unexpected peritoneal tearing. 

Result: The average period between the initial operation and 

the second operation was 10 months. Two cases were recurrent 

indirect hernias after repair for indirect hernia. The hernia 

defects were located between inferior epigastric vessels medially 

and plug laterally. Mesh prostheses were placed on the 

plug and abdominal wall to cover hernia defect and fixed with 

stapler. The lateral dissection was not possible due to dense


adhesion between plug and peritoneum in these two cases. 

The third case was newly developed direct hernia after indirect 

hernia repair and the operative procedure was not unusual. 

The operative time averaged 56 min (range, 28-90) and all 

patients were discharged within 23 h. These patients were followed 

3 to 32 months and no recurrences were observed. 

Conclusion: We have found that laparoscopic TEP repair of 

recurrent hernia with previous mesh and plug repair is feasible 

without removing plug. Comprehensive understanding of the 

anatomy of the hernia is critical. Further investigation with 

long term follow-up is needed to assess the safety and efficacy 

of this technique for recurrent hernia with previous mesh and 

plug repair. 


TEP INGUINAL HERNIA REPAIR: WHICH MESH AND HOW TO 

FIX IT?, Asim Shabbir BS, Shridhar Iyer BS, Wei Keat Cheah 

BS,Raj H Sidhu BS,Charles TK Tan BS,Davide Lomanto MD, 

Minimally Invasive Surgical Centre (MISC), National University 

Hospital, Singapore 

Laparoscopic hernia surgery is gaining its role because of the 

benefits to patients that are evident from many published RCT 

when compared lap to open repair: less postop pain and analgesic 

consumption, earlier return to normal activities and 

work,less chronic pain and permanent paraesthesia. But technical 

factors are important to achieve satisfactory results. A 

review of our experience was undertaken involving 280 consecutive 

patients who underwent 350 extraperitoneal inguinal 

hernia repair (1998-2003) at the National University 

Hospital,Singapore. We performed 234 unilateral repair and 

116 bilateral repair. The hernia repair was performed using 

three methods.In group 1: polypropilene mesh was anchored 

with spiral tacker (n=229);group B, polypropylene mesh without 

anchoring (n=51)and in group 3 a multifibre polyester 

anatomic mesh was utilized (n=70). The mean age was 49 

years (range 20-81)and 85% were men. The overall mean operative 

time was 50 min (range:35-180 min); bilateral repairs 

took 27% longer than unilateral repairs. Complications rate 

was significantly lower in group 3 (2.8%) compared to group 2 

(13.7%) and group 1 (5.6%). The recurrence rate was: 11.3% 

when the mesh was not anchored, 1.6 % when the mesh was 

anchored and no recurrence was recorded when anatomic 

mesh was utilized (mean follow-up:9 mnths). There was no 

recurrence detected in the last 112 cases (70: anatomic mesh; 

42: polypropilene mesh and tacker). The overall mean inpatient 

hospital stay was 1.4 days, and of the last 30 cases, 70% 

were performed as outpatient. Laparoscopic inguinal hernia 

repair is a relatively new approach in the long history of groin 

hernia repair. To achieve an acceptable recurrence and complication 

rate, surgical technque is very important. An adequate 

anatomical dissection together with a correct mesh placement, 

orientation and anchoring are the key factors. Data from our 

study showed that using anatomic mesh we can achieve the 

same recurrence and morbidity rate as using mesh plus fixation 

with tacker but with lesser cost. Laparoscopic approach 

remains an alternative and feasible method to open hernia 

surgery. In our 6 years experience, TEP hernia repair can be 

done with minimum morbidity and in the majority of cases 

can indeed be performed in the Day Surgery setting especially 

once the learning curve has overcomed, and the repair can be 

accomplished with good clinical outcome. 


LAPAROSCOPIC TOTAL EXTRAPERITONEAL (TEP) INGUINAL 

HERNIA REPAIR UNDER EPIDURAL ANAESTHESIA: A 

DETAILED EVALUATION, Pawanindra Lal MD, Nikhil Gupta, 

Prejesh Philips MD,RamKrishna Kajla MD,Jagdish Chander 

MD,Vinod K Ramteke MD, Department of Surgery, Maulana 

Azad Medical College & Lok Nayak Hospital, New Delhi, India. 

BACKGROUND: Laparoscopic total extraperitoneal (TEP) 

inguinal hernia repair is as efficacious as the open 

Lichtenstein?s, can be learnt with proper training, incurs lesser 

post-operative pain, better cosmesis and early return to work. 

The one major factor preventing the widespread acceptance of 

laparoscopic TEP is the requirement for general anaesthesia 

(GA) for its conduct. This study attempts to evaluate whether 

laparoscopic TEP can be performed under lesser invasive 

anaesthesia such as regional anaesthesia, its feasibility and 

limitations. 

Method: A total of 22 patients were studied between Jan 2002 

and March 2003 in a tertiary care referral hospital. Epidural 

anaesthesia was given using a lumbar epidural catheter and 

2% Lignocaine with Adrenaline (Adr) achieving a sensory level 

of T6. Standard technique for laparoscopic TEP using three 

midline infraumbilical ports was used. 

Results: A total of 22 cases (20 unilateral, 2 bilateral) were 

operated. The mean operating time was 67.8 (range 40-110) 

mins. All 22 cases were started using epidural anaesthesia of 

which 15 (68.1%) were completed under epidural anaesthesia 

and 7 (31.9%) were converted to GA. No cases were converted 

to open. The only intraoperative complications were pneumoperitoneum 

and shoulder tip pain (9 cases each). There was 

no statistical difference between the cases conducted under 

epidural (67.6 mins) and those converted to GA (69.3 mins) or 

between the conversion rates of smaller versus larger hernias 

in this study (p value 0.22). Significant association of success 

of the procedure was seen with a sensory level of T6 (cases 

upto T6 and above :15 cases of which 2 were converted-conversion 

rate 13.3% and cases with sensory level was below T6: 

7 cases of whoch 5 were converted: conversion rate 71.4%. 

p=0.014) and adequate epidural catheter length (P=0.015).Of 

the 9 cases with severe shoulder tip pain, 6 were converted to 

GA-67%; p=0.006, p



METHODS: A closed insertion technique is used for peritoneal 

access and three 5mm ports are placed lateral to the hernia in 

a standard fashion. After adhesiolysis and reduction of the 

hernia contents, a 2-2.5 cm incision is made over the existing 

hernia defect and is extended through the hernia sac into the 

peritoneal cavity. The mesh is inserted through this incision 

into the abdomen through the existing fascial defect and is 

positioned and anchored using standard techniques. The mesh 

insertion site is closed in two layers with absorbable suture; 

no port sites require fascial closure. Data (given as mean ± 

S.D.) from patients undergoing LVHR utilizing this technique 

were collected prospectively and analyzed. 

RESULTS: LVHR for incisional hernia repair using 5mm ports 

exclusively was carried out in 10 patients. Mean patient age 

was 60.7±10.8 years and the mean BMI was 35.1±7.0. Four 

patients were operated on for recurrent incisional hernias. 

Mean operative time was 118±45.4 minutes. Mean size of the 

defect repaired was 133.1±150.2 cm2 and the mean mesh size 

used was 363.2±234.7 cm2 (range 144-825 cm2). There were 

no conversions to open repair and the average length of stay 

postoperatively was 2.5 days. Three patients developed a seroma; 

one was aspirated once and the other two resolved spontaneously. 

One patient developed Candida sepsis from a urinary 

source that led to secondary Candida peritonitis that 

required mesh removal. Over a mean follow-up period of one 

year, there was one hernia recurrence (the patient who had 

mesh removed) and there were no port site recurrences or 

complaints of prolonged port site discomfort. 

CONCLUSION: This approach appears to be safe and can be 

utilized for most patients undergoing laparoscopic incisional 

hernia repair with acceptable morbidity and a short length of 

stay. The 5mm port technique eliminates the fascial defects 

associated with larger ports and should result in fewer port 

site hernias and possibly less postoperative pain as well. 


USE OF PERI-OPERATIVE FLOMAX TO PREVENT POST-OPER- 

ATIVE URINARY RETENTION FOLLOWING LAPAROSCOPIC 

INGUINAL HERNIA REPAIR, Abdelrahman A Nimeri MD, 

L.Michael Brunt MD, Department of Surgery and Institute for 

Minimally Invasive Surgery, Washington University School of 

Medicine, St. Louis, MO 

Background: Postoperative urinary retention is one of the 

more common complications after laparoscopic inguinal hernia 

repair (LIHR). The development of urinary retention in this 

setting leads to increased patient discomfort, prolonged recovery 

room stays, and possible hospital readmission after discharge. 

Since alpha 1 receptor antagonists reduce urinary 

symptoms in patients with bladder outlet obstruction, it was 

hypothesized that the oral alpha 1 antagonist Flomax could be 

used to decrease the urinary retention rate in patients undergoing 

LIHR. 

Methods: Data from all patients undergoing laparoscopic total 

extraperitoneal (TEP) inguinal hernia repair by a single surgeon 

from March 2003 through July 2004 were collected 

prospectively. Patients received Flomax 0.4 mg/day orally for a 

total of five days beginning two days prior to surgery. All TEP 

procedures were done under general anesthesia without a urinary 

catheter in place. Patients were discharged home after 

voiding in the recovery area. Data are expressed as mean ± 

SD. 

Results: Flomax was administered to 24 of 26 consecutive 

patients undergoing outpatient TEP inguinal hernia repair. 

Mean patient age was 50.5 ± 10.9 years (28-72 yrs). Eight 

patients were operated on for recurrent inguinal hernias; 12 

patients (50%) had bilateral hernias repaired and two patients 

had concomitant umbilical hernia repair. Mean operative time 

was 59.2 ± 21.5 minutes. The mean amount of intra-operative 

fluids given was 963 ± 230ml. None of the patients given 

Flomax preoperatively developed urinary retention and all 

were discharged home the same day of surgery. In contrast, 

the 2 patients undergoing TEP repairs who did not receive 

Flomax starting 2 days preoperatively both developed urinary 

retention that required catheter placement. 

Conclusion: Peri-operative administration of Flomax in the setting 

of laparoscopic inguinal hernia repair under general anesthesia 

was associated with no cases of post-operative urinary 

retention in this small pilot study. The use of peri-operative 

Flomax should be tested in larger numbers of patients and in a 

prospective, randomized trial to determine its impact on the 

postoperative urinary retention rate. If successful, this 

approach could result in shortened outpatient recovery room 

stays and potential savings in health care costs. 


HERNIAL RELAPSE IN LAPAROSCOPY: PERSONAL EXPERI- 

ENCE, Annibale Casati MD, Giovanni Perrucchini MD, Eugenio 

Guidotti MD,Luca Magni MD, Clinica Castelli (BG) 

Background: Since 1998 we started our approach to the repair 

of the inguinal and crural hernias with a laparoscopic method, 

even for the primitive hernias. 

Methods: from October 1998 to October 2003, we saw 1611 

people suffering from inguinal hernial pathology. 1502 people 

were operated using the transperitoneal laparoscopy technique 

(TAPP) and 109 ( 6,9% ) using the traditional technique( 

Linckenstein ).Patients that underwent the laparoscopy technique 

were divided M=1021 ( 68% ), F= 481 (32%) ranging from 

25 to 82 years old, bilateral hernia was 7%. 

Results: The accidents were 4 ( 0,26% ); one due to the bleeding 

of a trocar wound, one due to the jejunal perforation an 

intestinal occlusion due to an ileal ansa incarcerated and one 

severe infection haematology due to the prosthesis infection. 

Conclusion: basing ourselves on our results and on our data, 

we can state that the laparoscopy technique represents a safe 

repair method for the inguinal hernia., with few accidents and 

a low chance to have the appearance of recurrences, but only 

if done by operators who have performed a good number of 

such an operation. The surgical timing overlaps the traditional 

technique, the functional recovery is faster and the aesthetic 

result is better. Regarding the costs, we need to say that the 

limited use in disposable material and the less expensive 

social cost for a more rapid renewal of the working activity, 

allow this technique to be done from the economic point of 

view. 


A MODIFIED, OPEN, VENTRAL HERNIA REPAIR WITH FENES- 

TRATED MESH: LESSONS LEARNED FROM LAPAROSCOPY, 

Todd A Ponsky MD, Arthur Nam MD,Bruce A Orkin MD,Paul P 

Lin MD, The George Washington University 

Introduction: Recent literature suggests that the laparoscopic 

repair of ventral hernias may have the lowest recurrence rates. 

Laparoscopy, however, may not be feasible in certain situations. 

For those situations in which laparoscopy cannot be performed, 

we describe an open technique that utilizes the tension-free 

principles of the laparoscopic repair without the need 

for subcutaneous flaps. 

Methods: A midline incision is made over the hernia. The peritoneum 

is entered and the adhesions are taken down to at 

least 5cm from the fascial edge circumferentially. A piece of 

DualMesh (Gore, Inc.) is then measured to fit around the 

defect with a 5cm circumferential overlap. A vertical incision is 

then made in the mid-portion of the mesh and Gore-Tex 

Sutures (Gore, Inc.) are then sutured circumferentially around 

the mesh and the tails are left long to serve as anchoring 

sutures similar to a laparoscopic approach. The mesh is then 

placed into the peritoneal cavity over the bowel. Using a 

suture passer (Gore Inc.), the ties are brought out through the 

abdominal wall though 2mm skin incisions on the left side and 

tied down. The right side of the mesh is then raised in order to 

visualize its underside and it is tacked to the fascia with a spiral 

tacking device. The right sided sutures are then brought 

through the abdominal wall with a Suture-Passer and tied 

down. The right side of the mesh is then tacked to the overlying 

fascia by passing the spiral tacking device through the incision 

in the mesh. The incision in the mesh is then closed with 

suture. The overlying fascia may then be closed if feasible. 

Conclusion: For those situations in which laparoscopy cannot 

be performed, we describe an open technique for ventral hernia 

repair that utilizes the tension-free principles of the laparoscopic 

repair without the need for subcutaneous flaps. 




LAPAROSCOPIC VERSUS OPEN EPIGASTRIC HERNIA REPAIR, 

Kyle N Remick MD, Colin A Meghoo MD,John P Schriver MD, 

William Beaumont Army Medical Center 

INTRODUCTION: 

Epigastric hernias represent a subset of ventral abdominal wall 

hernias. They arise from a midline, supraumbilical fascial 

weakness and commonly present in an adult population. 

Laparoscopic repair of these hernias may reduce the incidence 

of wound complications and recurrence compared to the open 

approach. We aim to verify this and identify additional benefits 

of the laparoscopic approach. 

METHODS: 

We reviewed our recent experience with 30 patients with epigastric 

hernias repaired either by an open or laparoscopic 

approach. We compared the two groups based upon demographics, 

intraoperative findings, short-term wound complications, 

and long term recurrence. 

RESULTS: 

We reviewed our institution?s experience with epigastric hernia 

repairs between May 2000 and July 2004 and discovered 

30 eligible patients. Seventeen were repaired using an open 

technique and 13 were repaired laparsocopically. There was 

no significant difference in age, sex, or Body Mass Index (BMI) 

among the two groups. Additional fascial defects were identified 

intraoperatively in 46% of the laparoscopic group versus 

18% in the open repair group (p=0.12). Concurrent procedures 

were performed in 39% of laparoscopic repairs versus 12% in 

the open repair group (p=0.19). There were two short-term 

complications in the laparoscopic group (one post-operative 

ileus and one incidental enterotomy) versus none in the open 

group. Thus far, there are no wound complications in either 

group and there is one recurrence in the open repair group 

with further follow-up pending. 

CONCLUSION: 

Benefits of a laparoscopic approach to the repair of epigastric 

hernias include a thorough evaluation of the ventral wall fascia, 

identification of additional fascial defects, and the simultaneous 

performance of additional laparoscopic procedures. It 

may be preferred in the initial repair of epigastric hernias in an 

adult population, and larger study groups are needed to determine 

statistical significance. 


THE USE OF PERICARD FOR LAPAROSCOPIC REPAIR OF VEN- 

TRAL HERNIAS, Danny Rosin MD, Moris Batumsky MD,Moshe 

Shabtai MD,Yaron Munz MD,Amram Ayalon MD, Sheba 

Medical Center, Tel Hashomer and Sackler School of Medicine, 

Tel Aviv, Israel 

Objective: Laparoscopic repair of ventral hernias is an accepted 

technique. The optimal material to reinforce the abdominal 

wall has not yet been defined, due to problems of cost, infection 

and adhesion formation. We have evaluated the effectiveness 

of bovine pericard as a biomaterial for laparoscopic ventral 


Methods: 52 patients with incisional or primary ventral hernia 

were operated laparoscopically over an 18 months period. 

Pericardial patch (n=45) or perforated pericardial patch (n=7) 

was used to cover the fascial defect. Data regarding the surgery 

and the followup period was prospectively collected. 

Results were compared to a group of 55 consecutive patients 

operated laparoscopically over a period of 18 months, just preceding 

the study period, in whom Goretex patch was used to 

repair the hernia. 

Results: Mean BMI was 31.5 in the pericard group and 30.3 in 

the Goretex group. Mean followup duration in the pericard 

group was 8.2 months, as opposed to 23.9 month in the 

Goretex group. 7 patients (13.5%) required removal of the pericard, 

due to infection, as opposed to 2 (3.6%) removals of 

infected goretex. Non of the 7 perforated pericardial patches 

got infected. 5 recurrences of hernias were noted in the pericard 

group (9.6%), as opposed to 16 in the Goretex group 

(29%). Overall failure rate is therefore 23.1% in the pericard 

group, as opposed to 32.6% in the goretex group. 

Conclusions: Overall failure rates were comparable in the both 

groups, with some advantage to the pericard group. 

Recurrence rate was lower in the pericard group. This may be 

related to the longer followup in the Goretex group. High 

infection rate was found in the pericard group, but not in the 

subgroup of perforated pericardial patch. 

The use of pericard is a viable alternative for laparoscopic ventral 

hernia repair. The use of perforated material, better selection 

of patients and refinement of surgical technique may 

improve the long term success. 


POLIPROPILENE MESH REPAIR FOR HIATAL HERNIAS ? A 

CENTER EXPERIENCE, Jose Francisco de Matos Farah 

MD,Alberto Goldenberg MD, Vladimir Schraibman MD, 

Discipline of Gastric Surgery, Federal University of Sao Paulo, 

Brazil 

Many centers report recurrence rates of up to 25% for hiatal 

hernia recidive, due to the opening of the hiatus. It is an 

increasing problem for hiatal hernia correction by laparoscopy. 

In this paper, the authors present a method of fixation of a 

polipropilene mesh to augment the resistance of the diaphragmatic 

pillars, without contact to the abdominal organs. 

Thirty patients were treated with this technique. Main indications 

included hiatus opening higher than 5 centimeters and 

hiatal hernia recidive. The technique consisted of a polipropilene 

mesh measuring 5X2cm, fixed in each pilar, augmenting 

the tissue resistance. 

Surgery was done in all patients without complications. 

Minimal follow-up is 2 years without signs of recidive. 

Laparoscopic re-inforcement of diafragmatic pilars with 

polipropilene mesh, presents great results for short and medium 

term follow-up for the treatment of selected cases. 


LAPAROSCOPIC VS OPEN VENTRAL HERNIA REPAIR: A 

PROSPECTIVE STUDY, Asim Shabbir MS, Shridhar Iyer 

MS,Wei Keat Cheah MS,Davide Lomanto MD, Minimally 

Invasive Surgical Centre ? MISC, Dept of Surgery, National 

University of Singapore, Singapore 

few operative challenges are more vexing in the history of surgery 

than the incisional hernia,because of high recurrence 

rate,r social and economic implications. Some recently technical 

options as mesh repair has significantly reduced the recurrence 

rate compared with that of primary suture repair, but 

recurrence still remains in the ranges of 10% to 24%. Since its 

introduction in 1992, laparoscopic incisional hernia repair has 

revolutionized the management of ventral hernia achieving 

good results in the early studies. In our study we compared 

laparoscopic with open ventral hernia repair to determine the 

clinical outcome of both technique and its efficacy. Data of 71 

consecutive patients (63 F / 8 M; mean age 55.66 yrs; range 30- 

83 yrs) with ventral hernia mesh repaired by either laparoscopic 

(n=34) or open technique (n=37) from January 2000 to 

January 2004 were collected. In the laparoscopic group 23.5% 

of the pts had a previous open repair while only 16.2% in the 

open group. In both groups the hernia was reducible in 65% of 

cases. In open repair we utilized Rives-Stoppa technique with 

polypropilene mesh while laparoscopic repair was performed 

using three trocars placed laterally in the abdominal wall. For 

laparoscopic repair an IPOM was utilized with both transfascial 

suture and spiral staplers for fixation of double-layer polyester 

mesh coated with collagen membrane.Open repair was done 

in 37 pts and 34 had laparoscopic repair. Mean hernia size for 

the lap. group was 93 cm2 vs that for open of 55 cm2, mesh 

sizes 216-cm2 vs. 110 cm2 and mean OT time were 96 min vs 

116 min respectively. A short post-operative stay 2.29 days for 

laparoscopic group was statistically significantly different 

(p=0.002) from open repair. Post-operative pain score (VAS) 

was significantly different at 72 hrs (p=0.017). No conversion 

to open repair. In the lap. group 2 pts had seroma vs 2 wound 

infections and 3 pts with prolonged ileus in open group. 2 pts 

in the open group vs one in laparoscopic required removal of 

mesh for infection. Mean follow-up time is 12.1 ± 9.81 mnths 

for lap patients vs 13.6 ± 7.54 mnths for open group. 2.94% 

have recurrence in the laparoscopic group while have been 

reported much higher (10.81%) in the open group. Our study 



213



showed that laparoscopic ventral hernias repair is safe , with 

shorter operative time, lesser pain, fewer complications, shorter 

hospital stays, less recurrence and more satisfied patients 

compared to open repair. 


LAPAROSCOPIC AND OPEN GROIN HERNIA REPAIR ? A 

CHANGING PATTERN IN A BUDGET-CONSTRAINED PUBLIC 

HOSPITAL., Y Munz MD,B Bar Zakai MD,EL Shabtai MSc,D 

Rosin MD,Y Goldes MD,M Khaikin MD,A Ayalon MD, M 

Shabtai, Dept.of Surgery, Sheba medical Center and Statistical 

Service, TelAviv Sourasky Medicalcenter 

Background: Recent reports have questioned the advantage of 

laparoscopic groin hernia repair (LHR) compared to the open 

method (OHR). However, wide availability coupled with readily 

accessible information on the internet, have made LHR a procedure 

very much in demand by patients and referring physicians 

alike. This study portrays the changes in the inter-relationships 

between LHR and OHR in a single, large, academic 

surgical service in a public government hospital. 

Patients and Methods: Data regarding LHR and OHR were 

prospectively collected and retrospectively reviewed starting 

from date of the first LHR performed in 1997. The trend of the 

relative proportion of each method through the years and the 

absolute number of procedures performed by attending surgeons 

and residents were calculated. The overall burden on 

operating room time (OT) by each method was correlated to 

the operating surgeon?s experience. LHR costs were reduced 

by avoiding use of hernia balloons. 

Results: Between 1997 and 2003, a total of 1474 groin hernia 

(LHR=868, OHR=606) repairs were performed. A steady 

increase in the relative fraction of LHR from 15.6% in 1997 to 

98.7 % 2003 was clearly observed (p=0.0001). The majority of 

both LHR and OHR (>80%) were performed by residents. 

Overall mean OT for LHR and OHR were 71±24 and 66±29 minutes 

respectively (p=NS). OT was significantly shorter in the 

non-teaching (70±24) compared to teaching setting (79.5±25 

minutes, p=0.001). Furthermore, OT correlated with point in 

time after 1997 and decreased significantly towards 2003 

(p=0.0001). The interaction between OT, repair method and 

year (1997 and on) was statistically significant (p=0.001). 

Conclusions: The last decade has witnessed profound changes 

in the inter-relationship between LHR and OHR, mostly due to 

readily available information and more knowledgeable 

patients. Even in a public, budget-constrained institution, the 

majority of patients request and get LHR. It appears from our 

data, that OT is similar in LHR and OHR albeit longer, as 

expected, in a teaching setting. We conclude that a proper balance 

must and can be kept so that patients’ request, safety and 

cost considerations are met. This, however, must be carried 

out while maintaining adequate residents training in academic 

institutions. 


CONSOLIDATED FIVE YEAR EXPERIENCE WITH 

LAPAROSCOPIC INGUINAL HERNIA REPAIR, Tarun Singhal 

MS,S Balakrishnan MS,S El-Hasani, Princess Royal University 

Hospital, Kent, U.K. 

Introduction: After the introduction of Laparoscopic Hernia 

repair to the National Health Service (NHS), we studied the 

benefits and practicality of carrying out this specialised hernia 

repair technique in a District General NHS Hospital. 

Methods: A total of 830 hernias were operated upon in 572 

patients, aged between 16 and 89 years. 312 patients had the 

operation as a day case procedure and the remaining 260 were 

treated as inpatients. 

Conclusion: Laparoscopic tension-free TAPP method of hernia 

repair, as we do it, is cost-effective and efficacious. Most 

patients can be treated as day cases. We discovered incidental 

hernias in19.1% patients, which were treated simultaneously. A 

low recurrence rate (0.12%) with low morbidity makes it an 

attractive method for routine treatment of groin hernias in the 

NHS. All patients were followed up by outpatient clinic visit 

and questionnaire. 


LAPAROSCOPIC TREATMENT OF PARAESOPHAGEAL HIATAL 


HERNIA WITH AN INCARCERATION OF PANCREAS AND 

JEJUNUM: A CASE REPORT, Masashi Tachibana MD, Nobumi 

Tagaya PhD,Hiroaki Kijima MD,Yasuharu Kakihara 

MD,Kiyoshige Hamada MD,Tokihiko Sawada PhD,Keiichi 

Kubota PhD, Second Department of Surgery, Dokkyo 

University School of Medicine, Tochigi, Japan 

Hiatal hernia is generally divided into sliding and paraesophageal 

types. The latter with an incarceration of the pancreas 

is rare and has been provided with critical conditions. 

We present a successful laparoscopic treatment of paraesophageal 

hiatal hernia with an incarceration of the pancreas 

and jejunum. The patient was a 75-year-old woman who had 

complaints of epigastric pain and dysphasia. A chest x-ray 

revealed a mediastinal air-fluid level. Chest computed tomography 

showed intestinal contents, body and tail of the pancreas 

and the splenic artery within the mediastinum. An upper 

gastrointestinal series identified jejunum within the mediastinum 

without dislocations of esophagogastric junction and 

stomach. The patient underwent laparoscopic treatment for 

the diagnosis of paraesophageal hiatal hernia with an incarceration 

of pancreas and jejunum. At laparoscopy, jejunum was 

incarcerated into the mediastinal cavity through the internal 

hernia of transverse mesocolon. After resolving this incarceration, 

body and tail of the pancreas and the splenic artery were 

identified and also dislocated within the hernia sac. After 

dividing and removing both of them from the mediastinal cavity, 

the crural defect was repaired with non-absorbable sutures. 

The operation time took 115 min and the estimated blood loss 

was minimal. The patient tolerated a regular diet on the first 

postoperative day and was discharged uneventfully. There 

were no recurrence or abdominal symptoms during the 11 

months follow-up period. In the case of asymptomatic paraesophageal 

hiatal hernia with incarcerating pancreas on diagnostic 

imagings, elective surgical treatment is required to prevent 

a critical outcome. 


LONG TERM RESULTS OF LAPAROSCOPIC TOTALLY 

EXTRAPERITONEAL INGUINAL MESH HERNIORRAPHY, Craig 

J Taylor MD, Tim Wilson MD, Peninsula Private Hospital, 

Sydney Australia 

INTRODUCTION: The short term advantages of laparoscopic 

totally extraperitoneal mesh herniorraphy (TEP) are well documented, 

however the long term results remain unclear. We 

seek to clarify this issue with particular reference to the incidence 

of hernia recurrence and chronic groin pain. 

METHODS: A retrospective case series of one hundred consecutive 

patients undergoing TEP 5 years previously by a single 

surgeon were followed up prospectively with a focused physical 

examination. 

RESULTS: During the period between 1997 and 1999, 100 consecutive 

patients underwent 110 TEP hernia repairs. The mean 

age was 56 years. Median follow-up was 64 months. Follow-up 

was complete (interview and physical examination) in 88% and 

partial (telephone interview only) in a further 5%. There was 

no major morbidity or mortality. Hernia recurrence rate was 

1%. Chronic pain occurred in 14 patients (14%), which was 

mild in 13 patients and moderate in one. Ninety eight percent 

of patients were satisfied with their repair and would or had 

recommended TEP to others. 

CONCLUSION-: Long term results of TEP demonstrate it to be 

an effective and safe procedure with a low recurrence and low 

prevalence of chronic pain which is generally of a mild, infrequent 

nature. 

P336–Minimally Invasive Other 

A RELIABILITY ANALYSIS OF VIDEO-BASED RATING SCALES 

FOR TECHNICAL SKILLS ASSESSMENTS IN LAPAROSCOPIC 

SURGERY, R Aggarwal MD, T Grantcharov PhD,K Moorthy 

MD,P Papasavas MD,T Milland,S Sarker MD,A Darzi MD, 

Department of Surgical Oncology & Technology, Imperial 

College London, United Kingdom; Department of Surgical 

Gastroenterology, Glostrup University Hospital, Glostrup, 

Denmark; Department of Surgery, Western Pennsylvania 

Hospital, Pittsburgh, PA, USA. 

