Surg Endosc (2001 ) 15: S 104-S 176 DOI: 10.1007/s00464-001-0015-5 Surgical Endoscopy Ultrasound and Interventional Techniques

9 Spnngcr-VerlagNew York Inc. 2001

2001 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) St. Louis, Missouri, USA, 18-21 April 2001 Poster presentations*

LAPAROSCOPIC "RADICAL APPENDECTOMY" IS AN EFFECTIVE LAPAROSCOPIC RESECTION OF A BLEEDING ILEAL ALTERNATIVE TO ENDOSCOPIC REMOVAL OF CECAL POLYPS LYMPHANGIOMA Gina L. Adrales, M.D., Sharon L. Goldstein, M.D., Brent D. Matthews, Gina Adrales, M.D., Sharon Goldstein, M.D., Brent Matthews, M.D., Richard L. Sigmon, Jr., M.D., Kent W. Kercher, M.D., B. Todd M.D., Robert T. Yavorski, M.D., William C. Sugg, M.D., B. Todd Heniford, M.D., Department of Surgery and Charlotte Clinic for Heniford, M.D., Gastrointestinal and Liver Diseases, Carolinas Medical Center, Department of Surgery and Charlotte Medical Clinic, Carolinas Charlotte, North Carolina Medical Center, Charlotte, North Carolina. The endoscopic approach to cecal polyp resection harbors several possible complications, including the risks of perforation and bleeding. Gastrointestinal lymphangioma is a rare entity. These benign In addition, failure to remove the polyp in its entirety frequently requires tumors are composed of abnormally dilated lymphatic channels. multiple endoscopies for resection and confirmation of resection. Though often asymptomatic, small intestinal lymphangiomas may Laparoscopic "radical appendectomy" represents a safe alternative to become clinically significant as the cause of intestinal obstruc- endoscopic treatment with the potential to reduce the risk of recurrence tion, intussusception, or hemorrhage. We present an unusual and subsequentmalignancy. case of laparoscopic resection of a bleeding ileal lymphangioma Four I~atientswith edenomatous polyps of the cecum were treated with and a review of the literature. laparoscopic resection of the appendix and cecum to the level of the ileocecal valve ("radical appendectomy") and intraoperative A 33 year-old man presented with progressive fatigue and syn- colonoscopy. Three of the four patients had villous adenomas of the cope. The finding of severe microcytic anemia prompted an cecum (3 to 4.5 cm). One patient had a 3 cm tubulovillous adenoma. upper and lower endoscopic evaluation, which were both nega- There were two male and two female patients, ages 46 to 61 years, tive. Subsequent enteroclysis revealed a 3.0 cm ileal tumor sug- (mean 54). Two patients presented with occult gastrointestinalbleeding. gestive of a hemangioma. Exploratory laparoscopy, intraopera- Three of the four patients had significant co-morbidities, including dia- tive liver ultrasound and resection of a mid-ileal nodular tumor betes and coronary atheroscterotic disease. One patient, with a history were performed. The pathologic findings were consistent with of alcoholic cirrhosis, underwent intraoperative liver ultrasound and liver benign lymphangioma of the ileum. The patient remains stable biopsy and had the longest operative time. Operative time ranged from at two months follow-up. 53 to 184 minutes. Length of hospital stay (1 to 3 days) was consider- ably short. Final pathology revealed carcinoma in situ in two specimens Lymphangioma of the small intestine are highly unusual with adequate margins. There have been no postoperative complica- tumors. However, the frequency of diagnosis is increasing with tions observed during the 2 to 12 month follow-up. the expanding role of endoscopy in patient care. There are Laparoscopic "radical appendectomy" can be a safe and effective reports of resection of these tumors endoscopically in the litera- alternative to endoscopic removal in the treatment of cecal adenoma- ture. Lymphangiomas are often sessile and widely-based neo- tous polyps. This procedure can attain definitive resection, allow com- plasms, which may limit endoscopic evaluation and resection. As plete and accurate pathologic evaluation, and negate the need for illustrated in this case presentation, laparoscopy provides an repeated endoscopiesand piecemeal removal of polyps. Our brief oper- effective method of diagnosis and curative resection of intestinal ative times and absence of complications support this laparoscopictech- lymphangiomas. nique as a reasonableapproach in the managementof cecal polyps.

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LAPAROSCOPIC SURGERY OF THE DISTAL PANCREAS: AN INITIAL EXPERIENCE OF LAPAROSCOPIC PSEUDOCYST EXPERIENCE ON THE LEARNING CURVE DRAINAGE. William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin MD, Michael J William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and MD, Michael J McMahon, MD., Leeds Institute for Minimally Academic Surgical Umt, Leeds General Infirmary, Leeds, UK Invasive Therapy (LIMIT) and Academic Surgical Unit, Leeds General Infirmary, Leeds. UK Fourteen consecutive patients (age 28-75 years, median 51.5) with symp- tomatic pseudocysts were treated laparoscopically.(Table) When present, Laparoscopic surgery for distal pancreatic pathology presents necrosis was debrided. Cyst-gastrestomy was initially performed through a longitudinal gastrostomy but is now performed by an intreluminal approach new challenges. These have been evaluated in a review of our to minimise trauma to the anterior stomach wall. The patients have been fol- initial experience. lowed for a median of 9 months (range 1-63). Seventeen patients underwent laparoscopic distal pancreatec- Excellent visualisation of the interior of the cavity was obtained, allowing tomy and two had enucleations of benign tumours, age range removal of necrotic tissue and clipping of a large, potentially troublesome 14-82 yrs (median 60). Indications included cystadenomas, vessel under direct vision. There were two recurrences, both in the drainage endocrine tumours, chronic or familial pancreatitis and a pseudo- group (p=O.005), which were managed successfully by interventional radiolo- gy. There was one minor chest infection and an episode of acute urinary cyst. Operative times ranged from 130-550 mins (median 300) retention among the cyst-gastrostomy group. One wound infection occurred and the median postoperative stay was 11 days (range 3-63). in a patient who was converted to laparotomy. Patients have been followed for 5-78 months (median 27). Although endoscopic or percutaneous methods for pseudocyst drainage There were five conversions, due to intra-operative bleeding have been advocated, the surgical approach of effective drainage and (n=2), unsuspected malignancy (n=2) and uncertain anatomy debridement of necrotic tissue remains the gold standard with lower recur- (n=l). Four collections required interventional radiology. There rence and infection rates. Intra-luminal, laparoscopic cyst-gastrestomy com- bines these principles with a safe, minimally invasive approach. It provides were also two pancreatic fistulae, two wound infections and two excellent visuahsation of the cavity and is superior to drain insertion. subsequent laparotomies; one for bleeding and one for a splenic infarct. One patient with chronic obstructive airway disease died lirne Converted Diet Dischazge. from MRSA pneumonia. (min) (day) (day) Collections and fistulae ceased when oversewing of the pan- Cy~~ creatic stump was abandoned. Serious wound infections were - Gast~ (n=3) 270 0 6 9 eliminated by the introduction of a totally waterproof bag. Cyst~ Troublesome bleeding due to fibrosis, obesity and access has -Intraluminal(n=7) 180 1 4 7 become less of a problem with use of the Harmonic Scalpel and lately, the Ligasure. Drain (n=4) 180 1 5.5 25.5 With experience and appropriate equipment, laparoscopic dis- tal pancreatic surgery is both feasible and safe. Cyst-jejunostomy(n= 1) 250 I 5 10

LAPAROSCOPIC GASTROJEJUNOSTOMY FOR BENIGN AND LAPAROSCOPIC CHOLECYSTOJEJUNOSTOMY FOR MAUGNANT DISEASE. AN INITIAL EXPERIENCE MALIGNANT DISEASE. AN INITIAL EXPERIENCE William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin MD, William G Ainslie, MBChB, Basil Ammod MD, Michael Larvin MD, Michael J McMahon, MD., Leeds Institute for Minimally Invasive Michael J McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and Academic Surgical Unit, Leeds General Infirmary, Therapy (LIMIT) and Academic Surgical Unit, Leeds General Leeds, UK Infirmary, Leeds, UK

Objective. To evaluate the outcome and problems of laparoscopic Patients with obstructive jaundice due to pancreatic and hepatobil- gastro-jejunostomy. iary malignancies have a poor prognosis. Palliation should be mini- Method. Review of our experience mally invasive to optimise quality of life. The purpose of this review is Results. Twelve gastrojejunostomies were performed on eleven to evaluate the outcome and problems encountered during our initial patients, age range 50-83 years (median 78), with gastric outlet experience of laparoscopic cholecystojejunostomy. obstruction due to malignancy (n=9) or chronic pancreatitis (n=2). Both Fourteen patients with obstructive jaundice secondary to cholangio- antecolic (n---8) and retrocolic (n=4) anastomoses were performed. Two carcinoma (n=2), pancreatic cancer (n=11) or an islet cell tumoux patients also had a concomitant cholecystojejunostomy. Eight anasto- (n=l) had a laparoscopic cholecystojejunostomy. Two patients had moses were stapled and the remainder, were sutured. The method of concomitant gastrojejunostomy for gastric outlet obstruction. Five anastomosis did not significantly affect the operating time, which was a patients had the procedure performed at a staging laparoscopy ant median 162.5 minutes (range 130-290). Impenetrable adhesions, a fri- two progressed to pancreatico-duodenectomy once their jaundic~ able gallbladder and sheer tumour bulk prompted three conversions. had been relieved. Four procedures followed failed ERCP stent inset. Post-operatively there were two episodes of haematemesis; one settled tion. spontaneously and the other required laparotomy and oversewing of There was one conversion due to a friable gallbladder the staple line. Diet was recommenced by 7.5 days (median) but three Postoperatively, one patient had a bile leak and another, a suture line patients continued to vomit. Two died on days 6 and 8 from camino- bleed - both settled spontaneously. In the latter patient, the jaundice matosis. failed to resolve, and pemutaneous insertion of a metal stent wa., Two patients experienced late recurrences of gastric outlet obstruc- necessary. tion. The first, due to an inflammatory pancreatic mass, settled with Excellent relief of jaundice was achieved in the other thirteer conservative treatment. The other, with tumour infiltration of the anasto- patients, with bilirubin level falling from a median of 358.5pmol/1 pre mosis, had a new gastrojejunostomy formed laparoscopicatly, 98 days operatively to 102h'mol/I by discharge, and 31.5pmol/I at subsequen after the initial procedure. follow-up (p<0.001). Relief of jaundice was obtained for 115.5 day.' Follow-up of oncology patients for 6-390 days (median 73) found that (median, range 0-895) with a follow-up of 153.5 days (median, rang~ palliation was obtained for a median of 68 days (range 0-390). "lime in 14-895). Only two patients had recurrent jaundice just prior to death. hospital as a result of gastric outlet obstruction was a median of 16 Laparoscopic cholecystojejunostomy is an effective palliative proce days (range 6-31). dure for obstructive jaundice and is easily performed when stagin(. Conclusion. Lapamscopic gastrojejunostomy can offer good palliation laparoscopy reveals the turnout to be inoperable. It can also reliev~ of gastric outlet obstruction without a laparotomy. However, it is still sub- severe jaundice prior to a definitive procedure where endoscopic ject to gastric paresis and the nature of the underlying disease process. stenting is unavailable. SI06

LESS INVASIVE NEEDLETHORACOSCOPIC LASER ABLATON FOR C O M P U T BULLA OF PRIMARY SPONTANEOUSPNEUMOTHORAX. Akinori Akashi. F U NodhisaShigemura, MD, TomoyukiNakagid, MD, TakeshiOriyama, MD*, N SWINE. Robed J. Albrecht, MD; Victor B. Kim, MD; James A. Young, Toshihiro Okada,MD ~ Uko Chou, MD*, Shigeto Maeda,MD',Gakuhei Son, MD; L. Wiley Nifong, MD; W. Randolph Chitwood, Jr., MD; William H. Chapman, MD., Departmentof Surgery, East Carolina University School MD*, SatoshiMatsuzaka, MD', YuuichiKondo, MD*, and Hisashi Kosaka, of Medicine,Greenville, NC MD'. Departmentof ThoracicSurgery, and Generalsurgery*, Takarazuka MunicipalHospital, Hyogo, Japan Recent developmentsin minimally invasive surgery include computer enhanced robotically assisted surgery. We investigated the feasibility of OBJECTIVE: Video-assistedthoracoscopic surgery (VATS) for the bullectomy roboticallyassisted Nissen fundoplicationin a swine model. of patientwith primaryspontaneous pneumothorax(PSPJ has become~e Nissen fundoplicationswere performed in ten anesthetizedswine using popularprocedure. Without bullectomy,we haveperformed laser ablarion for the daVinci(tm) robotic surgical system (Intuitive Surgical, Mountain View, CA). Following the creation of a pneumoperitoneum,a three-dimensional bdla by needlethoracoscopy(nsedle-VATS:2-3mm in diameter)as less thidy-degreeendoscope was introduced through a 12mm port in the mid- invasivesurge~. To clarify its usefulness,prospective study was performed line 6cm below the xiphoid process. Two robotic instrument arms were about indication,anaJgesia, complication, and recurrence.METI.IODS: From introduced through 10mm ports placed bilaterallyat the level of the umbili- 1997to 2000, 95 caseswhich undanHentVATS procedurewith stapler cus in the anterioraxillary line.An accessory 10mm port was placed in the 10ullectomy(bullasize: >2 cm) or needle-VATSprocedure with only laser left midclavicularline 3cm below the left instrument arm for the ultrasonic ablationfor bulla(<2on) were analyzed.We haveour protocolto determinea dissector and suture delivery. In addition, a fourth 10mm port was placed 3cm inferior and lateral to the right instrument arm for liver retraction. indicationof VATS or needI-VATSprocedure, according to the sizeof bulla Times were recordedfor the foUowing: robot preparation;port placement; iden~ed by high-reselubonchest CT. RESULT:43 cases(45%)underewent dissection of the esophagealhiatus; stomach mobilization;and placement VATS procedure,and 52 cases(55%) underwentneedle-VATS procedure. In of sutures. Meantimes are expressedin minutes+standard deviation. the needle-VATSgroup, operatarion time was shorter thanthet of VATS Setup rime was 17+-3 min. "13mefor port placement was 12+-4 min. groulX39.8• 17.5minutes vs. 56.6• minutes;p<0.0f). Usageof non- Short gastric vessels were divided in 10+-5 min. Hiatal dissection and fun- steroidalanti-inflammatory drugs for postperarivewound pain could he dus mobilizarionwas completed in 19+-12 rain. Sutures were secured in 18+-5 min. Total proceduretime was 59+-25 min. reduced in needle-VATSgroup (11.2% vs. 58.8"/0; p<0.001).There were no Superior three-dimensionalvideoscopic imaging and precisionof motion complicationin the needle-VATSgroup, 10ut3 complications(6.9%) in the are afforded by the roboticsystem. The procedureswere performedeffica- VATS group, includingprolonged air leakage(>5days) in 2 and refractory ciously, with times comparable to conventional laparoscopic techniques. intercostalpain in 1(p<0.01).The rateof recurrenceafter operation was similar The seven degrees of freedom supplied by the robotic instrument arms in bothgroups(1.9% vs. 2.3%). CONCLUSION:Needle-VATS procedure was provide identical motion to that of the human shoulder, elbow, wrist, and thoughtto be less invasivethan VATS procedureand as usefulas VATS grasp. Computerenhancement facilitates suture placement, knot tying, dissection of the hiatus, and developmentof the postesophagealwindow. primaryspontaneous pneumothorax. This technique may prove to be a beneficial adjunct to laparoscopic Nissen fundoplicerion.

LAPAROSCOPIC DONOR NEPHRECTOMY THROUGH A LAPAROSCOPIC RIGHT HEMICOLECTOMY: NINE PFANNENSTIEL INCISION AS AN ALTERNATIVE TO YEAR PROSPECTIVE RESULTS FROM A SINGLE CONVENTIONAL OPEN TECHNIQUE INSTITUTION Shaghayegh Aliabadi-Wahle M.D., Ashutosh Tewari M.D., Viken J.ARTURO ALMEIDA MD, DARREN MITER DO, MORRIS E. Dzoudjian M.D., John Ferrara M.D., Departments of General and FRANKLIN MD, DANIEL ABREGO MD, DAVID PAULSON Transplant Surgery, Henry Ford Hospital, Detroit, Michigan BS, TEXAS ENDOSURGERY INSTITUTE. SAN The explosion of endoscopic technique has had a groat impact =n ANTONIO,TEXAS many fields of surgery. Most recently, laparoscopic donor nephrectomy has been introduced as an alternative to the conventional open proce- While much has been published in the literature about dure. The less invasive nature of laparoscopy, reduced recovery time laparoscopic colon surgery, there is minimal focus on roght- and improved cosmesis may augment the potential donor pool. The sided disease. Herein we describe our nine-year experience current review was undertaken to assess this institution's experience with laparoscopic right hemicolectomy (LRH) in an unselect- with laparoscopic donor nephrectomy using pneumosleeve through a ed group of patients. Special emphasis is placed in our tech- pfannenstiel incision. nique for intracorporeal anastomosis. The records of all patients who had undergone donor nephrectomy METHODS AND RESULTS: From April 1991 to April over the past 16 months were reviewed. Data with regards to patient 2000,ninety patients underwent a LRH at our Institution. demographics, operative time, safety, hospitalization course as well as transplant recepient outcome was collected. Information regarding indication for operation, surgical proce- Forty-three patients successfully underwent donor nephrectomy dur- dure, operative time, blood loss, pathology and postoperative ing this time period. Twenty-six of these procedures were accom- course were recorded in a prospective, non-randomized fash- plished by the laparoscopic technique. The two groups were similar ion. Eighty-six percent were completed laparoscopically by with regards to age, gender and the presence of previous abdominal either total intracorporeal anastomosis or by laparoscopically surgery. The average operative time was longer for the laparoscopic assisted extracorporeal anastomosis. To date there have group (264 minutes vs. 123 minutes, p<0.05); however, average hospi- been no port site metastases, and the rate of wound infection tal stay was shorter (3.9 days vs. 4.8 days, p<0.05) in the open group. is 1%. The conversion rate diminished significantly with expe- Intraoperative complications occurod in 2 patients in the open group rience. Operative time, blood loss and postoperative morbidi- and none in the laparoscopic patients. Postoperative complications ty and mortality are all comparable to published results. requiring re-admission occurred in 2 of the open group patients. The incidence of delayed graft function in the recepients was higher in the CONCLUSION: Laparoscopic righ hemicolectomy is feasi- minimally invasive procedures, though overall long term graft function is ble, safe and effective therapy for the treatmet of benign and similar in the two groups. malignant proximal colonic pathology under both elective and We offer laparoscopic donor nephroctomy using the pneumosleeve emergent conditions. The combined use of totally intracorpo- through a Pfannenstiel incision as a viable option to the conventional real anastomosis and strict adherence to principles of once- technique. logic surgery can effectively prevent postoperative complications SI07

LAPAROSCOPIC SPLENECTOMY: THE IMPACT OF EXPERIENCE SELECTION OF GASTROESOPHAGEAL REFLUX PATIENTS WITH AND TECHNOLOGICAL ADVANCES ON OPERATING TIME PRIMARY RESPIRATORY SYMPTOMS FOR ANTI-REFLUX SURGERY BJ Ammori, N Georgopoulos, D Davides, W Ainslie, DR Norfolk, M M Anvari MB BS PhD, CJ Allen MB BCh, Departments of Surgery and Stringer, MJ McMahon, The General Infirmary at Leeds, United Kingdom Medicine, McMaster University,Hamilton Ontario Canada Objective of the Study: The laparoscopic approach to splenectomy appears to offer advantages over open surgery in the management of Studies have dernenstrated that 60 to 80~ of patients with chronic respira- refractory heematologic disorders, but was associated with a consider- tory disorders such as asthma and COPD suffer from gastmesophageal able increase in operating time. The objective of this study was to deter- reflux disease (GERD). Respiratory symptoms such as cough, choking mine the impact of experience and technological advances on operating attacks, wheezing, shortness of breath and recurrent chest infections maybe times of laparoscopic splenectomy. Methods and Procedures: Between the pfirnary prasenting symptoms in a patient with gastmesophageal reflux 1993 and 2000, 36 consecutive patients with haematologic disorders disease. Surgical selection of patients who have not responded to medical underwent laparoscopic splenectomy at our institution. Electrocautery therapy with proton pump inhibitors may be difficult. Over the last eight and metal clips were applied for the dissection and division of the short years we have performed laparoscoplo fundoplications in 172 patients with gastric and splenic vessels in the initial 13 patients. Division of the short confirmed GERD who presented pdrnarily with respiratory complaints: 56% gastric vessels was effected with the ultrasonic coagulator (Harmonic with cough, 24% with asthma, 10% with recurrent aspiration. 78% of Scalpel) in the subsequent 23 patients, whilst the smart bipolar coagula- tor (Ugasure) replaced clips for the division of the splenic vessels in the patients have undergone s~x month follow up assessment including 24 hr most recent 7 patients. The groups were compared using the Mann- pH, manometry, symptom score and quality of life. While laparoscopic Whitney U test, and the results are expressed as medians and interquar- surgery was effective in control of heartburn in 93% of patients, it was only tile ranges (IQR). effective in improving the respiratory symptoms in 81% of patients at six Results: The procedure was converted in two of three patients with gross months. Multiple regression analysis showed that preoperative cough splenomegaly and in none of the patients with normal-sized spleens score, association of respiratory symptoms and reflux events on 24 hr pH (5.5%). In-hospital mortality and postoperative morbidity were 0% and and randomized Bemstein test, and a score > 7 for lipid laden macrophages 11% respectively. Median postoperative hospital stay was three days. on sputum analysis was associated with greater improvement of respiratory The operating time was significantly shortened with the growth in exped- symptoms after surgery. enca and the introduction of the ultrasonic coagulator [electrocautery and Laparoso~ic anti-reflux surgery is effective in controlling the respiratory clips 240 (195-265) minutes vs. Harmonic Scalpel and clips 150 (120- 160) minutes; p=0.007] and subsequently of the bipolar coagulator symptoms associated ~ chronic gastmesqEnageal reflux disease, if there [Harmonic Scalpel and clips 150 (120-160) minutes vs. Harmonic Scalpel is dear correlation between symptoms and reflux events prior to surgery. A and ligasurel00 (70-120) minutes; p=0.007]. randomized Bemstein test, sputum lipid index and objective assessment ot Conclusion: With the growth in experience and the introduction of techno- symptoms on and off PPI may be useful preoperative tools for selection cl logically-advanced instrumentation, laparoscopic splenectomy can be patients with primary respiratory complaints from GERD for anti-reflux accomplished safely and within a significantly reduced operating time. surgery.

LAPAROSCOPIC GASTRIC SURGERY FOR BENIGN AND VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR PULMONAR~ MALIGNANT DISORDERS METASTASIS OF COLORECTAL CARCINOMA M Anvad MB BS PnD, D Hong MD, M Lewis BSc, Depertrnent of Surgery, Motoi Aoe, M.D., Hideki Itano, M.D., Itaru Nagahiro, M.D., Yoshihum McMaster Univem,.,h.'y,Hamilton Ontario Canada Sana, M.D., Hiroshi Date, M.D., Akio Andou, M.D., Nobuyoshi Shimizu M.D., Department of Surgery II, Okayama University Medical School Lapamscopic techniques are increasingly used for surgical tP_.atmentof Okayama, JAPAN disorders. We reviewed our experience with 23 patients who had We think Videe-assisted thoracoscopic surgery (VATS) is useful for pul undergone laparoscopic gasthc surgery for benign (14) and rnalignant (9) monary metastatectomy. Resection of solitary pulmonary metastasi., patients over the last 5 years. The mean age of patients with benign cKsor- from colorectal carcinoma provides additional survival and we think VAT~ dam was 70 (range 48-76), and 71 years (range 63-95) for malignant disor- should be chosen for this procedure. ders. The most common indication for surgery of benign disorders was Objectives: To evaluate the usefulness of VATS for pulmonary metastate complicated peptic ulcer disease (10 patients) for which a variety of proce- ctomy of colorectal carcinomas. dures including vagot~w and distal gasb'ectomy,vagotomy and pyloroplas- Methods: Twenty-one cases of pulmonary metastatectomy of colorecte ty, posterior vagotomy and seromyotomy were performed. The procedures carcinoma were performed from January 1985 to December 1999. Nin, for the gastiic carcinoma included three distal gas'cectornies, three subtotal out of 21 cases were treated with VATS, 12 were treated with standan gastrectomies, one total gesb'ectomy, one esophagegastrectomy and one thoracotomy. We compare the patient_fs back ground, operative time wedge resection. The mean operating time for benign and malignant surg- volume of blood loss, use of analgesics, hospital stay, medical costs, an~ eries were 163.4:L452 min (range 119-280 min) and 215d=84.5min (range survival between VATS group and thoracotomy group. Additionally, medi astinal lymph nodes sampling were performed five out of nine VAT,c 104-370 rain) respectively. There was no difference in mean blood loss cases to determine whether mediastinal lymph node dissection is nece~ the two groups which was 250 ml and 100 ml respectively.Patients sary or not. in the benign group tolerated clear fluids earlier, median of 1 day versus 4 Results: The mean of operative time, blood loss during operation, dur~ clays in the malignant group. The length of hospitalization was significanT tion of epidural analgesia, and post-operative hospital stay is 105 rain., 3 different between the two groups wi~ a median of 4 days for the benign ml, 3 days and 8 days in VATS group and 137 min., 72 ml, 6 days, an gr~Jp and 14 days for the malignant gr~Jp. There were no major complica- 16 days in thoracotomy group. There are no differences of medical cost tions in the benign group and two major complications in the malignant between two groups because of expensive disposable devices. Thre group. One patient developed a myocardial infarction following the surgery out of nine VATS cases were dead and 6 were alive. Eight out of 12 the and died on day 42 alter surgery. A second patient suffered a tibia fracture racotomy cases were dead and 4 were alive. The mean survival time an requiring operative therapy. Follow up of cancer patients has revealed two observation time after pulmonary procedure is 32.6 and 35.6 months i patients with a recurrence after a median of 12 months and seven other VATS group and 43.2 and 95.0 months in thoracotomy group. None ( patients are disease free with a follow up of 25.75=17.7 months (range 3-53 five cases, which were performed VATS metastatectomy and mediastin= ~). lymph nodes sampling, showed mediastinal lymph nodes involvement. Conclusions: 1, VATS metastatectomy is better way than metastatectorr Conclusion: Laparoscoplo gastric surgery is effective and cardes a signifi- via standard thoracotomy for solitary pulmonary metastasis of colorec~ cant improvement in length of I'x~d:~ization and recovery for patients with carcinoma, because of its shorter hospital stay, less invasivenese, at~ benign disorders. The application of these techniques for gastric cancer equal pest-operative survival. 2, Mediastinal lymph nodes dissection requires further assessment. not necessary for solitary pulmonary metastasis of colorectal carcinoma S 108

IMPROVED RESULTS WITH A MODIFIED TECHNIQUE FOR INCIDENTAL GALLBLADDERE CANCER- A TERTIARY LAPAROSCOPIC REPAIR OF VENTRAL HERNIAS HOSPITAL EXPERIENCE Bart Appeitans MD, Hans Zengerink MD, Hank ten Cate Hcedemaker MD, Chandrakanth Are MD, Pierre Chanoine, Mark A Talamini MD, Department of surgery, Academic Hospital Groningen, Groningen, The Charles J Yeo MD, Keith D LUlemoe MD., Department of Surgery, Netherlands The Johns Hopkins Medical Institutions, Baltimore, Maryland Introduction: OBJECTIVE: The frequency of incidental gallbladder cancer Laparoscopic repair of indsional hemias larger than 4 cm2 (i.e. peritoneal (IGBC) detected by post-operative histo-pathology (HP) has been onlay with an expanded polytetrafluoroethylene (ePTFE) patch) is an attractive alternative to conventional open repair. reported to be around 0.3-1.5%, While uncommon, the intra or However, the use of the ePTFE patch is frequently (up to 16 to 43 % in post-op diagnosis of IGBC creates a unpleasant dilemma.We some series) complicated by a seroma between the patch and the abdomi- decided to determine the incidence in a tertiary referral centre and nal wall. analyze our experience with the IGBC. In order to reduce the incidence of seroma formation, we have modified the METHODS: Data was reviewed from patients that underwent standard technique by adding coagulation of the hemial sac with the Argon routine LC for benign disease from January 1995 to June 2000. enhanced etectrosurgicel beamer. Patients with known gallbladder cancer or pre-operative suspicion Methods: for the same were eliminated. History, indication for surgery and Our modified technique was applied in 30 consecutive patients (mean age HP were analyzed 57 yrs, range 30-83 yrs). Hemia sizes varied between 4 and 20 cm diame- RESULTS: A total of 1106 LC were performed during this peri- ter (mean 8,6 cm). All patients were seen for follow up at 10-14 days, 6 od. Two patients (incidence of 0.18%) with unsuspected gallblad- weeks, 3 months, and 6 months after surgery. der cancer pre-operatively were found to have the same on HP Results: post-operatively. These patients had similar findings intra-opera- Conversion to conventional repair was necessary in 6 patients. In all tively, where the GB's were found to be hard, thick walled, unyield- remaining 24 patients repair with the ePTFE patch was performed with our ing to the graspers and surrounded by adhesions raising the suspi- modified technique. The coagulation procedure was technically easy to cion of cancer. These findings along with inability to perform the perform. Seroma was seen in 2 patients of whom one was an acute repair procedure laparoscopically led to conversion to an open procedure for strangulation of a recurrent umbilical hemia. Mean operating time was in both patients. One patient had adenocarcinoma of GB and the 93 min (range 40-150 min). Hospital stay was 6 days (range 2-8 days). second was diagnosed with small cell cancer of the GB. Both One recurrence occurred which was repaired using the same technique. patients underwent gallbladder liver bed resection and portal lymph Conclusions: node dissection at a subsequent stage within one week from the Our findings confirm that laparoscopic repair using the ePTFE patch is original surgery. technically feasible and effective with short hospitalization and quick return CONCLUSIONS: We conclude that, the frequency of IGBC is to normal activ'~desafter surgery. Our results suggest that coagulation of the hemial sac shohld be added to the standard procedure as it substantially very rare and in our experience is even rarer than other reported reduces the formation of seroma. Definite proof requires further evaluation, series. If the cancer is missed pre-operatively, characteristic find- preferably in a comparative study. ings at the time of surgery should raise a suspicion of cancer to prompt conversion to an open procedure.

ENDOSCOPIC ROBOTIC TELEMANIPULATOR VERSUS CONVEN- A SIMPLE AND EFFECTIVE TECHNIQUE FOR FUNDUS DOWN TIONAL LAPAROSCOPIC INSTRUMENTS: COMPARISON OF LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC TASK PERFORMANCE FOR SURGICALLY [1mothy R Barnett, MD, Prasanta K Raj, MD FACS, Richard C. Treat, MD, NAIVE SUBJECTS George Castillo, MD, Falrview Hospital - DeparlTnent of Surgery Cleveland William Arnold MD, David Brock PhD, Raymond J. Connolly PhD, Ibrahim Clinic Health System AbdelKaderSalama MD, Woojin Lee PhD, Gary Rogers MD, Steven D. Schwaitzberg MD, Center for Minimally Invasive Surgery, Department of Introduction: For the past decade, the performance of laparoscopic chole- Surgery, New England Medical Center, Boston, MA. Brock Rodgers cystectomy has mainly been limited to a single technique: commencing dis- Surgical, Norwood, MA section of the gallbladder at the infundibulum, and proceeding upwards toward the fundus. Descriptions of fundus down cholecystectomy have Background: Endoscopic robotic devices may overcome the limitations of been reported in recent surgical literature, but these techniques often conventional laparoscopic instruments. The distally articulated instruments involve additional pertWtrocar sites, special liver retractors, or use of the utilize additional degrees of freedom useful when performing complex harmonic scalpel. While these methods have been successful, they often endoscopic maneuvers. Most robotic systems, however, lack haptic feed- increase the cost and time associated with performing fundus down chole- back. We assessed the performance of surgically naive participants using cystectomy. a robotic device versus conventional laparoscopic instruments. Methods: 10 medical students were given three endoscopic tasks to per- Methods: For the past year, we have been performing fundus down chole- form with the robot (BrockRogers, Norwr MA) and conventional laparo- cystectomy for both elective and acute cholecystectomies. In our series, scopic instruments: peg transfer, pattern tracing, and needle driving in axial this technique has proven to be equally and sometimes more useful than and non-axial orientations. For the robot, pattern tracing was performed on standard cholecystectomy. We use the same trocars and instruments that fiat and cushioned surfaces. Performance was assessed on the basis of we routinely employ in laparoscopic cholecystectomy. As is usually done, timing and accuracy. we first bluntly dissect the cystic duct and cystic artery in the triangle of Results: The average time to complete the peg transfer was 76+-25 sec for Calot. Then, we perform our fundue down dissection by using two 5 mm the conventional vs 120+-50 sec for the robot (10=0.0069) with similar error smooth graspers, with which to create a fold in the peritoneum at the apex rates. Pattem tracing was performed faster with the conventional, 69+-30 of the gallbladder. Hook electrocautery is used to start the dissection. One sec vs. the robot (flat and cushioned surface), 122+-47 sec (p=0.004). forceps is then placed on the tag of peritoneum left on the apex of the liver When tracing on a hard surface, the robot group had a significantly greater bed, and the other is used to grasp the gallbladder, providing adequate number of errors than the conventional group. Tracing on a cushioned sur- countertrection to continue the fundus down dissection with electrecautery. face that provided visual clues to the amount of pressure applied reduced As we near the infundibulum, any branches of the cystic artery are ligated the robot error to the level of the conventional group and was significantly with clips, and the gallbladder is removed from the liver bed. lower than robot tracing on a flat surface. For the needle driving task, there was no significant difference between the two groups in terms of timing or Results: Our technique was successful in all patients in whom it was errors with the exception of superior time and accuracy for the robot work- employed. Even for acute cholecysititis, no conversion to the standard ing in the 12 - 6 o'clock orientation versus off-axis conventional suturing. approach or to open cholecystectomy was required, and often times Conclusion: Articulated robotic instruments improve performance when dri- proved more beneficial in correctly identifying anatomy. Further, no addi- ving a needle in a non-axial direction. Despite the tele-manipulator's ability tional instruments were used, proving our technique cost effective. Finally, to maneuver with greater degrees of freedom, the surgically naive operator this technique prevented any significant increase in operative time that is hindered by the lack of haptic feedback. The use of certain visual clues might occur in other methods described. seems to partially ameliorate this loss. SI09

FORMAL INTERPRETATION BY RADIOLOGIST OF INTRAOPERATIVE DOES KEYHOLE REALLY NECESSARY? RESULTS OF A PROSPECTIVE CHOLANGIOGRAM IS NOT NECESSARY RANDOMIZED STUDY David Earle, MD, Bernard Benedetto, MD, Department of Surgery, Metin BERBEROGLU, M.D.1, Feyzan ERCAN M.D.1, Ferruh BALABAN Baystate Medical Center, Springfield, Massachusetts M.D.1, Erol AKBULUT M.D.2, Yakup OZEL M.D.3, Hulagu KARGICI M.D.4, II.T.E.M. Advanced Medical Technologies Education and Training Center- Most intraoperative cholangiograms(IOC) are read by the surgeon and a Ankara, 2Korkuteli and 3PolaUi State Hospitals, 4SSK Ulus Hospital-Ankara, radiologist. We examined the need for 2 official interpretations in a retro- TURKEY spective comparison. We developed an IOC interpretation score(IOCscore) with 1 point assigned for each of the following: cystic duct, intra-& extra- Objective: Some surgeons are preferred to cut the meshes half way in size hepatic ducts,filling defects & flow into the duodenum. and lay half of it under the cord structures. However, numbers of surgeons RESULTS: 52 IOC's were performed in 59 patients. 45 females & 14 males leaves the meshes over the spermatic structures without cutting. We compared had a these two different way of mesh placement technique and recorded the duration of dissecting, mesh placement and total operating pedods, with surgeon and mean age of 49.4 years(20-80). Indication for operation was biliary patient satisfactions. colic(38),acute cholecystitis(8),gallstone pancreatitis(6),biliary dyskine- Method: In this clinical study, 20 male patients were operated under general sia(4),other(3). Mean surgeon & radiologist IOC score was 4.3 & 3.0 anestheasla in two groups by totally extraperitoneoscopictechnique which pre- respectively. The radiologist never read 2 cases, and dictated 9 as "see op senting unilateral hernias. In group I, keyholed meshes were used. In group II, note". The most commonly omitted details were the cystic duct(surg- meshes were placed over the spermatic vessels without making any keyhole. 21,rad-18) and intrahepatic ducts(surg-11,rad-17). Other details were rarely Meshes were secured with tacks in beth groups. Patients were operated with omitted. Nearly all of the surgeon's interpretations were recorded the day of these two different technique consequently. Meshes were dimensioned 15x12 surgery. Radiologist reading was dictated an of average 4.4 days (1-8) after cm in size. the study was completed. There was one case of discordant interpretation Results: There were 40 (ages 23-76, mean 58) patients with 15 right (7/8) and between readers that presented with acute cholangitis, had pre-op 25 left (13/12) hemias having 13 direct (6/7) and 27 indirect (14/13) sacs. There ERCP/sphincterotomy and extraction of 1 of 2 stones. At operation, clear- were significant differences between the groups for total operation time (Mean ance of the duct was successful laparoscopically. The final IOC interpreta- operating time were 35.05-M,.91 in group I and 24.1r in group II) and mesh tion by the radiologist was "filling defect in CBD", and surgeon as no filling placement times (mean times were 10.6e3.15 in group I and 3.9-~1.7 in group defects. Cholangifls developed 4 months later with widely patent ampulla & II). Dissection time's shows no significant differences and mean values were no CBD stones on ERCP. 2 cases of retained CBD stones presented 3&4 23.9~-6.3 in group I and 20.2-~4.63 in group II. Cord edema was seen in 5 days post.op, both managed with ERCP. One case revealed CBD stones patients (25%) in group 1 and 2 (10%) in group II. According to the subjective cleared laparoscopically with the final IOC interpreted as normal by the sur- pain scale method, scrota] pain average was 27.5+7.16 in group I and 43.5-z9.8 geon. Radiologist interpretation was "see cp note". The other case was for in group I1. The differencesbetween the groups was significant (p>0.01). acute cholecystitis. Filling defects noted on IOC were interpreted as air Conclusion: Placing the meshes without splitting, reduces the operative time bubbles by the surgeon, and as "normal, but limited study" by the radiolo- and specially the dissection and mesh placing time. Meanwhile, we encoun- gist. tered less edema in cord structures. Surgeon satisfactionswere excellentdue to easier laparoscopicdissections and mesh placement by mason of fewer move- CONCLUSION: Interpretation of IOC by surgeons who routinely perform ments to achieve the proper mesh placemenL We recommend that surgeons IOC is comparable to a radiologist, and eliminating this step should lower should not make keyholes on the meshes during laparoscopichernia repair. the overall cost of IOC with no disadvantage.