Introduction: The assessment of surgical technical skill 

requires the development of valid, objective and reliable meas-


urement tools. Rating scales used during live observation of 

operative performance may be divided into global, procedurespecific 

and checklist-based. These scales may also be used 

for retrospective video-based observation with a resultant 

increase in objectivity of the assessment, though it is unclear 

which type of scale would be the most reliable for this purpose. 

The aim of this study is to define the optimal scale for 

video-based assessment of technical skill in laparoscopic surgery. 

Methods: Twenty-eight laparoscopic cholecystectomies (LC) 

performed by a total of 17 surgeons were recorded, following 

the confirmation of informed consent from all patients and 

surgeons involved in the cases. Each LC was assigned a code, 

and rated by three other experienced laparoscopic surgeons in 

a blinded manner on each of four rating scales. These were 

the OSATS global rating scale of technical skill, a modified 

OSATS global rating scale specifically adapted for video-based 

assessment of laparoscopic surgery, a procedure-specific rating 

scale, and finally a procedural checklist. Scores for each 

procedure were collated, and analysed using Cronbach?s 

alpha test for inter-rater reliability. 

Results: The inter-rater reliabilities for each of the four rating 

scales were as follows: OSATS (0.79); modified OSATS for 

video-based observation (0.75); procedure-specific rating scale 

(0.82); and procedural checklist (0.48). 

Conclusions: OSATS, modified OSATS and the procedure-specific 

scale all possess high inter-rater reliabilities, even though 

the assessment is based upon retrospective, blinded, videobased 

observation of performance. Such a method can ensure 

increased objectivity and may be performed after the event, 

making the assessment more feasible by not requiring the 

presence of expert faculty to be available at the time of the 

procedure. Finally, this study did not find the checklist to be a 

reliable method of assessment, replicating the results of previous 

work in this field. 


THE OPTIMAL METHOD OF TRAINING ON A VIRTUAL REALI- 

TY LAPAROSCOPIC SIMULATOR, R Aggarwal MD, G Dew,J 

Hance MD,N Selvapatt,A Darzi MD, Department of Surgical 

Oncology & Technology, Imperial College London, UK. 

Introduction: Virtual reality (VR) laparoscopic simulators have 

been shown to teach the skills required for laparoscopic surgery. 

However, with increased fidelity and on-screen feedback, 

the question should be asked whether it is necessary to have 

an expert tutor available during every training session? It is 

the aim of this study to determine the optimal method of feedback 

to teach the skills required for laparoscopic suturing. 

Methods: Forty laparoscopic novices trained on laparoscopic 

VR simulators in a stepwise approach, commencing with a 

previously validated basic skills curriculum on the MIST-VR 

simulator. Subjects then completed five half-hour sessions on 

the laparoscopic suturing module of the LapSim VR simulator. 

Prior to their first LapSim session, subjects were randomly 

allocated to one of four groups, each group receiving a different 

type of feedback during their training sessions. The groups 

received either expert tutor feedback, checklist feedback, VR 

simulator feedback, or no feedback. Assessments of laparoscopic 

suturing skill were carried out at the beginning and end 

of each subject?s training period, using a synthetic bowel 

model placed in a video trainer. Each subject?s performance 

was scored objectively using a validated motion analysis system, 

together with blinded checklist scoring of videos of each 

procedure. Data analysis used non-parametric tests, p



method uses traditional laparoscopy (LAPD). OBJECTIVE: To 

justify the increase in medical resources for laparoscopicassisted 

peritoneal dialysis catheter placement. METHODS: 

This was a retrospective chart review of the LAPD group and 

the most recent consecutive STPD. The Chi-square test was 

used to compare the two groups. RESULTS: 25 patients had 

LAPD from 9/13/02 through 6/30/04. One patient was lost to follow-up 

and another patient?s records were not available, making 

this group 23 patients. 25 patients from 2/21/01 through 

2/21/03 had STPD. Three of these patients were lost to followup, 

and two of these patients’ records could not be retrieved, 

making this group 20 patients. 16 of 23 (69.6%) and 9 of 20 

(45%) patients in the LAPD and STPD groups respectively had 

had previous abdominal surgery. 5/23(21.7%) and 6/20(30%) of 

the LAPD and STPD respectively had PDC malfunction post 

placement. Other complications are listed in the table: 

CONCLUSIONS: Although statistical significance was not 

obtained with this small sample size, STPD trended to an 

increased complication, malfunction, and PDC removal rate. 

More malfunctioning catheters in LAPD were able to be salvaged 

via a repeat laparoscopic procedure than in STPD. LAPD 

trended to an increased rate of dialysate leak, but this was easily 

repaired, salvaging the PDC. LAPD can be used to place 

PDC in more patients with previous abdominal surgery. LAPD 

seems to be superior to STPD. 


COSMETIC LAPAROSCOPIC CHOLECYSTECTOMY-A 7 YEAR 

REVIEW OF RESULTS, Michael Bozuk MD, Nicole Fearing 

MD,Phillip P Leggett MD, Department of Surgery, Houston 

Norwest Medical Center, University of TX-Houston 

Abstract 

Background: Today?s patients expect more attention to cosmesis 

in their surgical incisions. In 2001 we described a case 

report of a cosmetic laparoscopic cholecystectomy. Our goal 

was to improve the cosmetic results for patients while performing 

a safe cholecystectomy. We report here our results of 

43 cosmetic laparoscopic cholecystectomies over the last 7 

years. 

Method: A retrospective review of all cosmetic laparoscopic 

cholecystectomies was performed. The procedure was accomplished 

with three, five millimeter ports. A port was placed in 

the umbilicus. Two additional ports were placed to the right 

and left of midline just above the pubic hairline. 

Results: Forty-three cosmetic laparoscopic cholecystectomies 

were performed between June 1997 and July 2004. All 

patients were female with an average age of 31years old (15- 

50yo). The average BMI was 23 (18-27). The indications for 

cholecystectomy were biliary dyskinesia in 22 patients, symptomatic 

cholelithiasis in 16 patients, gallbladder polyps in 2 

patients and acute cholecystitis in 3 patients. No conversion to 

standard trocar placement or open cholecystectomy was necessary. 

Blood loss was minimal in all cases and no intraoperative 

complications were noted. Three patients had other procedures 

performed concurrently including appendectomy, lysis 

of adhesions, and tubal ligation. Two major complications 

were noted in our series. The first was a bile leak which was 

treated conservatively. The second was a partial bile duct 

occlusion secondary to a clip which was treated with ERCP. 

Gallbladder pathology was abnormal in all patients. Chronic 

inflammation was found in 23 patients, cholelithiasis in 16, 

smooth muscle hypertrophy in 10 and 3 had acute cholecystitis. 

Conclusion: We propose that cosmetic laparoscopic cholecystectomy 

can be safely performed in a carefully selected patient 

population. It can be performed for a variety of diagnoses, 

with minimal morbidity. It adds to the laparoscopic armamentarium, 

especially in patients concerned with their cosmetic 

results. 


SYMPTOMATIC ADRENAL HEMORRHAGE FOUND DURING 


ELECTIVE ADRENALECTOMY, Johelen Carleton MD, Michael S 

Gold MD,Steven J Heneghan MD, Mary Imogene Bassett 

Hospital 

Objective: The purpose of this study was to examine the relationship 

between preoperative pain and preoperative hemorrhage 

in patients with adrenal tumors. Although nontraumatic 

adrenal hemorrhage is rarely described, it is a relatively common 

finding in our series. 

Methods: Consecutive adrenalectomies done by a single surgeon 

from 2000 to 2004 were reviewed retrospectively for presenting 

symptoms, biochemical function, imaging, surgical 

indications, operative technique, pathology, complications and 

postoperative symptoms. 

Results: Twelve cases of adrenalectomy were performed. 

Indications for surgery were biochemical function or size. 

Pathology confirmed four pheochromocytomas, five cortical 

adenomas, one cortical hyperplasia, one aneurysm, and one 

paraganglioma. Five patients undergoing adrenalectomy gave 

a history of flank, back, or abdominal pain prior to resection. 

Four out of the five patients presenting with pain were found 

to have pathologic evidence of previous hemorrhage within 

the adrenal gland. The specimens with hemorrhage included 

two adenomas, a pheochromocytoma, and an aneurysm. The 

only patient with preoperative pain who did not have evidence 

of preoperative hemorrhage was found to have an intrinsically 

painful paraganglioma. All patients had resolution of pain following 

adrenalectomy 

Conclusion: Patients with pathologic evidence of previous 

hemorrhage were more likely to present with pain. 

Presentation with pain appeared independent of tumor characteristics 

or patient demographics. Laparoscopic adrenalectomy 

was done safely in all cases and produced relief of the preoperative 

pain symptoms. Hemorrhage within an adrenal gland 

should be considered in patients found to have an adrenal 

mass on imaging and have a history of abdominal or flank 

pain. Based on our limited series, underlying adrenal pathology 

should be considered likely in cases of nontraumatic bleeding. 


LAPAROSCOPIC FUNCTION PRESERVING SURGERY FOR 

NON-PARASITIC SPLENIC CYST, yoo shin Choi MD, hyung ho 

Kim PhD, Department of Surgery, Seoul National University, 

College of Medicine, 

INTRODUCTION: Concerns about overwhelming postsplenectomy 

sepsis have led to the development of splenic preservation 

procedures, so splenic preservation and conservative 

management is now accepted norms when dealing with 

pathologic benign splenic conditions and traumatic splenic 

injuries. Recently, we performed successfully laparoscopic 

function preserving procedures in two splenic pseudocysts. 

These procedures are rarely published in English literature in 

worldwide. A thorough understanding of splenic anatomy permits 

laparoscopic partial splenectomy or cyst unlooping 

hemisplenectomy with the resultant benefits including a 

decreased risk of postsplenectomy sepsis by preserving 

splenic function, short hospital stay, smooth convalescence, 

superior cosmoses and non-recurrence. 

METHODS AND PROCEDURES: Case1. A 53-year-old man presented 

with left upper-quadrant abdominal pain. He had no 

history of trauma or tropical travel. MRI demonstrated 6cm 

sized cyst at lower pole of spleen. Laparoscopic partial 

splenectomy underwent successfully. Case2. A 24-year-old 

woman presented with left upper-quadrant abdominal palpable 

mass. She had no history of trauma or tropical travel. CT 

demonstrated 20cm sized huge mass with wall calcification at 

upper pole of spleen. Laparoscopic cyst unlooping procedure 

with sagital hemisplenectomy was performed without any 

events. 

RESULTS: In all two cases, pathologic findings were splenic 

pseudocyst. Operative times were 120 minute in case 1 and 

156minute in case 2. In case 1, he discharged at postoperative 

day 5th and in case 2, at postoperative day 3rd. On the CT 

checked 3 month after operation, we confirmed that cysts 

were completely excised without operation related complication 

and there were no evidence of recurrence in all two cases. 

Also splenic function is preserving completely normally.


CONCLUSION: The success and relative ease of performing 

this laparoscopic function preserving procedure will pave the 

way for its future use in other selective cases involving splenic 

pathology. 


LAPAROSCOPIC RESECTION OF LYMPH NODE POSITIVE 

COLON AND RECTAL CANCER: 24-MONTH FOLLOW-UP OF 90 

PATIENTS, Gyu-Seog Choi MD, In-Taek Lee MD,Jong-Ho Lee 

MD,Soo-Han Jeon MD, Division of Colorectal Surgery, 

Department of Surgery, Kyungpook National University School 

of Medicine 

Purpose: Despite laparoscopic colon resection for benign and 

early malignant lesions is quite acceptable beacause of fast 

recovery and minimal morbidity, laparoscopic curative surgery 

for advanced colorectal cancer remains controversial. The purpose 

of this study was to evaluate the postoperative outcomes, 

and short-term survival of laparoscopic resection for 

lymph node positive colorectal cancer. Methods: A single-institution 

retrospective trial was undertaken between June 1996 

and April 2004, during which 266 patients had curative laparoscopic 

surgery for colorectal cancer by a single laparoscopic 

colorectal surgeon. Lymph node metastasis was confirmed at 

postoperative pathology in 90 patients. The surgical outcomes 

were evaluated in lymph node positive colorectal cancer 

patients, focusing on the results of the surgery, postoperative 

complications, oncologic clearance and recurrence rate. 

Results: In this study, 30 right hemicolectomies(RHC), 1 left 

hemicolectomy, 21 anterior resections(AR), 35 low anterior 

resections(LAR, including 5 coloanal hand-sewn anastomosis), 

and 3 abdominoperineal resections(APR) were performed. The 

tumor site was the ascending colon in 30 cases, the descending 

colon in 23 cases, and the rectum in 37 cases, including 15 

mid-low rectal cancers. Six laparoscopic procedures (6.7%) 

were converted to open surgery. There was no hospital mortality, 

and the hospital morbidity was 15.1%. The mean operation 

time were 202(125-340) minutes for RHC, 205(145-265) 

minutes for AR, 250(135-415) minutes for LAR, and 224(145- 

265) minutes for APR. The mean postoperative stay was 

10.5(6-42) days. The mean number of lymph nodes retrieved 

and metastatic were 25.7(4-91) and 3.3(1-17), respectively. The 

mean distal margins were 6.8 (1.5-12.5) cm for AR, 2.7 (1.-3.5) 

cm for LAR, and 0.7 (0.5-1) cm for coloanal hand-sewn anastomosis. 

Recurrence was identified in eleven patients(three local 

recurrences (3.5%) and eight distant metastases (9.3%)). There 

was no port site recurrence. One patient was died for distanst 

metastasis. Conclusions: Laparoscopic resection for lymph 

node positive colorectal cancer is a safe procedure in terms of 

postoperative outcome, oncologic clearance, and short-term 

survival. However, further follow-up and multicenter, randomized 

trials will be required to determine whether the laparoscopic 

approach will play a significant role in the treatment of 

colorectal cnacer in the future. 


COMPARATIVE THERMAL SPREAD OF THREE RADIOFRE- 

QUENCY BIPOLAR VESSEL SEALING DEVICES, Tanuja Damani 

MD, Lawrence W Way MD,Arnold Advincula MD, University of 

California at San Francisco, San Francisco, CA; University of 

Michigan at Ann Arbor, Ann Arbor, MI 

Radiofrequency (RF) bipolar vessel sealing devices facilitate 

laparoscopic dissection and surgical hemostasis, but can also 

cause undesirable collateral thermal damage. This in vitro 

study evaluated the thermal effects on adjacent tissue using 

real time infrared thermography during bipolar vessel sealing 

in pigs. The following RF vessel sealing devices were compared 

: Enseal Vessel Fusion System; Ligasure LS1100; and 

Ligasure Atlas V. A thermal imaging camera was used to 

record dynamic thermal images of the RF vessel sealing 

device in use. A 7.9 mm harvested porcine vessel was sealed 

on separate occasions using each of the three devices. Room 

temperature was 23.8 C and relative humidity, 50%. Protein 

denaturation, with subsequent collagenous tissue breakdown 

and reformation into a seal, begins at 54C. Consequently, two 

thermal zones lateral to the jaws of the instrument were 

defined- a “hot” zone with temperatures greater than 54C 

immediately next to the jaws of the instrument, and a “cool” 

zone with temperatures equal to or less than 54C distant to the 

“hot” zone. Thermal spread was defined as the length of the 

“hot” zone. Thermal spread for Enseal, Ligasure Atlas V, and 

Ligasure LS1100 was 1.4 mm, 1.6 mm and 5.0 mm, respectively. 

Peak temperatures were 83.7C, 82.3C and 92.0C, respectively. 

Conclusion: The different thermal vessel sealing devices left 

different thermal imprints. In this in vitro study, the SurgRx 

Enseal 5 mm laparoscopic vessel sealing device produced the 

least thermal spread to surrounding tissues. 


THE ROLE OF LAPAROSCOPY IN THE DIAGNOSIS AND MAN- 

AGEMENT OF CHRONIC SMALL BOWEL OBSTRUCTION: A 

CASE REPORT., Alexander J Ernest Jr. MD, M Chung MD,S 

Zagorski MD, Department of Surgery, Tripler Army Medical 

Center. Honolulu, HI. 

Abstract 

Background: We present a case of laparoscopic exploration 

performed for a chronic small bowel obstruction, which was 

diagnostic and therapeutic. 

Case Report: A 46-year-old woman with a 20-year history of 

chronic abdominal pain presented with frequent nausea, emesis, 

and diarrhea. Her past surgical history is significant for a 

leiomyoma of the jejunum excised as an infant. The patient is 

an avid martial artist so we planned to perform a laparoscopic 

resection of the likely stricture at the jejunum versus a limited 

incision laparotomy guided by laparoscopy. During the 

exploratory laparoscopy we encountered extensive adhesions 

and a massively dilated segment of jejunum. Thus, a limited 

laparotomy incision was placed in the midline for open exploration, 

entailing adhesiolysis and resection of the dilated small 

bowel with primary anastomosis. An area of mesenteric 

adenopathy was also identified and resected. The pathology 

and subsequent work-up revealed stage 1 low-grad follicular 

lymphoma for which observation has been recommended. The 

patient was discharged on post op day number 5 and has 

returned to her normal activities, including martial arts training, 

within 6 weeks of the operation. 

Conclusion: This case illustrates the role of laparoscopy in the 

diagnosis and treatment of chronic small bowel obstruction. 

Its use can result in ?minimal laparotomy?, if needed, to facilitate 

rapid recovery. 


THE ROLE OF ERYTHROPOIETIN IN SURGERY, Sameh A Fayek 

MD, Raymond L Horwood MD,Joseph Thomas RN, FAIRVIEW 

HOSPITAL,DEPARTMENT OF SURGERY, CLEVELAND CLINIC 

HEALTH SYSTEM 

INTRODUCTION 

In surgical patients anemia is a predictor of mortality and morbidity; 

its prevalence ranges from 5-75% and is often the only 

reason for blood transfusion. Pretreatment hemoglobin (Hb) is 

a predictive factor of transfusion (1). Transfusion is a common 

practice but blood is a limited resource and is associated with 

significant risks (2). Recombinant human erythropoietin 

(rHuEPO) stimulates erythropoiesis. Preoperative HuEPO is 

proposed to increase preoperative Hb to produce a higher 

early postoperative Hb. Also it is expected to accelerate postoperative 

erythropoietic recovery hence, preventing anemia 

and reducing the need for transfusion. 

METHODS AND PROCEDURES 

This is an observational study comparing data from two 

patient groups. Study group included eighteen patients undergoing 

major orthopedic surgery from October 2003 to May 

2004, with Hb >10 and



RESULTS 

There was a smaller change in Hb levels from pretreatment to 

postoperative day 1 Hb in the study group (P=0.002). However, 

there was no statistically significant difference in the proportion 

of patients receiving a blood transfusion, number of units 

transfused/patient transfused, LOS, morbidity or mortality. The 

cost of rHuEPO course is equivalent to the cost of 3 units of 

homologous blood. 

CONCLUSION 

rHuEPO is safe with many advantages, however the overall 

clinical benefit should be further evaluated. Time lag and cost 

are considerable limitations for its use in surgery. 

REFERENCES 

1.Shander A.; et al. Prevalence and outcomes of anemia in surgery: 

a systematic review of the literature. Am J Med 2004; 

116 (suppl 7A): 58S-69S. 

2.Robin de Andrade J.; et al. Baseline hemoglobin as a predictor 

of risk of transfusion and response to epoetin alfa in orthopedic 

surgery patients. Am J Orthop 1996; 8: 533-542. 


DEFINING THE ROLE OF DIAGNOSTIC LAPAROSCOPY IN 

PATIENTS WITH ABDOMINAL PAIN, Jeannine Giovanni MD, 

Ibrahim M Daoud MD, Saint Francis Medical Center 

The work up of patients with acute or chronic abdominal pain 

can be lengthy, costly, and sometimes unyielding of a diagnosis. 

Diagnostic laparoscopy is currently being used as an effective 

means to discern the etiology of various abdominal disorders. 

Its advantages over diagnostic laparotomy make it a better 

alternative in cases of diagnostic uncertainty. Laparoscopy 

can potentially avoid unnecessary laparotomies, provide diagnoses, 

and enable therapeutic interventions. 

We describe our single institutional experience with diagnostic 

laparoscopy as a minimally invasive tool in the work up and 

treatment of patients with acute and chronic abdominal pain. 

We retrospectively reviewed patient demographics, type and 

frequency of preoperative diagnostic tests, operative findings, 

and therapeutic interventions. We propose that diagnostic 

laparoscopy is a valuable tool in cases of diagnostic uncertainty. 

From 1991 to 1998, 78 patients underwent diagnostic 

laparoscopy following equivocal physical exam findings, laboratory 

tests, and noninvasive radiological procedures. The 

majority of patients were female (82.1%) ranging in age from 

13-85 years old. Most patients (74%) presented with chronic 

pain defined as greater than 7 days duration. It was found that 

33.3% of subjects had at least one X-ray, 44.9% had at least 

one computed tomography (CT) study, 16.7% had at least one 

ultrasound, and 44.9% had multiple tests including barium 

studies, cystoscopies, endoscopic retrograde cholangiopancreatograms 

(ERCP), magnetic resonance imaging (MRI), and 

endoscopic evaluations. None of these preoperative evaluations 

yielded diagnostic results. With diagnostic laparoscopy, 

we were able to establish a diagnosis in 76 patients (97.4%). 

The most common findings included hernias (27%), adhesions 

(18%), appendicitis (17%), gynecologic pathology (9%), malignancy 

(6.4%), and bowel obstruction (2.6%). 

In our experience, diagnostic laparoscopy is a helpful tool to 

diagnose and treat patients with obscure causes of abdominal 

pain. It can potentially yield a diagnosis when conventional 

preoperative studies have failed to do so. It should be considered 

early on to avoid extensive workups and prolonged 

patient suffering. 


THE EFFICUSY OF LAPAROSCOPIC SURGERY FOR THE 

OBSTRUCTION BOWEL, Ken Hayashi MD, Yasuhiro Munakata 

MD,Takahide Yokoyama MD, Center of Endoscopic Surgery. 

Showa-Inan General Hospital 

[Objectives] I compared results of laparoscopic surgery for 

obstruction bowel with open surgery and reviewed utility. 

[Methods] We performed 65 cases of laparoscopic surgery and 

38 cases of open surgery in the same period for the obstruction 

bowel during ten years. We diagnosed as an adhesion 

area by a dynamic ultrasonography, and digestive organs contrasting 

examination for all cases preoperatively, and made an 

adhesion map. We used scissors or an ultrasonic wave appliance 

for adhesion detachment. The art type of laparoscopic 

surgery was classed to three groups.; laparoscopic group without 

window cases are classed as group A (n=39), laparoscopy 

assisted with small incision (4-8cm) are group B (n=22), and 

converted to open surgery are group C (n=4). In addition, I 

compared it with a group of initial open surgery. 

[Results] The mean operation time was 102 minutes in group 

A, 137 minutes in group B, and 238 minutes in group C. Oral 

intake had a short in group A for 3.3 day, group B for 5.9 day, 

and 13.0 day for group C, and hospitalization was a short for 

10.2 day in group A, 18.2 day in group B, and 35.0 days in 

group C. One case was needed open surgery postoperatively, 

because of a complication of peritonitis in group B, but there 

was not the surgical trouble else. In addition, 3 cases of group 

A, and 2 cases of a group B required readmission in obstruction 

bowel, but retrograded for a save. Readmission was 

required 7.7% of a laparoscopic group. The readmission rate 

of initial open group was 16.7% and 3 cases (7.8%) was. needed 

for next surgical procedure. 

[Concluding remarks] Laparoscopic surgery was feasible for 

obstruction bowel diseases with no-adhesion area. This procedure 

was safely completed with minimally invasiveness and a 

low recurrence rate. 


LOCAL ANESTHESIA REDUCES POST-LAPAROSCOPY PAIN: A 

PROSPECTIVE, RANDOMIZED TRIAL, Dennis L Fowler MD, 

Nancy J Hogle RN, Edward Borrazzo MD,Andrew J Duffy MD, 

Columbia College of Physicians and Surgeons 

Background: Local anesthesia at port sites during laparoscopic 

surgery has not been proven effective. We hypothesize that 

local anesthesia at port sites reduces postoperative pain and 

the need for narcotics. 

Methods: Patients were prospectively randomized to receive 

local anesthesia at port sites prior to incision (Group 1), local 

anesthesia at port sites at the end of the procedure (Group 2), 

or no local anesthesia (Group 3). Patients were blinded to 

group assignment and were evaluated with a visual analog 

pain scale at 1, 2, 4, and 8 hrs postop. Below, pain scores at 

each time interval and mean number of narcotic doses (meds) 

are documented after analysis with ANOVA. 

Conclusions: Local anesthesia at port sites during laparoscopic 

cholecystectomy significantly reduces pain at 2, 4, and 8 hours 

after surgery, more so if infiltrated prior to incision than if infiltrated 

at the end of the operation. Patients who received local 

anesthesia required fewer narcotic doses, although not statistically 

significantly so. Nonetheless, this reduction in narcotic 

use may have clinical relevance. 


LAPAROSCOPIC MANAGEMENT OF IATROGENIC COLONIC 

PERFORATION, I M Ibrahim MD, S Vaimakis MD,F Silvestri 

MD,R B Wellner MD, Englewood Hospital and Medical Center 

Background: Iatrogenic perforation (IP) of the colon is a relatively 

uncommon event [incidence 0.1-0.8 % of diagnostic and 

0.15-3 % of therapeutic colonoscopies]. Laparotomy with or 

without diversion has been recommended conventionally for 

management. Few authors have advocated a laparoscopic 

approach to this problem. 

Methods: Retrospective chart review of our 5- year community 

hospital experience with 13 IP of the colon referred to our 

service. Ages ranged from 37 to 82. Male/female ratio was 2/1. 

12 perforations were discovered immediately post-endoscopy, 

which was attributed to impressive clinical presentations characterized 

by severe abdominal pain and marked abdominal 

distension/tympany. A single right-sided colon perforation was 

diagnosed 24 hours later. In all cases, patients underwent 

laparoscopic treatment. 



Results: 7 perforations occurred proximal to the recto-sigmoid 

junction and 5 were identified distal to the descending colonsigmoid 

junction. One patient (on high doses of steroids) 

demonstrated a proximal ascending colon perforation with 

localized fecal peritonitis. Lacerations ranged in size from an 

approximately 1 cm lesion to a near- circumferential transection. 

The latter was treated with segmental resection followed 

by primary anastomosis. The remaining twelve perforations 

were managed utilizing lateral sutures. Extensive peritoneal 

lavage was performed, and broad-spectrum antibiotics were 

administered. There was a 0% incidence of anastamotic leaks, 

intraperitoneal abscesses, or trocar site infections. 

Conclusions: One stage laparoscopic management of early 

iatrogenic colonic perforations is a safe, effective, and minimally 

invasive method of treatment. The procedure was 

notably met with a high level of patient satisfaction. From our 

series, we have encountered 0% mortality and negligible morbidity 

employing laparoscopic management. Further study 

comparing subjects undergoing laparatomy versus 

laparoscopy following IP is certainly warranted. At this stage, 

we recommend laparoscopy as a potentially superior management 

strategy for patients, particularly for those with comorbidities 

that limit operability. 


LAPAROSCOPIC BIOPSY OF PARA-AORTIC LYMPHNODE-COM- 

PARISON BETWEEN TRANSPERITONEAL APPROACH AND 

EXTRAPERITONEAL APPROACH, Takashi Iwata MD, Nobuhiro 

Kurita MD,Masaki Nishioka MD,Tetsuya Ikemoto MD,Mitsuo 

Shimada PhD, Department of Digestive Surgery, School of 

Medicine, Tokushima University. 

INTRODUCTION: Improvements in instrumentation and video 

technology have allowed the surgeon to perform more complex 

and major operations through the laparoscope. The technique 

of laparoscopic para-aortic lymphadenectomy is usually 

performed via a transperitoneal approach (TP). In the gastrointestinal 

surgery, adhesions and complications using a 

extraperitoneal approach (EP) have been scarcely reported to 

be fewer than those in a TP. We experienced cases of laparoscopic 

lymph node biopsy, and evaluated effect of TP versus 

EP regardly the intraoperative blood loss, operation time and 

postoperative complications. 

METHODS: A transperitoneal laparoscopic lymph-node biopsy 

was attempted with 3 ports on one patient of esophageal cancer 

(Mt,T2) with massive abdominal lymphadenopathy. Biopsy 

of the para-aortic lymph-nodes was difficult in the TP, therefore 

1.5cm sized lymph node along the common hepatic artery 

was biopsied. On the other hand, the EP lymph-node biopsy, 

5cm sized para-aortic lymph-node, was successfully performed 

with 4 ports on the other patient with malignant lymphoma. 

RESULTS: Intraoperative blood loss was 270ml v.s. 100ml (TP 

v.s. EP, respectively) and operation time was 150 minutes v.s. 

143 minutes. After operation oozing from lymphadenectomy 

continued for 5 days in TP case, EP case could walk 1st operative 

date. 

CONCLUSIONS: The extraperitoneal laparoscopic biopsy of 

para-aortic lymph-nodes is useful method for para-aortic lymphadenectomy 

compared with transperitoneal approach. 