NEW TECHNIQUE FOR SUTURING TROCAR HOLES LAPAROSCOPIC TRANSPERITONEAL BILATERAL NATIVE Metin BERBEROGLU M.D.1, Feyzan ERCAN M.D.1, Ferruh NEPHRECTOMY FOLLOWING RENAL TRANSPLANTATION BALABAN M.D.1, Turhan SAYGIN M.D.2, Can ERTURK M.D.3, Daniel W Birch MD MSc, Anil Kapoor MD, Department of General Surgery Atila AKOVA M.D.4 and Urology, St Joseph's Hospital, McMaster University, Hamilton, II.T.E.M. Advanced Medical Technologies Education and Ontario, Canada Training Center-Ankara, 2Eregli-Konya, 3Antalya and 4Adana Numune State Hospitals Renal transplant recipients are susceptible to significant morbidity from their native, non-functioning kidneys. Open nephrectomy in this immuno- suppressed population places the patient at risk for post-operative wound Objective: As very well known, suturing of the instrument port complications and a lengthy recovery period. Minimal Access Surgery is incisions is difficult, time wasting and special instrument an option to reduce morbidity and recovery time in this select group ol required part of the laparoscopic operations. Sometimes sur- patients. However, these patients have often had peritoneal dialysis geons are unable to stitch specially in fatty patients with bleed- catheters, episodes of peritonitis and there is concem regarding the effecd ing from the trocar site in absence of special instrumentations. of the pneumoperitoneum on renal graft function. At our institution, a team We describe an easy method for suturing trocar site incisions approach has been used to successfully complete bilateral laparoscopic by using a conventional needle holder and laparoscopic grasper nephrectomy in a renal transplant patient. The team comprises a General which can also be performed by beginner laparoscopists. Surgeon and Urologist who have fellowship training in advanced laparo- Description: Step 1: An atraumatic straight needle grasped scopic procedures. which is headed at the same direction of a conventional needle The patient is a 51 year old female with a renal transplant and document. holder and passed far edge of the incision of the target trocar ed vesico-ureteric reflux. Despite combined antibiotic therapy she contin- ued to have symptomatic bacteriuria and recurrent pyelonephritis and when emerged from peritoneum, it is grasped by an grasp- Ultrasound demonstrated bilateral hydronephrotic kidneys with thin ing instrument. The tail of the suture must be clamped for parenchyma. anchoring. Step 2: Then the needle is retrieved from the trocar The patient underwent bilateral nephrectomy via a transperitoneal which is used for grasping instrument. Thread is cut in half way approach. She was positioned in right decubitus for left nephrectomy, all and clamped. Step 3: Same suture is passed from the near port sites were closed after the completion of the procedure and ths edge of the same incision of the target trocar and first two steps patient re-positioned in left decubitus for right nephrectomy. For this pro- are applied identically. Step 4: Needle is cut and two free ends cedure, 4 trocars were used on each side: 1-10mm trocar and 3-5mm tro. were tied to each other at the grasping forceps trocar. Step 5: cars. Specimens were morcellized through the 10mm trocar sites. Tota Then, both tails is fully pulled and tied securely at the target port OR time, including repositioning and sterile preparation was 6.5 hrs, is being sutured. Removing the target trocar is making this pro- There were no intra-operative or post-operative complications. The cedure easier. patient was discharged home on the 2nd post-operative day. She was Conclusion: We are applying this method in port bleedings seen at 4 weeks following surgery, fully recovered and without limitation,r in activity. and stitching the 10 mm trocar sites. We are recommending this We have used a team approach in the performance of advanced lapa~ method in absence of special laparoscopic instruments such as scopic procedures with good success. Given our initial success wiU- puncture closure device, laparoscopic needle holder. these and other procedures, we will continue to develop our laparoscopir experience in the transplant and urology population. SIlO

FACTORS PREDICTIVE OF CONVERSION FROM LAPAROSCOPIC TO OPEN THE EFFECT OF INSUFFLATION GAS VOLUME ON INTRA- CHOLECYSTECTOMY IN GANGRENOUS CHOLECYSTITIS ABDOMINAL TUMOUR CELL MOVEMENT S Brundell BS, K Tucker Karin Binmofe, MD; Sandeep Devata, BS; Sherri Yong, MD; Ellen Yetter, MD; Vafa Shayeni, MD BSci, P J Hewett BS, Division of Surgery, The Queen Elizabeth Hospital, Department of Surgery Loyola University Medical Center Woodville South, South Australia Maywood, IL Earlier work has demonstratad that trocar site metastases may be due Background: Laparoscopic approach is the standard of cure for elective to the deposition of free intra-abdominal tumour cells on trocars and trocar cholecystectomy. Although acute cholecystitis is no longer a contraindication for laparoscopic cholecystectomy, there is a high incidence of conversion to laparotomy sites. Such free intra-abdominal tumour cells move within the abdomen when gangrenous cholecystitis is encountered. Identifying factors predictive of cavity during insufflation and we hypothesised that the volume of conversion from laparoscopic to open cholecystectomy may help reduce operative insufflated gas may influence the degree to which this occurs. length and cost. Radiolabeled LIM 1215 human colon cancer cells were injected into the Methods: Between August 1996 and August 1999, 39 patients underwent cholecystectumy for gangrenous cholecystitis, defined histologically as acute peritoneal cavity of 22 female pigs. Three 12ram trocars were inserted at cholecystitis with transmural necrosis. Eight patients underwent open cholecystectomy the umbilicus, left and right lilac fossa and the abdomen was insufflated without attempted laparoscopy. The remaining 31 patients were retrospectively with CO2. The movement of cells within the abdomen was traced on a assessed for factors predictive ofcunversion to open. Patient demographics (age and gamma camera for a 2-hour study period. The b'ocars were removed and ~cnder), clinical prc.wnt~tinn (len~,-~hof %-"---.7.!."~'; "~ ho:,pi.*=lLT.:tionprior tc ~u."ge.'3', weight and maximum temperature), laboratory values O,VBC, liver and pancreatic the trocars sites excised and the numbers of cells on each was calculated. enzymes), sonographic findings (wall thickness, presence of air in the wall, ductal The movement of cells out of 6 intra-abdominal regions was calculated dilatation, pericholecystic fluid, maximum gallbladder and gallstone size and and analysed against the volume of insufflated gas. sonographic Murphy's sign), and surgeon's experience were reviewed. Increased gas insufflation volumes resulted in increased intra-abdominal Results: Fourteen of the 31 procedures were converted to open. Patient demographics, clinical presentation, laboratory values and sonographic findings were movement of tumour cells (Kendalrs tau, p=O.01), however no correlation not different between the two groups. Thirteen of the operations were performed by 1 existed between contamination of trocars or trocar sites and insufflated surgeon, I I of which (85%) were completed laparoscopically. The remaining 18 gas volume (Kendalrs tau, p=0.82). operations were performed by 10 other surgeons, 6 of which (33%) were completed This study demonstrated that the movement of free intra-abdominal laparoscopicaliy (p<0.0l). The incidence of complications was the same in both groups. tumour cells is increased when larger insufflated gas volumes are used. Conclusions: Laparoscopic cholecystectomy for gangrenous cholacystitis may be However, this does not result in additional cells being deposited on trocar performed safely and with a low incidence of conversion to open. Surgeon's sites and it is unlikely that this factor by itself may increase the rate of experience is the only factor predictive of eonversion from laparoscopic to open trocar site metastases. cholecystectomy for gangrenous cholecystitis.

THE EFFECT OF TR0CAR CHOICE ON TUMOUR CELL ADHERENCE, HAEMATOGENOUSSPREAD AS A MECHANISMFOR THE GENERATION OF ABDOMINAL WOUND METASTASES FOLLOWING S BnJndell+ BS K TuckerBSci, B ChattertonBM, P J HewettBS, Divisionof LAPAROSCOPY. S Brundell BS, T Ellis BSci, T Dodd MD, D I Watson MD, P J Hewett BS, Division of Surgery, The Queen Elizabeth Hospital, Surgery,The Queen ElizabethHospital, W00dville South, South Australia Woedville South, South Australia.

It has been suggested that direct contamination of port sites with tumour A modelto examineof tumourcell adherenceto laparoscopictrocars and ceils is the etiological mechanism responsible for the majority of port site to trocarsites was developed. metastases following laparoscopic surgery, but it is unlikely to explain the development of all. We sought to determine whether haematogenous Thi~/-six plasticsmooth and thi~-six metal trocarswere introduced spread might also play a role in the development of some port site throughthe shavedabdominal wall of a cadavericsheep and suspendedin metastases. Two groups (30 rats) of male Dark Agouti rats were studied. Under a water bath containingradiolabelled LIM 1215 humancolonic cancer cells general anaesthesia the first group (20 rats), underwent a period of 15 minutes of laparoscopic insufflation, followed by injection of 10s for 30 minutes.Radioactivity on both trocarsand trocarsites was adeno~rcinoma cells in a cell suspension into the internal jugular vein and measuredand the numbersof cells adherentto each structurecalculated. a further 15 minutes period of insufflation. The laparoscopic ports were then removed and wounds dosed and marked. Increasednumbers of cellswere detectedon metalb'ocars (p<0,0001) In the second group (10 rats), an identical procedure was followed, when comparedwith plastictrocers. Si#cantly greaternumbers of cells except a 2.5cm midline laparotomy was performed 15 minutes after the commencement of anaesthesia, and insulflation was not used. The were also detectedon the trocarsites throughwhich metal ~ocars had laparotomy was dosed in 2 layers. Rats were killed 15 days later and the injection site, laparoscopy wounds and laparotomy wound were examined passedthan on ~ocar sitesthrough which plastictr~rs had passed histologically by a =blinded" histopathologist. One port site tumour was detected in the laparoscopic group and no wound metastases were found in the laparotomy group. In this model,the use of metal trocarsas opposedto plastictr0cars Whilst haematogenous spread is a possible mechanism in the resultedin increaseddeposition of tumourcells bothon the trocarand on development of port site metastases, the low number of port site metastases in this study suggests that this mechanism is unlikely to be a the site throughwhich the trocarhad been passed. major contributor to the problem of wound metastasis following laparoscopy. $111

INCREASEDINSUFFLATION PRESSURE DECREASES TUMOUR LAPAROSCOPIC SURGERY FOR GASTROINTESTINAL STROMAL CELL CONTAMINATIONOF TROCARSAND TROCARSITES DURING TUMORS: TECHNIQUE AND RESULTS L. Michael Brunt. MD. J. Chris OPERATIVELAPAROSCOPY. S Brundell BS, K Tucker BSci, P J Hewett Eagon, MD, Mary A. Quasebarth, RN, Nathaniel J. Soper, MD. Department of BS, Divisionof Surgery, The Queen Elizabeth Hospital,Woodville South, Surgery, Washington University School of Medicine, St. Louis, MO. South Ausb'alia Aims: The purposeof this study was to review our surgical technique and results in patients with gastrointestinal stromal tumors (GIST) treated laparoscopically. This study was designed to evaluatethe effect of insufflation pressure Methods: From Feb. 1996 - March 2000, 12 patients with GIST underwent on tumour cell contamination of trocars and trocar sites during operative laparoscopic resection. Data were obtained reu'ospectively by review of medical laparoscopy. records and by telephone interview with patients. Data are reported as mean + SD. Radiolabeled LIM 1215 human colon cancer cells were injected into the Results: Mean patient age was 64 + 14. years (range 42-88 yrs). Presenting features peritoneal cavity of a total of 8 female pigs. The insuftiation pressurewas were upper GI bleed (N=9), reflux (N--2), and incidental finding (N--l). Ten tumors varied in 4 groups between 0 and 12mmHg. Three 12mm trocars were were in the stomach, one in the distal esophagus, and one in the jejunum. inserted at the umbilicus, left and right lilac fossa and the abdomen was Mobilization was carried out with an ulU'asoniccoagulator and tumor excision with a insufflatedwith C02. At the end of a 2-hour study period the pigs were linear stapler, either totally laparoscopically (8 cases) or in a laparoscopic-assisted euthanised. The lmcars were removed and the trecars sites excised. fashion (4 cases). Concurrent intraoperative gastroscopy was used in 9 cases. Mean These were placed on a gamma camera and the numbers of cells present operative time was 142 _+ 61 rain and blood loss averaged 90 + 107 ml. Ten tumors on each were calculated. were removed by wedge excision and 2 required resection and reanastomosis The use of increased insufflation pressure, possibly by a mechanical (antrectomy in 1, jejunal resection in I). Patients ate a regular diet at 2.7 + 2.2 days effect in I~ing the b'ocars awayfrom intra-pedtonealcells reduced trocar postoperatively and median postoperative hospitalization was 3 days. Complications and trocar site contamination,(Kendalrs tau, p=0.01). were a hypertensive exacerbation in 1 patient and a peripancreatic fluid collection If as is likely, this study parallelsclinical practice, increasing insufflation and prolonged ileus in one patient. Mean tumor size was 4.2 :l: 1.4 cm (range 1.8- pressure may help to reduce the numbers of viable tumour cells displaced 6cm) with negative margins in all cases. Tumors were benign in 7 cases, indeterminate in 3 cases, and malignant in 2 cases. There have been no further to trocar sites during laparoscopicsurgery for an intra-abdominal episodes of GI bleeding, or tumor recurrences at a mean follow-up interval of 20 malignancy. Furthermore if ~'ocar site metastasesare related to the months (range 4-54 mos) postoperatively. deposition of tumour cells within trocar sites, this may also have a role in Conclusions: Lapasoscopic resection of GIST is safe and should be the preferred helping to reduce the rate of trecar site metastases. surgical approach unless the tumor is locally invasive.