CAN INTRAOPERATIVE LAPAROSCOPIC ULTRASOUND 

REPLACE INTRAOPERATIVE CHOLANGIOGRAPHY DURING 

LAPAROSCOPIC CHOLECYSTECTOMY?, Teresa L LaMasters 

MD, Nicole M Fearing MD,R Stephen Smith MD,Jonathan M 

Dort MD, University of Kansas School of Medicine - Wichita, 

and Via Christi Regional Medical Center - St. Francis Campus 

Background: Controversy surrounding the proper evaluation of 

the common bile duct during laparoscopic cholecystectomy 

has existed for several years. Recently, intraoperative laparoscopic 

ultrasound (ILUS) has been proposed as a safe alternative 

to intraoperative cholangiography (IOC). We hypothesized 

ILUS is a faster alternative to IOC with increased ability to 

determine anatomy. 

Objectives: (1) To evaluate the ability of ILUS to evaluate biliary 

anatomy compared to IOC. (2) To evaluate the amount of 

time necessary to perform ILUS compared to IOC. 

Methods: The use of ILUS vs. IOC in a university-affiliated tertiary-care 

center was prospectively evaluated. Seventy-five 

patients were included in the study. Each patient underwent 

ILUS followed by IOC. The ability to define biliary anatomy 

and the time required to complete each procedure was recorded. 

Results: ILUS was performed more expeditiously than IOC (5.7 

min vs. 11.2 min, p



Results 

Patient was positioned supine on the operating table. For 

access we used a 6 cm-long midline supraumbilical incision 

for the hand port, 5 mm ports in the epigastrum, left upper 

quadrant on the mid clavicular line and left flank on the axillary 

line. An additional 12 mm port was placed on the left mid 

clavicular line just above the umbilicus. An extended right 

hemicolectomy was performed. A distal pancreatectomy was 

performed with an attempt at splenic preservation. However, 

at the end of the procedure, the spleen was found to be nonviable 

and a splenectomy was performed as well. There were no 

complications. Patient was discharged home after 6 days. The 

postoperative recovery was unremarkable. Her pathology 

demonstrated a T3N0M0 adenocarcinoma of the colon with 

negative margins and a mucinous cystadenoma of the pancreas 

with negative margins and no invasive malignancy. 

Conclusions 

A combined hand?assisted laparoscopic right hemicolectomy 

and distal pancreatectomy is technically possible and requires 

an optimal placement of the trocars and the hand port. This 

technique allowed us to treat both conditions concomitantly, 

using a minimally invasive approach, with important benefits 

for the patient. We are not aware of any description of this 

combined approach in the surgical literature. 


OUTCOME OF LAPAROSCOPIC SPLENECTOMY FOR THE 

TREATMENT OF HEMATOLOGICAL DISEASES, Jacques 

Matone MD, Gaspar Lopes Filho PhD,Wagner Marcondes 

MD,Elesiário Caetano MD,Ramiro Colleoni MD,Milton 

Scalabrini MD, Federal University of Sao Paulo - Brazil 

Objective: The aim of this study was to review our experience 

with laparoscopic splenectomy, to determine its overall success 

and applicability. 

Introduction: Splenectomy is considered to be the best available 

treatment for severe forms of hematological diseases, 

such as hereditary spherocytosis, idiopathic thrombocytopenic 

purpura (ITP) and other hematological conditions, refractory to 

conservative management. With the advancement of laparoscopic 

skills and technology, the minimally invasive approach 

was applied to many open procedures, including splenectomy. 

Over a short span of time laparoscopic splenectomy has largely 

replaced open splenectomy regardless of operative indication 

and has also resulted in an overall increase in the number 

of splenectomies performed. However, several aspects of this 

procedure remains as yet undefined and thus, several 

attempts have been made to modify the standard technique to 

try to optimize the procedure. 

Methods: A retrospective analysis of 20 laparoscopic splenectomies 

performed due to hematological diseases at our institution, 

between February 2001 and January 2004, was carried 

out. Patients were followed in the surgical and hematology 

outpatient clinics and data was reviewed. 

Results: The indications for the procedures were ITP (80%), 

non-Hodgkin lymphoma (10%), hereditary spherocytosis (5%) 

and hypersplenism due to erytematous lupus (5%). Mean age 

was 31-year old (range 19 to 55) and 80% were female. Mean 

operating time was 155 minutes. Concerning acessory spleen, 

we performed routine search preoperatively. It was detected in 

three patients before surgical approach. Conversion rate was 

10%, due to an injury during hilar dissection in one case and 

to multiple adhesions from previous surgery in another. Two 

patients required blood transfusion and postsurgical complications 

occurred in four patients (20%), including hematoma, 

diaphragm perforation, pulmonary embolism and infection of 

the port site. A small transverse incision in the lower abdomen 

was made for an intact removal of the spleen. In all cases, 

splenectomy improved patient?s hematological profiles. 

Conclusion: The laparoscopic approach should be considered 

the first option in cases of hematological conditions that 

require splenectomy, whenever contraindications are absent. 

The procedure requires extensive laparoscopic experience and 

meticulous dissection of the spleen to lower the complication 

rate. 



LAPAROSCOPIC SPLENECTOMY IN SEVERE THROMBOCY- 

TOPENIA, Roger D Moccia MD, Tejinder P Singh MD, Albany 


Introduction: The purpose of this study was to determine if 

severe thrombocytopenia (platelets < 35,000) affects morbidity, 

mortality, or the need for transfusions in patients who have 

undergone laparoscopic splenectomy. 

Methods: Retrospective case review of all patients who have 

undergone laparoscopic splenectomy (LS) by one surgeon in 

one institution between 1/1995 and 4/2004. Charts were 

reviewed to determine indication for procedure, pre-operative 

platelet count, post operative transfusions, morbidity, mortality, 

length of hospital stay (LOS) and conversion to open operation. 

Results: Thirty five laparoscopic splenectomies were performed 

by one surgeon at Albany Medical Center over a 9 year 

period. Twelve patients (34%) had preoperative platelet counts 

of less than 35,000. There were 6 men and 6 women with a 

mean age of 35 years (13 ? 62). Ten of the patients had a diagnosis 

of ITP, one had TTP and one had CLL. Mean operative 

time was 130 minutes (range 103 ? 166). Mean EBL was 61 ml 

(range 5 ? 300ml). Median post op LOS was 2 days (range 1 to 

24). Three patients required post operative blood transfusions 

(1unit, 2units and 14 units). One patient (TTP) continued to 

have ongoing bleeding after operation requiring transfusion of 

14 units of packed red blood cells. There were no post operative 

deaths and none of the patients required conversion to 

open operation. 

Conclusions: Laparoscopic splenectomy can be performed 

safely in patients who have severe thrombocytopenia. 

Bleeding risk is not increased in this patient population and 

there does not appear to be a need for pre-operative transfusion 

of platelets in patients who are not actively bleeding. 


A SIMULTANEOUS LAPAROSCOPY-ASSISTED HEPATECTOMY 

AND SIGMOID COLECTOMY FOR A PATIENT WITH COLON 

CANCER AND LIVER METASTASIS : A CASE REPORT, 

masanori nishioka MD, tetsuya ikemoto MD,tsutomu ando 

MD,takashi iwata MD,nobuhiro kurita MD,mitsuo shimada PhD, 

Department of Digestive Surgery, Tokushima university 

[Introduction] The rate of recurrent cancer was recently reported 

similar after laparoscopically assisted colectomy and open 

colectomy for colon cancer. Laparoscopic approach is an 

acceptable alternative to open surgery for colon cancer recently 

because of its radicality, safety and minimal invasiveness 

(The Clinical Outcomes of Surgical Therapy Study Group. 

NEJM 2004). Laparoscopic hepatectomy has been reported a 

feasible option for liver malignancy (Shimada M, et al. Surg 

Endosc 2002). Laparoscopic hepatectomy, as well as laparoscopic 

colectomy, allows for radical local treatment of liver 

cancer, while causing minimal stress to the patient. Herein, we 

report a case who underwent a laparoscopy-assisted hepatectomy 

and colectomy for colon cancer with liver metastasis. 

[Case] A 69-year old women, who was indicated high CEA, was 

found having a 20mm tumor in the sigmoid colon by colonal 

endoscopy. On abdominal CT scan, abdominal magnetic resonance 

imagingscan and angiography, a 40mm metastatic liver 

tumor in the lateral segment from colon cancer was diagnosed. 

Laparoscopy assisted hepatectomy of lateral segment 

and sigmoid colectomy were performed. Hepatectomy with a 

small abdominal incision was performed by abdominal wall 

lifting method. Sigmoid colectomy was performed by pneumoperitoneal 

method, and the bowel was exteriorized through 

a small incision for resection and anastomosis. The operation 

time was 480 minute and the blood loss was 250 ml. The postoperative 

course was uneventful. 

[Conclusion] In case of colon cancer with resectable liver 

metastases, a simultaneous laparoscopic procedures of hepatectomy 

and colectomy is useful option because of the less 

invasiveness and the cosmetic. 


LAPAROSCOPIC ARTICULATED GRASPER, Dmitry Oleynikov 

MD, Tim Judkins MS,Katherine Done MS,Allison DiMartino


MS,Susan Hallbeck PhD, University of Nebraska Medical 

Center 

Introduction:A prototype articulating laparoscopic grasper tool 

which includes an articulating end effector, an ergonomic handle, 

and an intuitive hand/tool interface has been developed. 

This study investigated the evaluation of the prototype tool by 

surgeons and comparison with existing tools. 

Methods: A questionnaire was developed to ask surgeons 

about problems they experience associated with use of conventional 

tools and then query their opinions of the prototype 

tool. Generalized results were obtained through use of a 

Wilcoxon Signed Rank Test utilizing ranking with zeros for 

each hypothesis test. Results: Tests on problems such as 

hand/wrist pain, shoulder pain, finger tingling/numbness, etc. 

produced significant results for the number of surgeons experiencing 

each of the queried problems. A significant number of 

surgeons (p=0.045) identified the prototype handle as either 

comfortable or extremely comfortable. A significant number of 

surgeons (p=0.015) preferred the prototype tool over conventional 

tools, based on general impression. Fifteen of the 18 

surgeons queried said they would try a commercially available 

version of the prototype tool. 

Conclusion: Articulation of the tip has been successfully 

designed in the prototype and 90% of the respondents 

believed the articulation to be a useful addition to laparoscopic 

graspers. The new shape of the handle is considered comfortable 

by a significant number of respondents. Most respondents 

believe the new design will relieve at least one problem 

currently experienced during surgery. 


PERCUTANEOUS GASTROJEJUNOSTOMY AFTER LAPARO- 

SCOPIC ROUX-EN-Y GASTRIC BYPASS FOR MALNUTRITION, 

Anthony E Pucci MD, Alexander Abkin MD,Nicholas Bertha 

MD,Sean Calhoun MD,Fred Brody MD,Edward A Pucci MD, 

Department of Surgery and Interventional Radiology, 

Morristown Memorial Hospital, Morristown, NJ and The 

Department of Surgery, The George Washington University 

Medical Center, Washington, D.C. 

In the severely malnourished postoperative patients, nutritional 

support is necessary to maintain normal body structure and 

function. Currently, percutaneous placement of feeding 

catheters for these patients is performed utilizing an endoscopic 

approach. However, a Roux-en-Y gastric bypass prohibits 

endoscopic techniques and other methods must be considered. 

This paper documents a patient that required a CT 

guided placement of a feeding catheter following a Roux-en-Y 

gastric bypass. 

A 49-year-old male with a history of atrial fibrillation, morbid 

obesity, and insulin dependant diabetes mellitus, underwent 

an uneventful laparoscopic Roux-en-Y gastric bypass. One 

month post operatively, the patient was readmitted with nausea 

and vomiting. Laboratory data revealed that the patient 

was profoundly coagulopathic with an INR of 6. His workup 

included an upper gastrointestinal series which was negative 

for a leak. A CT scan of the abdomen and pelvis revealed a 

large mesenteric hematoma. The patient was resuscitated with 

fresh frozen plasma, packed red blood cells and crystalloid. 

Subsequently, he developed ARDS requiring prolonged ventillatory 

support. The patient then had a protracted course in the 

intensive care unit for secondary complications including sepsis 

and malnutrition. Parenteral nutrition was initially started. 

Nasoenteric tube feeds were started. However, a permanent 

feeding catheter was required for nutritional support. 

Subsequently, the patient underwent a CT guided placement 

of a 14 French gastrostomy tube. This tube was placed into the 

gastric remnant with interventional radiology. However, due to 

high gastric residuals and poor gastric emptying, the gastrostomy 

tube was converted to a gastrojejunostomy tube utilizing 

fluoroscopy. An 18 French, 30 cm gastrojejunostomy tube was 

placed. Enteric feeds were resumed through the jejunostomy 

port while the gastric remnant was decompressed via the gastric 

port. 

CT guided percutaneous gastrojejunostomy offers a minimally 

invasive way to provide enteral feeding as well as gastric remnant 

decompression after Roux-en-Y gastric bypasses. This 

method provides a safe alternative to conventional open surgery 

in high risk patients and should be considered over gastrostomy. 

As the number of gastric bypasses continues to 

increase, this technique may become more prevalent. 


WHO GETS LAPAROSCOPY FOR APPENDICITIS, DO DISPARI- 

TIES EXIST?, R Ricciardi MD, R J Town PhD,T A Kellogg MD,S 

Ikramuddin MD,N N Baxter MD, Department of Surgery, 

University of Minnesota, Minneapolis, MN 

INTRODUCTION: Laparoscopic approaches to appendectomy 

are feasible and are associated with reduced pain, faster 

recovery, and fewer complications. Utilization of laparoscopic 

approaches for the treatment of appendicitis has increased 

steadily since its introduction. No previous research has evaluated 

the utilization of laparoscopic techniques or potential factors 

influencing access to laparoscopic appendectomy (LA). 

METHODS: We used data from the Nationwide Inpatient 

Sample (NIS), a 20% stratified random sample of US community 

hospitals in 33 states. Utilizing standard ICD-9-CM diagnostic 

and procedure codes, we identified patients who were 

admitted to the hospital with a diagnosis of uncomplicated 

appendicitis and subsequently underwent appendectomy from 

2001 to 2002. Standard procedure codes were utilized to identify 

patients who underwent LA or open appendectomy (OA). 

We determined the influence of demographic factors, such as 

gender, race, payer information, and provider factors such as 

hospital size, rural or urban setting, geographic location, funding 

structure, teaching status, and hospital procedure volume 

on the utilization of LA. A multivariate model was constructed 

to determine the influence of demographic and provider factors 

on utilization of LA. RESULTS: A total of 77,909 patients 

were admitted with a diagnosis of uncomplicated appendicitis 

and underwent appendectomy during the two year time period, 

of these 33.9% underwent LA. In multivariate analysis 

women, older patients, and patients with private health insurance 

were more likely to undergo LA while African-Americans 

were less likely to undergo LA. Private for profit hospitals and 

hospital procedure volume were associated with increased utilization 

of LA, but teaching status, geographic location, and 

hospital size were not. CONCLUSIONS: Overall, despite known 

advantages, in 2001-2002 only one third of patients with 

appendicitis underwent LA in the US. Utilization of LA appears 

to be influenced by demographic and provider factors, a number 

of which (including race and hospital financial structure) 

are unlikely to be related to disease severity. These data indicate 

disparities in the application of laparoscopic techniques. 


LAPAROSCOPIC SUTURING OF TENCKHOFF CATHETER TO 

PREVENT RE-OPERATION FOR DISPLACEMENT, Sam Rossi 

MD, Dai Nghiem MD,Chris Haughn MD,Roberto Bergamaschi 

PhD, Minimally Invasive Surgery Center and Transplantation 

Service, Allegheny General Hospital, Pittsburgh, PA 

Patients with end-stage renal disease (ESRD) may need to 

undergo placement of a Tenckhoff catheter for peritoneal dialysis. 

The prevention of displacement of the catheter has been 

traditionally based on the length of the tunnel within the 

abdominal wall. However, re-operation rates due to displacement 

of the catheter have not been low. This study aims to 

evaluate prospectively the impact of laparoscopic suturing of 

Tenckhoff catheter on rates of re-operation for displacement. 

From 1986 to 2003, 216 patients underwent Tenckhoff catheter 

placement for ESRD at Allegheny General Hospital. Over these 

18 years, there was a re-operative rate of 16.6% (32/216 

patients) due to persistent abdominal pain with displacement 

of the catheter towards the upper abdominal quadrants. 

Laparoscopic suturing of Tenckhoff catheter was started in 

2003. The surgical technique involves general or local anesthesia, 

CO2 pneumoperitoneum and three ports. A Hasson port is 

placed below the umbilicus to establish the pneumoperitoneum. 

Two 5-mm ports are placed in the upper quadrants. 



221



Under direct visualization, the tip of the catheter is brought 

thru a tunnel within the abdominal wall deep to the pelvis and 

sutured to the parietal peritoneum using a 3-0 absorbable 

suture with intracorporeally tying a surgeon?s knot. 

During 2003, five patients with a mean age of 61 (range 37-91) 

years underwent laparoscopic suturing of Tenckhoff catheter. 

A 91-year-old man underwent the procedure under local anesthesia. 

All five patients underwent immediate discharge and 

dialysis with no complications. Mean operative time was 24.6 

(range 15-45) minutes. All patients have been followed-up over 

the past year with no complaints of pain and with functioning 

Tenckhoff catheters. 

Laparoscopic placement of Tenckhoff catheter with suturing its 

tip to the pelvis seems an effective way to prevent re-operations 

for displacement. 


FASCIAL AND PERITONEAL INJECTION OF LOCAL ANALGE- 

SIA AT TROCAR SITES PRIOR TO INCISION SIGNIFICANTLY 

DECREASES POST-OPERATIVE PAIN AFTER LAPAROSCOPIC 

SURGERY, Ragui w Sadek MD, sanam ahmed MD,micheal 

castellano MD,sabido frederick MD,anthony kopatsis MD,gene 

f coppa MD, staten island university hospital 

ABSTRACT 

Background: 

since the introduction of laparoscopic cholecystectomy in 

1986,amajor benefit has been the reduction in Postoperative 

pain in patients undergoing this common procedure. This has 

been manifest by the reduction in use of pain medications particularly 

narcotics. standard pain medications in our institutinafter 

laparoscopic cholecystectomy is Oxycodone/APAP or 

Hydrocodone/APAP.There are however, a number of patients 

with complaints of pain in the region of trocar placement after 

laparoscopic procedure.A number of studies have evaluated 

the use of local injections of anasthetic medications into skin 

incision in order to further lower postoperative pain.this study 

evaluates the use of fascial and peritoneal injection as well as 

skin injection in the relief of postopertaive pain. 

METHODS: 

A retrospective analysis of two groups of patients was performed 

using a pain scale to quantify the variation in pain 

level.Group A patients recieved local analgesia.The skin, fascia 

and the peritoneum were injected under direct visualization 

with local ansthesia prior to incision and introduction of the 

laparoscopic trocars.Group B patients did not recieve local 

analgesia.the records of 98 consecutive patients who underwent 

laparoscopic cholecystectomy in our ambulatory center 

during the period of 2003-2004 were examined retrospectively.There 

were 48 in group A and 50 in Group B.Patients in each 

group were selected consecutively.pain postoperatively was 

evaluated by a telephone call made on the first postoperative 

morning.An incremental scale begining with 0 as the lowest 

possible degree of pain,and ending with 10 as the most was 

used as the pain assessment tool. 

RESULTS: 

Group A patients with the local anasthetic infilteration had significantly 

less complaints of postoperative pain as compared 

to the Group B( p < 0.5).In addition Group A returned to normal 

activities of daily living more quickly than Group B 

patients (p < 0.5). 


TIMING OF LAPAROSCOPIC APPENDECTOMY IN ACUTE 

APPENDICITIS IN CHILDREN - A COMMUNITY HOSPITAL 

EXPERIENCE., Radhakrishnan Satheesan MD, Peter S Midulla 

MD,Edward Shlasko MD, Division of Pediatric Surgery, 

Department of Surgery, Maimonides Medical Center, Brooklyn, 

NY 11219 

Appendicitis is the most common condition requiring surgery 

in the pediatric population. Most surgeons in the United States 

consider emergent or urgent appendectomy the standard of 

care. There is a significant body of evidence that demonstrates 

antibiotic therapy to be highly effective as well. Various factors 

affect the scheduling of surgical intervention, such as availability 

of Operating Rooms (OR), availability of surgeons, and 

staffing of the OR. Surgeons often justify timing and classification 

of surgery (as medically emergent) based on satisfying 

those exigencies. In our institution we schedule patients with 

acute appendicitis for laparoscopic appendectomy for the next 

available time during regular OR hours, even if this means 

waiting until the next day. We reviewed a series of 299 consecutive 

laparoscopic appendectomies during the period January 

2000 to June 2004 to correlate the timing of surgery the perforation 

rate, the occurrence of complications, and influence on 

length of stay. No patient clinically diagnosed to have acute 

non-perforated appendicitis was found to have a perforation at 

operation. Our review did not reveal any increase in adverse 

outcome, nor was hospitalization significantly prolonged. A 

prospective study is underway to confirm these findings. 


100 LAPAROSCOPIC ADRENALECTOMIES - A CRITICAL 

APPRAISAL, Stefan Schmidbauer MD, Felix Hohenbleicher 

MD,Sybille Lüderwald MD,Thomas Mussack MD,Klaus K 

Hallfeldt MD, Chirurgische Klinik Innenstadt, Ludwig- 

Maximilians Universitaet, Munich, Germany 

Objective: Laparoscopic adrenalectomy is today widely accepted 

as the gold standard for the resection of benign adrenal 

tumors. However questions remain open such as up to which 

size tumors should be resected laparoscopically. In the present 

study we also focuse on the resection of solitary metastasies, 

partial adrenalectomy, diagnostic problems regarding the 

treatment of large adrenal cysts and report on one patient who 

died following bilateral adrenalectomy for Cushing?s desease. 

Methods and procedures: Between 1997 and 2004, 100 laparoscopic 

adrenalectomies using a lateral approach were carried 

out in 93 patients. Indications for surgery were benign adrenal 

tumors < 8 cm ( 30 aldosterone producing-adenomas, 30 operations 

for Cushing?s syndrome, 21 pheochromocytomas, 13 

incidentalomas, 2 cystic tumors) and in 4 cases solitary metatstases 

of bronchial carcinoma. 7 patients underwent bilateral 

adrenalectomy. Two cystic tumors caused diagnostic problems, 

as it was impossible to determine preoperatively 

whether the lesions originated from the liver or the adrenal 

gland. Results: Mean tumor size was 3,7 cm with a maximum 

tumor size of 9 cm and 11 tumors > 6 cm. Mean operating 

time was 135 min with an average bloodloss of 250 ml. In 3 

cases partial adrenalectomy was carried out, preserving the 

unaffected adrenal cortex. There were 3 conversions to open 

adrenalectomy due to diffuse bleeding, all in patients with 

Cushing?s desease. We observed 2 major complications (postoperative 

bleeding from the spleen necessitating a laparotomy 

and one patient with Cushing?s desease and severe COPD 

who died 16 days after bilateral adrenalectomy due to pulmonary 

complications). All tumors >6cm were resected laparoscopically 

without complications. Resection of metastases 

included in all cases local lymphadenectomy. 3 of 4 patients 

are free of disease after a mean followup of 16 months. 

Conclusions: Laparoscopic adrenalectomy is a safe and reliable 

procedure, displaying all the common advantages of minimal 

access surgery. However, special attention should be 

given to patients with Cushing?s desease and concomitant 

COPD. In these cases we refrain from bilateral adrenalectomy 

in one session. Benign tumors > 6 cm as well as large cystic 

lesions can be resected without technical problems. Partial 

adrenalectomy is indicated in selected cases. The resection of 

adrenal metastases may be beneficial in selected patients. 


THE UTILITY OF LAPAROSCOPY IN THE DIAGNOSIS AND 

MANAGEMENT OF VENTRICULOPERITONEAL SHUNT COM- 

PLICATIONS: A CASE SERIES AND REVIEW OF THE LITERA- 

TURE., Ross D Segan MD, Michelle D Taylor MD,J. Scott Roth 

MD, University of Maryland Baltimore 

Minimally invasive approaches for placement ventriculoperitoneal 

(VP) shunts have been well described. Multiple case 

series have demonstrated excellent results for shunt placement, 

revisions and management of abdominal complications. 

We present our series of 13 patients who underwent de novo 

placement or revision of VP shunts. 100% of our patients had 

successful interventions with laparoscopic techniques. 



All complications of previous open approaches were able to 

be managed laparoscopically. The laparoscopic approach has 

multiple advantages over open techniques including 

decreased morbidity, ability to manage complications and 

more rapid recovery. In patients with recurrent neurologic 

symptoms or where concern exists for distal patency, 

laparoscopy offers direct assessment of shunt position and 

CSF drainage. Laparoscopy should be the standard of care for 

peritoneal catheter placement, management of distal shunt 

malfunction, diagnosis of abdominal pain etiologies and 

assessment of shunt function. A detailed review of the current 

literature is provided. 


TOTALLY EXTRAPERITONEAL LAPAROSCOPIC LYMPH NODE 

BIOPSY FOR LYMPHOMA, Robert J Wilmoth MD, Michael E 

Harned MD,Craig S Swafford MD,Matthew L Mancini MD, 

Department of General Surgery, University of Tennessee 

Medical Center, Knoxville, TN. 

Objective: The extraperitoneal space has become widely used 

for many surgical procedures. We present a case in which 

laparoscopy was used to obtain tissue diagnosis for pelvic 

lymphadenopathy after CT guided biopsy failed adequate 

specimen for diagnosis. 

Case Report: Patient is a 27-year-old male who initially presented 

with supraclavicular adenopathy in March, 2003. 

Subsequent lymph node biopsy and PET staging revealed 

Hodgkin?s disease with no evidence of disease below the 

diaphragm. The patient underwent systemic treatment and follow 

up imaging out to two years revealed no evidence of 

recurrence. In November, 2003, the patient demonstrated left 

pelvic adenopathy on CT scan. CT guided biopsy was obtained 

on two separate occasions without tissue diagnosis. At this 

time there was no evidence of adenopathy at any other location. 

Results: Balloon expandable trocar was utilized to gain access 

to the extraperitoneal space. Two additional 5mm ports were 

placed in the midline in a similar fashion as utilized in the TEP 

hernia approach. The left pelvis nodal chain was dissected and 

lymph node samples were obtained with biopsy forceps. The 

procedure was performed on an outpatient basis. Pathology 

revealed recurrent Hodgkin?s lymphoma. 

Conclusion: Advanced laparoscopic skills continue to expand 

the clinical applications for the surgeon. We applied a facile 

technique used for the TEP hernia repair to obtain tissue from 

a deep location. We conclude that this is a safe and effective 

means evaluation of nodal pathology which would otherwise 

require a more extensive operation. 


OUTCOME OF ELECTIVE LAPAROSCOPIC SPLENECTOMY IN 

89 CONSECUTIVE PATIENTS., I Takemasa MD, M Sekimoto 

MD,M Ikeda MD,T Shuji MD,M Yasui MD,T Hata MD,T Shingai 

MD,M Ikenaga MD,M Ohue MD,H Yamamoto MD,M Monden 

MD, Department of Surgery and Clinical Oncology, Graduate 

School of Medicine, Osaka University 

Background and purpose: Laparoscopic splenectomy (LS) is 

the procedure of choice for elective splenectomy at our 

Institution. Technical feasibility and safety of elective LS in 89 

consecutive patients were examined. 

Methods: We studied retrospectively reviewed a consecutive 

series of LS from November 1995 to March 2004. Patient 

demographics, operative indications, morbidity, mortality and 

clinical outcome were evaluated. 

Results: A total of 89 LS splenectomy including 12 hand-assisted 

LS (HALS) were performed. Indications were idiopathic 

thrombocytopenic purpura (ITP) 59, malignant lymphoma 9, 

splenic tumor or cysts 4, hereditary spherocytosis 3, hypersplenism 

3, autoimmune hemolytic anemia 2, and others 9. 

There were no deaths. Two patients (2%) who underwent 

HALS required conversion to open splenectomy, one for dense 

intraabdominal adhesion, and the other for bleeding of splenic 

vein. Complication occurred in 7 patients (8%), 4 patients in 

HALS and 3 in LS. All complications were treated conservatively. 

Patients who underwent LS had significantly shorter 

operation time, decreased estimated blood loss, and small 

spleen than those underwent HALS (141 vs 267 min, 132 vs 

1050g, and 196 vs 1381g, respectively). 

Conclusions: LS is feasible, and the incidence of severe complications 

is rare. 


IS THE LAPAROSCOPIC SURGERY AFFECT THYROID FUNC- 

TIONS?, Ali Uzunkoy MD, Harran University, School of 

Medicine, Department of Surgery, Sanliurfa, Turkey 

It is known that laparoscopic operations cause less tissue 

injury and systemic stress response. However, it has not been 

researched yet the response of thyroid functions, which is a 

stress organ, against trauma. Although there are a few studies 

to evaluate open surgery, there is not available report about 

the effect of laparoscopic surgery on thyroid function. The aim 

of this study was to evaluate the effects of surgery trauma on 

thyroid functions in subjects with laparoscopic cholecystectomy. 

Methods: Forty subjects who underwent laparoscopic cholecystectomy 

were included in this study. Venous blood samples 

were taken before operation 30th min and 2nd and 24th hours 

afterwards for measurement of the levels of TSH, free T3, total 

T3, free T4, total T4, cortisole and albumin. 

Results: Free T3 and total T3 levels were decreased significantly 

at postoperative 2nd and 24th hours than preoperative time 

(p



24 of the patients were male and 22 were female in LigaSure 

group and 30 of the patients were male and 20 were female in 

endoclip group. The median age was 29 years (range 16-75) in 

LigaSure group and 26 years (range 15-58) in endoclip group. 

There was no difference in mean hospital stay, postoperative 

pain and return to work between the groups. The mean operative 

time was 41 minutes (range 23-93) in LigaSure group and 

53 minutes (range 20-120) in endoclip group and the difference 

was found to be statistically significant (p< 0.01). 

Conlusions: 

LA is a safe and easily performed method, along with having 

the advantages of laparoscopic surgery. The use of ligasure in 

LA facilitates the dissection of mesoappendix and shortens the 

operation time. 


LAPAROSCOPIC REPAIR OF MORGAGNI HERNIA, Nihat Yavuz 

MD, Rafet Yigitbasi MD,Oguzhan Sunamak MD,Abdullah As 

MD,Ceyhun Oral MD,Sabri Erguney MD, Istanbul 


Department 

Introduction: 

Morgagni hernia is a rare type of diaphragmatic hernia which 

represents less than 5% of all congenital diaphragmatic hernias. 

Patients are generally asymptomatic and are diagnosed 

incidentally.When symptomatic,it generates symptoms due to 

the compression of thoracic organs or compression of herniated 

intraabdominal organs. Once diagnosed, the condition 

requires prompt surgical correction .The defect is repaired 

either by primary suture or by the use of a prosthetic mesh. In 

adults,prosthetic mesh repair is preferred. Recently laparoscopic 

repair of Morgagni hernia has been introduced and 

gained wide acceptance. 

Materials and Methods: 

Between Jan 2002 and May 2004 ,5 patients with Morgagni 

hernia were treated laparoscopically at our department. 

Female/male ratio was 3/2. Mean age was 56 years (range 41 

to 69 years). Diagnosis were made by chest x-ray and CT scan. 

Herniation was on the left in two patients, and on the right in 

three. The content of hernial sac was transverse colon and 

stomach. There were two separate defects in a patient with left 

sided hernia. All cases were laparoscopically treated using 

prosthetic material. 

Results: 

All operations were completed laparoscopically. The postoperative 

hospital stay was 3 to 5 days with a mean of 4 days. 

None of the patients developed any complication in the early 

postoperative period. The mean follow-up period is 7 months 

(range 3 to 24 months). All patients are actually in good health 

and without recurrence. 

Conclusion: 

Laparoscopic repair of Morgagni hernia is a safe ,simple and 

reliable procedure which presents all the advantages of the 

minimally invasive surgery. 


LAPAROSCOPIC REPAIR OF VENTRAL AND INCISIONAL HER- 

NIAS:OUR EXPERINCE IN 150 PATIENTS, Nihat Yavuz MD, 

Turgut Ipek MD,Abdullah As MD,Metin Kapan MD,Erhun 

Eyuboglu MD,Sabri Erguney MD, Istanbul 


Department 

Introduction: Incisional hernias develop in 2 to 20% of laparotomy 

incisions. Approximately 100.000 ventral hernias are 

operated each year in the United States. Recurrence rate of 

open repair is 25 to 52% for primary and 12.5 to 19% for mesh 

repair. Compared to open technique, laparoscopic repair has 

low complication and recurrence rates, greater patient acceptance 

and shorter hospital stay. 

Materials and Methods:. Between April 1999 and April 

2004,150 patients with ventral and incisional hernias were 

treated laparoscopically. Data concerning the age and sex of 

patients, the location, number and size of fascial defect(s), the 

type of hernias and their contents, the size and type of meshes 

used in repair,the operative time,the length of hospital stay, 

and postoperative complications were collected. 

Results: Among 150 patients, 111 were female, 39 were male. 

92 patients had incisional; 58 had umbilical hernias. In 85 

cases, polypropylene, in 40 cases, Dual, in 25 cases, Composix 

meshes were used. Mean age was 56.0 years (33 to 81 years). 

Mean operative time was 63 minutes (30 to 125 minutes). 

Mean postoperative hospital stay was 2.5 days (1 to 15 days). 

Postoperative complication rate was 8.6% (seroma, paralytic 

ileus, small bowel injury, and suture-site neuralgia). Mean follow-up 

period was 32 months (4 to 60 months). Recurrence 

rate was 3%. Three subileus cases detected during follow-up. 

Conclusion: Laparoscopic approach to ventral and incisional 

hernias is safe, feasible and a good alternative to open 

approach. Our results are comparable with those of other 

reports in the literature. 

P373–New Techniques 

ARE ANTROPOMETRIC AND VOLUME MEASUREMENT PRE- 

OPERATIVE PREDICTORS OF OPERATIVE DIFFICULTY AND 

CONVERSION NEED DURING LAPAROSCOPIC APPROACH TO 

RECTAL DISEASES?. PRESENTATION OF PROTOCOL AND 

PRELIMINAR RESULTS., Eduardo M Targarona PhD, Carmen 

Balague PhD, Jaun Carlos Pernas PhD,Jose Monill 

PhD,Carmen Martinez PhD,Jorge Garriga PhD,Manuel Trias 

PhD, Service of Digestive Surgery. *Service of Radiology. 

Hospital Sant Pau. Univ of Barcelona. 

In rectal cancer, factors as the pelvic characteristics and tumor 

size can determine the degree of technical difficulty to perform 

the surgery by laparoscopic approach. 

Objective: - To identify the anthropometric and pathologic features 

that posses predictive value of operative difficulty or 

conversion need to open surgery in the laparoscopic approach 

to rectum cancer. - To identify through volumetric measurements 

the relation between the pelvic and rectal or tumoral 

volume that could permit to predict the degree of technical difficulty, 

or the risk or need to convert to open surgery during 

laparoscopic approach to rectum cancer. 

Design: Prospective study of all patients diagnosed of rectum 

cancer and submited to laparoscopic approach in our Dep of 

Lap Dig Surgery of Hospital de Sant Pau, Univ of Barcelona. 

The radiological study is performed by Abdominal CTScan 

with CT Siemens SOMATON plus 4. Axial scans since iliac 

crests to ischiatic tuberosities, 5 mm wide. Multiplanar reconstruction 

in a in SIEMENS Magic View 1000 workstation measuring 

in an axial and sagital and oblique planes the net axis: - 

promontorium-retropubic, -subsacral-retropubic, -lateral (axial 

oblique), -maximum and minimal lateral and ant-post pelvic 

diameter in tumoral location, craneal-caudal, lateral and antpost 

tumor diameter, and prosthetic craneal caudal, lateral and 

ant-post diameter in men. 

Volumetric analysis is performed by Volumetric analysis of 

minor pelvis, rectal ampulla, rectal tumor and prostate with an 

specific software (3D Doctor, Able Software Corp., 5 Appletree 

Lane, Lexington, MA 02420-2406, USA). 3D reconstruction is 

done from a DICOM file obtained during CT scan. 

Statistics analysis: Univariate and Multivariate analysis. 

Factors evaluated as predictive variables: BMI, previous 

abdominal surgery, prosthetic and tumoral volume, tumoral 

location, the different pelvic axis (refered in design), neoadjuvant 

RT-QT. As dependent variables will be evaluated operative 

time, technical difficulty (4 degrees), peroperative blood 

loss, conversion rate, postop complications and hospital stay. 

We present the basis of protocol and preliminar results.The 

protocol began on Jan/04 and 20 patients (6 w and 14 m) 

(mean age 74 7 y) have been included. First statistical 

study will be performed on Dec/04-Jan/05 in order to evaluate 

and present the results of the first year of the study. 

We expect to obtain statistical differences on depending of volumetric 

paramethers. 


ADVANTAGES OF A NEW MANUAL SUTURING SYSTEM 

INCLUDING ADDITIONAL DEGREES OF FREEDOM, Gerhard F 

Buess 1,2 PhD, Jens Burghardt 1,Marc O Schurr 2 PhD,Marcus 

Braun 2, 1. Helios Klinik Muellheim, Germany 2. Tuebingen 

Scientific, Germany 

Description of the methods 



In the past we focused on robotic systems development, with 

which we were the first to experiment internationally. We continued 

research towards the development of a simple mechanical 

suturing device, enabling angulation and rotation of the 

tip. 

The instrument was developed by the company Tuebingen 

Scientific in Tuebingen, Germany. The handle system is 

designed ergonomically and it is hold by the whole hand. 

Angulating the handle means flection of the tip, stretching the 

handle means to put the tip in a straight position. Rotation of a 

knob at the tip of the handle allows rotation of the tip of the 

instrument. 

Following experimental evaluation which was highly successful, 

we started clinical application. Today we have performed 

the suturing of meshes on 10 patients in inguinal hernia. The 

technique is based on continuing suture of the mesh to the 

inguinal ligament. Also the fixation to the anterior abdominal 

wall together with the peritoneum is performed by the use of 

the suturing device. 

In 3 patients mesh was sutured to the anterior abdominal wall 

in patients with abdominal wall hernias. In 2 patients the 

mesocolon was closed following right colonic resection. 

Conclusions 

The new suturing device permits in an easy and ergonomic 

way sutures at the front of the tip of the instrument and 

sutures at the anterior abdominal wall. The principles of suturing 

can be compared to the robotic system DaVinci. Compared 

to this, the handling of the RADIUS surgical system is much 

more easy, does not need any time for installation of the technology 

and the price of the system is much less, compared to 

robotic systems. 

We are convinced that mechanical manipulators, as the 

RADIUS surgical system, will allow better and more precise 

manual suturing, compared to conventional straight instruments. 


SIS MESH FOR LAPAROSCOPIC INGUINAL HERNIA REPAIR- 5 

YEAR FOLLOW UP, David S Edelman MD, Laparoscopic 

Surgery Center, Baptist Hospital, Miami, Florida 

Intro: Synthetic mesh is routinely used for inguinal hernia 

repair. Porcine small intestine submucosa (SIS) mesh has been 

successfully tested and used in animal models with excellent 

results. This mesh is degradable, resorbable and had significant 

fibroblastic ingrowth equal to polypropylene mesh. 

Methods: Beginning August, 1999 a prospective study was 

begun using SIS mesh and laparoscopy in a pre-peritoneal 

approach to repair per-primum hernias. A 7x10 cm mesh was 

placed, uncut, over the myopectinate orifice and secured with 

5 tacks. Patients have were followed at 2 weeks, 6 weeks, 6 

months and yearly. 

Results: The surgeon has an experience of over 800 laparoscopic 

inguinal hernia operations. There were 50 patients having 

61 hernias studied. There were 16 direct, 42 indirect, 2 pantaloon 

and 1 femoral hernia repaired. Operative time averaged 

32 minutes. There were no major complications. Nine (9) 

patients developed seromas, 12 had pain lasting over 7 days 

requiring medication, 4 had swelling/orchitis and 5 patients 

(10%) developed a recurrent hernia. 

Conclusions: The recurrences were technical complications 

due to the small mesh size. It is unclear if the pain, seroma 

and swelling is a host versus graft reaction to the mesh which 

led to the hernia recurrences. The subgroup of 10 Sport?s 

Hernia patients did not have the same problems. However, it is 

concluded that at 5 years, SIS mesh can be used for inguinal 

hernia repairs and further technical modifications along with a 

prospective- randomized trial comparing SIS to other mesh is 

necessary. 


REPAIR OF A COMPLEX FOREGUT HERNIA AIDED BY NOVEL 

THREE-DIMENSIONAL SURGICAL RECONSTRUCTION, 

Stephen M Kavic MD, Ross D Segan MD,Patricia L Turner 

MD,Ivan M George,Adrian E Park MD, University of Maryland, 

Baltimore 

Recent imaging technology has allowed sophisticated reconstructions 

based on high-resolution computerized tomography. 

Here, we present a case of complex foregut herniation in 

which image reconstruction was invaluable. An 84-year-old 

woman was referred with a diagnosis of incarcerated paraesophageal 

hernia. Her medical history was significant for a history 

of hiatal hernia and a remote motor vehicle collision. She 

described left-sided chest pain and nausea, and was found to 

have leukocytosis. Polygonal mesh surface modeling techniques 

with color enhancement were utilized to render dynamic 

three-dimensional (3-D) CT-based models of the patient?s 

hernia. Reconstruction revealed a large herniation of both the 

stomach and a portion of the liver through a defect in the 

diaphragm (see Figure). 

Images obtained using this novel technique suggested a posttraumatic 

etiology. The accuracy of the predicted anatomic 

relationships by 3-D reconstruction was demonstrated at 

laparotomy, where the patient was noted to have a diaphragmatic 

hernia with incarcerated stomach and liver. After reduction 

of the hernia contents, gastropexy with gastrostomy tube 

placement was performed in preparation for staged, definitive 

repair of the diaphragm. This case illustrates that 3-D anatomic 

reconstructions can be a powerful aid in preoperative planning. 


LAPAROSCOPIC VERTICAL SLEEVE GASTRECTOMY (VG) FOR 

MORBID OBESITY: A NEW RESTRICTIVE BARIATRIC OPERA- 

TION, Crystine M Lee BA, Janos Taller BA,John J Feng 

BA,Paul T Cirangle MD,Gregg H Jossart MD, Dept. of Surgery, 

California Pacific Medical Center 

INTRO: The VG is the restrictive part of the technically difficult 

biliopancreatic diversion with duodenal switch operation (DS). 

The rationale of performing the VG as an independent operation 

was as the first stage of a two-stage DS that would reduce 

perioperative mortality and morbidity in high-risk super-obese 

patients through a shorter OR time and lack of anastomoses. 

METHODS: Typically, 5-6 trocars are placed in the supine 

patient. Starting at a point 6cm proximal to the pylorus, a 

greater curvature gastrectomy is performed along a 32 Fr 

bougie, using 5-7 firings of 45-60mm linear 3.5mm GI staplers, 

thus creating a 60-80ml gastric tube. Bioabsorbable 

Seamguards® are used to buttress the staple-line from the 

third firing onwards. A methlyene blue leak test is performed 

prior to removal of the bagged stomach from an enlarged trocar 

site. 

RESULTS: Between Nov 2002 and Sep 2004, 68 patients underwent 

VG. The mean age was 46.1±11.2 years and 72% were 

female. The mean preop weight and BMI was 335±89 lbs and 

53.2±11.9 kg/m2, respectively. Compared to 66 patients who 

underwent laparoscopic DS, the mean OR time was 102±29 vs 

229±43 for DS; the mean EBL was 44±22 cc vs 94±48 for DS 

(P



DS patients, 21 (32%) had complications (P


Materials and Methods: We retrospectively reviewed the charts 

of 10 consecutive patients undergoing hand-assisted bilateral 

nephrectomy between March 2002 and October 2004 using the 

following technique. With the patient in the supine position, a 

5-7cm periumbilical incision is made through which a hand 

assist device is positioned. Port sites are created at 5cm 

(12mm) and 8cm (5mm) lateral to the umbilicus on the side of 

the initial nephrectomy. After pneumoperitoneum is established, 

one hand is employed for blunt dissection while the 

other hand is used for instrumentation; the right hand is 

inserted for right nephrectomy and the left hand for left 

nephrectomy. A 5mm laparoscope is used interchangeably 

between port sites. The renal hilum is dissected. The renal vessels 

are divided with a vascular stapler and the ureter is divided 

using plastic locking clips. The kidney is mobilized using 

the surgeon?s intra-abdominal hand. Finally, a 12mm curette is 

inserted through the 12mm port site. The suction curettage 

machine is used to aspirate cysts on the anterior and medial 

surface of the kidney providing a significant decrease in the 

overall size and allowing easy extraction through the 5-7cm 

midline incision. 

Results: All 10 patients underwent successful laparoscopic 

bilateral nephrectomy with a mean operative time of 193 minutes. 

The average size of the kidneys removed was 717g and 

average length was 19cm. No intraoperative complications or 

deaths occurred. All patients did well postoperatively with 

complete resolution of their presenting symptoms. Patients 

with renal allografts had stable function at the time of discharge. 

Conclusion: In patients with symptomatic ADPKD, laparoscopic 

bilateral hand-assisted nephrectomy using suction curettage to 

minimize the size of the kidneys is fast, safe and effective. 

P384–Robotics 

TEACHING ROBOTIC SURGERY: A STEPWISE APPROACH, 

Mohamed R Ali MD, Bobby Bhasker-Rao MD,Bruce M Wolfe 

MD, University of California, Davis 

Background: As robotic surgery becomes more established, 

strategies should be developed to integrate this technology 

into MIS education. After an initial institutional experience 

with 50 robotic-assisted laparoscopic Roux-en-Y gastric bypass 

procedures, a curriculum was developed for fellow training in 

robotic surgery. Methods: The MIS fellow was required to 

attend a structured training seminar and complete a laboratory 

training program in robotic suturing. Thirty consecutive robotic 

gastric bypasses were then performed using the Zeus robotic 

surgical system to fashion a 2-layer gastrojejunostomy (GJ). 

Three robotic suturing tasks (posterior layer (A), inner layer 

(B), and anterior layer (C)) were assigned to the trainee in 

cumulative order in 10-case increments (cases 1-10=task A, 

cases 11-20=tasks A+B, cases 21-30=tasks A+B+C). The surgical 

staff performed tasks B+C in cases 1-10 and task C in cases 

11-20. Results: Total robotic operative time did not vary significantly 

as the trainee gained more operative responsibility 

(cases 1-10=65min, 11-20=56min, 21-30=61min, NS by 

ANOVA). Similarly, mean robotic task time did not vary significantly 

over the fellow’s experience. There was no statistically 

significant difference between trainee and staff, respectively, in 

mean time for task B (18.3min vs. 19.1min, p=0.16) but a significant 

difference for task C (21.3min vs. 17.1 min, p



obstruction prompted a re-exploration but no abnormalities 

were found and his ileus resolved by post-op day 5. He was 

discharged on post-op day 6. He has since undergone bone 

marrow transplant and is still in therapy. 

Conclusion: Robotic surgery is a safe and effective method for 

resecting malignancies in selected pediatric patients. 

Dissection can be facilitated by the ability to articulate the 

robotic instruments and the magnified 3-D image. Further 

study of this technology is warranted as it may increase the 

variety of procedures which can be safely performed using a 

minimally invasive approach. 


ROBOTIC-ASSISTED HELLER MYOTOMY REDUCES THE INCI- 

DENCE OF ESOPHAGEAL PERFORATION, Carlos Galvani MD, 

Santiago Horgan MD,M V Gorodner MD,F Moser MD,M 

Baptista MD,A Arnold MD,G Jacobsen, University of Illinois at 

Chicago 

Background: Laparoscopic Heller myotomy has become the 

standard treatment option for achalasia. The incidence of 

esophageal perforation reported is about 5 to 10%. Data about 

the safety and utility of the robotically assisted approach are 

scarce. The aim of this study is to assess the efficacy and safety 

of the robotically assisted Heller myotomy (RAHM) for treatment 

of esophageal achalasia. 

Methods: Review of prospectively maintained database was 

performed. We analyzed demographic data, symptoms, esophagogram, 

esophageal manometry, intraoperative and postoperative 

data of all the RAHM performed at our institution 

between 9/02 and 2/04. 

Results: 54 patients underwent RAHM for achalasia; 26 were 

men, mean age of 43 years (14-75). Dysphagia was present in 

100% of patients. 

Of the 26 patients (48%) who had previous treatment, 17 

patients had pneumatic dilation, 4 patients had BOTOX injections, 

and 5 patients had both. The dissection was performed 

laparoscopically and the robotic surgical system was used for 

the myotomy. Operative time averaged 162 minutes (62-210), 

including robotic setup time. Blood loss averaged 24 ml (10- 

80). No mucosal perforations were observed. Average length 

of hospital stay was 1.5 days. There were no deaths. At the 

average follow-up of 17 months, 93% of patients had relief of 

their dysphagia. 

Conclusions: this study proved RAHM to be a safe and effective 

alternative at our institution, since it decreases the incidence 

of esophageal perforation to 0% and provides relief of 

symptoms in 93% of the patients. 


LAPAROSCOPIC ROBOTIC ASSISTED SWENSON PULL- 

THROUGH FOR HIRSCHSPRUNG?S DISEASE IN INFANTS, 

Andre Hebra MD, Claudia B Moore MPA,Beverly McGuire 

RN,Gail Kay MD,Richard Harmel MD, All Children’s Hospital, 

University of South Florida 

Purpose: Infants with Hirschsprung?s disease can be treated 

with a one stage laparoscopic colo-anal pull-through without a 

colostomy. However, the feasibility and benefits of performing 

this operation using robotic technology has not yet been evaluated. 

Methods: We reviewed our experience with 10 infants (age 

less than 7 months of age) treated with either laparoscopic 

pull-through (n=5, group 1) or robotic pull through (n=5, group 

2). The average age was 16 weeks for patients in group 1 and 

20 weeks for group 2. 

Results: The average operative time was 190 minutes for 

group 1 and 260 minutes for group 2. Group 1 patients 

received a modification of the Soave technique (partial proctectomy 

with mucosectomy) and group 2 received a modification 

of the Swenson operation (total proctectomy). Average 

length of stay was 3 days for patients in either group. No complications 

were recorded. All patients in group 1 required postoperative 

rectal dilations for management of rectal strictures. 

Only 3 patients in group 2 required dilations. 

Conclusions: Our experience indicates that robotic assisted 

pull-through can be safely performed in young infants. 

Operative time was longer in patients treated with robotic surgery 

and length of hospital stay was the same. An important 


observation was the fact that the robotic technology provided 

superior dexterity and visualization, essential in performing a 

more complete rectal dissection beyond the peritoneal reflection. 

Thus a complete proctectomy, as originally described by 

Swenson, could be accomplished. This may account for the 

fact that rectal strictures were less common in patients of 

group 2. Although our experience is limited because of the 

small number of patients, we were able to identify technical 

advantages unique to the use of robotic technology that will 

likely be of great benefit to pediatric patients undergoing 

laparoscopic colo-rectal surgery. 


LAPAROSCOPIC ULTRASOUND NAVIGATION IN LIVER 

SURGERY - TECHNICAL ASPECTS AND ACCURACY, Markus 

Kleemann MD, Phillipp Hildebrand MD,Hans-Peter Bruch 

MD,Matthias Birth MD, University Hospital of Schleswig- 

Holstein - Campus Lübeck, Germany 

Introduction: Despite recent advances in laparoscopic techniques 

and instrumentation, laparoscopic liver surgery is still 

limited to selected patient population. One major reason may 

be the lack of orientation during dissection of liver parenchyma. 

After establishing an ultrasound navigated system for 

open liver surgery with online-navigation, we will use this 

technique also in laparoscopic surgery to navigate under 

laparoscopic ultrasound control e.g. interventional ablation 

procedures or liver resections. 

Material and Methods: We used a six-degrees-of-freedom electromagnetic 

tracking system. First the adapter was placed at 

the head of the laparoscopic ultrasound probe to connect the 

electromagnetique tracker to the adapter. For calibration with 

an ultrasound phantom, the distance between adapter and 

ultrasound probe has to be determined and calibrated with the 

software of the navigation system. Then the other tracker was 

placed at a laparoscopic dissection instrument built for laser 

dissection and calibrated as mentioned above. In phantom 

testing and in a liver organ model the virtual resection line is 

then overlain to the laparoscopic ultrasound picture and offers 

the possibility of navigated ablation or resection. In a second 

step the system was integrated in a liver organ model to 

detect disturbances due to trocar and camera instruments. 

Results: Laparoscopic navigation of the dissection instrument 

under ultrasound navigation is technically feasible. Even in 

cases of angulation of the tip of the ultrasound probe no disturbances 

of the navigation system were obvious, due to close 

approximation of the laparoscopic ultrasound head and electromagnetique 

sensor. Anatomic landmarks in liver tissue 

could be safely reached. No interaction of the electromagnetique 

tracking system and the lapaoscopic equipment could be 

seen. 

Conclusions: Laparoscopic navigation opens a new field in 

minimally invasive liver procedures. 


THE EFFECTS OF TRAINING ON THE PERFORMANCE OF 

ROBOTIC SURGERY: WHAT ARE THE OBJECTIVE VARIABLES 

TO QUANTIFY LEARNING?, Kenji Narazaki BS, Dmitry 

Oleynikov MD,Jesse J Pandorf BS,Benjamin M Solomon 

BS,Nicholas Stergiou PhD, University of Nebraska Medical 

Center and University of Nebraska at Omaha 

Computer assisted surgery promises ease of use and mechanical 

precision. However, little is known about the learning 

strategies for this new surgical technique. The aim of this 

study is to evaluate the effects of a training program on 

enhancing surgical performance using the da Vinci surgical 

system and to identify objective variables to quantify the 

extent of learning and dexterity. 

Seven medical students, completely novice users of the system, 

were asked to participate in a designed training protocol. 

Each subject practiced three inanimate surgical tasks, bimanual 

carrying (BC), needle passing (NP) and suture tying (ST), 

with the robotic system for a total of six training sessions during 

a three weeks period. Kinematic data from the force transducers 

built within the system were collected with the help of 

a computerized user interface. Task completion time (T), correlation 

of variation between cyclic intervals in a task (CVI) and 

between maximum velocities in respective intervals (CVV),


total traveling distance of the tips of the surgical instruments 

(D), and mean absolute relative phase between both instrument 

tips (MARP) were measured and statistically analyzed. 

The results revealed significant reduction in T for all three 

tasks and in D for the NP and ST tasks (p



10.6 min. (range 21-49 min.). The mean robot time was 110 +/- 

44.6 min (range 74-229 min.). The mean LOS was 1.54 +/- 1.1 

days (range 1-5 days). Two failures occurred: chronic coughing 

(1) and retching with the flu (1). This early experience suggests 

that robotic assistance is a safe and feasible adjunct to the 

treatment of GERD. The port setup time was stable. The operative 

and robotic times had similar patterns and improved with 

greater experience. Future investigations warrant a comparison 

to laparoscopic Nissen Fundoplication. 


ROBOTIC ASSISTED COLON RESECTIONS: 23 CASES, Arthur 

L Rawlings MD, Jay H Woodland MD,David L Crawford MD, 

Division of Minimally Invasive Surgery, Dept. of Surgery , 

University of Illinois College of Medicine at Peoria 

This study describes the experience, advantages, and disadvantages 

of using robotic assistance for a colectomy based on 

23 consecutive cases by a MIS fellowship trained surgeon. 

Since the introduction of the DaVinci Robotic System, minimally 

invasive surgeons have explored the feasibility of its use 

for a variety of procedures. This study was based on information 

that was prospectively collected in an Access database 

from 9/2002 to the present. Data analyzed included indications 

for surgery, demographics, and operative times using range, 

mean, and standard deviations. There were 12 males and 11 

females. Patient age: average 60.0 ± 13.7; range [32-83]. 

Operations included 12 sigmoid colectomies with splenic flexure 

mobilization and 11 right colectomies. Preop diagnosis: 

Cancer (4); Diverticulitis (8); Polyp (10); Carcinoid (1). Port 

setup time in minutes: ave 31.1 ± 7.9; [17-50]. Total robot operating 

time in minutes: ave 147.7 ± 59.8; [69-306]. Total case 

time in minutes: ave 245.2 ± 45.7; [147-380]. Length of stay in 

days: ave 6.0 ± 7.0; [2-30]. One case was converted to open 

secondary to dense bladder/sigmoid colon adhesions. Six 

complications were encountered: 1) Patient slid off OR table to 

floor after the robotic portion of the procedure; 2) Persistent 

left hip parasthesia; 3) Transverse colon injury from ultrasound 

shears; 4) Cecal injury from cautery; 5) Anastomotic leak; 6) 

Urinary retention beginning POD 5. Advantages of robotic 

assistance were: 1) Enhanced visualization of the operative 

field; 2) Wristed instrumentation facilitated dissection; 3) 

Camera controlled by operating surgeon; 4) Reduced surgeon?s 

fatigue; 5) Increased marketability of surgeon as 

?regional MIS expert.? Disadvantages specific for this procedure 

included: 1) Inconvenience of altering port placement of 

camera/instruments during the case; 2) Difficulty working in far 

lateral extensions of the operative field; 3) Difficulty changing 

table position during procedure. Robotic assisted colon resections 

are feasible as demonstrated in this series with the 

above-mentioned advantages and disadvantages. 


A NOVEL DRILL SET ALLOWS ASSESSMENT OF ROBOTIC 

SURGICAL PERFORMANCE, Charles Y Ro MD, James J 

McGinty MD,Joseph J DeRose MD,Ioannis K Toumpoulis 

MD,Celina Imielinska PhD,Tony Jebara PhD,Seung H Shin 

MD,Haroon L Chughtai MD,George J Todd MD,Robert C 

Ashton MD, St. Luke’s-Roosevelt Hospital Center, Columbia 

University 

Inanimate simulation is a useful tool in overcoming the learning 

curve of minimal access surgery. Unique skills are required 

for mastery of robotically assisted minimal access surgery. We 

have developed inanimate exercises to simulate and assess 

the skills necessary for robotic surgery. 

Expert surgeons (n=4) (> 50 clinical robotic procedures and > 2 

years of clinical robotic experience) were compared to novice 

surgeons (n=17) (< 5 clinical cases and limited laboratory 

experience) using the da Vinci Surgical System. Seven drills 

were designed to simulate clinical robotic surgical tasks. Time 

to completion, minor errors and major errors were recorded 

for the appropriate drill. Performance score was calculated by 

the equation Time to Completion + (minor error) x 5 + (major 

error) x 10. The Robotic Learning Curve (RLC) consists of a 

trend line of the performance scores corresponding to each 

repeated drill. Data was analyzed with the Friedman Test and 

Mann-Whitney U Test. 