A PROSPECTIVE COMPARISON OF PEG PLACEMENT IN LAPAROSCOPIC CHOLECYSTECTOMY IN THE MULTIPLE SCARRED PATIENTS WITH AND WITHOUT CUNICAL INFECTION Maureen G. ABDOMEN. Roger Buzatu MD, Presanta Raj MD, Department of Surgery, Burdett, MD, Brian J. Dunkin, MD, Joel Turner, MD, William Chiu, MD, Falrview Hospital, Cleveland, OIL Eugene Cho, MD, John L. Flowers, MD, Department of Surgery, Division of Surgical Endoscopy, University of Maryland School of Medicine, Baltimore, Maryland Laparoscopic Cholecystectomywas first performed by Dubonis et al. in the late 1980's. Subsequently it gained rapid ___ao,~tanceand application because of its The timing of PEG placement has implications regarding discharge promise of more rapid recovery. In the past, patients with previous extensive planning in hospitalized patients. Endoscopists have avoided placing abdominal surgery were excluded from the benefits of the minimally invasive PEGs in patients with clinical evidence of active infection for fear of a technique, Initial epigastric port placement technique was developed with this in higher rate of complications. This study investigates the incidence of mind The following report is a caseseries of the experience of one surgeon in wound complications in patients with active infection undergoing PEG applying the technique initial epigaslric port placement for laparoscopic placement. A prospective evaluation of 116 patients undergoing PEG placement cholecyst~omy in the multiple scarred alxlomen. between 2/99 and 4/00 formed the basis of this study. Patients with clin- This apprmoh was performed on p~ents with prior history of alxlominalsurgery, ically active infection were defined as having a temperature > 101.5F, with dominant abdominal scars,in which dense alxluminaladhesions were leukocytosis > 11,500/ul, culture positive or radiologic evidence of infec- anticipated.Informed consent was olXained,and the poss~ilityof r to tion. These patients were compared to controls with no evidence of open was outlinedprior to proceeding. The techniqueinvolves placement of an infection. PEG sites were monitored for an average of 7 days. PEG site initial lOmm Hasson trocat under direct visualization in a subxiphoid location. The infection was defined as the presence of purulent discharge and/or ery- camera is then introduced, and the adhesions as a guide, second thema. The two groups were age matched. The rates of PEG site infec- using locationof a tion were compared using beth the Chi Square and Fisher exact meth- 5ram trocar is placed in the right aMominal wall. The 5mm port is then esed as a ods. working port to lyse perinmbilical a~esions. Once successful a&esiolysis is There were 81 patients in the active infection group and 35 patients performed, a 10ram umbilical port is established, the camera changed to this with no clinical infection. The overall incidence of PEG site infechon location, and dissection continued in standard fashion. was 9.5% (11/116). The incidence of PEG site infection in the active The technique was successfully performed in 9 of 11 patients. Conversion to opez infection group was 7.4% (6/81) and 14.3% (5/35) in the no infection occurred in cases where density ofa~esions made continued laparoscopic group. Patients with PEG site infection in the active infection group had erythema alone (3/6) drainage alone (2/6) or drainage and erythema dissecgonunsafe. (1/6) versus those in the no infection group with erythma (1/5), drainage in recent reviews of the reasons for conversion to open technique, adhesions fror (1/5), and drainage and erythema (3/5). previous abdominal surgery are consistently listed as one of the top two. At the Active clinical infection does not effect the incidence of exit site infec- same time, numerous studies have shown the multiple advantages of la~oscopic tion in patients undergoing PEG placement. This data supports early Vs. open cholecystectomy. This technique offers an approach that can allow for placement of PEGs in patients with ongoing clinical infection with the laparoscopy to be performed on abdomens previously considered prohibitive potential for decreased complications from nasogastric tubes and earlier bcaa~ of duminant scarring and history of previous multiple surgmes discharge. Sll2

LAPAROSCOPICASSISTED RESECTION FOR CARClNOIDTUMOR OF Efficiencyin ThoracoscopicProcedures: A Modelfor all Minimally lnvasive THE TERMINALILEUM RoserBuzatu. M.D., PrasantaRaj, M.D., Procodum. Depadmentof Surgery,Falrview Hospital, Cleveland, Ohio. Roan Caccavale,M.D., J.P. Bocage,M.D., W. PeterGels, M.D., StevenW. Petenon,D,O., departmentof Surgeryand Minimallylnvasive Learning Center, Cardnoidtumors, 1/3 of small boweltumors, developfrom intraepithelial St. Peter'sUniversity Hospital, New Brunswick,Hew Jersey. serotoninpcocludng endocrine cells and are locatedtypically in the terminal Introduction:Historically,thoracuscopic procedures have dramatically diminished ileum. Patienteusuelly present in ~le eixthor seventhdocade with insultto patients,but havebeen cumbersome to performdue to positioningof the complaintsof vagueabdominal pain, or in casesof advanceddi~ with patient,single lung ventilation, and impositionof the rib cage. We haveaddressed obstructivesyml:~ms. DiagnosiJcdelay is commonresulting in advanced stsge at Ixesentationin mont__~-ses__. eachof theseissues and shortenedprocedures dramatically. Methods:In the past36 The followingis a casempod of the pioneeringuse of Laparoscopyin months we haveused a combinationof teamdevelopment, video assessment of team performinga dght hemicolectomyand terminalillectorny with pdmary performance,minimizing instruments, Jod facilityenhancement to safelyshorten all anastamodsfor a locallymetastatic 1.5 cm cardnoidtumor of the terminal segments of VATSproced~:~. To document the results, 45 consecutive procedures ileum. The surgerywas performedin 1901, end the pa~e~has remained were evaluated as to (I) pat;-=t entrance to OK, (2) intubatinn, (3) bronchoscopy- ~ _~.~__ __ free at 9 yr. followup. single lung occlusion, (4) patient positioning, (5) set-up drape, (6) procedure time, The patientis a 58 year-oldmale who presentedto his gastroenterologist (7) closure --dressing, (8) exit from room, (9) turnover times. Procedures included" the complaintsof chronicdiarrhea and right-sidedvague abdominal 30 lung resections, (wedge, Iobectomy, pneumonectomy), two esophagectomies, and pain. Work up includeda BE and ~ ~ich revealed2.5cm multiple biopsies and pleurodesis. Time intervals for each segment of each ~!e pol~e of the Cecumand Hepaticflexure. En6~___-:(r l~pay ms procedure and the mechanisms of efficiency were recorded. Results: Average time nagativefor malignancy,but giventhe dze and n~ surgerywas from room entry to surgical incision for all procedures was 21.7 minutes (separated recommended. into 4 segments). Technical procedure times averaged 37 minutes; the shortest being The procedurewas performedusing a 10raminfraumbilical tronar for initial wedge resection (18 minutes) and the longest being pneumonectomy (162 minutes). exploration,follold by the Introductionof four additionalpods for di~. ~ was L~ in mobilizationof the colonand terminal Lobectomies averaged 49 minutes. Wound closure, exit from room, and turnover ileum. A limitedRUQ transvermindsion allowed for limitedexploration and time cumulatively averaged 36.5 minum. Factors influencing these data included daliveryof the specimen. On limitedexidoredon a masswas palpaidein the cooperative team approach, specific identification of tasks, surgeon participation in temllnalileum. Cam ws takento obtainadequate margins proxlrnally, and team effort, minimizing number of instruments, strategic use of sophisticated to Indudethe rootof the mese~ery. Reenaetamodswas performedusing a technology, and video assessment of procedure choreography. Conclusions: These GIA ~alder in side-to-ddafashion. Pathologicexamination revealed a 1.5 data delinate that focusing on maximum efficiency during sophisticated VATS cm cardnoldtumor of the torminalileum, with 1 of 10 LN positivefor procedures allows a minimum of resource utilization, diminished anesthesia time, decreased the length of operative risk, and promotes improved outcomes per unit This casedemonstrates serty innovativeuse of iapm','~co~,and given~e cost. Further, this experience provides a "best practices" model for minimally excellentoutcome with icogte~n followup, suggestsa ~_no~__bie role for invasive surgery. I~ assisted~re~ ~_on of surly stagedistal small bowaltumor~

OPEN CECECTOMY IS ASSOCIATED WITH SlGNIRCANTLY MORE LAPAROSCOPIC TREATMENT OF GROIN HERNIA: 1350 PULMONARY METASTASESTHAN LAPAROSCOPIC CECECTOMY CASES TREATED Luciano Casciola, M.D., Graziano OR ANESTHESIA ALONE IN MICE Joseph Carter, MD; Irena Kirman, Ceccarelli, M.D., Lelio Di Zitti, M.D., Walter Mazzoli, M.D., MD, PhD; Anthony Oh, MD; Peer Wildbrett, BS; George Stapleton, E~S; Michele d'Ajello, M.D. Zishan Asi, BA; Ryan Fowler, BS; Marc messier, MD; Richard L. Whelan, MD; Department of Surgery, Columbia College of Physicians and We present a review of our experience of 1670 inguinal Surgeons, New York, NY herniorrhaphy over the past 8 years, 1350 cases treated by laparoscopic approach (TAPP technique), and 320 by conven- Objective: The surgical resection of malignancies may result in the hematogenousspread of tumor cells which, in turn, may lead to metas- tional tension-free open technique. We compare the results tases(mets). Further, iaparotomyis associated with greater postoperative (patients compliance, post-operative pain, recurrences, mor- immunosuppression and increased tumor cell proliferation than either bidity) of the laparoscopy with open herniorrhaphy. pneumoperitoneum(pneumo) or anesthesia alone. It has been demon- This is a retrospective review of 1670 inguino-femoral her- strated, in a munne model, that sham iaparotomy is associated with a nias treated between August 1992 and March 2000. The higher incidence of lung mets than C02 pneumo. The purpose of this laparoscopic approach was exclusively the trans-abdominal study was to determinethe incidence of lung mets after open and laparo- pro-peritoneal (TAPP) technique, it was performed in 948 scepic-assisted bowel resection. Methods: A murine pulmonary metasta- patients (1350 hernias), 276 (20,3%) were recurrent hernias, sis model was used. Six week old female A/J mice(n=30) were random- 855 males and 93 females (ratio: 9/1), median age of 45,6 ized into 3 groups: 1) anesthesia control(AC), 2) laparoscopiccecectomy years (range:19-82). The bilateral case were 42% (11% of under C02 pneumo(LC), or 3) open cecectomy (OC). Immediatelyafter them were discovered during laparoscopy), they were treated the procedure, all animals were given tail vein injections of 7.5 x 10'~4 using two different prosthesis. In 87 patients were performed TA3Ha tumor cells. After 14 days, mice were sacrificed and the lungs/tra- additional surgical treatment (cholecystectomy, treatment of chea exdsed en bloc after injection the trachea with India ink. The lungs varicocele, lysis of adhesions, etc.). were later immersed in Feket's solution to bleach the tumor nodules. Our overall recurrence rate using TAPP technique was of 8 Surface metastases were counted by a blinded observer. Results: The mean number of lung mets for the groups were: AC, 36; LC, 71.2; and cases (0,6%), with a median follow-up of 4 years (minimum 5 OC, 124.4. The OC group had significantly more mets than the AC months). In only one case it was necessary to convert in open group(p<0.05, Mann-Whitney Test). There were no significant differ- technique because of an important abdominal adhesion syn- ences noted when the LC group was compared to eider the AC or OC drome. Only one important complication (bowel obstruction), groups. Conclusion: Open cecectomy is associated with significantly 16 seromas, 2 trocar site hernias, 9 abdominal wall more lung metastases than anesthesia alone, in this model. Although hematomas. The median operative time was of 35 minutes for laperoscopic cecectomy resulted in less mets than the open group the unilateral and 55 minutes for bilateral hernias, after the first differencewas not significant.Although not proven in this study, these dif- 100 cases (learning period). ferences may be the result of laparotomy related immunosuppression In our experience laparoscopic hemiorrhaphy, using TAPP and trophic stimulation of tumor cells. Further studies are needed to technique, is safe, well accepted by all patients (general anes- assess whether laparoscopic procedures are, in fact, associated with a thesia wasn't a problem), with very good results; of course it lower rate of metastases. need an adequate training and experience in laparoscopy. Sll3

COMPLETELY LAPAROSCOPIC COLECTOMY FOR CANCER. ANASTOMOTIC STAPLE-LINE REINFORCEMENT ENHANCES THE Luciano Casciola, M.D., Lelio Di Zitti, M.D., Graziano Ceccerelli, M.D., SAFETY OF LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR MOR- Massimo Rambotti, M.D., Raffaele Valeri, M.D., Department of Vascular BID OBESITY and Mininvasive Surgery, San Matteo Hospital, Spoleto, Italy Frank H. Chae, M.D., Robert C. Mclntyre, M.D., Greg V. Stiegmann, M.D., Department of Surgery, University of Colorado Health Sciences Center, Laparoscopic colectomy is possible, safe and widely accepted by now; Denver, Colorado, USA. it offers patient-related benefits similar to those described for other Anastomotic staple line failure (leakage or bleeding) is a major complication laparoscopic procedures. Some indications for laparoscopic bowel resec- associated with Lapamscopic Roux-an-Y Gastric Bypass (LRYGB) for morbid tion (i.e. cancer) are still controversial. We present a retrospective analy- obesity. Although staple line failure occurs infrequently, such complications are sis of a series of 106 colonic malignancies laparoscopically performed. potentiallydevastating. We hypothesized that staple line failure could be dimin- 138 completely laparoscopic colonic resections were performed ished or eliminated by the use of a staple line reinforcement. The purpose of between May 1994 and July 2000. Surgical indications were: benign dis- this study was to assess the feasibility and efficacy of bovine podcardiai strips orders (diverticulitis) 32 cases (23,2%), 106 colonic malignancy (76,8%). as an anastomotic staple line reinforcement in LRYGB surgery. We prefer to perform the vascular control by clips "step by step"; the sta- pler is used for bowel resection, a mechanical completely intra-corporeal METHODS: Patients with body mass index (BMI) of 39 kg/m2 or greater had tension-free anastomosis is performed at last. To remove the bowel spec- totally Laparoscopic Roux-en-Y Gastric Bypass. Bovinepericardiai strips were imen from the abdominal cavity we use to put it in a large bag and to pull incorporated into the Endo-GIA stapler cartridgas to reinforce the staple lines it out of a 3-4 cm enlargement of a trocar-site (in the left lower quadrant created. or in the umbilical ring). An important contribution is offered by ultracision dissector. RESULTS: Since May 1999, 17 of 17 morbidly obese patients (all female) had In 10 patients (8,6%) of 116 laparoscopic approach for colonic tumors, successful LRYGB with staple line reinforcement. The mean age was 39 we decided, after a laparoscopic beginning, the convertion to open proce- (range 22-53) and the mean BMI was 44 (range 39-60). Co-morbiditiss includ- ed hypertension (12), heart disease (4), diabetes (8), chronic lung disease (3), dure. The right hemicolectomy were 18, the left colectomy (hemicelecto- sleep apnea (15), hypercholesterolemia (5), gastroesophageal reflux disease my, sigmoid resection, low anterior resection of rectum) were 88. No (11), and osteoarthritis (12). The mean operating time was 4.7 hrs (range 3.5- intra-operative complications were observed; post-operative complication 6.5). Addition of the anastomotic reinforcement added an average 12 minutes were: 2 wound infection, 1 abdominal haemorrhage, 2 trocar hernias. No operating time per case. Minorcomplications included 1 port site wound infec- anastomotic leak were observed. The median operation time is of 150 tion. No anastomotic failures or other major complications were observed. The min for righ hemicolectomy and 165 for left colectomy. One case of port- mean time to retum to oral intake and hospital stay was 1.5 and 3 days respec- site recurrence. tively. All patients lost weight (mean 9.5 kg/month) with a mean follow-up of 6.5 The laparoscopic colon-rectal surgery can reproduce the techniques months (range 1-15). performed in open surgery, respecting all oncologic principles. After a period of adequate training all can appreciate the advantages of CONCLUSION: Anastomotic staple line reinforcement using a bovine pericar- laparoscopy: shorter hospital stay, less postoperative pain, short-term dial stnp is feasible, safe, and may enhance the safety of Laparoscopic Roux- post-operative ileus, earlier retum to daily activity, etc.. en-Y Gastric Bypass surgery. Definitive proof that staple line reinforcement diminishes or eliminates anastomotic staple line failure will require additional study.

LAPAROSCOPIC SURGERY OF THE pANCREAS R Campaqnacci, F. LAPAROSCOPIC RESECTION AF A JUXTAGLOMERULAR CELL Feliciotti, A.M. Paganini, M. Guerderi, A.Tamburini, S. Perretta and TUMOR OF THE KIDNEY R. Campagnacci, F. Feliciotfi, A.M. E.Lezoche Istituto di Scienze Chirurgiche Universit~ degli Studi di Paganini, M. Guerrieri, A.Tam~dni, S. Perretta and E.Lezoche, Ancona. ITALY Ist~r di Scienze Chirurgiche Univers~ degli Studi di Ancona. ITALY

In pancreatic surgery laparoscopy has a role in diagnosis, staging The juxtaglomerular cell tumor is an extremely rare tumor of the and curative or palliative surgical procedures.. kidney. Hypertension is the most common clinical finding due to the Since 1993 four spleen.preserving laparoscop=c distal renin production but the correct preoperative diagnosis is very difficult pancreatectomies and three enucleations of pancreatic solid and cystic to reach. We report the case of a patient that was b'eated lesions were performed in our institution. Spleen preservation was considered in order to avoid the risk of sepsis and thrombosis as laparoscopically with kidney preservation. reported in the literature. A 45 old male was referred to our department because of a solid In the distal pancreatectomy group (A) there were three female and mass of undear origin located in the right mesorenal region, detected one male (mean age 51.3 years, range 20-70 years). In the enucleation by ultrasonography, CT scan and cdoncscopy. This patient was group (B) two patients were female and one male ( mean age 52,3, previously investigate for persistent hypertension. The serum levels of range 42-63 years). All patient underwent preoperatively MRI. In all renin, plasma renin acth~'7 (PRA) and aldosterone were normal. cases intraoperative ultrasonography (6,5 MHz laparoscopic probe) was Laparoscow was performed in order to obtain a correct diagnosis performed. Mean operative time was 172.5 rain (range 120-240 rain). In and to resect the lesion. Five 10/12mm ports were placed and a 45 ~ group A hystology revealed two mutinous and one serous iaparoscope was used. Alter a wide dL~=ectJon of the right and cystadenomas, and one insulinoma. In group B. two insulinomas and colon the mesorenal lesion was visualized. Laparoscopic one serous cyst were observed. ultrasonography ( 6.5MHz probe) was peffom,,ed confirming a well In group A no postoperative complications were observed patients capsulated lesion of the kidney. Ultrasonic shears and cautery were were discharged on avarage 6 postoperative (p.o.) day. In group B one used to r__~,ct__,the lesion with a five millimeters tumor free margin. pancreatic fistula was observed that prolonged hospital stay until p.o.day 23. The other two patients were dismissed on p.o. day 6 and 7. Fibnn glue was fappiied on the resect~ margin to opt~ize the Return to daily activities was rapid as in the case of a young female (20 h~is. Postoperat~ly a acute acalcoulous cholecys~s was years old) of group A that returned to her agonistic sport activity in observed, tn~ated with medical therapy. The patient was then three weeks. At a mean follow up of 28 months (range 4-84 months) discharged on p.o day g. Blood pressure returned to normal values. no late pancreatic fistula or recurrence are reported. Juxtaglomerular cell b.rnors of the kidney are rare CaL~_~.eS r In conclusion our experience suggests that laparoscop=c surgery for hypertension that are frequer(dy t~'eated with nephrectomy. In this benign lesions of the pancreas is feasible and safe in the hands of ia_parc~___~ allowed a curatve resection of tile tumor with ~dnr surgeons skilled with advanced laparoscopic expertise. presen,ation.. Sl14