Performance scores for experts were better than novices in all 


7 drills (p


Patients in both groups had similar ages (33 vs 39 years) and 

sex distributions (60% vs 61.5% female). Operative time (200 

vs 203min), complication rates ? intra-operative (0 vs 0 cases) 

and post-operative (1 minor vs 3 minor) - and length of stay (6 

vs 6 days) were comparative. There were more conversions to 

open surgery in the laparoscopic group (40%) than among the 

robotic group (20%) 

Conclusion - 

Robotic ileocolectomy is a safe and effective procedure. The 

robotic approach is at least comparable to conventional 

laparoscopic surgery and may allow more Crohn?s patients to 

receive surgery through a minimally invasive approach. 


EFFICACY OF NOVEL ROBOTIC CAMERA VERSUS A STAN- 

DARD LAPAROSCOPIC CAMERA, Vivian E Strong MD, Nancy 

Hogle RN,Andrew Miller PhD,Marc Bessler MD,Barry Inabnet 

MD,Aku Ude MD,Prashant Sinha MD,Dennis L Fowler MD, 

New York Presbyterian Hospital - Columbia University 

INTRODUCTION: To improve visualization during minimal 

access surgery, a novel robotic camera has been developed. 

The prototype camera is totally insertable, has 5 degrees of 

freedom, and is remotely controlled. The aim of this study is 

to compare the performance of laparoscopic surgeons on a 

validated assessment tool using both a laparoscope and the 

robotic camera. 

METHODS AND PROCEDURES: Using the MISTELS (McGill 

Inanimate System for the Training and Evaluation of 

Laparoscopic Skill) tasks, six laparoscopic fellows and attending 

surgeons were tested using both a standard laparoscope 

and the new robotic camera. Half the surgeons used the 

laparoscope first and half used the robotic camera first. Total 

scores from the MISTELS?s sessions using the laparoscope 

were compared to the sessions using the robotic camera and 

then analyzed using a paired t-test (p



When considering small (100ml) tumors 

separately, although the slope remains close to 1 for both, R2 

was 0.98 for small tumors and 0.37 for large tumors (CI 95%; 

1.052 - 1.30 and 0.31 - 1.64 respectively), indicating that VR 

recon was less accurate for large tumors. 

Conclusion: Use of VR in the measurement of diameter and 

volume of adrenal tumors is promising. VR can estimate 

tumor volume with high accuracy for small lesions (500gm) from 2000 ? 2004 

were reviewed at two hospitals. At one hospital, LS was used 

exclusively while the other hospital used OS exclusively. 

Demographic, intraoperative and postoperative variables were 

compared. Data are expressed as medians and were analyzed 

using Mann Whitney U test (continuous data) and Yates corrected 

chi-square (proportions). p


P406–Solid Organ Removal 

LAPAROSCOPIC SPLENECTOMY FOR DELAYED SPLENIC RUP- 

TURE FOLLOWING EMBOLIZATION, Edward A Pucci MD, 

Harry Zemon MD,Todd Ponsky MD,Fred Brody MD, 

Department of Surgery, The George Washington University 

Medical Center, Washington, DC 

Over the last several years, nonoperative management has 

become the standard of care for hemodynamically stable 

patients with splenic trauma. Successful nonoperative management 

is secondary to advances in intensive care monitoring, 

splenic embolization and radiologic techniques. When 

nonoperative management and embolization fail, surgery is 

required. A laparoscopic approach has been utilized in only a 

few cases. Furthermore, only one case of a totally laparoscopic 

splenectomy (LS) has been reported following splenic rupture. 

We report the first case of a totally laparoscopic splenectomy 

for a delayed splenic rupture following embolization. 

A 32-year-old male bicyclist was admitted to the hospital after 

a bus struck him. On presentation, he was hemodynamically 

stable with a GCS of 15 and no loss of consciousness. A CT 

scan of the abdomen and pelvis showed a significant hemoperitoneum 

with a splenic rupture. Celiac angiography 

revealed extravasation of contrast from a terminal segmental 

branch from the lower pole of the spleen. Three titanium coils 

were placed in order to embolize a splenic artery pseudoaneurysm. 

The patient remained stable until post procedure day 

4 when he developed acute right lower quadrant pain with 

abdominal distension. Concurrently, his systolic blood pressure 

fell to 84 mmHg. He was then taken to the operating 

room emergently for a diagnostic laparoscopy and LS. 

At surgery, 1.5 liters of blood was evacuated and a large laceration 

was apparent across the body of the spleen. A gauze pad 

was inserted and used to tamponade the laceration while the 

splenectomy was performed. The avascular attachments and 

short gastric vessels were divided with the ultrasonic scalpel 

and the hilum was divided with endovascular staplers. 

Ultimately, he was discharged to home on post operative day 

six without complications. At three weeks after his surgery, he 

returned to work and his normal activities. 

This is the first case report of a LS for a ruptured spleen following 

embolization. Currently, the role of diagnostic and therapeutic 

laparoscopy has increased over the last decade for 

blunt and penetrating trauma. At this time, the exact role of LS 

for trauma is unclear. As the indications for laparoscopy 

expand with trauma, LS should be considered for splenic rupture. 

Surgical expertise and patient selection are crucial for a 

successful LS. 


LAPAROSCOPIC VS. OPEN DONOR NEPHRECTOMY: COMPAR- 

ISON OF DONOR AND RECEPIENT OUTCOMES, Eugene 

Rubach MD, Andrew Isenberg MD,T. Paul Singh MD,David 

Conti MD, Albany Medical Center, North Shore - Long Island 

Jewish Healthcare System 

**Objective** Renal transplantation is the only available cure 

for end-stage renal disease. To alleviate the need for cadaveric 

organs, live donation was developed. Laparoscopic donor 

nephrectomy was introduced to minimize postoperative donor 

morbidity while providing results equivalent to open operations. 

This study is a review of our institution’s initial experience 

with laparoscopic donor nephrectomy. This is a case-control 

study comparing laparoscopic donors with matched open 

controls. There are 2 arms to the study: donor outcomes and 

recipient outcomes. 

**Study design** 11 donors underwent laparoscopic nephrectomy 

in 1999-2002. They were compared to 11 matched 

donors who underwent open nephrectomy during the same 

time period. Recipients of all 22 kidneys were followed for 18- 

60 months. 2-tailed t-test with Bonferroni correction and 

repeated measures ANOVA were used for data analysis. 

**Donor outcomes** Open and laparoscopic donors were 

similar in terms of age, sex, number of arteries and veins, preoperative 

and postoperative hematocrit and estimated blood 

loss. However, laparoscopic donors had longer operating 

room time (368 vs. 256 min, p




Adrenalectomies were transperitoneal and were performed 

using sequential, full lateral decubitus positioning. 

RESULTS: Both patients were 61 year old females. Operative 

times including repositioning were 240 and 245 minutes. Right 

lobe wedge liver biopsy was added in one case. Estimated 

blood losses were minimal and the operations were uncomplicated. 

Regular diets were resumed on the first postoperative 

day. Hospital stays were three days, mainly for intravenous 

steroids. Pathology confirmed diffuse cortical hyperplasia. 

Both patients noted rapid improvement in their Cushing?s syndromes, 

including fatigue, emotional lability, supraclavicular 

fat, and hyperglycemia. Both are maintained on hydrocortisone 

and fludrocortisone, carry injectable dexamethasone and 

wear medical alert bracelets. Neither has experienced an 

Addisonian crisis at 12 and 2 months follow-up. 

CONCLUSIONS: Bilateral total adrenalectomy for ectopic 

ACTH-dependent Cushing?s syndrome can be performed 

laparoscopically with minimal morbidity, is followed by rapid 

clinical improvement, and is a viable alternative to medical 

management. 


SURGICAL AUDIT OF FIRST 48 LAPAROSCOPIC SPLENEC- 

TOMIES,, Mohammad m Talebpour PhD, godrat m toogeh 

PhD,ali m yagoobi PhD, Department of Surgery, Sina Hospital, 

Tehran, Iran 

Aim: To assess the safety and clinical outcome of laparoscopic 

splenectomy. 

Method: All consecutive patients referred for laparoscopic 

splenectomy to a tertiary centre were included in the audit. 

Open splenectomy was carried out on those with huge spleen. 

Patients were positioned at 60 degrees semi-supine. 

Exploration of upper abdomen was carried out routinely for 

presence of accessory spleen. Homeostasis of vessels performed 

by intracorporeal suturing routinely and in some conditions 

by clips. Spleen put in a bag after emptying of its blood 

by cutting hilar vein and removed from bag by splitting. 

Results: During 30 months 48 laparoscopic splenectomies 

were performed; 39 ITP, 3 spherocytosis with gallstone and 6 

moderate splenomegaly with hypersplenism. Mean splenic 

size was 9.5*4.5*3.5cm , with the biggest spleen measured at 

30 x 12 x 9 cm. Splenic vessels were tied using intra-corporeal 

suturing (41 cases) or clips (7 cases). There was one case of 

conversion to open surgery. Four cases of ITP did not respond 

ideally to splenectomy. In cases of moderate splenomegaly, 

spleen was divided into 3 parts prior to use of bag. Mean operative 

time was 56 min; and mean length of hospital stay was 

2.9 days. All patients discharged from hospital without any 

morbidity or mortality. 

Conclusion: Laparoscopic splenectomy including moderate 

splenomegaly is safe, with good patient outcome. 


EARLY IN-HOSPITAL SPLENECTOMY MAY IMPROVE OUT- 

COMES IN IDIOPATHIC THROMBOCYTOPENIA PURPURA (ITP). 

D. Tseng MD, T. Deloughery MD, B. Sheppard MD, J. Hunter 

MDOregon Health and Sciences University 

Objective: For patients who require hospital admission for 

exacerbation of ITP, early splenectomy is effective in providing 

long lasting remission. 

Methods: A retrospective review of patients charts between 

1994-2004 at a single tertiary referral center was performed, 

identifying 32 patients who underwent splenectomy for ITP. 

Results: Long lasting medication free remission was accomplished 

in 87% of splenectomized patients up to 9 years. 

Incidence of minor complications was 10% with no major complications 

or death. In our subset analysis, there were 16 

patients who required hospitalization for ITP exacerbation 

prior to splenectomy at which time 5 had immediate in-hospital 

splenectomy, whereas the other 11 returned for later 

splenectomy. Of the 11 who returned for a separate admission, 

3 had no platelet improvement after splenectomy, and 3 had 

delayed platelet improvement. However, the 5 patients with 

immediate in-hospital splenectomy all went on to have expected 

platelet response and be medication free. 

Conclusions: Immediate in-hospital splenectomy is a reasonable 

alternative to chronic steroid use and may be associated 

with a higher chance of success compared to later splenectomy. 


HAND-ASSISTED LAPAROSCOPIC SPLENECTOMY FOR A 

HUGE SPLENIC CYST: TECHNIQUE AND CASE REPORT., 

Hiroshi Yano MD, Takushi Monden MD,Shigeru Okamoto MD, 

Department of Surgery and Pathology, NTT West Osaka 

Hospital 

Splenic cyst is a relatively rare disease, and most cases are 

classified as epidermoid cysts. Splenectomy is generally indicated 

for the treatment of a huge splenic cyst to prevent possible 

enlargement, rupture, and infection. We report the case of 

a huge splenic cyst that was successfully treated by handassisted 

laparoscopic splenectomy (HALS). A 17-year-old girl 

with a chief complaint of left-sided abdominal pain was admitted 

to our department for investigation of a splenic tumor. 

Ultrasonography, computed tomography, and magnetic resonance 

imaging revealed a huge cystic lesion in the spleen 

measuring approximately 10 cm in diameter. HALS was safely 

performed to diagnose and treat the splenic tumor. First, a 

mini-laparotomy was performed with a 7-cm skin incision in 

the mid upper abdomen. A Lapdisc device was inserted 

through the mini-laparotomy wound to prevent the leakage of 

carbon dioxide gas. Pneumoperitoneum was maintained at a 

pressure of 10 mm Hg during the surgery. The cyst was percutaneously 

decompressed via a drainage catheter inserted into 

the midportion of the cyst. The spleen was mobilized from its 

peritoneal attachments with the surgeon?s left hand and 

laparoscopic instruments. The hilar vessels were managed 

with a vascular stapler. The specimen was delivered out of the 

abdominal cavity through the 7-cm skin incision using a vinyl 

bag. The intraoperative and postoperative course was 

uneventful. The duration of surgery was 100 minutes, and 

intraoperative blood loss was insignificant. The histologic 

diagnosis was an epithelial cyst of the spleen with no atypical 

cells in the cyst wall. The patient was discharged on the fourth 

postoperative day in excellent condition. HALS may be a good 

method of managing a huge splenic cyst that becomes symptomatic 

and potentially life-threatening through enlargement, 

rupture, and secondary infection. 


LAPAROSCOPIC TRANSPERITONEAL ADRENALECTOMY 

USING LIGASURE, Nihat Yavuz MD, Istanbul 


Department 

Introduction: 

Laparoscopic adrenalectomy is being performed with increasing 

frequency in the surgical treatment of adrenal tumors. 

Among many laparoscopic approaches to adrenal glands, the 

transperitoneal access is the most preferred. Along with the 

advancement in technology, the use of different energy systems 

has been taken into consideration. The realization of 

laparoscopic adrenalectomy has become easier with the use of 

LigaSure vessel sealing system(LVSS) which is one of these 

energy systems. 

Methods: 

Between January 2002 and August 2004,23 laparoscopic 

transperitoneal adrenalectomies were performed in 22 patients 

with the use of LigaSure vessel sealing system. 16 of the 

patients were female, 6 were male and the mean age was 44 

(range between 17-70). Indications for surgery were non-functioning 

adenoma (n=10), pheochromocytoma (n=4), Cushing?s 

syndrome (n=5), Conn?s syndrome (n=2) and lymphoma (n=1). 

The mean diameter of lesions was 4cm (range between 1-7).12 

left,9 right and 1 bilateral adrenalectomies were undertaken. 

Results: 

The mean operation period was 57 minutes (range between 

30-75). The operation period for the patient with Cushing?s 

disease in whom bilateral adrenalectomy was performed was 

180 minutes. All operatios were completed laparoscopically .A 

nonsteroidal antiinflammatory drug (Lornoxicam) has been 

sufficient for postoperative analgesia.Oral feeding was started 

at the 6th postoperative hour . When used,drains were 

removed at the first postoperative day.Postoperative hospital


stay period was 1.5 days (range 1-3 days). Wound infection 

developed in two patients with Cushing?s syndrome. There 

was no mortality. Histopathological exam of specimens 

revealed a cortex adenoma in 16 cases (10 of which was nonfunctional),a 

pheochromocytoma in 4, a bilateral cortical 

hyperplasia and a lymphoma in case each. 

Conclusion: 

Laparoscopic adrenalectomy is an established method in the 

treatment of adrenal masses. The performance of laparoscopic 

adrenalectomy as well as of other laparoscopic procedures has 

become easier with the introduction new energy system, 

LigaSure. In fact, vascular control and dissection of the gland 

by LigaSure reduces the blood loss almost to nil and shortens 

significantly the operation period. Laparoscopic adrenalectomy 

by the use of LigaSure is an easy,safe and reproducible procedure. 


RADIOFREQUENCY ABLATION FOR PARTIAL LAP SPLENEC- 

TOMY. AN EXPERIMENTAL STUDY., DIMITRIS ZACHAROUIS 

MD, KONSTANTINOS TEPETES MD,GEORGE TZOVARAS 

MD,ANTIGONI POYLTSIDIS MD,KONSTANTINOS 

HATZITHEOPHILOY, Department of Surgery. University 

Hospital, University of Thessaly,Larisa,Greece. 

Introduction 

Partial Splenectomy is performed infrequently by either the 

laparoscopic or the open approach. The most common indications 

include trauma, hamartomas, diagnosis and treatment of 

non-parasitic cyst and staging of Hodgkin disease. In this 

experimental study the radiofrequency ablation (RFA) probe 

(Radionics / Tyco Hellas) has been used laparoscopically for 

division of the splenic parenchyma. 

Material and Methods 

In the surgical experimental lab, 5 pigs underwent lap partial 

splenectomy (LPS) under general anesthesia. The three trocar 

technique, as in laparoscopic splenectomy were used. Two 

applications of the RFA probe were enough to create a zone of 

desiccation approximately 1cm from the splenic hilum. The 

division of the splenic parenchyma was carried out using scissors. 

The specimen was removed using an endobag. The animals 

then underwent exploratory laparotomy. 

Results 

No blood loss was recorded during the splenic parenchyma 

division. The medium operating time was 30min. (range 25- 

35). There were no obvious thermal injuries to the adjacent tissues. 

Conclusions 

The RFA probe can be used successfully for LPS in pigs. There 

was no blood loss and no thermal injury. The RFA looks promising 

as another tool for hemostasis and bloodless splenic 

resection. 

P415–Thoracoscopy 

FIFTY-TWO CONSECUTIVE THORACOSCOPIC SYMPATHEC- 

TOMIES FOR PALMARIS HYPERHIDROSIS OR COMPLEX 

REGIONAL PAIN SYNDROME, Justin M Burns MD, B Todd 

Heniford MD,Nicholas H Tinkham BA,Michael A Cowan 

MD,Craig A Van Der Veer MD,Kent W Kercher MD,Brent D 

Matthews MD, Carolinas Medical Center 

Introduction: The purpose of this study is to evaluate the efficacy 

and outcomes of consecutive thoracoscopic sympathectomies. 

The indication for the procedure was either palmaris 

hyperhidrosis (PH) or complex regional pain syndrome (CRPS). 

Methods: Patients undergoing thoracoscopic sympathectomy 

between July 1998 and June 2004 were identified. Medical 

records were reviewed and standard descriptive statistics were 

performed. 

Results: There were a total of 50 patients that received 52 

operations (two patients had a contra lateral sympathectomy 

performed as a second procedure). Patients had a mean age of 

29 years (M:F 20:30). Forty-eight procedures were performed 

for PH while 4 were for CRPS. The mean operating time was 

78 minutes; mean blood loss, 50cc; and mean postoperative 

stay, 1.1 days. Forty-five procedures were performed for bilateral 

disease (87%). Nine patients developed a unilateral pneumothorax. 

Eight required tube thoracostomy (removed after 

1.25 days) while 1 patient received percutaneous evacuation. 

One patient developed a chest wall hematoma at a trocar site 

that resolved spontaneously and one patient developed a transient 

Horner?s syndrome. After a mean follow-up of 5.3 

months, 59% (27/46) of patients treated for hyperhidrosis 

reported compensatory sweating. Forty-six (92%) patients 

(both PH and CRPS) were satisfied with their outcome. Four 

patients were dissatisfied due to excessive compensatory 

sweating. Three patients (75%) treated for CRPS were asymptomatic 

although all four patients reported satisfaction from 

the procedure. 

Conclusion: Thoracoscopic sympathectomy is a safe and effective 

alternative treatment for PH and CRPS. Compensatory 

sweating occurred in >50% of patients although the majority of 

patients were satisfied with their short-term outcome. 


CASE REPORT: MEDIASTINITIS AND EMPYEMA ARISING 

FROM INFECTED PANCREATIC PSEUDOCYST SUCCESSFULLY 

TREATED BY VATS, Yi-Chen Chang MD, Department of 

Surgery, Far Eastern Memorial Hospital 

CASE REPORT: MEDIASTINITIS AND EMPYEMA ARISING 

FROM INFECTED PANCREATIC PSEUDOCYST SUCCESSFULLY 

TREATED BY VATS 

Yi-Chen Chang, Li-Ming Tseng, Min-Shi Wang* 

Surgical Department, Division of Gastroenterology*, Medical 

Department 

Far Eastern Memory Hospital, Taipei, Taiwan 

Objective: Mediastinitis is a life threatening disease. 

Treatments include antibiotics treatment and adequate draiage. 

Traditionally, thoracotomy is necessary for drainage of 

mediastinitis extending below carina. As the advance of VATS, 

thoracoscopic surgery can achieve adequate drainage of mediastinum. 

Methods: Common causes of acute mediastinitis include surgical 

infection, esophagus rupture, descending infection from 

oral pharynx. Ascending infection from pancrease to mediastinum 

is rare. Anatomically, the retroperitoneum space can 

communicate to the posterior mediastinum. However, the 

most common thoracic complications of acute pancreatitis are 

pleural effusion or empyema, and frank mediastinitis is very 

rare. We reported a case of 41 year-old male who was sent to 

our hospital because of chest pain, dyspnea and fever. Chest X 

ray showed widening of mediastinum and bilateral pleural 

effusion. Pleural tapping showed purulent pleural effusion and 

high level of amylase. Chest CT was done and showed 

enlarged paraesophagus tissue. Besides, a cyst at pancreatic 

tail with cephald extension was noted. Esophagogram did not 

showed perforation of esophagus. Surgical intervention was 

arranged under the impression of acute mediastinitis and 

empyema. The operation was approached by VATS from right 

side. We clear the pleural cavity and then open the mediastinal 

pleura. Pus and necrotic tissue at paraesophagus area were 

debrided. Chest tubes at pleural cavity were placed after operation. 

NPO for one week was prescribed after operation. 

Antibiotics treatment continued for 2 weeks. Postoperative 

course was uneventful and follow-up chest CT one month later 

showed complete resolution of medistinitis. However, the pancreatic 

pseudocyst did not resolve. 

Conclusion: VATS can achieve adequate drainage of mediastinitis. 


ENDOSCOPIC TRANSTHORACIC SYMPATHECOTOMY FOR 

PALMAR HYPERHIDROSIS, David S Edelman MD, Mariner’s 

Hospital, Tavenier, Florida 

Intro: Endoscopic Transthoracic Sympathecotomy (ETS) has 

been shown to be an effective treatment for palmar hyperhidrosis. 

Compensatory Sweating (CS), although usually mild, 

is a side effect that occurs in 100% of patients. CS is the reason 

for regretting having the operation in 2% of patients operated 

upon. Horner?s syndrome is another common side effect 

if operating at the T2 ganglion level of the sympathetic chain. 

Methods: Beginning March, 2002 I began offering a T3 clamping 

of the sympathetic chain as an alternative to a T3 cutting 

sympathecotomy for palmar hyperhidrosis. Some patients had 

an additional T4 sympathecotomy for axillary sweating. The 

surgeon had an experience of over 700 ETS operations. Single 



235



lumen general endotracheal anesthesia was used in all 

patients. One hundred (100) patients were retrospectively 

reviewed during the same time period in 2003 who had a T3 or 

T3,4 sympathecotomy. 

Results: Fifty-two (52) patients had cutting at the T3 level (17 

men, 35 women). Ages ranged from 16 to 60 years with age of 

26. No patient experienced a Horner?s syndrome and no 

patient was prescribed medication for CS. Forty-eight (48) 

patients had clamping at the T3 level ( 20 men, 28 women). 

Ages ranged from 15 to 51 years with a mean of 26. No patient 

experienced a Horner?s syndrome and 3 patients were prescribed 

glycopyrrolate (Robinul) for CS. One patient in the 

clamping group experienced mild recurrent palmar sweating. 

All patients were discharged on the same day as surgery and 

none required readmission for pneumothorax , pain or bleeding. 

Conclusion: It is concluded that cutting or clamping at the T3 

sympathetic ganglion level is a safe and effective treatment for 

palmar hyperhidrosis. It may further diminish the risk of 

Horner?s syndrome and perhaps decrease the severity of 

Compensatory Sweating. It is further postulated that removing 

the clamp within 3 months of surgery may reverse the CS side 

effect if it is debilitating but cause a recurrence of hyperhidrosis. 


TRANSCERVICAL MEDIASTINAL LYMPH NODE DISSECTION 

FOR ESOPHAGEAL CANCER, E Fitzsullivan, M Maish,R 

Cameron, Department of Surgery, UCLA Medical Center 

Introduction: The lymph node drainage of the esophagus is 

complex. Obtaining these lymph nodes for the purposes of 

staging or local control in esophageal cancer can be challenging 

and requires a three field operation: neck, chest and 

abdomen. A thoracotomy can be done to obtain the lymph 

nodes in the chest but it is invasive and morbid. We propose 

that extended mediastinoscopy can be used to obtain the thoracic 

lymph nodes that are involved in esophageal cancer, 

using a less morbid, minimally invasive technique. 

Method: 10 patients with esophageal cancer were identified. 

Each patient underwent a preoperative staging work-up that 

included a CT scan of the chest and abdomen, a PET scan, an 

EGD, and an EUS. All patients underwent a transcervical mediastinal 

lymph node dissection using a mediastinoscope and, if 

necessary, a rigid esophagoscope. Nodal tissue in stations 2R, 

2L, 4R, 4L, 8R, 8L, 5, 6 and 7 were visualized and completely 

resected. 8 patients underwent esophagectomy. In two 

patients, lymph node metastases were found in the paratracheal 

region, and these patients were sent for definitive 

chemoradiotherapy. All specimens were sent to pathology for 

routine examination. 

Results: There were 7 women and 3 men. The median age was 

65. 8 patients underwent neoadjuvant chemoradiotherapy. A 

mean of 31 lymph nodes per patient were resected. Three 

patients had postoperative pulmonary complications that 

resolved with aggressive respiratory therapy and antibiotics. 

All patients went to the floor postoperatively and none 

required a stay in the ICU. The median length of stay was 7 

days. There were no intraoperative complications or deaths. 

Conclusions: A transcervical mediastinal lymph node dissection 

is a minimally invasive procedure that is safe and effective. 

Patients may avoid a thoracotomy and a lengthy hospital 

stay. Lymph nodes from all thoracic stations can be obtained 

with minimal risk to the patient. This nodal information may 

aid in preoperative staging and guide multi-modality therapy 

for patients with esophageal cancer. 


VIDEO-ASSISTED SEGMENTAL RESECTION FOR LUNG 

TUMORS WITH COMPUTED TOMOGRAPHY GUIDED LOCAL- 

IZATION., Masahide Murasugi PhD, Toyohide Ikeda 

PhD,Takuma Kikkawa MD,Naoko Wachi MD,Toshihide Shimizu 

PhD,Kunihiro Oyama PhD,Masahiro Mae PhD,Takamasa Onuki 

PhD, First Department of Surgery, Tokyo Women?fs Medical 

University, Tokyo, Japan 

BACKGROUD: Although video-assisted thoracic surgery (VATS) 

is now widely accepted. However, VATS procedure is seldom 

used for pulmonary segmental resection. 

METHODS: Between 1987 and 2003, 455 patients underwent 

video-assisted thoracic surgery for primary lung cancers or 

metastatic lung tumors at the Tokyo Women?fs Medical 

University. Among then, 27 patients underwent VATS segmental 

resection because of tumor location, there population consisted 

of 18 males and 9 females with a mean age of 

66.2(range, 27 to 82). 

RESULTS: VATS was carried out with three surgical ports and 

small thoracotomy. Simultaneous segmental resection was 

performed with basic operation, and anatomical segmental 

resection was performed in 4 cases. Median operation time 

was 272 minutes and average blood loss was 219 mL. We performed 

preoperative computed tomography-guided localization 

of lung tumors with use of a hook wire needle. Two cases 

were performed two point CT guided hook wire marking for 

excision line. Resected segment was S6 (n=18), S8 (n=3), S7 

(n=2), S2 (n=1), S4 (n=1), S5 (n=1), S7 (n=1) and S9 (n=1). 

There was no surgical mortality. 

CONCLUSIONS: This report demonstrates that preoperative 

CT-guided localization can facilitate safe VATS segmental 

resection of a small deep pulmonary nodule. VATS segmental 

resection is safe and may be an acceptable for lung tumors. 


THORACOSCOPIC LINGULECTOMY IN AN IMMUNOCOMPRO- 

MISED PATIENT WITH PULMONARY ASPERGILLOSIS, Bryan A 

Whitson MD, Michael A Maddaus MD,Rafael S Andrade MD, 

Division of General Thoracic Surgery, University of Minnesota 

Department of Surgery 

INTRODUCTION ? Invasive Pulmonary Aspergillosis (IPA) has a 

very high mortality in the immunocompromised patient. The 

mainstay of treatment is medical therapy, however, surgical 

resection has a therapeutic role in selected cases. When resection 

is performed, lung preservation is attempted, usually 

resulting in simple wedge resection. Occasionally, larger 

lesions, or those deeper within the parenchyma, may require 

anatomic resection such as lobectomy or segmentectomy. 

Although thoracoscopic lobectomy is described, thoracoscopic 

anatomic segmentectomy for localized IPA has not been 

reported. We present a case of thoracoscopic lingulectomy for 

localized IPA in an immunocompromised patient resistant to 

medical treatment. 

METHODS AND PROCEDURES ? A 66 year old male with acute 

myeloid leukemia presented with progression of symptoms 

from localized IPA that was resistant to optimal medical therapy. 

Computerized tomography showed a 4.7 cm x 5.2 cm centrally 

located lingular mass. Three ports and a 6 cm access 

incision were used similar to that of thoracoscopic lobectomy. 

Sequential dissection and transection of the lingular vein, 

bronchus, and arteries was performed. The lung parenchyma 

was then transected with endoscopic staplers along the lines 

of inflation demarcation. Blood loss was 100cc. Pathology 

showed a 4.5 cm mass with IPA and clear margins. The patient 

had an uneventful recovery and was discharged on the 5th 

post-operative day. 

CONCLUSION ?Video assisted thoracoscopic segmentectomy, 

although technically challenging, can be safely performed, 

allowing the benefits of a less invasive approach with lung 

sparing. 


EMERGING TECHNOLOGY LUNCH ORAL ABSTRACTS 

ET001 

OPTIONS FOR VENTILATORY ASSIST IN AMYOTROPHIC LAT- 

ERAL SCLEROSIS(ALS): THE POSSIBILITY OF DIAPHRAGM 

PACING VIA LAPAROSCOPICALLY PLACED INTRAMUSCULAR 

ELECTRODES, Raymond P Onders MD, Anthony R Ignagni 

MS,Robert Schilz DO,Bashar Katirji MD,Mary Jo Elmo RN, 

University Hospitals of Cleveland 

Background: ALS(Lou Gehrig?s Disease) is a progressive neurodegenerative 

disease that affects around 1.4/100,000 individuals 

annually. The cause of death for most patients is respiratory 

failure unless the only available option of long-term positive 

pressure ventilation is used. Therapeutic electrical stimulation 

has been shown to maintain the strength of other peripheral 

muscles in ALS by maintaining physiologic activity, contractile 

properties and calcium levels. Motor units can be compensated 

for by collateral axon sprouting and the rate of 

sprouting increases with electrical stimulation. We have shown 

in spinal cord injured patients that the laparoscopic diaphragm 

pacing system is a low-risk, cost-effective outpatient system 

that will support the respiratory needs of patients. The objective 

of the present study is to assess the use of this system to 

slow or temporarily arrest the rate of respiratory decline of 

patients with ALS. 

Method: With FDA and IRB approval a phase one study of ten 

patients with ALS and FVC greater than 50% has begun. Each 

patient will be followed for three months pre-implantation with 

a series of tests including: pulmonary function tests, ultrasound 

analysis of diaphragm thickness and phrenic nerve conduction 

tests. Patients will undergo outpatient laparoscopic 

mapping of their diaphragm to locate the phrenic nerve motor 

points and two electrodes will be implanted in each hemidiaphragm. 

Two weeks after surgery, stimulus/output characteristics 

of each electrode will be determined. The patients will 

then condition the diaphragm with three to five 30 minute sessions 

of therapeutic electrical stimulation per day. Success will 

be measured by stopping or reversing the rate of progression 

of the decreasing pulmonary reserve. 

Conclusions: Therapeutic electrical stimulation has been used 

for patients with ALS in the past but it could never help the 

end result of the respiratory decline. We now have an easy 

laparoscopic way to stimulate the diaphragm and this study 

will show whether this will help the quality of patients? respiration 

with ALS. 

ET002 

IMAGE FUSION-INTRA-OP CT WITH MINIMALLY INVASIVE 

SURGERY, Jay A Redan MD, Gary Onik MD, Florida Hospital- 

Celebration Health 

1. OBJECTIVE OF THE TECHNOLOGY OR DEVICE: The purpose 

of this evaluation is to determine the use of intraoperative CT 

scanning to aid in the localization and treatment of intraabdominal 

and intra-thoracic tumors that were otherwise difficult 

or unable to be localized by conventional methods. 

2. DESCRIPTION OF THE TECHNOLOGY AND METHOD OF ITS 

USE OR APPLICATION: Intraoperative CT scanning is used as 

an adjunct to minimally invasive surgery to aid in the localization 

of otherwise non-visualized tumors that have required 

conventional open surgery for removal. The device uses a 

laser guidance system incorporated into a 16 slice CT scanner 

in a completely anesthetized and paralyzed patient. This technology 

aids for exact real time localization of a lesion and 

avoids the localizing methodology used in the radiology 

department from disruption during transport to the operating 

room. Additionally, the patient is under a general anesthetic, 

therefore, suffers no pain and makes the procedure safer and 

easier. 

3. PRELIMINARY RESULTS: 16 patients have undergone a 

combined intra-op CT/minimally invasive surgical procedure. 

The tumors are listed. 

I. Recurrent ovarian carcinoma/Fallopian tube carcinoma.2 

patients 

II. Retroperitoneal tumor. 2 patients 

III. Lung cancer. 2 patients 

IV. Recurrent colon cancer. 1 patient 

V. Renal cell carcinoma. 3 patients 

VI. Painful bony metastasis from prostate cancer.1 patient 

VII. Liver Metastasis.4 patients 

VIII. Mediastinal tumor 1 patient 

In all 16 procedures, the tumors were perfectly localized followed 

by a minimally invasive surgical resection and/or ablation 

in conjunction with radiologists and minimally invasive 

surgeons. There were no mortalities and zero morbidity in our 

series. 

4. CONCLUSION/FUTURE DIRECTION: The use of this technology 

is clearly an advance in the field of minimally invasive surgery. 

The ability to localize these tumors through otherwise 

undetectable or extremely difficult localization means have 

aided the minimally invasive surgeons? capabilities to expand 

into areas that otherwise would have required either an open 

operation or a very prolonged and difficult minimally invasive 

surgical procedure. This technology is still investigational and 

further studies will be reported when concluded. 

ET003 

FLUORESCENT CHOLANGIOGRAPHY: A NEW METHOD FOR 

IMPROVED IDENTIFICATION OF THE BILIARY TRACT DURING 

LAPAROSCOPIC CHOLECYSTECTOMY, Brendon M Stiles MD, 

Prasad S Adusumilli MD,Amit Bhargava,Yuman Fong, 

Memorial Sloan-Kettering Cancer Center 

Introduction: Correctly identifying biliary anatomy remains an 

obstacle to safe, timely completion of laparoscopic cholecystectomy 

(LC). We sought to use autofluorescence of bile (fluorescent 

cholangiography) to facilitate in vivo identification in 

mice. This technique requires no extraneous dye or radiography. 

Methods: Fluorimetry was performed on samples of mouse 

bile to determine excitation and emission spectra. In mice 

(n=7), midline laparotomy was performed, followed by liver 

retraction to expose the porta hepatis. Using stereomicroscopy, 

photographs were taken in brightfield and fluorescent 

modes, without changing depth or focus. Surgical residents 

(n=6) evaluated the pictures and identified the gallbladder, 

cystic duct, common bile duct, and whether the cystic duct 

joined the right hepatic duct or the common bile duct. 

Results: Fluorimetry demonstrated autofluorescence of bile at 

an excitation wavelength of 475nm. Intense emission was 

observed at 480nm. Using fluorescent stereomicroscopy at 

these settings, the gallbladder and biliary tree were easily 

identified in mice. 

This technique decreased diagnostic errors of biliary anatomy 

by 11-fold (2% v/s 22%, p<.01) compared to brightfield visualization. 

Fluorescent stereomicroscopy was also used to diagnose 

bile leak, obstruction, and complex anatomy. Using a 

prototype 5mm Olympus laparoscope equipped with fluorescent 

filters, results were reproduced.Conclusions: By incorporating 

fluorescent filters into standard laparoscopes, fluorescent 

cholangiography, based solely upon the autofluorescence 

of bile, may facilitate real-time identification of biliary anatomy 

during LC, without the need for extraneous dye administration 

or the use of radiography. 

ET004 

A NEW LAPAROSCOPIC IMPLANT FOR THE TREATMENT OF 

GERD, Todd A Berg, Torax Medical, Inc 

Research has shown that GERD is a disease with a complex 

pathology. Numerous factors including lower esophageal 

sphincter (LES) tone, transient relaxations, and the hiatal 

diaphragm, have all been discussed as physiologic barriers to 

reflux. Multiple attempts have been made to address defects 

of these physiologic barriers however, no device or treatment 

to date can completely restore the physiologic function of the 

LES. Surgery is anatomically invasive, presents morbidities, 



237



and has limited precision of efficacy. Drugs only inhibit acid 

production; they do not address the physiologic dysfunction of 

the LES. Opportunity remains for a comprehensive treatment 

which is minimally invasive, safe and restores the LES to normal 

function. Our approach is to correct the LES by providing 

an implant to directly augment its function. It is our objective 

that this implant provides a precise pressure barrier in the 

LES. It is our further objective that the implant can actuate to 

allow normal swallow functions. 

The technology is an active implant which is attached to the 

distal esophagus. The implant provides a barrier to gastric 

pressures, yet yields to normal swallow pressures. 

At rest the implant provides a compressive resistance to opening 

of the esophagus with a magnitude of 10-20mm Hg. 

When swallowing, the implant?s resting tone barrier decreases. 

This allows the implant to distend to the maximum diameter 

of the esophagus and immediately return to the minimum 

diameter of the esophagus after the food bolus passes. 

The device has been extensively tested in animal studies both 

acutely and chronically. All animals have undergone pre- and 

post-implant manometry testing which consistently yields an 

average 15 mm-Hg pressure increase over baseline. 

Fluoroscopically viewed barium swallows were also performed 

to verify normal swallow function and device actuations; all 

have been normal. Additionally, histopathology assessment 

has demonstrated a stable healing process and incorporation 

of the implant. 

Pre-clinical testing of the device is being completed. The 

implant provides a definitive and physiologic increase in pressure 

resistance to gastric reflux. To date, data suggests the 

implant is safely incorporated to the esophagus and maintains 

its position. Additionally, the implant?s function of providing a 

gastric pressure barrier and allowing full distention for normal 

swallow function appears permanent. 

ET005 

MULTISPECTRAL THERAPEUTIC ENDOSCOPY—IMAGING 

AND INTERVENTION, John L Bala BS, Ronald Franzino MD, 

Micro Invasive Technology, Inc. 

OBJECTIVES: This paper’s objective is to redefine conventional 

endoscopes so that they can efficiently transmit Visible (VIS), 

Ultra Violet (UV) and Infrared (IR) images from within the 

body, and can guide laser energy into it. 

DESCRIPTION: Current endoscopes cannot combine visual 

imaging and therapeutic intervention because their light 

source is static; their fiber optic bandwidth is limited; and their 

optics are inefficient, responding only to light between 400- 

700nm. The multispectral endoscope uses Pulsed Xenon 

Flashtubes which offer a broad optical spectrum (190-1200nm), 

and which generate high-powered micro-second light pulses 

that convert non-visible light into visual images. These images 

can become visible with the use of photodynamic dyes or IR 

Sensors. Multiplexing technology can also direct lasers for 

ablation/coagulation by sharing the fiber optic illumination 

pathway into the body between intervention and imaging. 

Pulsed Xenon’s UV output can directly kill some infectious 

bacteria in seconds and also activate diagnostic dyes in situ. 

During laser surgery, this technology can also identify thermal 

variations in solid tissue temperature; the IR spectrum may be 

able to delineate solid tissue from blood vessels as well. 

The multispectral endoscope uses optical concepts that 

replace up to 22 optical elements with a single component to 

increase the transfer efficiency and resolution of visual and IR 

images. It can be equipped with different, interchangeable, 

low-cost, disposable illuminators which can be optimized for a 

given surgical procedure. 

RESULTS: Working prototypes of the “Pulsed Xenon Imaging 

and Intervention System “ demonstrate the efficacy of multiplexing. 

Laboratory tests utilized pulsed UV light to kill 


Staphylococcus. In vivo tests demonstrated multiplexing of 

lasers with visual imaging. Image-guided intestinal biopsies 

using a disposable illuminator multispectral endoscope integrated 

with a snare were performed. 

CONCLUSIONS/FUTURE DIRECTION: Current results represent 

“proof of concept” rather than FDA clinical test requirements. 

These results demonstrate the multispectral endoscope’s 

potential as a therapeutic surgical imaging device. Integrating 

laser targeting with visual imaging will further increase the 

capability of both technologies. Multispectral imaging and 

intervention, combined with application-based optics, is the 

enabling technology for the future of endoscopy. 

ET006 

NICKEL TITANIUM (NITI) CLIP FOR SIDE-TO-SIDE BOWEL 

COMPRESSION ANASTOMOSIS. PRELIMINARY RESULTS IN 

HUMANS., Amir Szold MD, Doron Kopelman MD,Shlomo 

Lelcuk MD, Tel Aviv Sourasky Medical Center, Ha’emek 

Medical Center, Rabin Medical Center 

Aim: NiTi is a Shape-memory alloy with unique physical properties. 

These properties were used to design a device for sideto-side 

bowel anastomosis. After preliminary testing in animals 

proved safety and efficacy, and after a feasibility proof of 

concept in limited number of humans, the device was first 

used in humans over the past year. 

Methods: The device consists of a double coil inserted sideways 

into the two bowel loops to be anastomosed, through 

small incisions. A deployment instrument inserts the device 

and creates a small slit between the bowel loops to allow passage 

of gas and fluids until the anastomosis is patent. The clip 

has memory shape; it is inserted after cooling, allowing 

spreading of the coil for easy introduction and after warming 

to body temperature it closes over the tissue in constant and 

controlled force. During 5-10 days following the procedure the 

clip compresses the bowel loops. Pressure necrosis and fibrosis 

that take place simultaneously create a healed anastomosis 

within that time period, and the device detaches and is 

expelled naturally. 

Results: Following animal studies the device was used in over 

60 patients for the creation of small bowel and large bowel 

anastomoses. Following some design adjustments the device 

was found to be easy to use, and effective. There were no 

adverse effects attributable to the device, and the anastomoses 

functioned within 3-6 days following the operation. 

Conclusions: The NiTi device was found to be safe and effective. 

A large, multi-center is currently undertaken to further 

study the use of this side-to-side compression Anastomosis 

device. 

ET007 

DEPLOYMENT & EARLY EXPERIENCE WITH REMOTE PRES- 

ENCE ROBOTIC-ASSISTED PATIENT CARE IN A COMMUNITY 

HOSPITAL, Joseph B Petelin MD, Jonathan Goodman MD, 

Surgix Minimally Invasive Surgery Institute, Univ of Kansas 

School of Medicine Dept of Surgery 

Introduction: Telemedicine has been discussed for decades. 

The widespread implementation of a remote true patientphysician 

interaction has awaited useful devices, adequate 

communication bandwidth, and protocols that would make it 

practical. The introduction of the RP-6? (InTouch Health, Santa 

Barbara) remote presence ?robot? appears to be a useful 

telemedicine device. The authors describe the deployment and 

early experience with the RP-6? in a community hospital, and 

provide a live demonstration of the system. 

Methods: The RP6? is a 5?4? tall, 215 pound robot that can be 

remotely controlled from an appropriately configured computer 

located anywhere on the Internet (i.e. this planet). The system 

is composed of a control station (a computer), a mechanical 

robot, a wireless network (at the home facility—the hospital), 

and a high-speed Internet connection at both the home 

(hospital) and remote locations. The robot itself houses a 

rechargeable power supply. Its hardware and software allows 

communication over the Internet with the remote station, 

interpretation of commands from the remote station and conversion 

of the commands into mechanical and non-mechanical


actions at the home location which are communicated back to 

the remote station over the Internet. The RP6? system allows 

the remote party (physician, etc.) to control the movements of 

the robot itself, see and hear at the home location (hospital), 

and be seen and heard at the home location (hospital) while 

not physically being there. 

Results: Deployment of the system at the hospital was accomplished 

in less than a day. The wireless network at the institution 

was already in place. Control station setup ranged from 1 

to 4 hours and was mostly dependent on the quality of the 

Internet connection (bandwidth) at the remote locations. 

Patients visited with the RP6? on their discharge day were able 

to be discharged > 4 hours earlier than with conventional visits, 

thereby freeing up hospital beds on a busy med-surg floor. 

Patient visits during ?off hours? (nights and weekends) were 3 

times more efficient than conventional visits during these 

times, (20 minutes/visit vs. 40 minutes round trip travel + 20 

minute visit). Patients and nursing personnel both expressed 

tremendous satisfaction with the remote presence interaction. 

Conclusions: Our early experience suggests a significant benefit 

to patients, hospitals, and physicians. The implications for 

future development are enormous. 

ET008 

ULTRASOUND-GUIDED LAPAROSCOPIC SURGERY SYSTEM, 

Philip Bao MD, Robert Galloway PhD,Alan Herline MD, 

Vanderbilt University Hospital 

Objective: Metastatic and primary liver tumors pose a significant 

clinical problem for patients and cancer surgeons. Only 

approximately 20% of these lesions are resectable with standard 

open surgery, and this has motivated interest in less invasive 

alternative procedures such as laparoscopic radiofrequency 

ablation (RFA). Intra-operative imaging with ultrasound is 

critical to successful positioning of the RFA probe especially 

during laparoscopic surgery, as the surgeon cannot rely easily 

upon tactile cues. Also, needle placement is important for 

tumors larger than 3cm because they are often more irregular 

in shape and require multiple overlapping ablations. To augment 

tumor visualization and targeting, we have developed a 

tracked laparoscopic ultrasound targeting system for liver RFA. 

Description of technology and application: A laparoscopic 

ultrasound probe has been modified to permit tracking by an 

infrared camera. By tracking the standard two-dimensional 

images output from the ultrasound machine, we are able to 

reconstruct three-dimensional ultrasound volumes that can be 

examined from multiple views much like computer tomography 

reconstructions of the spine or blood vessels. Moreover, 

this volume is spatially related to the physical space of the 

patient and can be used to guide a tracked RFA probe. After 

the tumor is identified in the volume and an insertion point for 

the RFA needle is selected, a targeting system is activated 

which displays the proposed trajectory to the tumor and its 

distance from insertion. The user may then inspect the path to 

ensure that no critical structures intervene. A new insertion 

point and needle path may be chosen, or if satisfactory, the 

probe is advanced until the distance between target and probe 

reaches zero. Preliminary results using this system on an 

experimental model show that we can target the center of a 

tumor within 10mm. 

Conclusions: Image-guided technology has a future role in 

assisting surgeons particularly during complex laparoscopic 

procedures which already depend to some degree on intraoperative 

imaging. This technology is a powerful and relatively 

cost-effective tool that has the potential to allow surgeons to 

perform procedures more efficiently and safely. In the future, 

we hope to apply this tracked ultrasound system to laparoscopic 

liver resections as well. 

ET009 

REFLUX (ACID OR NON-ACID) DETECTED BY MULTICHANNEL 

INTRALUMINAL IMPEDANCE-PH TESTING PREDICTS GOOD 

SYMPTOM RESPONSE FROM FUNDOPLICATION, Inder Mainie 

MD, Radu Tutuian MD,Amit Agrawal MD,Amine Hila 

MD,Janice Freeman RN,Donald O Castell MD, Medical 

Universtity of South Carolina 

Background: Combined Multichannel Intraluminal Impedance 

(MII) detects gastroesophageal reflux (GER), of all types and is 

used in the diagnosis of typical and atypical symptoms persisting 

despite PPI therapy. Laproscopic Nissen fundoplication 

(LNF) is a recognized treatment for patients with a diagnosis 

of GER. 

Aim: To determine the outcome of LNF as a treatment for 

patients with persistent symptoms identified as due to reflux 

by MII-pH on PPI BiD. 

Method: 14 patients (Female 12; mean age 40; range 8 months 

? 78 years) evaluated using MII-pH were followed after LNF. All 

patients except one had a positive symptom index (SI) for acid 

(AR) or non-acid (NAR) reflux during pre-operative testing. 

Chart review or contact by phone was used to document 

patient response to surgery. 

Results: Mean period of follow-up was 6.5 months (1 month ? 

15 months). Eleven patients after LNF were asymptomatic and 

off anti-reflux medication. Of the 11 asymptomatic patients 6 

were diagnosed with a positive SI for cough with NAR, 3 with 

a positive SI for heartburn with acid reflux, 1 with a positive SI 

for nausea with acid reflux and 1 with a positive SI for regurgitation 

with NAR. 1 patient did improve after surgery but at 10 

months was taking a proton pump inhibitor on a required 

basis and 1 patient had a recurrence of her symptoms 

(hoarseness) 8 months after surgery. One patient had a recurrence 

of symptoms (heartburn) at 8 months but was noted to 

have a negative symptom index on MII-pH evaluation. 

Conclusion: A positive SI for non-acid or acid reflux using MIIpH 

predicts successful response to laproscopic Nissen fundoplication. 

ET010 

LAPAROSCOPIC TREATMENT OF EARLY STAGE COLORECTAL 

TUMORS CHASED BY MAGNETIC CLIP DETECTING AND 

CHASING SYSTEM (MCDCS): USEFULNESS OF A MAGNETIC 

FORCE CHANGEABLE FORCEPS, Takeshi Ohdaira MD, Hideo 

Nagai MD, Jichi Medical School Hospital 

Aim: In laparoscopic surgical treatment of early stage colorectal 

carcinomas, intraoperative tumor site identification is often 

difficult. We have developed a novel detecting and grasping 

device of laparoscopic usage. We used a magnetic clip for the 

marking and the staying point of the lesion. Methods: We 

applied a 300 mT magnetic marking clip near the oral edge of 

the tumor during preoperative colonoscopy and identified the 

clip by using a magnetic clip detecting and chasing system 

(MCDCS) with magnetic force changeable ability. At first, during 

operation, we identified the lesions under a condition of a 

weak magnetic force of MCDCS. Then the magnetic force level 

of MCDCS was increased to obtain efficient holding power, 

and the colon was resected under simultaneous chasing and 

grasping of the marking site. Results: In a basic ex vivo study, 

100 mT magnetic force was easily detected with 100% of 

detection ratio and 600mT magnetic force was necessary to 

constantly chase and grasp the lesion. In a clinical study, the 

marking site was detected in all the 13 patients. The mean 

length between the detected site and the clip along the longitudinal 

bowel axis was 10.8 mm (S. D., 4.6). The mean detection 

time was 8.4 seconds (S. D., 2.5). Even the marking clip 

on the retroperitoneal and mesenteric side, MCDCS can readily 

detect the site through the anti-mesenteric bowel wall. 

Conclusion: MCDCS accurately identifies a tumor site and easily 

treats the colon and rectum with chasing tumor site. This 

device may be useful to easily resect the tumor in laparoscopic 

surgery. 



239

EMERGING TECHNOLOGY LUNCH POSTER ABSTRACTS 


TP001 

HAPTIC FEEDBACK SYSTEM FOR ROBOTIC SURGERY, Erik P 

Dutson MD, Roy Hwang,Ali Douraghy,John Zhang,Arthi 

Vijayaraghavan,Carlos Gracia MD,Warren Grundfest MD, 

1UCLA Interdepartmental Biomedical Engineering 

Department2UCLA Section of Minimally Invasive and Bariatric 

Surgery, 3UCLA Center for Advanced Surgical and 

Interventional Technology (CASIT) 

OBJECTIVE 

Currently available surgical robotic systems do not provide the 

surgeon with classic tissue-level haptic feedback. This presentation 

will outline a plan for introduction of the tactile component 

in a force sensing robotic grasper based on technologies 

developed in our Institute. 

DESCRIPTION OF THE TECHNOLOGY 

The proposed instrument design will relate forces sensed by a 

surgical grasper directly to the surgeon. The actuation of 

measured forces is done through a unique finger glove design 

which related forces using micro-actuating balloons. The actuation 

balloons comprise a non-linear surface array which will 

allow feedback information directly to the surgeon?s hands. 

The design incorporates finger glove actuation controls onto a 

Da Vinci surgical robotic system. The device transmits force 

information from the surgical field to the surgeon using MEMS 

actuation, via micro-balloons originally used for the delta wing 

aircraft. Balloon actuation is the deformed shape of the silicone 

rubber, activated by pressurizing and decompressing via 

a miniature solenoid valve. The balloon actuators can deflect 

up to 2-mm, with a step response under 50 Hz for a force of 

greater than 100 mN, and have a pressure range from 0 to 20 

psi. The balloons do experience deformation at high pressure 

and the pressure deflection relationship can be easily characterized. 

The final concept is a force sensor on the instrumentation 

that transmits information to a processing circuit and the 

micro-balloon actuator, which will then provide tactile feedback 

information to the operating surgeon. 

CONCLUSIONS/FUTURE DIRECTIONS 

There is an overwhelming body of evidence suggesting minimally 

invasive surgery is a superior method of surgery with 

proper patient selection based on cost, complications, short 

term quality of life, and return to normal functioning. The profound 

alteration in tactile feedback has contributed to the long 

learning curves of laparoscopic procedures. Robotic surgery 

offers some potential benefits in the transition to minimally 

invasive techniques for the learner, however, lack of tactile 

feedback is a major drawback that currently undermines its 

true potential. Reintroduction of tactile feedback may reduce 

the training time needed, and may also allow for more precise 

control during delicate laparoscopic and robotic surgical procedures. 

TP002 

ENDOSCOPIC INTRALUMINAL SUTURING IN POSTOPERA- 

TIVE ROUX-EN-Y GASTRIC BYPASS PATIENTS, Michael A 

Schweitzer MD, The Johns Hopkins University School of 

Medicine 

Objective: Endoscopic intraluminal suturing devices are currently 

being used to treat gastroesophageal reflux disease. 

These suture devices now afford us the opportunity to operate 

on the stomach pouch of post-operative gastric bypass 

patients. 

Methods: Five postoperative gastric bypass patients underwent 

endoscopic intraluminal surgery from November 2002 to 

October 2003 using a flexible endoscopic suturing device with 

a standard 11mm endoscope. Four patients with a dilated gastrojejunostomy 

(GJ) anastomosis and weight regain had their 

stoma’s reduced in size. One patient had a leak after undergoing 

a conversion from a vertical banded gastroplasty to a gastric 

bypass. A gastric pouch false diverticulum remained after 

the drain had finally been removed. The false diverticulum 

was closed with 3 sutures after injection of fibrin glue. 


Results: Successful stoma plication was performed on all four 

patients to narrow their dilated stomas that were measured at 

over 2cm preoperatively too less than 15mm postoperatively. 

Two patients had their gastric pouch plicated near the stoma. 

The one patient who had a gastric pouch false diverticulum 

closed with fibrin glue into the tract and suture closure of the 

opening has been asymptomatic. 

Conclusion: Upper endoscopic intraluminal suturing is an 

exciting new field of emerging technology that will, in time, 

find its role in gastric surgery. The gastric pouch and stoma of 

postoperative gastric bypass patients is within reach for endoscopic 

intraluminal therapy. The current devices available were 

designed for gastroesophageal reflux disease. They will need 

further refinement to allow more flexibility so as to gain easier 

access to the rest of the stomach and not just the gastroesophageal 

junction 

TP003 

ENDOSENSE: THE FUTURE OF FORCE FEEDBACK, Kathryn 

Done’ MS, Timothy N Judkins MS,Allison DiMartino 

MS,Dmitry Oleynikov MD, Human Centered Designs, 

University of Nebraska Medical Center 

OBJECTIVE: The EndoSense, patent-pending, was designed 

primarily to provide the laparoscopic surgeon with ever more 

information about the surgical area. This is a laparoscopic 

grasper tool which provides force feedback from the grasper 

tip to the fingertips controlling the force. The EndoSense is 

also a more comfortable and functional tool, using ergonomic 

concepts to design a tool which better fits the user. 

DESCRIPTION: The EndoSense is specifically designed to provide 

the user with an intuitive, comfortable, and functional surgical 

tool. The force feedback felt at the fingertips, which provides 

the user with information about the magnitude of force 

being exerted on what he/she is grasping, is one of the major 

functional advantages of this tool. When the surgeon has 

more information about what is happening inside the patient, 

this will make for a safer and less stressful procedure. 

(Laparoscopic surgery is an artificial interaction, but this helps 

make it feel more real.) The unique features of this tool include 

the following: 

-Force feedback of grasping tissue via a novel spring-motor 

system 

-Ergonomic handle that decreases discomfort during lengthy 

use 

-Two finger paddles that have an intuitive movement imitating 

the movement of the graspers 

-Use of the thumb and index finger to reduce fatigue on the 

hand. 

As the graspers receive resistance from the tissues within the 

patient, a force sensor within the tool transmits that force into 

resistance in the two finger paddles. This transmission of force 

mimics what the surgeon would feel if he/she were working 

with traditional open surgical tools. 

CONCLUSIONS: Endoscopic surgery is one of the fastest 

growing surgical fields, and in need of continued improvement 

and innovation. Sensing the forces being exerted on tissue is 

one more way to equate endoscopic surgery to open surgery 

and thus decrease training time before surgery and errors during 

surgery. 

TP004 

ROBOT-ASSISTED 3D STRAIN IMAGING FOR MONITORING 

THERMAL ABLATION OF LIVER, Emad M Boctor MSc, Michelle 

DeOliveira MD, Gabor Fichtinger PhD,Russell H Taylor 

PhD,Michael Awad MD,Michael A Choti MD, Johns Hopkins 

University 

Objective: Primary and metastatic liver cancer represents a 

significant source of mortality worldwide. An increasing interest 

has been focused on thermal ablative approaches, in which 

monitoring the ablation process in order to document adequacy 

of margins during treatment is a significant problem. 

Ultrasound is the most commonly used modality for target 

imaging and ablation monitoring. However, the appearance of 

ablated tumors in conventional ultrasound only reveals hyperechoic 

areas from microbubble and outgasing, but cannot sufficiently 

visualize the margin of tissue coagulation.


Materials and Methods: We capitalize on the changes of tissue 

elastic properties occurring during heating and protein denaturation, 

based on prior work of Ophir et al. They also measured 

elastic properties indirectly by creating mechanical disturbance 

such as compression and evaluating the resulting response in 

ultrasound, In contemporary practice, however, lack of controlled 

compression often results in compromised or false 

reading. Our approach to this problem is to apply precise 

mechanical compression by mechanical arm. We acquire 

radiofrequency ultrasound (RFUS) data from the tissue in both 

rested and stressed states and then estimate the induced 

strain distribution by tracking speckle motion. The experimental 

system consists of a Siemens Antares ultrasound scanner 

to generate RFUS measurement, a robotic arm to provide 

accurate compression and controlled 3D sonography, and 

Radionics and RITA ablators. 

Experiments and Results: We performed proof-of-concept in 

vitro experiments on fresh bovine liver. The samples were 

degassed and placed in a gel-based phantom. The ablation 

protocol was repeated for different ablation durations (2, 3, 5, 

and 7 minutes) and temperature ranges (50, 75, and 100 

degree Celsius). We compared the strain images, pathological 

examination, and conventional B-mode images of the thermally 

treated liver samples. The strain images were found to be 

consistent with the pathological margins, while the B-more 

images were inconclusive. 