COMPUTER ENHANCED ROBOIICALLY ASSISTED TELEMANIPU- MULTIPLE FRAME INTEGRATION IMPROVES VISIBLE CON- I.AllVE CHOLECYSTECTOMY William H.H. Chapman, M.D., Robert TRAST USING MINIMALLY INVASlVE SURGICAL INSTRUMENTA- J. Albrecht, M.D., V'ctor B. Kim, M.D. James A. Young, M.D., L. Wiley liON W. Charash*, M. Shaw, A. Park, Depts. of Surgery, University of Nifong, M.D., W. Randolph Chitwood Jr., M.D., Department of Surgery, Kentucky and Boston University* East Carolina UniversitySchool of Medicine, Greenville, N.C. Objective: Visiblecontrast during minimally invasive surgery (MIS) is Considerable developments have occurred over the last 10 years in limited by available light. We devised and tested a novel method of the field of computer enhanced robotically assisted surgery. With the improving perception of low contrast detail in 'real time'. recent approval of the da Vinci(tin) system (Intuitive Surgical, Mountain Methods: Video images were obtained using a standard color video View, CA) by the FDA for general abdominal surgery, we initiated assist- camera and a 10mm 0degree laparoscope. Images were digitized and ed elective cholecystectomiesat our institution. We present data to date analyzed in 'real time' utilizing a digital signal processor. Images were from our initial series of ten patients. displayed using a NTSC standard video monitor. Ten cholecystectomies were performed using the robotic system. Custom software was designed to allow display of the actual camera Following the creation of pneumoperitoneum,a three-dimensionalview- output or the digital sum the most recent 2, 3, or 4 frames. This yields ing thirty-degree endoscope was placed through a midline 12 mm port an effective frame rate of 30, 15, 10, and 7.5 fps, respectively. Target located 2 cm above the umbilicus. The two robotic instrument arms were images of known contrast were created. Random sequences of 12 placed through 8 mm ports bilaterally in the midclavicularline at the level numbers of density 0.5000 (1.0000 = black, 0.0000 = white) were print- of the camera port. An accessory 10 mm port was placed in the midaxil- ed on backgrounds with densities that varied between 0.4875 and 0.5 lary line 3 cm lateral and inferior to the robot's right instrument arm giving in 7 steps of 0.00125. Contrast was defined as the difference between access for a grasper. Length of time was recorded for the following: character and background density divided by character density. Thus, robot preparation; port placement; robot positioning; cystic artery and contrast was varied between 0.025 and 0. duct dissection and ligation; gallbladder dissection; total robotic assis- Normal volunteers (n=14) were used to determine the readability of the tance time; and total procedure time. Mean times are presented in min- target images. The actual number of errors was recorded for each of utes + s.d. the seven (12 digit) targets at each of 4 frame rates. An analysis of Robot preparationand draping time was 13+-4 min. Pods were placed Variance (ANOVA) was used to determine differences between frame in 6+-1 min. Dissection and ligation of the cystic duct and artery were rates. performed in 10+-4 min. The gallbladder dissection required 10+-7 min. Results: There was a significant improvement (p<0.0003) in readability Total roboticallyassisted time was 37+-10 min. Total procedure time was as frame rate was reduced for all targets with contrast between 0.0250 60+-25 min. There are no complications to date. and 0.0125. Improvement with each frame rate reduction was greatest All cholecystectomieswere completed efficaciously,with times compa- for images with the poorest contrast. A 10-fold improvement in read- rable to conventional laparoscopic methods. The robotic system is readi- ability was seen at 7.5 fps with a target contrast of 0.0125. ly mastered by OR assistants, and technical expertise is easily gained Conclusions: Multiple frame integration, with a consequent decrease in by an experienced laparoscopic surgeon. Telemanipulative robotically effective frame rate, results in a significant improvement in identification assisted choleoysteotomycan be performed safely, and this technique of low contrast detail. Future work to determine applicability of this may well be applicableto more complex laparoscopicprocedures. method to various surgical procedures is warranted.

NEEDLESCOPIC HELLER MYOTOMY Patrick M. Chiasson THORACOSCOPIC ESOPHAGECTOMY WITH PREOPERATWE CORTI- M.D., David E. Pace M.D., Christopher M. Schlachta M.D., COSTEROID FOR THORACIC ESOPHAGEAL CANCER REDUCES Joseph Mamazza M.D., Eric C. Poulin M.D., The University of SURGICAL INVASIVENESS AND MAINTAINS CURABILITY Masahiro Chin,M.D., Kiminebu Watanabe,M.D., Yasunori Morohoshi,M.D., Yoshiki Toronto Centre for Minimally Invasive Surgery, Toront.o, Kuriya,M.D., TakashiAkalshi,M.D.,Ph.D., Depatmentof Surgery,Sakata City Ontario, Canada Hospital,Sakata, Yamagata, Japan Minimally invasive surgical techniques and procedures con- We have inducedthoracoscopic esophagectomy with preoperativecorticos- tinue to evolve. This report examines our early experience teroid administrationfor patientswith thoracic esophagealcancer. However, applying needlescopic technology to the surgical management the applicationof thoracoscopicprocedure for advancedcase remainscon- of achalasia. troversial.We investigatedlow invasivenessand curabilityof this procedure. A retrospective analysis of Heiler Myotomy procedures per- Up to today, 47 patients of thoracic esophagealcancer were treated with thoracoscopicprocedure with lymph node dissectionsince 1995 March.And formed at our institution since January 1, 1997 was performed. we also induced preoperative corticosteroid administration since 1994 The results of 14 Needlescopic Heller Myotomy procedures January. So the serial 32 operative~atients with thoracicesophageal cancer (utilizing instruments with an external diameter of 2-3 mm) since 1993January were divided into three groups, group A: n=11wastreat- were compared with that of 15 Laparoscopic Heller Myotomy ed with thoracotomyprocedure without preoperativesteroid, group B: n--8 procedures. Both demographic and short-term outcome data was treatedwith thoracotomywith preoperativesteroid, and group C: n=13 were compared for each group. Analysis was performed utiliz- was treated with thoracoscopicprocedure with preoperativesteroid. These ing chi-square, Fisher exact test, and student t-test where items were compared among the three groups, such as operatingtime for appropriate. the thoracic part, the amount of intrathoracicblood loss, the amountof time the respiratorwas used and oxygenic inhalationwas needed,serum value Both groups were similar with respect to age (37.1 vs 43.3 of bilirubin, and the pestoparativeheart rate. Significanceof any valueswas yr., p=0.58) and gender (8/6 vs 8/7, p=0.84). However, the tested using Student_fs t-test or x2 test. Finally the survival rate of 47 needlescopic group weighed less (72.2 vs 83.5 kg., p=0.049). patientstreated with thoracoscopicprocedure was evaluated. Intra-operatively, the needlescopic procedures were shorter (98 Although there was no difference in operating time for the thoracic part vs 132 min., p=0.03). There were no conversions to open among the three groups, the amount of intrathoracicblood loss was signifi- surgery or difference in the number of intra-operative complica- cantly less in group C than in other two groups. The amount times of respi- tions (0/14 vs 1/15, p=l.0) for either group. Post-operatively, rator and oxygen inhalation used were significantly shorter in group C. the groups were similar with respect to complications (0/14 vs Occurrence of hyperbilirubinemiawas also significantlyreduced in group C. 1/15, p=l.0), time to normal diet (1.5 vs 2.0 days, p=0.23), and postoperativetachycardia was significantlyreduced in both group B and C. The 5 year survival rate of 47 patients ( 19 without lymph node metastasis, analgesia requirements (17.1 vs 29.6 morphine equivalents, 28 with lymph node metastasis ) treated with thoracoscopictechnique was p=0.86). Nonetheless, the needlescopic group had a shorter 55.6%. length of stay in hospital (1.1 vs 2.0 days, p=O.04). We concludedthat thoracoscopicprocedure with preoperativecorticosteroid In selected patients, Needlescopic Heller Myotomy is a viable reduced surgical ~nvasivenessand its curabilitycould stand comparisonwith treatment option resulting in a shortened operative time, a thoracotomy. decreased length of stay and improved wound cosmesis. Sl15

LAPAROSCOPIC GASTRIC WEDGE RESECTION : LAPAROSCOPIC REDUCTION OF AN ACUTE JEJUNOGAS- LOCALIZATION AND PERCUTANEOUS LESION LIFTING TRIC INTUSSUSCEPTION G.S.Choi M.D., W.u TECHNIQUE G.S. Choi M.D.1, W. Yu M.D.1, H.Y. Chung Department of Surgery, Department of Gastroenterology*, M.D.1, W.Y. Tak M.D.2, S.K. Kim M.D.2, Y.O. Kweon M.D.2, Kyungpeok National University Hospital, School of Medicine, 50, Y.H. Choi M.D.2, J.M. Chung M.D.2, Department of Samduk 2 ga, Jung-gu, Taegu, Korea Surgery1, Department of Gastroenterology, Kyungpook National University Hospital, School of Medicine, Jung-gu, Retrograde jejunogastric intussusception is a rare, also, laparo- Taegu scopic treatment of this complication is hardly to be found in the medical literatures. We successfully performed laparoscopic Background: laparoscopic surgery has been introduced into reduction of acute incarcerated jejunogastnc intussusception, the treatment of benign or malignant gastric tumors. A 52-year-old man was admitted to Kyungpook Nation Methods: From April 1996 to April 2000, laparoscopic wedge University Hospital emergency room with aggravated resection of the stomach has been undergone in 25 patients hematemesis and abdominal pain for one day. He had under- with 20 benign, 5 malignant tumors. In beginning of the peri- gone antrectomy and Billorth II gastrojejunostomy 20 years ago od localization of the lesion was tried by preoperative tattoo- due to chronic complicated duodenal ulcer. Initial vital signs and ing in 10 patients but in the later 15 patients, intra-operative laboratory findings were stable only except rapid pulse endoscopy was used. Resections with lesion lifting by percu- rate(119/min) and elvated serum amylase(209 IU/L.)leukocyte taneous suturing and anastomoses were performed by hand count(17900/mm3), we performed gastric endoscopy and and staplers in 9 and 16 patients respectively. abdominal CT scan which showed a typical bowel intussuscep- Results: Laparoscopic localization of the lesion failed in 3 tion. patients who had preoperative tattooing. Mean operative Under the general anesthesia and pneumoperitoneum, careful time was 155.4(65-260) min. Mean hospital stay was 6.72(2- reduction of intussusception of the efferent limb of jejunum out of 14) days. In two patients open conversion was done. One the stomach was commenced in a traction and counter traction suture line bleeding and trocar incision site hernia occurred manner which was guided by gastroscope to exclude presence in different three patients post-operatively. of any lead. No attempt to anchor the reduced bowel loop to the Conclusions: pre-operative tattooing was not a reliable other intra peritoneal viscera was done. method so that needed intraoperative gastroscopy. The patient resumed oral intake at the 2nd post-operative day Percutaneous lesion lifting was effective and could avoid and was uneventfully discharged at the 5th post-operative day. extratrocars. Laparoscopic wedge resection of benign or During 6 months- follow up showed no recurrence. malignant tumor was a feasible and useful procedure. Laparoscopic reduction of an acute jejunogastric intussuscep- tion was effective and safe method to treat it.

NUMBER OF MINIMIALLY INVASIVE SURGERY (MIS) CASES FLUIDREQUIREMENTS AND MOBLL1ZATIONIN LAPAROSCOPICVS OPEN RIGHT REQUIRED FOR COMPETENCY Uyen Chu, MD, Adrian Park, MD, Donald Witzke, PhD, Michael Donnelly, PhD.,Michael Mastrangelo, HEMICOLECTOMY PATIENTS MD, Department of Surgery, University of Kentucky Medical Center, H. Chut, MD, T. M. Young-Fad~ MD, M& Lexington, Kentucky Divi~io~of Coleecal Sure'y,Mayo Clinic,Rochmer, MN.

Objective: The purpose of this study was to obtain estimates from BACKGROUND:. Minimallyinwmive ma'gery may ha physiolollicallyIm ~e~ul to F~mt~. MIS surgeons regarding the number of cases a trainee must perform to Heeu~al ~ have Ix~n ludied,b~ fluidrequinm~m and m'inevolumm u diuimUy rd~mt be competent in 13 core laparoscopicprocedures. indi~ of streanmi~me haveu~ b~u repom~. Methods: Structured questionnaires exploring competency issues were mailed nationally to leading experts in the field of MIS. The AIMS: To comparefluid rec~iremm~t~ and urine velema of equivalentIN~u'esooplc v~ oponpationts. response rate to date approaches 50%. A smaller number of surveys METHOd: Rmr~aive chxqreview ofSO ~ undergoingIr d~t hcmimkctomy(LAP) were also administered to nonexperts. Data were analyzed using w~ im'fomed.Cues wee m.~ed to opm mnerols(OPEN) for petemiacenfouadee of~. ~d~.. ANOVA and post hoc Student-Newman-Keulstest. ~ ~dd~ ofop~fio~ l)iumi9 ~1 pdor ~ mrg~ w~ m~. Opaive dauih Results: Estimatesof the number of procedures to be performed for includedOR time md IV fluid. Fluidrequiremena and urine volume*pe" 24 hems wee remrdat f~ competency were not significantlyassociated with severaldemographic Ihe flnt 4 day,, i~luding day of ma'gmy. measures such as % of practice involvedin MIS procedures or years in surgical practice. Thus, the estimates of the experts and non-experts RESULTS: B~th greWswee nztchai for L,onda" (M:F = 2'.3 for inch 8reup)md ap (58 yrs OPEN n were pooled. The number of laparoscopic cholecystectomy and 57 ~ LAP).Sb~ p~ca~ (OPEN)md ~% (LAI')h~ ~ ,Moadml~ay. Twdve(OP~)md 7 inguinal hemiorrhaphy cases to be performed by an average, non- (LAP) p~mU us,d dinmicL Ibe mostcommoa ~q~amis wu cmc~ f~ b OPEN md Crohn's diseaeinflmLAF. MmnORfiazwu 176min(OFEN)vs157 rain(LAP)[P=0.2331. MmnOR~uld expenenced residentfor competency were 40+-31 and 40+-20, respec- vnm 3342ml (OPEN) ~ 2389ml (LAP) [1~0.002]. Mean fluid requinmem on day of stegmT were tively. The number of cases a surgeon, competent in laparoscopic 54.~lml (OPEN)vz 3685ml (LAP)iF- 0.002], whileurine volumes wee 1096mlvz 1039ml(P- 0.594~ cholecystectomy and inguinal hemiorrhaphy, needs to perform for the Fluid re~ on pea.,op day (POD) I wee 3385mlvs 3017ml(P- 0.726) tad mine 2071ml"a 11 additionalprocedures divided into 4 statisticallysignificantly different 3008ml re.ely. (~.01) Fluidre~ on POD 2 wee 2866mlva 2694ml(1~ 0.536) and levels. For example,colon surgery has to be performed about the same 2664ml n 3414mlrespectively. ~ 0.004). Fluidrequitemonts on POD 3 wee 2644mln 2174ml number of times as a lap chole. Laparoscopicbiliary surgery needs to (P-0.409) tad ta~ne2420ml n 1930udrespeaivdy (P= 0.322). be performed about 22 times; spleen about 15 times, and appendecto- my about 10 times. These and other procedure numbers will be report- CONCLUSIONS: ~k pto~date* comparedwith the open ceuuteq~t requirelea fluiddating the prou~dureand have~ fluidneeds in the fu~ 34 hom~while havlns equivdmt urine ont~. ed in detail. Expertsand non-experts tended to agree (within 15%) on Fluid needa on POD lee simibr, but LAP l~tieuts mebilizean additiemdlira" of urine. Thh ttond whether specific procedures should be core or not, with the exception continues on POD 2. Thus LAP i~ieru mobilizefluids etrlier and uvertll requirelea total fluidthan of laparoscopicadrenalectomy where they differed by 33%. OPEN. The LAP approachmay have benefitsin petieua intolmmtof fluid~ md my reducethe Conclusion: These data indicate the varying number of times core incidmoe of po~..op CHF md tttbl flbrill~t/on,both p,xt-op mmplimtionemneb,t~l with fluid laparoscopic procedures need to be performed by average surgical mobilization. residents to achievecompetency. Th~s information can be used to plan curriculum length and sequence for general surgery residents and fel- lows in MIS. Sl16

SLEEP ARCHITECTURE IN PATIENTS WITH GASTROE- LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH A NOVEL SOPHAGEAL REFLUX DISEASE JA Cohen MD, PA Harris ELECTROSURGICAL SNARE IN A PORCINE MODEL William PhD, DW Byrne MS, A Arain MD, L Khaitan MD, MD Collyer M.D., Jaime Landman M.D., Cassio Andreoni M.D., Ephrem Holzman MD, KW Sharp MD, WO Richards MD., Section of Olweny B.S., Chandru Sundaram M.D., and Ralph V. Clayman M.D., Surgical Sciences, Vanderbilt University, Nashville, TN Washington University Division of Urology, St. Louis, Missouri We evaluated the safety and efficacy of laparoscopic partial nephrec- Subjective questionnaire data suggest that patients with tomy with a novel arcing-gapelectrosurgical snare in a porcine model. gastroesophageal reflux disease (GERD) do not sleep as A novel electrosurgicalsnare based on high current density arcing and well as normal control subjects. The purpose of this study parenchymalcompression, was deployed with an ERBE generatorset at was to correlate reflux events with time spent in deep 200W in the ENDOCUT mode for renal transection. Five domestic pigs sleep. weighing 50 to 70 kg underwent unilateral laparcscopic partial nephrscto- We studied five male subjects, three of whom complained my; 6 weeks later each animal underwent contralateraipartial nephrecto- of nocturnal symptoms consistent with GERD, using my just prior to sacrifice. Three additional animals underwent hem- inephrectomyat the level of the renal hilum. overnight polysomn0graphy and simultaneous esophageal Mean transection time with the snare was 5.6 minutes. In 9 of 10 pH monitoring. cases, the snare provided perfect hemostasis. In one case, the snare detached from the handle and required re-placement to complete the Subject # of reflux events % of night in stage 3 sleep renal transection. In this case argon-beam coagulation controlled mini- 1 0 18.5 mal bleeding. 2 2 18.8 In all ten cases the renal collecting system was transected. In 6 cases 3 17 15.4 no urinary extravasationwas noted. In 3 cases argon-beamcoagulation 4 99 14.1 was used to seal small sites of leakage from the collecting system. In 1 5 312 8.3 case, three laparoscopicsutures were placed to close a defect in the col- lecting system resistantto argon-beam closure. No urinomas developed in the 5 chronic animals. Pathologic evaluation at 6-week's follow-up Correlation Coefficient: -0.96 revealed a maximum depth of injury/fibrosisof 5-mm. All 3 heminephrec- tomies were completed with perfect hemostasis; however, all 3 animals We conclude that the number of pH events in this group developed strictures of the renal pelvis; likely due to the proximity of the of subjects closely correlates with the time spent in deep snare to the pelvis. sleep. Laparoscopic partial nephrectomy with the arcing-gap electrosurgical snare is feasible in a porcine model. Application of the snare provides excellent hemostasis and often will seal the collecting system; however, the snare, in its current form, should not be used to incise any portion of the renal pelvis, as would be done with a hemi-nephrectomy.