Future Directions: Currently, we are in the process of repeating 

the in vitro studies with a refined experimental protocol, in a 

more controlled manner, and on a larger number of samples, 

before progressing onto in-vivo animal studies. We also investigate 

the integration of strain based and thermal imaging. 

Preliminary results promise the ability of deriving accurate 

temperature maps based on speckle motion. 

TP005 

PLUG-AND-PLAY INTEROPERABILITY OF MEDICAL DEVICES 

IN THE OR OF THE FUTURE, Julian M Goldman MD, Susan F 

Whitehead BA,David W Rattner MD, Massachusetts General 

Hospital and CIMIT, Boston, MA, USA 

INTRODUCTION: The OR is a complex and potentially dangerous 

environment, where clinicians rely on teamwork and a 

patchwork of systems to mitigate hazards instead of using 

automated safety systems (interlocks). Clinicians can?t easily 

achieve situational awareness or control devices in the OR 

environment. There is an absence of smart alarms and automated 

clinical decision support, and no technological infrastructure 

exists to implement the required solutions. 

Proposed Future State: Widespread implementation of openstandards-based 

Plug-and-Play (PnP) medical device interoperability 

in the OR of the Future (ORF) will facilitate comprehensive 

data COMMUNICATION and medical device CONTROL. 

Adoption of ORF PnP standards will lower the barrier to the 

deployment of innovative networked medical device technologies. 

- Benefits of COMMUNICATION interoperability: 

Comprehensive population of the EMR, enhanced clinical situational 

awareness and decision support tools, information for 

QA and process improvement. 

- Benefits of CONTROL interoperability: Device-device control 

with implementation of safety interlocks, remote user actuation 

of devices, ?distributed? medical devices such as distributed 

sensor networks, etc. 

METHODS and RESULTS: The MGH/CIMIT[1] ORF PnP program 

was established to produce a framework for the development 

of safe and effective consensus medical device interoperability 

standardization. The program was initiated by MGH and 

CIMIT with a DoD-supported meeting in May 2004. Meeting 

goals were to identify stakeholders, define the project scope, 

and form working groups. Over 80 attendees included clinicians, 

IHDNs, >20 manufacturers, FDA , and DoD[2]. We 

formed multidisciplinary working groups and agreed to concentrate 

initial efforts on identifying high-level clinical user 

requirements for the proposed system. At the 2nd meeting, 

hosted by the US FDA in Nov 2004, and at meetings at the 

American Society of Anesthesiologists and the Society for 

Technology in Anesthesia (STA), many clinical requirements 

were elicited and existing connectivity standards were identified 

for potential adoption. The STA formed a task force to 

support ORF PnP. Similar meetings with surgeons and nurses 

are planned. 

CONCLUSIONS: The “tipping point” for the standardization of 

medical device interoperability has clearly arrived. Clinicians 

and their professional societies must remain engaged to 

assure the clinical relevancy of the system. 

1. cimit.org 2. orfpnp.org 

TP006 

ENDOLUMINAL REMOVAL OF INTESTINAL METAPLASIA, 

LOW-GRADE DYSPLASIA, AND HIGH-GRADE DYSPLASIA 

USING A BALLOON-BASED DILATION/ABLATION TOOL, David 

S Utley MD, BARRx Medical, Inc., Sunnyvale, California, USA 

Objective: Esophageal intestinal metaplasia (IM) is surveyed 

regularly for dysplasia/adenocarcinoma. Esophagectomy or 

PDT is often employed for high-grade dysplasia (HGD). An 

endoscopic tool capable of removing IM +/- dysplasia, would 

serve to: 1) interrupt the metaplasia-dysplasia-carcinoma cycle, 

akin to the cancer risk reduction achieved with colon polypectomy, 

and 2) provide a less invasive alternative to surgery or 

PDT for HGD. 

Technology Description: Such an endoscopic tool must 

achieve circumferential ablation of IM uniformly to the level of 

the muscularis mucosae (MM). To achieve this goal, the tool 

described herein is a balloon-based electrode array. The balloon 

dilates the esophagus (0.5 atm) to transiently flatten the 

esophageal folds and stretch the wall. While dilated, a high 

power, ultra-short burst of ablative energy is applied. Key features: 

1) high power (300 W), 2) ultra-short energy time (



We have created “Ischemia Sensing Surgical Instruments” by 

adapting and incorporating real-time pulse oximetry techniques 

into the working surfaces of operative instruments. 

These instruments provide real-time tissue oxygenation data. 

In preliminary experiments, we monitored porcine hepatic 

oxygenation during retraction while performing the Pringle 

maneuver. Results demonstrated a correlation between our 

measurements and the manipulation of the porta hepatis. 

Future endeavors aim to develop a system for alerting the 

operative team to impending tissue damage through sensory 

substitution. In addition, we envision the system to extend 

directly into robotically controlled instruments in order to 

enhance the human - machine interface. 

TP008 

The Value of Video Intubation Techniques for Surgical 

Residents, (S.R.) 

Marshal Kaplan, MD, Denham Ward, MD, George Berci, MD * 

Cedars Sinai Medical Center, Los Angeles/University of 

Rochester, New York 

In many institutions, SR?s must contend with emergency airway 

situations where, unfortunately, an anesthesiologist is not 

immediately available. This can be a challenge to a successful 

intubation because of a lack of experience and technical difficulties. 

Traditionally, a Macintosh blade on a laryngoscope handle 

with a tiny battery powered globe is used to attempt intubation. 

The authors have developed a standard Macintosh blade 

and handle modified by the insertion of a TV camera into the 

handle from which a miniature, (3mm) image-light bundle is 

fitted in to the blade. An enlarged view is displayed on a monitor 

screen. The entire unit, (light, camera control, screen, etc?), 

is portable. Television techniques are well accepted in 

Minimally Invasive Surgery to obtain a magnified appearance 

of the anatomy. Should a second pair of hands be required, 

e.g. to provide external laryngeal pressure, the Video display 

is a great advantage as it allow both the intubator and the 

assistant to follow the movements on the screen. This system 

has been successfully used on several hundred patients by 

anesthesiologists. 

It is our hypothesis that if the SR?s are using a vastly 

improved visual technique with appropriate education, 

employing this mobile unit in the ICU?s or ER?s a greater safety 

margin with fewer attempts can be expected. 

It is definitely the method of choice in teaching. (A 7-minute 

video strip will be included in the 10-minute presentation). 

TP009 

SMART TUTOR: A NOVEL ADAPTIVE SIMULATION ENVIRON- 

MENT FOR TEACHING LAPAROSCOPIC MOTOR SKILLS, Thai 

Pham MD, Lincoln Roland MD,Kenneth A Benson BA,Roger W 

Webster PhD,Anthony G Gallagher PhD,Randy S Haluck MD, 

Penn State College of Medicine, Hershey, PA; Soundshore 

Medical Center, NYC, NY; Verefi Technologies, Hershey, PA; 

Emory University, Atlanta, GA 

Introduction: Optimal learning is best achieved in moderate 

stress situations and without frustration. The Smart Tutor 

Computing Algorithm (Verefi Technologies, Inc., Hershey, PA) 

was developed and integrated into the RapidFire PC based 

laparoscopic skills trainer (Verefi) to create real-time adjustments 

in difficulty settings based on the users? performance. 

The Smart Tutor algorithms aim to keep users of any level in 

their optimal ?zone? of learning by minimizing frustration and 

stress. The goal of this pilot study was to compare our first 

generation RapidFire/Smart Tutor (RF/ST) to the Mentice 


Minimally Invasive Surgery Trainer Virtual Reality (MIST VR) 

system by examining levels of frustration in training of 

novices, and measuring acquisition of laparoscopic motor 

skills. 

Methods: Three tasks from RapidFire were modified with two 

different Smart Tutor algorithms (emphasizing speed or accuracy) 

to create six tasks. For MIST VR, only the Acquire, 

Transfer, and Traversal tasks were used. Expert performance 

criteria (EPC) were established for RF/ST and MIST VR systems. 

Ten medical students were randomized to train on each 

system. For RF/ST, training was completed when subjects 

achieved EPC in four of the six tasks in two consecutive trials. 

For MIST VR, subjects were advanced from medium to master 

level and then to completion of training when EPC were 

achieved in two of the three MIST tasks for two consecutive 

trials. Users were assessed by a standard pre- and post-training 

laparoscopic paper cutting task. All subjects answered a 

questionnaire regarding levels of frustration based on a five 

point Likert scale. Data were compared using standard t-test. 

Results: Data show that novice users had significant improvements 

in their laparoscopic motors skill on both the RF/ST and 

MIST VR. The average number of training trails required to 

achieve EPC on RF/ST and MIST VR environments were 10±3 

and 15±4 respectively (p=NS). A difference in subjective frustration 

ratings was noted between RF/ST 2.0±0.8 and MIST VR 

3.2±1.1 (p < 0.05). 

Conclusion: Novices acquired laparoscopic skill as assessed on 

their pre- and post-paper cutting scores after training on 

RF/ST. Although not statistically significant, novice users were 

achieving EPC with less number of trails with RF/ST. Of importance 

is that RapidFire with Smart Tutor adaptive environment 

is providing a less frustrating learning environment, which 

may enhance laparoscopic skills acquisition. 

TP010 

VACUUM ASSISTED ABDOMINAL WALL LIFT FOR MINIMAL 

ACCESS SUGERY (M.A.S). A PRELIMINARY PORCINE STUDY 

TO EVALUATE SAFETY, EFFICACY AND FEASIBILITY, 

Tehemton E Udwadia MD, Biten K Kathrani MS,Ulhas S Gadgil 

PhD,William Bernie MD,V M Chariar MSc, Dept. of M.A.S. P. D. 

Hinduja National Hospital, Regional R & D, Johnson & 

Johnson Medical, Ethicon Endo Surgery Inc. 

Objective: In a porcine model, to design a vacuum assisted 

device for abdominal wall lift for Minimal Access Surgery 

(MAS) with the intent to make MAS cost effective in developing 

countries. Technology A transparent dome shaped device 

was placed on the pigs abdomen and negative pressure was 

applied between the device and the abdomen, which lifted the 

abdominal wall firmly against the undersurface of the device. 

The device was configured on mould casts made of the pig 

abdomen insufflated to 14mmHg with CO2. The device had a 

foam gasket in contact with the abdominal wall to maintain 

vacuum and appropriately sited ports for trocar entry. It is 

mandatory in this method to ENSURE free communication of 

air from outside the device to the peritoneal space through a 

sub-umbilical trocar placed by open entry passing through the 

device. The air enters the peritoneal cavity pari passu with 

vacuum creation and thereby preventing the viscera being lifted, 

creating intra peritoneal space at ambient air pressure. Due 

to ambient conditions gas leak is not a problem. Method The 

study was divided into three groups; 1)in 12 animals to assess 

the safety and feasibility of the method, 2)in 11 animals, in 

addition to 1 above, performance of MAS procedures like lap. 

chole., lap. salpingectomy, lap. assisted bowel resection and 3) 

in 4 animals long term survival monitoring studies as in group 

1 for 2 ? 8 days, after extreme and prolonged vacuum application. 

Results a) Safe limits of vacuum to create and maintain 

operative space were 50-150 mmHg for 2 hours. b) Continuous 

monitoring of vital signs (ECG, HR, SPO2, ETCO2, resp rate, 

rectal temp), biochemistry and histopathology- post procedure 

confirmed device safety. c) Intraperitoneal work space by actual 

measurement was comparable to CO2 insufflation. 

Conclusion This study confirms the safety and efficacy of the 

device. Every operating room has a suction machine which 

can easily be adapted to create a vacuum for this lift, whereas 

CO2 is not readily available in the developing world. This continuous 

communication of air between the peritoneal cavity


and ambient atmosphere provides several cost benefits like 

valve less simple trocars, suction aspiration without loss of 

work space, simplified hand instruments. It obviates deleterious 

effects of CO2 by maintaining a work space at ambient 

pressure, temperature and humidity. If feasible in clinical practice 

this device could help spread the benefits of MAS to all 

people in all places. 

TP011 

THE USE OF ACCELEROMETER DATA TO TRACK AND QUAN- 

TIFY LEARNING DURING TRAINING ON VIRTUAL LAPARO- 

SCOPIC SKILL MODULES, Michael J Dancisak PhD, James 

Korndorffer MD,Michelle J Pinette BS, Department of Exercise 

and Sport Sciences, 2Department of Surgery, 3Department of 

Biomedical Engineering, Tulane University, New Orleans, LA 

Objective of the Technology 

Accelerometer data have been successfully utilized to track 

and quantify reaching and grasping movements in infants and 

adult populations. Previous studies have used temporal measures 

such as time to peak acceleration and time to peak deceleration. 

Those measures represent single point data on a discrete 

reaching task. The present study examined the efficacy 

of acceleration data for determining skill levels of performers 

during several sessions on a virtual laparoscopic training 

device. It was hypothesized that the number of acceleration 

reversals (e.g., acceleration/deceleration) could be obtained 

from a single tri-axial accelerometer during virtual laparoscopic 

training sessions. 

Technology and Method 

The present study used a Biopac MP100 system with a triaxial 

accelerometer to assess acceleration reversals during a standardized 

laparoscopic training module. Acceleration reversals 

were defined as persistent 0-point crossings. Three levels of 

participants were assessed to determine if expert and novice 

performers could be determined from the number of reversal 

done by each performer. Novice performers were non-medical 

students from a private university. Intermediate performers 

were individuals trained on the virtual training modules but 

not practicing surgeons, and expert performers were practicing 

surgeons familiar with both the training modules and highly 

accomplished in their field. In the current study, the number 

of specific tasks as determined by the training module was 

held constant and time varied. 

Results 

Results from the acceleration reversals indicate that the number 

of reversals inversely correlates with skill level. Lower 

numbers of acceleration reversals were recorded for the higher 

skill level performers. The results from this study are consistent 

with reversal data seen in novice and expert reaching tasks. 

Conclusions/Future Directions 

The results from the present study indicate that the use of 

acceleration reversal data may provide a metric to assess skill 

level in individuals training on virtual skills modules. The 

reversal data may also provide feedback for current practitioners 

when developing skills on new equipment. The use of 

acceleration reversals may also provide information about 

practice schedules for medical students and others learning 

new surgical skills. 

TP012 

GASLESS HAND ASSISTED LAPAROSCOPY., Daniel T Farkas 

MD, Scott Laker MD,Vincent Iannace MD,Annette Wasielewski 

RN,Patrick F Leahy MD,Garth H Ballantyne MD, Hackensack 

University Medical Center 

Objective: The objective of this technology is to provide surgeons 

the ability to perform hand assisted laparoscopy, without 

the need for a carbon dioxide pneumoperitoneum. 

Description: A new hand access device (Freedom) was 

designed by Galileo Corporation (Dublin, Ireland). This device 

is essentially a sleeve, with multiple balloons around the outside 

of it. The device is inserted into the abdomen, and the 

balloons insufflated through a single tube. This has the effect 

of lifting the abdominal wall, and provides room within the 

abdominal cavity to work, without the need for a pneumoperitoneum. 

Preliminary Results: Using a ?proof of concept? design, we 

performed a hand assisted laparoscopic left hemicolectomy in 

a cadaver. With the use of the Freedom device, and no pneumoperitoneum, 

we were able to obtain excellent intra-abdominal 

views. We were able to mobilize the left colon and splenic 

flexure, as well as dissect out the rectosigmoid. The pelvic 

views were equally good using this hand access device. 

Conclusion: The Freedom hand access device allows the use 

of gasless hand assisted laparoscopy. Carbon dioxide pneumoperitoneum 

is not necessary when using this device, and 

this can eliminate some of the adverse effects and complications 

associated with laparoscopy. 

TP013 

COMPUTER MEDIATED, PER-ORAL CIRCULAR STAPLER (EEA 

TYPE) FOR CREATION OF THE GASTRO-JEJUNOSTOMY DUR- 

ING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS Alex 

Nagle MD, Eric Hungness MD, Jay B Prystowsky MD, 

Nathaniel J Soper MD, Northwestern Univeristy, Feinberg 

School of Medicine, Department of Surgery, Chicago, IL 

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is technically 

challenging and has a long learning curve. Morbidity and mortality 

are often associated with complications related to the 

gastro-jejunostomy (GJ), particularly early in the learning 

curve. Although stapling devices have simplified performance 

of the GJ, complications have not been eliminated. An FDAapproved 

computer mediated stapler (SurgASSIST; Power 

Medical Interventions, USA) has been introduced. This technology 

eliminates potential stapling errors and provides a precise, 

reproducible staple line by digitally establishing a staple 

height determined by the tissue thickness. SurgASSIST consists 

of a computer console, remote control, flexible shaft, and 

circular stapler. To facilitate passage through the esophagus, 

the length of the stapler has been shortened and a soft, conical 

shaped introducer tip has been added to the distal end. A 

hydrophilic coated sheath covers the stapler to provide a 

smooth trans-oral passage. Once passed through the esophagus, 

the introducer tip is unlocked and the sheath is retracted 

to expose the stapler head. A flexible wire trocar, centrally 

located within the stapler then penetrates the gastric wall. This 

long, thin trocar creates a small gastric defect compared to 

other EEA devices and allows easy and quick connection to the 

anvil. The anvil and stapler are then united and a computer 

mediated, circular 21-mm GJ is created. 

This technology has been evaluated in a human cadaver 

model. Trans-oral passage of the stapler was performed with 

no difficulties and several inherent advantages were confirmed. 

A trans-oral approach simplified performance of the 

GJ and provided a consistent, reliable anastomosis in a timely 

fashion. Based on this preliminary experience, we believe this 

device will shorten the learning curve associated with LRYGB 

and potentially decrease morbidity and mortality. Further 

prospective clinical evaluation will be conducted to validate 

these claims. 

TP014 

IMAGE OVERLAY FOR CT-GUIDED HEPATIC NEEDLE INSER- 

TIONS — CADAVER STUDIES, Michelle L deOliveira MD, 

Anton Deguet MS,Gregory Fischer MS,Emese Balogh 

MS,Laura M Fayad MD,S. James Zinreich MD,Gabor Fichtinger 

PhD, Johns Hopkins University 

OBJECTIVE: We present a two-dimensional image overlay 

device to assist hepatic needle placement on CT scanners. 

MATERIALS AND METHODS: The image overlay system consists 

of a flat display and a semitransparent mirror mounted 

on the gantry. When the physician looks at the patient through 

the mirror, the CT image appears to be floating inside the 

body with correct size and position, as if the physician had 



243



“tomographic vision”. The target, entry, and optimal path are 

drawn on the CT image. The composite image is rendered on 

the display and thus reflected in the mirror. The plane of the 

overlay image is also marked by laser. The reflected image is 

used to guide the physician in the procedure as follows: The 

physician places the needle at the entry point, fulcrums the 

needle to follow the trajectory drawn on the image, while 

keeping the needle in the plane of the overlay image, and 

finally inserts the needle to the predefined depth. The most 

useful feature of the 2D image overlay is that the physician 

can conveniently control the entry point, needle trajectory, and 

insertion depth without changing his/her posture. The 2D 

image overlay system is simple, inexpensive, and independent 

from the CT scanner. We tested the device on human and ventilated 

fresh pig cadavers. We implanted metal targets in the 

right and left hepatic lobe at various depths and assessed the 

accuracy of needle placement in CT imaging. 

RESULTS: The geometrical accuracy of needle placement was 

1.5 mm on mechanical phantoms. The average needle placement 

accuracy in the liver of human and animal cadavers was 

about 4 mm. Detailed statistical analysis was not possible 

because the experimental apparatus and protocol changed 

during the study. All targets clearly accessible with tilted 

gantry. 

CONCLUSION: The system promises to reduce X-ray dose, 

patient discomfort, and procedure time by significantly reducing 

faulty insertion attempts. It may also increase needle 

placement accuracy, compared to the conventional free-hand 

unassisted technique. 

FUTURE WORK: We will perform controlled studies with the 

CT image overlay system on human and fresh ventilated animal 

cadavers, focusing on hepatic needle placement under 

tiltled gantry. An MRI compatible version of the image overlay 

system has also been constructed and currently being tested 

on phantoms. 

FUNDING: Siemens Corporate Research, National Science 

Foundation #EEC-9731478, Brazilian Ministry of Education 

#CAPES-BEX1572/03 

TP015 

ANTI-FOGGING EFFECTS OF TITANIUM DIOXIDE (TIO2) COAT- 

ING LAPAROSCOPE WITH SUPER-HYDROPHILIC EFFECT: AN 

APPLICATION OF PHOTOCATALYSIS TECHNOLOGY TO 

LAPAROSCOPY, Takeshi Ohdaira MD, Hideo Nagai 

MD,Kazuhito Hashimoto PhD, Jichi Medical School 

Aim: Maintaining a clear view of laparoscope is a prerequisite 

for safe and accurate laparoscopic surgery. Conventional products 

used to prevent fogging of laparoscopic lenses include 

surfactant solutions to prevent water vapor condensation, 

lens-cleaning systems using a water jet, and systems to heat 

the tip of scopes. However, the effects of surfactants are only 

short-lived, and both water-jet and heater systems were 

proved to be totally ineffective for oily membrane. We developed 

a new anti-fogging device using titanium dioxide-coated 

glass, which has long-lasting anti-fogging properties against 

condensation, tissue debris, and blood, as well as oily membrane. 

Principles: The device is a cylindrical socket with titanium 

oxide-coated glass placed at its tip. Water, supplied 

through the socket device, produces a thin water barrier on the 

glass coated by titanium dioxide that protects the lens surface 

against oil, blood and tissue. Method of evaluation: 

Laparoscopic surgeries using conventional laparoscope and 

sockets with or without titanium dioxide coating glass were 

performed and video recorded. The time from laparoscope 

insertion to the first withdrawal and wash due to fogging was 

measured and compared among the three type sockets. The 

double-blind study included 20 patients, respectively, undergoing 

laparoscopic colectomy and laparoscopic gastrectomy with 

and without the anti-fogging glass. Likewise laparoscopic 

cholecystectomy was performed in 10 patients. Results: The 

anti-fogging effect of the titanium dioxide coated socket was 

significantly better than that of the uncoated sockets (p


Conclusions/Future Directions: A mechanical device has been 

developed that retains the desirable attributes of an endoscope, 

but incorporates features that overcome its inherent 

limitations. The ShapeLock Cobra is flexible like an endoscope, 

but can be locked to facilitate force transmission at the desired 

target in the desired plane. Future directions include using a 

CCD chip and LED light source for visualization. Using a CCD, 

wires can be routed through the dead space between the circular 

instrument lumens, thereby freeing space within the 

lumen for operating instruments. The Cobra is expected to 

facilitate advanced endoluminal procedures such as extended 

mucosal resection, full-thickness resection of gastric and 

colonic lesions, and gastric remodeling. Moreover, the Cobra 

may become an enabling technology in transluminal interventions 

to perform organ resection, anastomosis, bypass or 

other surgical indications within the peritoneal cavity. 

TP018 

CLINICAL, RESEARCH AND EDUCATIONAL APPLICATIONS 

FOR AUTOSTEREOSCOPIC DISPLAY AND PRINTING IN MINI- 

MALLY INVASIVE SURGERY, Michael J Mastrangelo, Jr. MD, 

Andrew H Joel, St. Charles Medical Center, Bend, OR and 

Volugraphics, Inc., Atlanta, GA 

Objective of the technology or device: A new technique is 

available that produces affordable, high-resolution, photographic-quality 

micro-lenticular transparencies and prints. 

Autostereoscopic printing of volumetric data and animated 

hardcopies (VolugramsTM) of cine, video and animation are 

applicable to clinical, research and educational content. 

Description of the technology: The Stereoscope was developed 

in 1838 and first applied to radiographic tomograms in 

1895. The ability to visualize and communicate volumetric 

medical data in stereo is becoming more important as the 

three-dimensional (3D) information produced by CT, MRI, PET 

and 4D ultrasound grows exponentially in complexity. 

Advancing technologies allow for routine stereo viewing and 

printing of the data. Previous display options have included 

active and passive stereo projection and display systems that 

require specialized polarized or shuttered glasses that control 

which image is seen by each eye. Autostereoscopic displays 

accomplish stereoscopic visualization without the use of glasses 

and instead use a lenticular lens system or a raster masking 

technique to achieve the same effect. The result is a visual 

sense of depth perception in the projected or printed image 

similar to what we naturally see with our binocular vision. 

Preliminary Results: Stereoscopic display technologies have 

been successfully used for clinical, research and educational 

applications including preoperative planning and surgical simulation. 

Autostereoscopic hardcopies of volumetric medical 

data are currently being utilized in scientific 

presentations/posters. 

Conclusions/Future direction: The micro-lenticular system is a 

method for producing prints and transparencies of animations, 

3D data and stereopairs that provides stereoscopic cues without 

the use of glasses or special viewing devices. This technique 

is applicable to volumetric medical imaging and holds 

promise for minimally invasive surgical planning, research, 

education and scientific presentation. 

TP019 

PROCEDURAL ALGORITHM FOR LCBDE USING MULTI-CHAN- 

NEL INSTRUMENT GUIDE, Donald E Wenner MD, James H 

Rosser, Jr. MD,Paul R Whitwam MD,David M Turner MD, 

Eastern New Mexico Medical Center 

Introduction: Laparoscopic Common Bile Duct Exploration 

(LCBDE) methods have evolved rapidly since the introduction 

of laparoscopic cholecystectomy. No unified approach or standardized 

LCBDE procedure has developed. Additional hurdles 

include damage to expensive fragile equipment and the organization 

of a complex operating room environment. These challenges 

have slowed the successful introduction of LCBDE into 

general surgical practice. 

Objective: The Multi-channel Instrument Guide (MIG) was 

designed to protect the choledochoscope from damage when 

guiding the choledochoscope into either the cystic duct or 

common bile duct (CBD). The MIG enhances control of the 

choledochoscope and lends itself to a systematic procedural 

algorithm and a standardization of the ?tool kit? required for 

LCBDE. 

Description and use of the MIG: The MIG is a J shaped three 

lumen guide tool. The largest lumen is 3.4mm diameter to 

accommodate a 2.8 mm flexible choledochoscope. The two 

smaller lumens are 1.9mm diameter. The flexible guide is 

pulled into an introducer sheath and straightened for insertion 

through a standard 10 mm laparoscopic port placed in the epigastric 

location. The surgeon guides the flexible choledochoscope 

into the cystic duct or into the CBD. The standardized 

?tool kit? needed for LCBDE includes the MIG, a flexible choledochoscope, 

balloon catheter, irrigation catheter, nitinol stone 

basket, and lithotripter or Holmium laser fiber. A video system 

that can accommodate two video inputs with picture in a picture 

feature is also needed. A procedural algorithm is followed 

based on patient anatomy, stone size and stone location. The 

algorithm progresses from simple to complex in a logical 

sequence. 

Results: A total of 54 LCBDE cases were completed using the 

MIG. A 96% rate of bile duct clearance was achieved. Damage 

to the flexible choledochoscope was reduced ten fold. The procedural 

algorithm was validated in cases with various stone 

sizes, numbers, and locations. Lithotripsy was effectively 

employed in cases with impacted or large stones. 

Conclusion: The MIG has achieved the goal of improved introduction, 

control, and protection of the choledochoscope. A 

standardized approach guided by a procedural algorithm has 

been achieved. For the future, this new approach to LCBDE 

needs to be validated in a teaching institution with general 

surgical residents so that LCBDE may be successfully integrated 

into general surgical practice. 

TP020 

DEVELOPMENT OF A PROTOTYPE ARTICULATING LAPARO- 

SCOPIC GRASPER., Dmitry Oleynikov MD, Tim Judkins 

MS,Katherine Done MS,Susan Hallbeck PhD, University of 

Nebraska 

A prototype articulating laparoscopic grasper tool which 

includes an articulating end effector, an ergonomic handle, 

and an intuitive hand/tool interface (Figure 1) has been developed. 

This study investigated the evaluation of the prototype 

tool by surgeons and comparison with existing tools. 

A questionnaire was developed to ask surgeons about problems 

they experience associated with use of conventional 

tools and then query their opinions of the prototype tool. 

Eighteen laparoscopic surgeons volunteered to complete the 

questionnaire. 

Generalized results were obtained through use of a Wilcoxon 

Signed Rank Test utilizing ranking with zeros for each hypothesis 

test. The level of significance for all statistical tests was 

0.05. 

Tests on problems such as hand/wrist pain, shoulder pain, finger 

tingling/numbness, etc. produced significant results for the 

number of surgeons experiencing each of the queried problems. 

A significant number of surgeons (p=0.045) identified the 

prototype handle as either comfortable or extremely comfortable. 

A significant number of surgeons (p=0.015) preferred the 

prototype tool over conventional tools, based on general 

impression. 

Articulation of the tip has been successfully designed in the 

prototype and 90% of the respondents believed the articulation 

to be a useful addition to laparoscopic graspers. The new 

shape of the handle is considered comfortable by a significant 

number of respondents. Most respondents believe the new 

design will relieve at least one problem currently experienced 

during surgery. Fifteen of the 18 surgeons queried said they 

would try a commercially available version of the prototype 

tool. 