LAPAROSCOPIC REPAIR OF TRAUMATIC PERFORATION OF AN INTERNET-BASED DATA COLLECTION AND REPORTING THE URINARY BLADDER. A CASE REPORT Daniel Cottam MD, TOOL FOR CLINICAL RESEARCH John Cowan, B.S, Susan L. Piotr J Gorecki MD, Marcio Curvelo, MD, David Weltman, MD, Nassau DeMeester, M.D., Kevin B. Johnson, M.D., Howard S. Kaufman, M.D., University Medical Center, East Meadow, New York Departments of Surgery and Pediatrics, The Johns Hopkins Medical, Baltimore, MD The role of laparoscopy as a diagnostic modality in trauma has been reported. However, therapeutic laparoscopy for trauma remains an Introduction: The objective of this study was to develop and imple- obscure and controversial subject. We present a case of a laparoscop- ment an Intemet-based data entry and management system for use in ic explorationwith suture repair of a traumatic bladder rupture. clinical research. Currently, clinical data collection frequently relies A 25-year-old man was brought to the Emergency Room after a head upon information transfer from static paper forms to database pro- on collision. On arrival he was alert, awake, orientated, and all his vital grams. Database files often reside on one or more desktoptlaptop signs were stable. Physical examination was unremarkable with the computers and are subject to inadvertent deletion, asynchronous merg- exception of gross hematuria upon insertion of the urinary catheter. CT ing, and breaches of confidentiality. Methods: A template-driven scan of the abdomen demonstrated a small amount of free intra-peri- Intemet data collection and reporting tool was developed using Cold toneal fluid. An antero-posterior cystogram was obtained which Fusion, r. v 4.0. The application and database were housed on an iP- showed no intraperitoneai or extraperitoneal leak. Repeat examinations protected Windows NT, r. server using a secure socket layer. A main of the abdomen revealed a mild tenderness in the lower abdomen. menu page provided options for entering and accessing patient data, Because of the presence of unexplained free intraperitoneai fluid and updating relational tables, and viewing statistics. The templates were equivocal signs of peritoneal irritation exploratory laparoscopy was per- compiled by the system and contained information regarding the data formed. to be collected, forms generation and validation, relational tables, and Three 5-mm ports and 5-mm camera were used. Laparoscopic data reporting and analysis. The application was applied to a retro- examination of the abdomen revealed free fluid and a 4-cm rupture at spective surgical series of patients who underwent treatment for rectal the dome of the bladder. The rest of the abdominal exploration was cancer. Results: Pre-, intra-, and postoperative clinical, laboratory, unramarkable.The laceration was sutured in two layers using a intra- radiographic, and pathologic data on >200 patients were successfully corporeal technique. His recovery was prompt and uneventful and he entered from multiple locations by several investigators. The database was discharged on the second postoperative day with a indwelling uri- could be downloaded only by users with the highest security access. nary catheter. Eight clays after the operation, a repeated cystogram Study statistics were obtained and will be demonstrated with the appli- revealed no evidence of leak and the catheter was removed. cation. Conclusions: Intemet-based clinical research systems provide We conclude that laparoscopic exploration for trauma in hemodynami- an efficient, secure, and versatile means for collecting and reporting caily stable patient can be safely performed. All principles of abdominal data. The application supported revisions in forms generation, data col- exploration for trauma can be adhered to while utilizing three 5-mm lection, and data analysis. Monitodng features alerted the investigators ports. The advantage of laparoscopic technique is not only to determine as to which subjects needed more data. This approach centralized the the need for laparotomy, but also to provide therapy for stable patients database and provided numerous portals for data entry. Although an using minimally invasive techniques. A prospective study is needed to initial capital investment in software, hardware, and Intemet connec- determine the role of advanced laparoscopy in managing the stable tions were required, this technology can be applied to numerous clinical trauma patient suspected of having an intraabdominalinjury. investigationsand may result in overall costsavings Slt7

LAPAROSCOPIC CHOLECYSTECTOMY: OUTPATIENT VS INPATIENT SPLENIC ARTERY ANEURYSM REPAIR: EVOLUTION OF A MINIMALLY MANAGEMENT Myriam J. Curet, MD, Michael Contreras, Diana M. Weber, INVASIVE APPROACH John de Csepel, MD, Michel Gagner, MD., Division of Lapamecopic Surgery, Mount Sinai School of Medicine, New York, NY MD, Roxie Albrecht, MD University of New Mexico School of Medicine, 2211 Therapy for splenic artery aneurysms (SAAs) has traditionally required a Lomas, Blvd., Albuquerque, NM laparotomy. A small number of case reports since 1993 have described laparoscopic management, usually consisting of an anterior approach to Objective: This prospective randomized trial was undertaken to determine if aneurysm resection or splenectomy. The purpose of this study was to patients undergoing an elective laparoscopic cholecystectomy may be evaluate our experience with laparoscopic SAA repair. discharged home 4 hours postoperatively with similar levels of pain and A retrospective review of medical records over a four-year period at two institutions was conducted. Six consecutive patients treated for SAA by a nausea, similar complication and readmission rates and equal satisfaction as single surgeon were identified. The follow up period ranged from 2 to 52 patients kept overnight. Methods: All patients presenting for an elective months. laparoscopic cholecystectomy underwent randomization to an outpatient There were five women and one man with an average age of 49 years group (OPD) who were discharged alter a 4 hour postoperative stay, or an (range, 37 - 63 years). Three patients were diagnosed with SAAs by inci- inpatient group (IP), admitted ovemighL Variables measured were degree of dental radiographic findings, while the rest were symptomatic. The first pain (scale of 1-10) and nausea/vomiting (scale of 1.4), amount of pain and three patients had aneurysm resection or splenectomy, while the last three underwent aneurysm exclusion. An anterior approach was used for the nausea medication taken, number of phone calls, readmissions or first five patients. The most recent patient underwent a lateral approach to complications, and degree of satisfaction with their procedure (scale of 1-4). aneurysm exclusion. The average aneurysm size was 3.1 cm (range, 2.5 - Statistical analysis was performed with t-test or Fisher's exact test as 5 cm), estimated blood loss was 82 ml (range, 20 - 300 ml) and operative appropriate. Results' Eighty patients were initially enrolled. Two were time was 143 minutes (range, 80 - 190 minutes). Aneursym resection and converted and 4 required admission after being randomized to outpatient, splenectomy patients had an average length of hospital stay of 3.3 days (range, 2 - 4 days) compared to 2.3 days (range, 1 - 4 days) for aneurysm leaving 37 OPD and 37 IP. The OPD patients received more oral pain exclusion patients. Complications consisted of an asymptomatic hyper- medication prior to discharge (2.1 doses vs 0.8 p<0.05). However, their amylasemia (n=l) and low-grade fevers (n=2). Postoperative spleen scan degree of pain was similar to IP patients (4.2 vs 4.3). Phone calls, revealed increased perfusion over time in patients who had undergone a readmission rates and complication rates were similar in both groups. Patient spleen-preserving procedure. There were no splenic abscesses. satisfaction was 3.8 at one month for both groups. Conclusions: Patients Our series of SAA patients demonstrates an evolution of laparascopic undergoing elective laparoscopic cholecystectomy, who are discharged treatment from an anterior to a lateral approach and from aneurysm resec- tion or splenectomy to aneurysm exclusion. A lateral approach permits a home at 4 hours postoperatively, will experience the same satisfaction with spleen-preserving procedure by providing excellent distal splenic artery no increase in complications as patients kept ovemighL Selected patients exposure without disruption of splenic collateral blood supply. Aneurysm should be offered outpatient management following laparoscopic exclusion avoids the morbidity associated with aneurysm resection and cholecystectomy. splenectomy

EXPERIENCE FROM 27 CONSECUTIVE LAPAROSCOPIC REOP- LAPAROSCOPIC RESECTION OF SMALL BOWEL LESIONS CAUSING ERATIVE BARIATRIC SURGERIES John de Csepel, MD, Michel LOWER GASTROINTESTINAL BLEEDING: THE IMPORTANCE OF Gagner, MD, Paolo Gentileschi, MD, Theresa Quinn, MD, Subhash METHILENE-BLUE STAINING BY INTRAOPERATIVE ANGIOGRAPHY Kini, MD, Daniel Hen'on, MD, Emma Patterson, MD, Alfons Pomp, MD, Salva Delgado MD, Miguel Pera MD, Juan C. Garoia-Valdecasas MD, Division of Laparooopic Surgery, Mount Sinai School of Medicine, New Manuel Pera MD, Oscar Estrada MD, Emilio Riera MD, Xavier GonzaJez York, NY MD, M.I. Real MD, Antonio M. Lacy., Service of Gastrointestinal Surgery. Institut de Malalties Digestives. Section of Interventional Radiology. Hospital Ten to 25% of patients undergoing obesity surgery will require a revi- Clinic. University of Barcelona. Spain sion. Reoperation is associated with increased morbidity and has tradi- tionally been done in open fashion. The purpose of this study was to Selective angiography has been demonstrated to be extremely useful in the determine the feasibility and safety of performing reoperative badatdc diagnosis of patients with gastrointestinal (GI) bleeding of obscure surgery using a laparoscopic approach. origin.One of the advantages of angiography is the ability to control the A retrospective review of medical records over a 22-month period bleeding either by mesenteric vasopressin infusion or supraselective tran- was conducted. Twenty-seven consecutive obesity surgery patients, scatheter embolization.However, the risk of complications,especially bowel who had undergone a laparosoopic revision, were identified. isquemia,is not dismissable.Laparoscopic-assisted small bowel resection is Twenty-six of the 27 patients were women. The average age was easy and allows a fast recovery.However, most of the lesions causing bleed- 40.3 years (range, 20 to 58 years) and original preoperative body mass ing may be difficult to lecalize.The aim here was to investigate the utility of index (BMI) was 51.6 kg/m2 (range, 42 to 66.5 kg/m2). Seventeen of angiography-guided methilene-blue staining in the laparoscopic treatment of the 27 primary badatdc surgeries were open procedures. They consist- small bowel lesions causing GI bleeding.Between October 1999 and August ed of a vertical banded gastroplasty (n=12), a gastric band placement 2000,we treated 4 patients with diagnosis of lower GI bleeding originated in (n=9), and a gastric bypass (n=6). After the primary surgery, the lowest the small bowel.Mean age was 61.5 years(2 males/2 females).Bleeding was average BMI was 37.6 kg/m2 (range, 21 to 52 kg/m2), which increased chronic in 3 patients and massive in 1.Previous diagnostic workup, inciuding to 42.7 kg/m2 (range, 29 to 56 kg/m2) before reoperation. Twenty-four endoscopy and scintigraphy was normal.Angiography of the superior of the 27 reoperations were for insufficient weight loss. On average, mesenteric artery identified small hypervascularized lesions in the ileum in the revision was undertaken 52 months after the primary procedure. all 4 patients.There was extravasation of contrast in 2 cases.Before the Twenty-four of the 27 reoperations were conversions to a gastric operation, a microcatheter was placed in the most distal branch supplying bypass. A second reoperation was required for insufficient weight loss the lesion. Pneumoperitoneum was established by the Veress on four occasions. The average operative time was 232 minutes technique.The laparoscope was inserted by a 12-ram trocar placed infraum- (range, 120 to 480 minutes) and length of hospital stay was 3.7 days bilically and the small bowel loops were explored.Four ml of methilane-blue (range, 1 to 9 days). Twenty-six percent of patients (n=7) experienced were infused and staining of a short segment of the ileum was complications including pneumothorax, gastric remnant dilation, gastro- observed.Laparoscopic-assisted resection was performed and a side to side jejunostomy stenosis, port site hemia and protein malnutrition. One extracorporeal stapled anastomosis was done by a 4-cm incision in the righl operation was converted to an open procedure. The average BMI was lower quadrant.Postoperative course was uncomplicated and the mear 35.9 kg/m2 (range, 27 to 45.5 kg/m2, p

LAPAROSCOPIC VERTICAL BANDED GASTROPLASTY WITH ROUX- LAPAROSCOPIC SPLENECTOMY IN THE TREATMENT OF EN-Y GASTRIC BYPASS FOR MORBID OBESITY. Aureo L DePaula, MD, SPLENOMEGALY Ostemo Q. Silva, Osvaldo G. Ramos Jr. and Klyoshi Hashiba, MD. Stanley DeTurris M.D., Robert Cacohione M.D., Alfonse Pecoraro M.D., Deparbnent of Surgery, Instituto ING, Goi~nia, Brazil. Anil Mungara M.D. and George Ferzli M.D, Department of Surgery, Staten Island University Hospital, Staten Island, New York The three most frequently used badatnc surgeries are the Roux--en-Y gastric bypass (RYGBP), the vertical banded gaskopiasty (VBG) and the Anecdotal evidence has suggested that spleens greater then 3000 adjustable gastnc banding (AGB). The RYGBP has achieved better weight grams may prove technically too demanding for laparoscopic removal. loss in long-term follow-up. The aim of this study is to demonstrate the We reviewed our experience with laparoscopic splenectomy from 1992 results of the association of VBG to RYGBP performed iaparoscopically to 1999. Of 86 laparoscopic splenectomies performed during this interval, (LVBG-RYGB). six patients had postoperative splenic weights greater than 3000 grams. In From November 1997 to July 2000, 156 patients undenvent LVBG-RYGB these six patients we examined age, operative indications, conversions to according to the criteria of the "NIH Consensus Development Panel" of open procedure, spleen weights, accessory incisions, operative times, badatdc surgery. Patients with previous esophageal and gastric surgew, blood loss, transfusions, drain placement, deaths, complications and hos- BMI greater than 85, age under 16 and over 65 and severe coaguiabon pital stay. disorder were excluded. Ninety-six patients were female and 60 ware male. Spleens were successfully removed in all six patients without conver- Mean age was 37.8 (16 - 65). Mean BMI was 49.1 (33.5 - 83). FiRy-seven sion. Mean age was 65 years (range 58-75.) Operative indications were (36.5%) paints were considered superobese. Associated diseases non-Hodgkin's lymphoma in four patients, sideroblastic anemia in one end included: diabetes(8.3%), hypertension (38.4%), sleep apnea(7%), hypersplenism in one. The average spleen weight was 3525 grams (range disUpidemia(27%), cholelithiasis (11.5%), o bes#y-hypoventilationsyndrome- 3050.4800.) All six required accessory incisions for spleen removal, two OHS (4.5%), arthritis (31%), GERD(14%), asthma(3.2%). using a hand-assisted transabdominal port. Mean operative time was 172 Mean operative time was 19groin (150min - 7h). Early postoperative minutes (range 127-250 minutes.) Estimated blood loss was 590 co complications included wound infection(1.4%), leaks(I.4%), pneumonia (range 400-700 cc) and 2 patients required transfusion (including one (1.4%), diges~ve bleeding (2.8%) and perforated jejunal ulcer(O.7%).Median patient with a preoperative hemoglobin of 7.9 mg/dl.) No drains were hospital stay was 3.1 days (2 - 25 days). Postoperative follow-up ranged placed. There were no deaths and no major complications. There were from 1 to 33 months. Late postoperative complications included 16 marginal three minor complications including an abdominal wall hematoma, postop- ulcerations, 1 anastomotic stricture treated endoscopically and 1 band erative diarrhea end atelectasis. There were no pancreatic leaks. Average erosion. Mean excess weight loss was 51% in 6 months, 73.4% in 12 hospital stay was 2.5 clays (range 2-4 days.) There were no port site months, 78.2% in 18 months, 76.9% in 24 months and 76.6% in 33 months. metastases on follow-up. All GERD, sleep apnea, cholelithiasis and OHS patients had resolution of Laparoscopic splenectomy for massively enlarged spleens greater then their medical problems. Hypertension, diabetes and asthma had papal 3000 grams is both technically feasible and does not appear to pose improvement. Quality of life was improved in all patients. undue risk to patients. Our conversion rate was much lower than anecdo. Laparoscopic vertical banded gastropiasty with Roux-en-Y gastric bypass tal evidence suggests for spleens of this size. Operative times, blood loss, proved to be technically feasible, with low complication rate, significant morbidity and hospital stays are consistent with published series. We con- weight reduction and improvement of associated diseases. clude that iaparoscopic splenectomy is appropriate for spleens greater than 3000 grams.