245




TP021 

INTRA-OPERATIVE TELECONSULTATION IN LAPAROSCOPIC 

SURGERY: A COST EFFECTIVE ALTERNATIVE FOR THE 

DEVELOPING NATIONS, Ajay P Singh MS, Ravinder P Singh 

MS,Harinder Kaur MD,Subash Batta MS, Punjab Health 

Systems Corporation Civil Hospital, Ludhiana 

Objective 

The objective of the current presentation is to highlight how 

the newer technologies of telementoring, live streaming and 

audio video modes of connection can influence the patient 

outcome by instant re-sourcing of expert opinion regardless of 

time and space. Broadband Internet which forms the platform 

for telemedicine in the developed nations is either not easily 

available or is very expensive in most parts of the third world 

and the required hardware may not be within the reach of 

many small centers. Hence we developed a device, which can 

communicate using the already existing telecommunication 

modes requiring minimum hardware and respecting the financial 

constraints. 

Method 

The basis of this technology is development of an image-synchronizing 

device constructed from the available videophones. 

This videophone was modified to improve its resolution and 

enhance its connectivity, which enabled it to receive and transmit 

real time images without compromising the quality, using 

the existing cellular and regular telephone networks. 

Broadband Internet although worked well was never used. 

This device consisted of a camera, a high-resolution screen 

and an audio channel. The size of this device is smaller than 

that of a Laptop computer. A group of 15 experts in the field of 

laparoscopic surgery was constituted and given one such 

device each and were requested to carry it at all possible 

times. One such device was kept in the operating room connected 

to the monitor of the laparoscope. In the time of need 

the device was switched on and the expert was contacted as 

per the preference order in the roster and was asked to connect 

the device to the telephone or the cellular channel used 

initially to contact him. He then gave his expert opinion after 

seeing the images being transmitted to his device. 

Results 

We have been using this system for more than six months and 

have sought help in 42 cases and received instant response in 

36 cases. In 4 cases the expert was unable to comment 

because of poor image quality. In the remaining 32 cases the 

operating surgeon was benefited by the expert advice. 

Conclusion: 

This technique is inexpensive and appropriate in procuring 

instant intra-operative consultation without having a setup for a 

formal video conferencing. It is very useful in the early phase of 

learning curve and still has a great potential for its upgradation 

TP022 

A DUAL-CHANNEL CO2 INSUFFLATOR: A MULTIFUNCTIONAL 

DEVICE FOR WIDER CO2 APPLICATIONS, Kiyokazu Nakajima 

MD, Keigo Yasumasa MD,Shunji Endo MD,Tsuyoshi Takahashi 

MD,Akiko Nishitani MD,Riichiro Nezu MD,Toshirou Nishida 

MD, Department of Surgery, Osaka University Graduate 

School of Medicine - Osaka Rosai Hospital, Osaka, Japan 

Background: Carbon dioxide (CO2), with its rapid absorptive 

nature, has been more widely used in various clinical settings. 

The authors first proposed simultaneous (i.e. intraoperative) 

use of CO2 insufflation for both laparoscopy and colonoscopy 

and presented the preliminary data at SAGES 2004 meeting: 

CO2-insufflated colonoscopy during laparoscopy is feasible, 

safe and is of practical value to minimize persistent bowel distention 

without impeding subsequent laparoscopic visualization 

and procedure (Nakajima K et al, Surg Endosc 2005, in 

press). In that study we used a CO2 feeding system (for 

colonoscopy) in addition to a conventional automatic insufflator 

(for laparoscopy), since conventional insufflators have 

been designed solely for creation and maintenance of CO2 

pneumoperitoneum and were not suitable for other purposes. 

In collaboration with Olympus R&D department, we therefore 

are developing more flexible device, a dual-channel CO2 insufflator, 

which provides one channel for standard pneumoperitoneum 

and the other for various applications (e.g. CO2-insufflated 

colonoscopy, CO2-leak test for rectal anastomosis). 

The prototype: The device prototype, sized 295mm (W) x 

340mm (D) x 150mm (H), provides one CO2 inlet connected to 

a regular CO2 gas cylinder, and two CO2 outlets positioned on 

the front and back of the device, respectively. The CO2 gas fed 

from the cylinder, is pressure-regulated and divided into two 

independent conduits inside the device. The front outlet feeds 

CO2 gas for pneumoperitoneum at electronically-controlled 

pressure and flow rate. The back channel supplies CO2 gas at 

fixed flow rate (1.8 L/min), allowing manual control of insufflation 

for various purposes. 

Preliminary results: CO2-insufflated colonoscopy was attempted 

during laparoscopy on 4 canine models using the above 

prototype. Pneumoperitoneum was established and maintained 

successfully by utilizing the front channel of the device. 

Colonoscopy was performed simultaneously with CO2 gas fed 

from the back channel. There was neither device malfunctions 

nor device-related complications. The overall performance of 

the prototype was satisfactory. 

Summary and future directions: The device enables two different 

modes of CO2 insufflation at the same time from a single 

CO2 cylinder. Although the current prototype provides only 

fixed mode of CO2 insufflation from the back channel, the 

authors are now improving its function to allow wider use of 

CO2 in the operating room. 

TP023 

TISSUE PRE-COAGULATION WITH THE NEW RADIO FRE- 

QUENCY INLINE® DEVICE IMPROVES SURGICAL HEMOSTA- 

SIS, Steven A Daniel BS, Koroush S Haghighi MD,Taras Kussyk 

MD,David L Morris MD, UNSW Department of Surgery, St 

George Hospital, Sydney 

Introduction 

Achieving adequate hemostasis during liver resections is particularly 

difficult due to the vascular nature and complicating 

factors including cirrhosis, post chemotherapy fibrosis, and 

fatty liver disease. High blood loss during liver resections is 

known to result in increased rates of both operative and post 

operative morbidity and mortality. The cost of poor hemostatic 

control can be significant. This paper presents clinical results 

for the InLine®, a new pre-coagulation Radio Frequency (RF) 

device that reduces both transection blood loss and transection 

time. 

Method 

45 patients with primary or metastatic liver tumors underwent 

open surgical resection with pre-coagulation of the resection 

plane using the InLine® RF device (Resect Medical, Inc., 

Fremont, CA) prior to the transection. Standard surgical procedures 

were used for all other aspects of the surgeries. These 

patients included livers with normal function, cirrhotic livers 

(Childs A & B), Fatty livers, and post chemotherapy fibrosis. 

Both anatomical and non-anatomical liver resections were performed. 

The amount of blood loss during the transection, transection 

time, resection method, and the total resected surface 

area were noted. Blood loss and transection time were then 

calculated based on a per unit of resected surface area. 

Results 

In all cases a pre-coagulated resection plane was achieved 

using the InLine® and without significant patient complications. 

Published blood loss during liver transection averaged 

20.4 (+/-8.7) mls/cm2 compared to 3.4 (+/-3.8) mls/cm2 for transections 

performed after pre-coagulation with the InLine® 

device. Similarly, transection time reduced from 50.0 (+/- 28.3) 

sec/cm2 compared to 33.2 (+/-24.7) sec/cm2 for transections 

performed after pre-coagulation with the InLine® device. In 

both cases the results were statically significant 

Conclusion 

A variety of tools and techniques have been created to help 

reduce blood loss during liver surgery, however blood loss 

remains a significant complication. This is particularly true for 

non-anatomical resections and for those suffering from liver 

cirrhosis, post chemotherapy fibrosis, or fatty liver disease. 

This study has shown that pre-coagulation of normal, cirrhotic, 

fibrotic, or fatty liver tissue with the InLine® device is a safe 

and effective technique that helps to reduce blood loss, transection 

times, and procedural costs for liver resections. 

Additional InLine® work with kidneys & spleens is ongoing


TP024 

A RETROSPECTIVE STUDY COMPARING STOMAL STENOSIS 

RATES OF THE GASTROJEJUNOSTOMY IN LAPAROSCOPIC 

ROUX-EN-Y GASTRIC BYPASS WITH AND WITHOUT THE USE 

OF NITINOL SUTURES (U-CLIP) James M Kane MD, James M 

Kane, Jr MD, Peter C Rantis MD, Paul J Guske MD, Stuart R 

Verseman MD, Jonathan W Wallace MD, Alexian Brothers 


Laparoscopic gastric bypass is becoming the most common 

bariatric procedure performed in the United States. Certain 

complications, such as stomal stenosis, have been reported at 

a higher prevalence. We have noted an increase in our 

patients. In an attempt to reduce our stomal stenosis rate, we 

started performing an interrupted reinforcement of the stapled 

GJ anastomosis using nitinol clip sutures (U-CLIP). 

Method - A retrospective review of 364 patients undergoing 

laparoscopic gastric bypass. Two methods of performing a GJ 

anastomosis were compared in order to determine a difference 

in stomal stenosis rates. The initial GJ anastomosis were 

reinforced with interrupted running 2-0 Polysorb sutures (Auto 

Suture) and the later group with interrupted 3.00 mm U-CLIPs. 

Results - Three hundred and sixty four patients underwent 

laparoscopic gastric bypass during the study period. There 

were 213 patients in the initial group and 151 patients in the U- 

CLIP group. The two groups were comparable with respect to 

age, sex and BMI. There were 21 stomal stenosis in the non U- 

CLIP group and 4 in the U-CLIP group with a rate of 9.85% and 

2.6 respectively (p=0.00067). The operative times were not statistically 

different. 

Conclusions - The interrupted U-CLIP suture reinforcement of 

the circular stapled GJ resulted in a significant reduction in the 

stomal stenosis rate. The U-CLIP provided an easy and fast 

method of interrupted suturing laparoscopically that better 

replicated our open gastric bypass method without increasing 

the length of the operation. 

TP025 

INTERACTIVE BIOMATERIALS, M C Hiles PhD, J P Hodde MS, 

Cook Biotech Incorporated 

Natural scaffold biomaterials hold the promise of recapitulating 

strong and functional patient tissues without the need for a 

long-term foreign body. The SIS Technology uses the extracellular 

matrix from mammalian intestinal tissues to provide a 

tissue repair scaffold into which the patient?s cells rapidly 

grow and actively restore natural tissue structure and function. 

The potential surgical applications of this natural mesh material 

are endless and current usage is already quite broad. The 

healing of chronic wounds, multi-year relief from incontinence, 

and successful hernia repairs in grossly contaminated fields all 

attest to the uniqueness and applicability of this technology. 

Future applications ranging from vascular valves and conduits 

to plastic and reconstructive tissue bulking can all benefit from 

the potential of these devices to grow with pediatric patients. 

The wide range of surgical applications of this biomaterial 

technology will be explored with examples of current uses and 

futuristic endeavors that hold great potential for advancing 

human medicine. 

TP026 

NEEDS BASED, “INTELLIGENT” SURGICAL SKILLS TRAINING 

SYSTEM David Earle MD, David Hananel BS, Neal Seymour 

MD, Baystate Medical Center 

OBJECTIVE Technologic advances have made it possible to 

enhance surgical training within the current framework of 

mainstream residency programs. Missing from curriculum 

design is a strategy to tailor training among residents, and for 

an individual resident over time. We will use an automated 

system based on individual performance to guide the surgeon 

educator inside the operating room, and the trainee utilizing 

simulation lab outside the operating room. 

DESCRIPTION Surgical residents are required to perform a 

series of tasks using a virtual reality, surgical education platform 

(SEP) in a simulation lab. The SEP includes didactic content 

and manual skills exercises. The assessment information 

from the lab will interface automatically with our online 

assessment form present in each operating room. Immediately 

before an operation, the surgeon educator will review this 

data, and during the operation, focus on areas identified as not 

being mastered. Immediately after the operation, the surgeon 

can give the trainee feedback on performance using the online 

assessment. The clinical performance data will then automatically 

interface with the SEP to guide the trainee to areas of 

need at the next self-guided lab session. 

CONCLUSION A feedback loop between the clinical setting 

and simulation lab will enhance both efficiency and safety of 

patient care taking place in teaching hospitals. It will help 

objectively quantify what surgeons deem competent behavior 

– something that is easily recognized, but difficult to define. It 

will help foster an environment where honest feedback from 

educators is constructively used by trainees. 

FUTURE DIRECTIONS Incorporation of emergency resuscitation, 

and procedures such as central venous access, airway 

management, and wound management. Access to an online 

surgical video library and additional didactic material will also 

be incorporated to enhance the educational experience. 

Additionally, data could be used to promote or re-direct 

trainees. 

TP027 

WWW.LAPSEARCH.NET, A SEARCH ENGINE FOR LAPARO- 

SCOPIC EQUIPMENT AVAILABLE IN THE UNITED STATES, M J 

Weiner MD, S A Laker MD, New York University, New York, NY, 

Hackensack University Medical Center, Hackensack, NJ 

Objection: To create an objective source for surgeons, nurses 

and OR purchasers to obtain information on all laparoscopic 

devices for use in the United States. 

Description: LapSearch (www.lapsearch.net) is a laparoscopic 

device search engine that was created to make the process of 

obtaining information about laparoscopic instruments more 

manageable. Surgeons can use LapSearch to find devices 

based on their physical dimensions, function or characteristics 

(i.e. all ligature devices 5mm in diameter with that use ultrasonic 

cutting). Currently there are over 1000 devices in the 

database, with plans to expand if there is interest. Lapsearch is 

continuing to add new features including the ability to store 

lists of devices, the option to view the most popular devices of 

the day, week or month and an upcoming option that will 

allow surgeons to share their experiences with one another 

and discuss the strengths and weaknesses of particular 

devices. Lapsearch intends to work together with the device 

companies allowing them to continually update the database, 

ensuring its currency. Lapsearch was designed by physicians 

for physicians and is and always will be free to all health care 

practitioners. 

Preliminary Results: The website serves as the only search 

engine available that allows the physician to obtain objective 

information on available laparoscopic equipment from multiple 

manufacturers. 

Conclusion: The website, www.lapsearch.net, aids the surgeon, 

nurse and hospital purchaser in making an informed 

decision on the products they choose to purchase and use. In 

addition, the site acts as a platform for the introduction of new 

devices and technologies by the manufacturers. Lapsearch 

ultimately hopes to serve as a platform for educating surgeons 

and providing timely, critical product information. 



247



TP028 

A BREAKTHROUGH IN SURGICAL VIDEOSCOPE TECHNOLO- 

GY, Matthew Fahy MS, Gina M Baldo BA, Joseph R Williams 

MS, Olympus America, Inc. 

The new Olympus LTF-VP 5mm Surgical Videoscope is a technological 

breakthrough in imaging engineering. It utilizes 

Olympus? unique EndoEYE technology, placing the CCD 

(charged coupled device) at the distal end of the scope. The 

resulting image is brighter with better color reproduction and 

resolution than any conventional laparoscope. This is due to 

the fact that the rod lens system of conventional laparoscopes 

is thereby eliminated, along with all its inherent limitations. 

Since fewer lenses are required, reflected noise that occurs at 

lens surfaces is educed. Light absorption that typically occurs 

inside the rod lens system is reduced, permitting bright, natural-color 

imaging and a deep, focus-free depth of field. A wider 

field of view presents more reliable orientation. Illumination 

lenses are placed at the distal tip, facilitating the most appropriate 

light distribution and contributing to a wider field of 

view. 

The distal tip is also deflectable (flexible) and provides unlimited 

degrees of visual freedom - up to 100° in any direction. 

This advanced deflectable design allows comprehensive 

observation of regions such as lateral, luminal and en face 

parenchyma. The deflectable tip design also allows areas to be 

viewed more expansively than ever before, even providing the 

capability of visualizing anatomical structures that were previously 

inaccessible with conventional laparoscopes. The LTF-VP 

Videoscope can be utilized through any access port 5mm or 

greater, enhancing the surgeons ability to view the 

anatomy from any desired perspective. Ergonomic progression 

includes a newly designed control body and deflector 

mechanism. The one-piece integrated design requires no manual 

focusing, no assembly and rapid reprocessing, improving 

product durability and reliability. 

TP029 

REAL-TIME 3-D MEASUREMENTS IN ENDOSCOPIC VIDEO 

IMAGES; A NOVEL ALGORITHM AND POTENTIAL FOR 

FUTURE DEVELOPMENTS., Amir Szold MD, Tel Aviv Sourasky 

Medical Center, Tel Aviv, Israel 

Aim: the use of a single stereoscopic sensor for video imaging 

enables to appoint three dimensional coordinates to each 

pixel. In order to develop machine ?understanding? of anatomical 

landmarks an algorithm capable of measuring 3-dimensional 

relative distances between key points is necessary. 

Methods: An algorithm has been developed that is capable of 

accurate 3-dimensional measurements during endoscopic procedures. 

Results: The algorithm was incorporated into a stereoscopic 

camera picture-processing unit. The resolution of the device is 

scalable according to application needs and is the result of the 

sensor resolution, distance and anatomical features. Currently 

the measurements are done in real time, while the image is 

frozen to increase accuracy. 

Future developments: 3D measurements enable 3-dimensional, 

real time picture analysis. This, in turn, is the theoretical 

basis for registering the streaming video to archived data, 

such as anatomical landmarks from anatomy pictures or even 

archived patient data such as CT or MRI. 

TP030 

THE SHAPELOCK: A UNIQUE AND VERSATILE TOOL FOR THE 

NEXT GENERATION OF DIAGNOSTIC AND THERAPEUTIC 

COLONOSCOPY, Pankaj J Pasricha MD, Gregory B Haber 

MD,Douglas K Rex MD,Gottumukkala S Raju MD, University of 

Texas Medical Branch, Lenox Hill Hospital, Indiana University 

Technology Objective: The ShapeLock? Endoscopic Guide 

(USGI Medical, San Clemente, CA) is a tool that facilitates intubation 

and provides a platform for next generation therapeutic 

procedures. 

Description of Technology: The ShapeLock? Endoscopic Guide 

consists of two components. The first component is a 

reusable, multi-link, flexible overtube with a squeeze-activated 

handle. The second component is a disposable, sterile sheath 

with a smooth external skin, a hydrophilic coated inner liner 

and an atraumatic tip that is loaded onto the reusable component 

prior to each use. 

Method of Application: The endoscope is inserted into the 

lumen of the ShapeLock and then inserted into the anatomy. 

Once inserted, the ShapeLock can be converted from a flexible 

to a rigid configuration without changing shape to stabilize the 

colon and prevent painful and potentially dangerous looping. 

Preliminary Experience: 

1. Preliminary studies from multiple centers involving over 200 

cases have shown that the ShapeLock device is safe and facilitates 

colonoscopy. Typical shortening and straightening 

maneuvers of the colon are not only feasible but appear to be 

abetted with the flexible ShapeLock in place. 

2. Pilot data has shown that the ShapeLock is useful in facilitation 

of colonoscopy to the cecum in patients with redundant 

colon in which previous colonoscopy was unsuccessful. 

3. The device serves as conduit for rapid redeployment of the 

colonoscope to facilitate removal of multiple large polyps 

located in the proximal colon and also serves as a decompression 

tube during prolonged procedures, thereby improving 

patient comfort. 

4. The ShapeLock provides a large and flexible conduit for 

evacuation and removal of semi-solid material or blood. The 

role of ShapeLock to enable conversion of an incomplete prep 

to a ?clean colon? is being investigated. The ShapeLock may 

also be useful to quickly prepare the colon in cases of colonic 

bleeds in which immediate colonoscopy is indicated. 

Conclusions/Future Directions: The ability of the ShapeLock to 

be converted from a flexible configuration to a rigid one that 

resists pushing forces represents a technological advancement 

in colonoscopy. The safe application of forces much greater 

than currently possible may enable the ShapeLock to assist in 

the development of next generation therapeutic procedures. 

Finally, a narrow-bore, longer length ShapeLock has the potential 

to enable the use of smaller colonoscopes. 

TP031 

LAPAROSCOPIC ASSISTED ENDOSCOPIC RETROGRADE 

CHOLANGIOPANCREATOGRAPHY: A NOVEL TECHNIQUE TO 

TREAT CHOLEDOCHOLITHIASIS DIAGNOSED AFTER LAPARO- 

SCOPIC ROUX-EN-Y GASTRIC, William R Silliman MD, Roger 

A delaTorre MD,Steven Scott MD,Nitin Rangnekar MD,Steven 

Eubanks MD, University of Missouri-Columbia 

Abstract: 

1.Objective of the Technology or Device: 

Morbid obesity has become a significant health problem in the 

United States. Many patients are undergoing surgical treatment 

for their obesity and, there has been a significant 

increase in the number of laparoscopic roux en y gastric 

bypass operations performed. Symptomatic cholelithiasis is a 

common problem in the morbidly obese population. 

Cholelithiasis may present either prior to or after the obese 

patient has had significant weight loss. Choledocholithiasis, a 

complication of cholelithiasis, is frequently treated with ERCP. 

Unfortunately, patients who have had a previous roux-en-y 

gastric bypass are not candidates for endoscopic removal of 

the common duct stones with ERCP. We describe a novel technique 

used to treat choledocholithiasis in a patient who had 

undergone a roux-en-y gastric bypass 6 weeks prior. 

2.Description of the technology and method of its use or application: 

Laparoscopic assisted gastrotomy was performed in the 

bypassed stomach allowing access to the stomach and duodenum 

with introduction of the endoscope through the abdominal 

wall and into the anterior mid-body of the stomach near 



the greater curvature. The ERCP was then performed performed 

and the gastrotomy was closed. 

3.Preliminary Results: 

The common bile duct stones were successfully removed via 

ERCP. The patient tolerated the procedure well and went home 

on post-operative day three. 

4.Conclusions/Future Directions: 

Laparoscopic assisted ERCP is a safe and effective method to 

treat choledocholithiasis in patients who have undergone previous 

roux-en-y gastric bypass. 

TP032 

REMOTE PRESENCE PROCTORING USING WIRELESS 

REMOTE CONTROL VIDEOCONFERENCING SYSTEM, C Daniel 

Smith MD, Kyle W Peterson PhD, Emory University School of 

Medicine 

OBJECTIVES: Remote presence in an operating room to allow 

an experienced surgeon to proctor a surgeon has been promised 

through robotics and telesurgery. While several such systems 

have been developed and commercialized, little progress 

has been made using telesurgery for anything more than live 

demonstrations of surgery. This pilot project explored the use 

of a new videoconferencing capability to determine if it offers 

advantages over existing systems. METHODS: The video conferencing 

system used is a PC based system with a flat screen 

monitor and an attached camera that is then mounted on a 

remotely controlled platform (Figure 1). This device is controlled 

from a remotel PC-based videoconferencing system 

computer outfitted with a joystick. Using the public internet 

and a wireless router at the client site a surgeon at the control 

station can manipulate the videoconferencing system. Controls 

include navigating the unit around the room and moving the 

flat screen/camera like a head looking up/down and right/left. 

This system (InTouch Medical, Santa Barbara, CA) was used to 

proctor 1st year medical students during an anatomy class 

human dissection. The ability to effectively monitor the 

student?s dissection and direct their activities was assessed 

subjectively by students and surgeon. RESULTS: This device 

was very effective at providing a controllable and interactive 

presence in the anatomy lab. Students felt they were interacting 

with a person rather than a video screen and quickly forgot 

that the surgeon was not in the room. The ability to move the 

device within the environment rather than just observe the 

environment from multiple fixed camera angles gave the surgeon 

a similar feel of true presence. CONCLUSION: A remote 

controlled videoconferencing system provides a more real 

experience for both student and proctor. Future development 

of such a device could greatly facilitate progress in implementation 

of remote presence protoring. 

TP033 

Augmented reality interface for laparoscopic skills training 

Gerard Lacey, Derek Young, Derek Cassidy, Fiona Slevin, 

Donncha Ryan 

Haptica Ltd, Dublin, Ireland. 

Purpose 

The surgical community have developed a range of simple but 

effective training scenarios for laparoscopic surgical skills. 

These “box trainers” allow surgeons to practice surgically relevant 

tasks safely. The skills taught in box trainers have been 

shown to transfer to live operative performance [1] and the 

surgeon’s hand movements have been shown to correlate well 

with surgical skill [2]. This abstract describes ProMIS an 

Augmented Reality (AR) training system that improves box 

trainer tasks by adding both objective assessment and interactive 

graphics to the training tasks. 

Method 

One method of providing objective assessment of surgical skill 

is to capture and analyse the movement patterns of the surgeon’s 

instruments while completing a standardised task. This 

tests both the surgeons dexterity and their familiarity with the 

instruments and by analysing the movement patterns the efficiency 

of motion can be determined. 

ProMIS achieves objective surgical skills assessment by capturing 

the 3D movement of commercial laparoscopic instruments 

while completing a standardised task. The surgeon’s 

view of training tasks is provided by a digital camera mounted 

within the bodyform. The position information is gathered 

using cameras thus a reliable and accurate non-contact measurement 

system is achieved. 

The main performance metrics are time taken, total path 

length swept by each instrument tip and the smoothness(efficiency) 

of the surgeons movement. Additionally task specific 

metrics are calculated to measure performance associated 

with different regions on and above the task plate. This is 

achieved because ProMIS has an accurate 3D model of the 

standard task and regions in space. A software tool called 

ProMIS LessonMaker allows a non-technical user to create 

these regions and their associated metrics as part of creating 

customised instructional materials. 

Augmented Reality in Training Tasks 

In addition to the capability to provide measurement ProMIS 

Lesson Maker uses advanced multi-media technology to allow 

the creation of Augmented Reality training materials. This is 

the combination of 3D interactive graphics with live video. 

This technology is normally associated with movie industry or 

fighter pilot displays is used to add additional instruction, 

interactive psychomotor challenges or proximal feedback on 

errors during the completion of a “standard box trainer task” 

Figure 1 Superimposed graphics interacting with instruments 

during live video trainer task. 

Results 

The construct validity of the ProMIS system has been 

demonstrated in 3 studies in Emory, Imperial College, London, 

UK and AMNCH, Dublin, Ireland [3, 4]. Interactive augmented 

reality content has been merged with the live video to improve 

the training content and efficacy. A number centres are conducting 

so called “VR-OR” studies to validate the transfer of 

skills developed in ProMIS transfer to the OR. 

Conclusions 

In the ProMIS system Augmented Reality has been shown to 

provide a clinically validated, flexible and engaging platform 

for training and objectively assessing the skills of laparoscopic 

surgery. Because the system uses non contact sensing, real 

surgical instruments and runs on a standard PC it is a very 

robust and cost effective method of surgical training. 

References 

[1] Datta, V. Bann, S. Beard, J. Mandalia, M. Darzi, A. 

Comparison of bench test evaluations of surgical skill with live 

operating performance assessments. J Am Coll Surg 2004 

volume 199 issue 4 pp. 603-6 

[2] Smith SG, Torkington J, Brown TJ, Taffinder NJ, Darzi A. 

Motion Analysis, Surg Endosc. 2002 Apr;16(4):640-5 

[3] D.A.M. McClusky K. Van Sickle, A.G. Gallagher Relationship 

Between Motion Analysis, Time, Accuracy, and Errors During 

Performance of a Laparoscopic Suturing Task on an 

Augmented Reality Simulator EAES 2004 

[4] D. Broe, P.F. Ridgway, S. Johnson, C. Tierney, K.C. Conlon, 

Validation of a Novel Hybrid Surgical Simulator, EAES 2004 

TP034 

PRELIMINARY EXPERIENCE WITH A NEW MECHANICAL 

MANIPULATOR: THE RADIUS SURGICAL SYSTEM 

Nicola Di Lorenzo MD, Giorgio Coscarella MD, Luca Faraci MD, 

Iwona Gacek MD, Fabrizio S Altorio MD, Achille L Gaspari, 

UNIVERSITA’ DI ROMA TOR VERGATA ITALY 

Objective of the device: 

Improvement of the four degrees of freedom (DOF) that limit 

conventional instruments in their range of movement: till now, 

only electronic robotic effectors have mimicked the human 



249



wrist freedom. 

Laparoscopy is associated with a stressing position, with high 

elbows and contracted back muscles. With ergonomic handles, 

the hands and arms of the surgeon are relaxed, avoiding discomfort 

and fatigue. 

Description of the technology: 

Manual manipulators represent a new class of endoscopic 

devices, positioned between conventional instruments and 

robotic systems. 

Radius Surgical System is a mechanical bi-manual instrument 

system (produced by Tuebingen Scientific, it received the CE 

mark in October 2003) with 6 DOF (such as in robotic surgery) 

and an ergonomic hand-arm movement and position, that can 

be used as simple as a conventional endoscopic instrument. 

The tip of the intrument can be deflected and rotated, a variety 

of interchangeable effectors can be used for the specific surgical 

tasks. All functions can be operated via a multi-functional 

ergonomic handle. 

Preliminary available results: 

The device is currently under surgical investigation in partnership 

with some leading groups worldwide. We report 

the results of an experimental study evaluating the learning 

curve of the instrument, with three groups of participants, 

demonstrating that the learning curve is not highly complex, 

and improvement is achieved in all groups our preliminary 

clinical applications in bariatric surgery and abdominal hernia 

repair. 

Conclusions/Future directions. 

Advantages of Radius are: 

Six DOF, with ergonomic hand-arm movements. 

Alignment of the instrument tip in difficult access angles. 

Versatility by simple change of endo effectors and compatibility 

to normal laparoscopic OR setting, with no additional set-up 

time required; 

Cost effectiveness: Radius is a surgical manipulator system 

that will be priced as a hand-guided instrument system, at a 

hundredth of the price of electronic robots. 

Current problems are: 

Precise and controlled needle guidance still to be improved; 

Limited number of tips: new effectors soon available 

More efficient when suturing in a small space, on the perpendicular 

axis. 

Ergonomic advantages can be better appreciated after an intuitive 

learning curve to control the instrument most effectively. 

Procedures that benefit of the Radius are those with maneuvers 

and suturing in recesses, like:Fundoplication; Prosthetic 

fixation; Bariatrics; Radical prostatectomy; IMA – take down. 

Key words: ergonomy – manipulators – laparoscopy – DOF

2005 SAGES Abstracts

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