LAPAROSCOPIC-ASSlSTED ILEOCOLIC RESECTION FOR TOTALLY LAPAROSCOPIC AORTOBIFEMORAL BYPASS FOR AOR- PEDIATRIC CROHN DISEASE Ivan Diamond and Jacob C. TOILIAC OCCLUSIVE DISEASE : EXPERIENCE WITH 39 PATIENTS Langer, MD, Department of Surgery, Hospital for Sick Children Yves M. Dion, M.D., M.Sc.*, Geoffroy Wamier de Wailly, M.D.*, Carlos and University of Toronto, Toronto, Ontario Gracla,M.D.**, Yvan Douville, M.D., M.Sc.*, Department of Surgery, Centre Hospitaliar Universitaire de Quebec,* Laval University, Quebec City, Canada and Celifomia Laparoscopic Institute,** San Ramon, CA Background: Laparoscopic-assisted ileocolic resection for Crohn disease has been reported as an acceptable alternative The aim of this case series was to assess the feasibility of a totally laparo- to the open procedure in adults. We evaluated our initial experi- scopic aortobifemoral bypass (LABF) for aortoiliac occlusive disease. ence with this procedure in the pediatric population. Thirty-nine patients (27 men, 12 women) were submitted to a LABF Methods: Fifteen adolescents underwent ileocolic resection for according to the "apron technique" we previously described. Three had rest documented Crohn disease. Retrospective analysis of intraoper- pain and the others incapacitating claudication. The mean preoperative ative and early post-operative results was done, comparing right ABI was 0.66 (0.16-1.00) end the left was 0.61 (0.26-1.02). those undergoing the laparoscopic-assisted approach with those Operative, aortic cross-clamp, end enastomotic times were respectively having open resection. Data were compared using Student t- 302 (185-510), 95(42-189), end 48 (18-155) minutes. Blood loss was 646 test. (200-3050) ml. Three conversions occurred among the first ten patients. Patient 1 required removal of a plaque fractured at the site of the aortic Results: Eight adolescents (mean age 15.6yrs) underwent open clamp. Patient 6 had the graft damaged during insertion, which, when rec- resection and 7 (mean age 16.2 yrs) underwent laparoscopic- ognized, needed repiaosmenL Patient 7 had an unsatisfactory anastomosis assisted resection. No patient had undergone previous resec- made in a calcified aoRtiCstump. Anastomotic bleeding followed endarterec- tion. The two groups did not differ with respect to time from tomy of the aoRtic stump and a second laparosoopic enastomosis, which diagnosis to surgery, indications for surgery, preoperative med- was ultimately judged adequate after conversion. Four minor intraoperative ical therapy, or length of intestine resected. Operative time for complications were recorded and one patient needed a concomitant the laparoscopic-assisted group was slightly longer than for the femoro-popiiteal bypass for iatrogenic femoral artery dissection. open group (160 vs.130 rain), but this was not statistically signifi- Mean intensive care unit (ICU) and postoperative hospital stays were cant. There were no intraoperative complications in either group. respectively 2.29 (1-6) end 6.35 (3-23) days. One patient suddenly died on While no statistically significant differences were noted for num- the sixth postoperative clay after a normal recovery, likely from arrythmia or pulmonary embolism. ber of days of narcotic, total dose of narcotic, and time to Mean follow up averages 17.5 months (1-49). Patient 5 needed a reoper- resumption of regular diet, the patients undergoing laparoscopic- ation for acute aoRtiCfalse eneurysm. One patient suffered a stroke three assisted resection were discharged 2 days earlier (5 vs. 7, months postoperatively, another one needed a left profundoplasty one year p<0.05) than the open group. Complications included 1 wound postoperatively and one patient had revision of a femoral anastomosis 10 infection and 1 intraabdominal abscess in the open resection months after the original surgery. group, and 1 patient with a prolonged ileus in the laparoscopic- Totally laparoscopic aortobifemoral bypass for occlusive aortoiliac disease assisted group. is safe and feasible. Surgery time is now almost comparable to open Conclusions: Laparoscopic-assisted ileocolic resection is a safe surgery. Benefits (ICU end post-op, stays) similar to those demonstrated in alternative to open surgery in adolescent patients with Crohn general surgery are becoming apparent. disease. $119

THE EDUCATIONAL IMPLICATIONS OF THE IMPOR- HAND ASSISTED LAPAROSCOPIC COLON SURGERY (HALS) Jan TANCE OF CLINICAL JUDGMENT IN PERFORMING Dostalik, M.D., Ph.D., Surgery Departmentof MunicipalHospital Ostrava, LARPAROSCOPIC SKILLS. Czech Republic Michael B. Donnelly, PhD., Donald Witzke, PhD., Michael AIM: Mastrangelo, MD, Adrian Park, MD., Department of Surgery, Laparoscopic colon surgery belongs to the category of the more difficult University of Kentucky Medical Center, Lexington, Kentucky ones to perform. Specially, low anterior resections or abdominoperineal resection are operationsthat take a long time. An insertionof a hand of an Objective: The purposes of this study were: 1) to deter- operating surgeon into the abdominal cavity makes the operation simpler mine the importance of clinical judgment in performing basic and faster. laparoscopic skills and 2) to discuss the implications of METHODS: those findings for training residents in MIS. We use a special device, Japanese hand-port LAPDISC, which allows a surgeon to insert a hand into abdomencavity while preservingpneumoper- Methods: 23 of 48 MIS experts and 14 non-experts from intoneum. For low anterior resections or abdominoperinealresections we convenience samples returned a questionnaire concerning perform an incision of 7.5 cm (3 in) in the left lower abdomen. In this short the influence of clinical judgment (CJ-a cognitively complex incision we input a hand-pertLAPDISC. This multi-functionaldevice allows skill)on the performance of 18 basic laparoscopic skills (LS). a small opening for a laparoscopicinstrument, or a wide opening for an In addition, the LS were evaluated on 5 other dimensions insertion of a hand into the related to technical skills (e.g. hand-eye-coordination). A abdomen cavity, or a complete closure of the hand-portwhile preserving technical skills complexity index (TSCI) was also developed the pneumoperitoneum. RESULTS: for each LS. Between 1993 and end of August, 2000 we performed 230 laparoscopic Results: The LS could be divided into 3 CJ levels (high, colon operations,including 34 low anterior resectionsand 30 abdominoper- middle, and low) based on their mean ratings. Similarly, ineal resections. We used a HALS method for 13 of them. The operating TSCI divided the LS into 3 levels of skill complexity. The cor- time of the low anterior resection and abdominoperinealresections with relation between the CJ and TSCI indices was .16 (p > .05) laparoscopicassistance was on average 187 minutes.The operatingtime indicating that a laparoscopic skill's cognitive complexity is of procedures using HALS method was on average 156 minutes. The independent of its technical complexity. E.g., Trocar posi- HALS methodallowed to shorten the operationsby 31 minutes. CONCLUSION: tioning requires significant CJ but little TSCI; while, "using The HALS method should be used when a pert of the procedure is per- non-dominant hand" requires little CJ but significant TSCI. formed in front of the abdominalwall, or if the operationresults in colosto- Conclusion: The results of this study have important impli- my. A surgeon with an inserted hand in the abdominalcavity can utilize a cations for training residents in laparoscopic skills. palpationexamination that is usually used at open surgery. Competent performance of laparoscopic skills is not devel- Soft palpationof organs and digital preparationtogether with the use of har- oped in a straight linear fashion; time must be allocated for monic scalpelcuts on the operatingtime. Also, the HALS methodkeeps all the maturation of the judgmental aspects of these skills. the advantagesof the mini invasivesurgery.

ESOPHAGEAL CLEARANCE AND GASTROESOPHAGEAL LOW PRESSURE LAPAROSCOPY FOR OBESITY SURGERY REFLUX AFTER LAPAROSCOPIC HELLER MYOTOMY Karen Moshe Dudai MD, Sasha Levin MD, Misgav Ladach Hospital, Jerusalem Draper M.D., Jonathan Cohen M.D., Leena Khaitan, M.D. Ronaid Israel Clements M.D., Peter Wang M.D., Kenneth Sharp M.D., Michael Holzman M.D., William Richards M.D., Department of Surgery, Morbid obese paUants are in high risk for surgery because of respirator~ Vanderbilt University Medical Center, Nashville, Tennessee complications, thromboembolic complications and cardiac complications, la general Laparoscopy reduces the operative dsk but because of th~ The addition of an antireflux procedure during Heller myotomy for pneumcperitoneum those tPd'ee groups of complicationsare paffiallyretained achalasia is controversial. We report the incidence of reflux and the To further reduce the operative risk of the obese patients, we developed rate of esophageal clearance for solid food following laparoscopic techniqueto eliminatethe CO2 pneumoperitoneumcomplica6ofls. Knowing the Heller myotomy with and without Dor fundoplication in 25 patients. "Gassless" Laparoscopyin obese patients is a great chalenge, we devalopeq Twenty two patients who had undergone laparoscopic Heller the "Low Pressure Laparoscopy"technique, it is a Laparoscopyin combinatioe myotomy and 3 patients who had undergone laparoscopic Heller with mechanical, abdonminalwan elevation by Endolift (Storzt), with Icy myotomy § Dor fundoplication were studied postoperatively. All pressure, 5-9Cm, Co2 pneumopedtoneum. Adding low pressure of Co2 to thq patients underwent postop esophageal manometry and 24 hr pH abdominal waU lift by the Endolift, allowedto pull awaythe excess fat and tc testing. Symptoms of dysphagia and reflux were evaluated using a achieve good exposure with clinical insignificant Co2 pneumoperitoneun Likert scale ranging from 0 to 100. Ten patients also had evaluation pressure. of esophageal clearance using a bolus of scrambled egg labeled After havingexperience with 312 (of total 386) patientsin prospectivestudy wq with technetium-99. Images of the esophagus were taken every ten realized that the 'Low Pressure Laparoscopy" technique has sever= seconds for 15 minutes. advantages:A) Anesthesia-"soft and stable': the expired Co2 didn't excee~ Seventeen men and 8 women (mean age=48 +/- 11 yrs) were 37ram Hg, the 02% was above 95%, blood pressure and pulse didn't rise a~ studied. Esophageal clearance for solids was poor in all 10 patients. maW times as often seen in Laparoscopy. The use of relaxants, anesthetics an~ 8 of 10 pts. cleared less than 10% of the bolus after 15 minutes. gesses was reduced up to 50%. B) Recovery- "Fast': recoverylime was shor Clearance rate was not related to postop LES pressure or to the 1-3 (2) hr, short time for 02 supply 1-5 (3)hr, only 0-3(1) doses of simple dysphagia symptom score. All patients had aperistaltic esophageal analgedcs was needed. Out of bed in 3hr and clear fluids in 6hr. Discharge pos op. was within 1-2/d (Max 4d), return to work/normalactivity in 3-7 days. C contractions on manometry testing. Pathological reflux (>4.2% total Complications 'Law': 1 leak 1 LLL pneumonia with effusion, 5 linear( time) was noted in 3/22 Heller patients and in 1/3 Heller-Dor athelectasis, 1 nonsurgical mortality. D) Surgery - this techniqueoffers bette patients postoperatively. The reflux incidence was not related to exposure and partial liver retraction and reduced operative time (60 rain in the postop LES pressure, dysphagia symptom score, or reflux symptom last 200 patients)by usingvariable pressure. score. "Low Pressure Laparcscopy~ for obesity surgery fadrdates the Anesthesia Postoperative clearance for solids is poor following laparoscopic Recovew and Surgery and enables to accept High Risk Patient otherwis~ Heller myotomy. This is likely due to continued esophageal aperi- refused. This methodcan be applied to all upper and lower abdomen operatior~ stalsis. Postop pathologic reflux can be found in a small number of - the way we operate on a dailybasis. patients with or without the addition of an antireflux procedure and is not related to postop LES pressure. Patients with postoperatnve reflux do not report higher reflux symptoms. SI20

COMB~EO PROSPECTIVECUNICAL AND EXPERIMENTALSTUDIES OF LAPAROSCOPIC LAPAROSCOPIC MANAGEMENT OF SEVERE ENDOMETRIOSIS WITH REPAIR OF INCISIONAND VENTRAL HERNIA. Moshe I~udai MD - Misgav Ladach COLORECTAL INVOLVEMENT, Hags-Joachim Dueorae. M.D.. Anthony J. Hospital, M. HerbertMD - Assaf Harofeh Medical Center, Israel Senagora, M.D,, T, Falcone, M.D., Peter Marcello, MD, Depaflment of We have conducted ongoing experiments to reduce adhesion formation and improve results in a two layer laparoscopio intrapedtoneal onlay mesh (IPOM) Colorectal Surgery, Minimal Invaslve Surgery Canter and Department of repair of incisional and ventral hernia and have applied the results clinically. Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio. Laparoscopic repair offers advantages over open technique in operating and recovery time, visualization of the defect and low recurrence rate, but concerns Symptom resolution and fertility alter surgical management of Stage IV remain about adhesion formation and intestinal obstruction. In prior experiencewe endometdosis requires exdsion of all endometnal deposits, including those found onlay Gortex patch was unsatisfactor7 because of slippage and adhesion involving the intestine. Data from open surgical sedes indicates that removal formation in one out of 16 patients. We have developeda two layertechnique using of intestinal disease requires bowel resection. The purpose of this report Is to Butterfly Mesh in the defects and on top a wide propylene (Prolen). Animal describe our expadence with simultaneous laparoscopic exdston of pelvic and experiments showed a way to protect the surface of the prolene to reduce Intestinal endometdosis. The surgical goal was complete ablation of all adhesions. In four sets of animal experiments we compared incorportation and endometdal deposits, mobilizaton of pelvic organs, and limited use of bowel re- adhesion formation of Prolene alone, Prolena embedded in PDS and Prolene section, oophoractomy or hysterectomy. covered on its visceral surface with Surg~cel. Because of fewest adhesion, we All patients with Stage IV endometdosis and bowel involvement from 2/1998- subsequently selected the Composite of Prolene and Surgical for a second set of 712000 were included. All visible disease was excised from the pelvic sidewalls expenmentsin attemptingto reducethe adhesions that formed predominantlyat the and intestinal semsal surfaces, with bowel.resection reserved for cases with edge of the mesh. We achieved this by overlapping the Surgical around the edge deep invasion or extensive involvement. Surgical procedure (exdsion versus and by orientingthe staples perpendiouladyto and around the edges. In a final set of experiments,we found that wetting the Surgical with saline once the composite resection), length of stay (LOS), complications, and symptom relief were was in position, transformed it to a gelatinous film that further reduced adhesion. al;aiysud. We appliedthe later experiencein the repair of the incisional ventral hernias in 127 The sedes consisted of 33 patients with mean age of 34.7t-0,9 years. Local patients. The patients ages were 32-86 years, individual defects ranged from 3-22 excision of intestinal and pelvic disease was accomplished in 23 cases with a cm, and with multiple defects, up to 35cm. Operating time was 0.75-2h with an mean LOS of 1.4r days (excluding 7 outpatient procedures). Bowel resec- averageof 1.2h, Liquid diet was started at 8-10h. Only non-narcoticsanalgesic was tion was only required in 10 cases: proctectomy (n=6);small bowel resection needed with 1-3 doses per patlenL Patients were discharged on the 1= to 3~ day (n=2); ileocoecectomy (n=l); and rectal disc-excision (n=l). The mean LOS in and returnedto normal activity between3 to 7 days (average5d). Five patients had resection cases was 6.2:1:1.5days. Only 3/33 patients (9.1%) required significant abdominalpain which resovedat 3-5 weeks. One patient each developed abdominal hysterectomy or bilateral salpingo-oophorectomy. Preoperatively, a superficial umbilical infection (not on port site), small bowel fistula (from a repaired enterotomy), and three developed recurrence. Two patients were all patients had pelvic pain which resolved in 85 %. One colorectal anastomo- converted to open because of massive bowel adhesion. There have bean no tic leak required a temporary laparoscopic loop ileostomy. Conversion was intestinal obstructionsafter a ma)dmumof 61/= years follow-up. necessary in n = 3 patients. We experimentally perfected a technique of incisional/ventral hernia repair and Even though technically demanding, radical laparoscopic excision with designed a composite mesh of surgical and Prolene that produced the smallest preservation of reproductive organs and limited use of bowel resection can be amount of adhesions. We have successfully applied this IPOM two layers accomplished in the majodty of patients. Impo[tantiy, the need to resect composite mesh repair in 127 patientswith good results and low morbidity. bowel can be minimized, allowing limited hospitalization in most patients.

LAPAROSCOPIC GASTRIC BYPASS HAS SHORTER LENGTH OF TECHNICAL REVIEW OF TROCAR SITE CLOSURE STAY AND LESS COMPLICATIONS BUT IS MORE COSTLY COM- David B. Earle, MD PARED WITH OPEN GASTRIC BYPASS J. Chris Eagon, M.D. and Dept of Surgery, Baystate Medical Center, Springfield, MA Donna Matin, R.N., Department of Surgery, Washington University School of Medicine, St. Louis, MO Incisional hemias after laparoscopicprocedures are not uncommon. The The laparoscopic approach to Roux-Y gastric bypass is safe and effec- incidence is estimated to be 0.021-3.1%, but the true incidence is unknown. It tive, but the relative cost is unclear. Our aim was to compare hospital is generally agreed to dose all pod sites >gmm. Necessity has spawned a costs of patients undergoing open (OGB) or laparoscopic (LGB) gas- vadaty of methodsto accomplishthis task. I have categorizedthem in a way tric bypass. From 7/97 through 8/00, 129 patients with BMI of 37-64 that is logical, and suggestsuses otherthan that o~ginallysuggested: underwent GB by a single surgeon at a teaching hospital, 65 OGB and 1) needle-sizedgraspers, 2) snares, 3) eyelet/spring-loadedneedles, 4) 64 LGB. Outcome variables were length of stay (LOS), presence of postop complications, and inpatient costs (total, OR, room, pharmacy, hook-type needles, and 5) standard open instruments. supplies). Statistical compadsons were made with chi-square and t- test analysis after removing cost and LOS outliers (20GB, 1 LGB). DEVICE DESCRIPTION TYPE USES The OGB cohort had a higher BMI (54 vs 48, OGB vs LGB), and lower NeedeFaeper R TSCI AWVI GS fraction of women (73% vs 91%). Subgroup analysis by BMI decile GmNw #, Rlzz-RIl~I~ (R- Ne~h 9mlplr 0 TSC, AWV, GS and among women did not affect results. Cohorts did not differ in age M~ (44y vs 43y) or comorbidity frequency: DM 28% vs 22%, HTN 48% vs sm~ik=~m O TSCI AMWT OS 58%, Sleep apnea 52% vs 48%. LOS was shorter with LGB (5d vs Reb'ctab~ Iloek.nmzdle 3d). There was one mortality at home on POD 8 from a PE (OGB). U~,H'~I Venm Nm~, spi~ Sp~gkm=d J*~ 0, R TSC, AWV, OS Morbidity was more frequent with OGB (53% vs 17%). Minor wound nNdlew"~m mm mlenl infection (25% vs 8%), incisional hernia (18% vs 3%), and stomal C.-d~suture nee~ (k~al ~ sprk~k~K~ rmde R i TSC,AWV, GS stenosis (15% vs 2%) were more common after OGB. Gastrograftin swallow in all patients between POD 4 and 9 showed one contained Cader.~ sXumpa~er Nee~ Graq~ R TSC, AWV, GS leak (LGB) in a patient after endoscopic treatment of an anastomotic bleed. One LGB patient developed a subphrenic abscess requiring ...Hogk-b/peneedle R TSCt AWV~ GS percutaneous drainage on POD 15. Transfusion was more frequent in Lo,,mde/retractor(Cbcon ACMI) EW,m= fan, proC=~ R TSC, AMV,GS LGB (4% vs 10%). Conversion of LGP to OGP occurred in 2 cases petm (3%) due to splenic bleeding and a proximal jejunal injury. Percent loss Sutw pmer (Laun~M~) Wud m=~rok~g 0 TSC, AMV, GS of excess weight at 1 year was similar within BMI deciles (78% vs 88%). Total costs were greater with LGB ($10755 vs $11588). OR St~ Inst.& 2OF Faklycaet Stmdlrd IlllUtlllenl= D,R TSC costs were higher in LGB (4089 vs 7878) due primarily to disposables so= Fw.~ Ogre (~ St=z) Ne~e 9req~ R TSCw/LJ~V, GS and OR time. This more than offset lower costs in areas such as room Stamaynude (Cook) Needleintroducer R TSC,/~/~ GS (2189 vs 1168) and pharmacy (1481 vs 970). LGB achieves similar R=c~mb~ D=d~t~ TSC=tmr edtor AWVqbd weMvl~= GS= gropingmJtum weight loss with shorter LOS, but OR and total costs are higher. Complications are less frequent but many occur in the outpatient set- ting and are not reflected in hospital costs. $121

USE OF MINIMALLY INVASIVE SURGICAL TECHNIQUES IN PROSTHESIS AUGMENTATION OF THE LOWER ESOPHAGEAL TRAUMA SPHINCTER IN SWINE David Easter, MD, R Summers, MD, I< David Earle, MD, Marwan Jaber, MD, Dept of Surgery, Baystate Binmoeller, MD, M Yurek, BS, G Johnson, MS, S Harris, MS, P Miles. Medical Center, Springfield, Massachusetts PhD., Department of Surgery, University of California at San Diego; and, Endonetics Inc., San Diego, CA. We examine our early experience with minimally invasive surgery(MIS) applied for trauma patients at an urban trauma cen- OBJECTIVE: We postulate that multiple, preformed, expandable pros. ter. 16 hemodynamically stable patients evaluated by a single theses can be easily and accurately placed within the submucosal plan~ surgeon between 3/97 & 11/98 were 80% male with a mean age of the esophagus in pigs using a simple endoscopic delivery system METHODS: An endoscopic overtube system was developed for th~ of 27.5. Mechanism of injury was blunt trauma (2), stab wound delivery of multiple expandable prostheses. Adolescent pigs (n = 25) hac (8), and gunshot wound (6). MIS techniques employed were 2-15 prostheses placed into the distal esophageal wall using these steps laparoscopy(11), thoracoscopy(3), or both(2). The mean injury 1) surveillance endoscopy, 2) passage of the overtube-endoscope sys severity score (ISS) was 9.4 (2-22) and overall length of stay tern, 3) stabilization of the delivery site, 4) saline expansion of the submu (LOS) was 6.8 days (9 hours-19 days). There were no deaths, cosa, 5) prosthesis delivery, and 6) repeat steps 3-5 as necessary and no missed injuries. The conversion rate to open operation Sessions were video recorded. Animals had post-procedure endoscop~ was 19% - two laparotomies and one thoracotomy. Patients with at I week, 2 weeks, and at sacrifice. Successful delivery was ultimatel~ thoracic injuries requiring tube thoracostomy had a mean LOS of assessed by explant histopathology. RESULTS: Prosthesis insertior 8 days (3-19) and a mean ISS of 12.4 (4-22). Those without tho- was successful in 92/94 delivery attempts, and required between 3-1.= racic injury had mean LOS of 4 days (9 hours-11days) and a minutes of effort per s~te. Five successfully-placed prostheses wer~ mean ISS of 6.8(2-17). There was one laparotomy requiring only unavailable for followup because of immediate animal sacrifice. Using minor debridement of a grade IV liver injury, and grade I right prototype system (n = 54): 44 prostheses remained safely within a sub renal injury. Therapeutic maneuvers performed were repair of mucosal location, 9 were lost at one week- presumably because o serosal intestinal injury(2), diaphragm repair(2), and evacuation superficial sloughing- and, 1 was found deep to the muscular layer of the of retained hemothorax(2). esophagus. A simple modificationto the delivery system resulted in 100% retention at one week (n=33), and no instance of esophageal perforation In conclusion, MIS techniques can be employed safely for a vari- No prosthesis was lost in any animal if endoscopically visible at 1 week ety of traumatic conditions. Both diagnostic and therapeutic Tissue explants revealed encapsulated and intact prostheses that were maneuvers can be performed with these techniques. The applica- surrounded by chronic histiocytic fibrosis within the submucosa. Then tion of MIS techniques should minimize morbidity from non-thera- was no sign of active inflammation or abscess formation. CONCLU peutic operations, but not at the expense of an elevated missed SIONS: We have demonstrated that expandable prostheses can be eas injury rate. Like other areas of MIS, results depend on the skill ily and accurately delivered into the submucosal esophagus of pigs Multiple prostheses are well tolerated and retained without significant tis level of the surgeon and the equipment availability at the institu- sue reaction. Futurestudies will attempt to assess 1) removability,and 2 tion. prosthesis-induced changes in esophageal sphincter function.

PREVENTING CYSTIC DUCT LEAKS-- BACK TO THE INFLUENCE OF HANDLE DESIGN ON THE SURGEON'S UPPEF BASICS David S. Edelman, MD, Department of Surgery, LIMB MOVEMENTS, MUSCLE RECRUITMENT AND FATIGUi Baptist Health Systems, Miami, Florida DURING ENDOSCOPIC SUTURING Tarek A Emam MCh; Tim ( Cystic duct leaks have increased since the introduction of Frank PhD; George B Hanna PhD; Alfred Cuschieri MD Department of Surgery Molecular Oncology& Surgical Skills Unil laparoscopic cholecystectomy (LC). An alternative technique Ninewells Hospital & Medical School, University of Dundee for cystic duct and artery ligation was developed. The tech- Dundee, Scotland nique returned to the basic surgical tenet of ligation using suture ties with an occasional clip used when further security Background: Little work has been done to investigate the kinemal was deemed necessary by the operating surgeon. The pur- ice (motion analysis) and kinetics (muscle work, muscle fatigue pose of this prospective review was to analyze cystic duct comfort) of surgeons during laparoscopic surgery. These wer~ leaks, complications and costs compared to a standard LC investigated in the present study in the dominant upper limb of suv using clips and disposible canulas. geons during endoscopic suturing. Methods: Three different handles (conventional finger-loop, rocke Four hundred-sixty (460) consecutive LC's were per- and ball handle prototype) were compared in a study involving Ii formed from March 1997 to July 2000. A 5mm angled dis- surgeons suturing porcine enterotomies with each of the 3 instrL ments. The endpoints were performance parameters, motion anal~ sector would mobilize the structures in the triangle of Calot sis and muscle work and fatigue of the surgeon's dominant upps and place 2-0 silk ties around them. A knot pusher would limb with subjective scores for comfort level and manoeuvrability. triple ligate the cystic duct and artery prior to division or Results: Task quality and efficiency were significantly better wit cholangiography and bile duct exploration. Three 5mm can- use of the ball and rocker handle needle drivers compared to fingel ulas were used in the upper abdomen and an 11 mm Hasson loop instrument during endoscopic suturing with lower angula canula in the umbilicus. velocity at the elbow and shoulder joints, more pronation and les supination. The integrated muscle work was much lower for bot OR time averaged 42 minutes compared to 40 minutes for rocker and ball handles. Significant muscle fatigue especially of th all other surgeons using clips and kits. There were no cystic arm flexors and deltoid was observed only with finger-loop instrL duct leaks, but a single duct of Lushka leak occured in the ments. Comfort and manoeuvrability rating scores were higher wit silk tie group. There were no bile duct injuries in the silk tie both handles compared to the conventional finger-loop. The ba handle was more manoeuvrable but somewhat less comfortabl group. There were 15 bile leaks in 2501 patients in the con- than the rocker system. trol group. Costs were $254 less using silk ties and reusable Conclusion: Different pattern of joint movements, reduced muscl canulas, a $100,000 cost savings. power exerted during endoscopic suturing and hence absence c muscle fatigue were documented with ergonomic needle driver This study showed that an alternative method of securing (rocker and ball) compared to the conventional finger-loop instrL the cystic duct and artery exists that lowers the incidence of ments. These differences translate to a better and more efficier cystic duct leaks while being extremely cost effect. task performance w~th enhanced comfort. S122

LAPAROSCOPIC APPENDECTOMY IN COMPUCATED APPENDICITIS LAPAROSCOPIC ENDOBILIARY STENTING: A SIMPLIFIED Thomas Fabian, M.D., Anita Gambhir, M.D., Patricia Camuto, M.D., APPROACH TO THE MANAGEMENT OF OCCULT COMMON BILE Madanne Ulcickas Yood, D.Sc., M.P.H., Steven M. Yood, M.D., M.P.H., DUCT STONES. Robert D. Fanelli, MD; Matthew J. Tiemey, DO; Keith S. Department of Surgery, Hospital of Saint Raphael, New Haven, CT Gersin, MD Surgical Specialists of Westem New England, PC; Berkshire Medical Center, Department of Surgery; University of Massachusetts Appendicitis is the most common surgical emergency and laparoscopic Medical School. appendectomy has become a more popular procedure for treating this Three years ago we described laparoscopic placement of biliary stents condition. Its use, however, has been questioned in cases of perforated as an adjunct to lapamscopic common bile duct exploration (LCBDE) for and gangrenous appendicitis because of concems regarding the risk of treatment of occult common bile duct stones (CBDS). LCBDE was per- intraabdominal infection. On the other hand, infection of the operative formed to clear all CBDS prior to stent placement in 16 patients by either incision is the most common cause of morbidity after open appendecto- my for complicated appendicitis. choledochotomy or transcystic methods. We now present a modification of our technique and our experience with 48 additional patients. To quantify and compare the outcomes of laparoscopic to open appen- All patients presenting for elective cholecystectomy were treated using a dectomy in patients with perforated or gangrenous appendicitis, we retro- standard 4-port laparoscopic approach. Routine intraoperative fluoro- spectively reviewed all laparoscopic appendectomies performed at a cholangiography revealed occult CBDS in 48 patients during 36 months. large community teaching hospital over a 3-year pedod (1997-2000). We In our initial series, stents were placed for biliary decompression, to protect evaluated postoperative length of stay, wound infection (defined as a the ductal closure, and guard against the complications associated with wound that required drainage and a positive culture) and intraabdominal retained CBDS. Closed suction drains were used routinely and all patients complications (including abscess and bowel obstruction). were admitted for 24 to 48 hours following surgery. In our current series, we made no attempt to clear CBDS prior to stent placement. All stants During the study period, 57 laparoscopic and 116 open appendectomies were placed transcystically, and extemal drains were not employed. were performed for complicated appendicitis (microperforation, perfora- Stant placement added 9 to 26 minutes to operative time over laparo- tion, or gangrenous). The mean length of stay for the laparoscopic group scopic cholecystectomy alone. Forty-four patients (92%) were discharged was 2.1 days, while the open group was 3.9 days (p = 0.0001). There the day of surgery, and 4 patients (8%) were observed overnight. were no wound infections in the laparescopic group and 11 in the open Outpatient ERCP 1 to 4 weeks after surgery was successful in clearing group (p = 0.02). There was 1 intraabdominal complication requiring CBDS in all patients. Stents were retrieved without difficulty in all cases, intervention in the laparoscopic group and 4 in the open group (p = 0.53). and 3 to 36-month follow up demonstrates no surgical, endoscopic, or Postoperative intraabdominal abscess and wound infection are known stent related complications to date. complications of open appendectomy. In this study the risk of both of Laparoscopic biliary stent placement for the treatment of CBDS is a these complications was lower in the laparoscopic group. Although the safe, rapid, technically less challenging alternative to existing methods of sample size in this series is small, the results indicate that laparoscopy LCBDE. It preserves the benefits of minimally invasive surgery for for perforated or gangrenous appendicitis is feasible and results in fewer patients, and provides all surgeons with a less difficult, highly successful complications and a shorter length of stay compared to open appendec- method for treating occult CBDS. Stent placement virtually assures suc- tomy. cess of postoperative ERCP with complete stone clearance.

Quality of life before and after laparoscopic Nissen fundoplication. MALPRACTICE LITIGATION INVOLVING LAPAROSCOPIC CHOLECYSTECTOMY Alberto R. Ferreres, MD and Vicente Marcus Feith, M.D., Hubert J. Stein, M.D., Christian MOebius, M.D., P.Gutidrrez, MD, Department of Surgery. University of Buenos Aires. Hubertus Feussner, M.D., J.ROdiger Siewert, M.D., Department of Forensic Advisory Council to the Supreme Court of Justice. Surgery, Technische UniversitSt MOnchen, Klinikum r.d.lsar, Munich, Background: Malpractice litigation has become widespread in our Germany country in the last decade, both in the criminal as in the civil courts. Since the introduction of laparoscopic cholecyst-ectomy (LC) in 1990 Introduction: Gastro-intestinal reflux disease (GERD)is a very common and the subsequent rise in biliary tract injuries, it has represented one of the most common surgical procedures involving malpractice disorder in the western world. The acute disease can be sufficiently claims. treated by medical therapy. To prevent relapse many patients require life- Material and methods: A total of 30 malpractice claims related to Ion~gmedication. In these patients lapar0scopic antireflux surgery offers a patients who underwent LC were retrospectively analyzed and their clinical charts reviewed. good altemative. The aim of this study was to evaluate the postoperative Results:The 30 claims originated after LC performed in public hos- results and compare pre- and postoperative quality of life alter pitals (17) and private ones (13)of the city of Buenos Aires. The aver- laparoscopic Nissan fundoplication. age age was 42.8 years and 12 were female. The injudes were the following: Methods: Clinical investigations including esophageal manometry, pH 1) Direct injuries to the bile duct: 14 cases (7 grade I, 3 grade monitoring and endoscopy and previously validated Quality of life Index II, 2 grade II1 and 2 grade IV) were applied before and a median of 41 month after surgery in 75 2) Vascular and bleeding mishaps: 5 patients. 3) Biliary leaks: 4 4) Injuries to the digestive tract: 3 Results: The percent total time with pH <4 decreased from 10.4% to 5) Others: 4 3.2% on 24 hour pH monitoring. The mean pressure of the lower Mortality was 36%.The age of the surgeons sued was: 25-35 y: 9, 35- esophageal sphincter improved from 8.1 to 12.3 mmHg. Esophagitis 45 y: 14, 45-55 y: 3 ana 55-65 y: 2.Three were surgical residents, 2 chief of service and the remaining 25, active surgeons,whose exper- healed in 93% of the patients, but intestinal metapiasia in the distal tise was: less than 50 cases: 4, 50-100 cases: 5, 100-500 cases: 12 esophagus persisted in all patients when it was present before surgery. and more than 500 cases: 4. 20 claims were filed in the criminal The overall Quality of life Index signiflcanUy improved from 86+_16 to courts and 10 in the civil courts. Mean time for filing the claim was 6.7 months after the first operation. 116+16. Conclusion: laparoscopic injuries after LC must be accepted as a Conclusion: The data show that the iaparoscopic fundoplicaUon risk of the performance of the procedure. Gross evidence of negli- provides effective and durable relief in patients with GERD. The Quality gence, imprudence or unskillfulness must be achieved for proof of of life Index significantlyimproved after surgery. guilt. $123

THE USE OF OCTYLCYANOCRYLATE TISSUE ADHESIVE IN THE Use d'~ n,=lo.~,c -r'..~e 5,,.L,~- D~re.Je~ P*,, A/'~," "fEP I~/'..r CLOSURE OF LAPAROSCOPIC INCISIONS Alberto R.Ferreres MD, Edmundo Cataldi MD, Juan J. Acoglani MD, Mercedes Patifio MD The standard TEP inguinal hernia repair was modified to detemine whether and Michael Cornwell MD, Department of Surgery Hospital the degree of early post-opentive and late persimat pains associated with even laparoscopic surgery could be improved upon without jepordifing the integrity Objective: to compare the use of octylcyanoacry-late tissue adhe- of the repair itself. sive (OTA) with subcuticular suture (SCS) for the closure of skin inci- Nine (9) male patients, ages ranging from 17-72, underwent ten (10) inginal sions of laparoscopic port sites. hernia repairs via the totally extra-peritoneal (TEP) approach with balloon Study design: between november 1998 and january 1999, 200 dissection and $cneralanesthe~L Supplementallocal anesthetic agents were not patients undergoing different laparoscopic procedures were random- used. A 10xl5 r polypropylene mesh was fixed in pos~ion flora the ized (using a computer-generated random numbers table) to one of contralstecal aspect of the pubis tO the ipsilateral meaccrest u"t~z~ l~J~ tiglUr two port-site skin closure techniques. Mean age was 48.5 years sealant {Tissed/Baxt=) rather than the 5nun. hdical titaaium screws. All the (range: 16-81) and 125 (62.5%) were females. The laparoscopic pro- procedures were uneventful without early or delayed complications. cedures included: 122 cholecystectomies (56%), 41 appendectomies Patients reported significa~ less pare =xl required fewer doses of oral (20.5%), 37 inguinal hernia repairs (18.5%) and 10 Nissen fundoplica- narcotic arudg~cs in the week following the procedure than that typical of our tions (5%). The techniques were: use of OTA (Dermabond, Ethicon practicc or in the literature. Inc.)or subcuticular closure with monofilament 4/0 sutures. If port site There have been no early recunenr incisions were enlarged for withdrawal of specimens a fascial closure All major series' comparing laparoscopic and open hemiordmphy report less with vycril 0 was used. pain aad an earlier return to normal function with the minimally invasive "13me, difficulty, complications and cosmetic results were evaluated. approach. Yet even lap~oscopic procedures can be associated with significant Results: a total of 732 port sites were included: a) 200 10 mm early post-opmU~e pdn and a dgnificant percentageof patients will exlxmence umbilical skin port sites, 115 (57.5 %) closed with OTA and 85 transient episodic pair= as late as one year, similar to open surgery patients. (42.5%) with SCS, b) 210 10 mm sites: 123 (58.5%) with OTA and 87 The= symptoms are larg~ a fimction of the meat= of E,r ofthe proshe~ (41.42%) with SCS, c) 322 5 mm sites: 169 (52.48%) with OTA and mesh to tissue, one which may be able to be successfldlymodified by the use of 153 (47.51%) with SCS. a biologic ageat. Early resu~ are promid~ as far as these ~ =d The preparation of incisions for closure and bleeding control took 2 Ioss-torm follow-up will be pursuedto dctcm~.e ~ the rate of recurrence minutes for the OTA group and 0.5 minutes for SCS. Average delay is the equal of mcdu=ic~ fixation. time for closure was 1 minute for OTA and 4.7 for SCS. The first OTA cases were considered more difficult due to unexperience. No post- operative hernias nor wound infections were registered. Cosmetic evaluation was better for OTA at 1 (6 vs. 4.5 points), 3 (6 vs. 5) and 6 postoperative months (6 vs.4.5). Conclusions: OTA effectively closes skin incisions due to laparo- scopic port sites and its advantages are reviewed. P,H.,L, sL, P4 LJ/P

RHABDOMYOLYSIS AS A COMPLICATION OF LAPAROSCOPIC LONG TERM EFFECTS OF ELECTROLYSIS AS A MODALITY FOR THE DONOR NEPHRECTOMY: A REPORT OF 2 CASES Frederick C. PALLIATIVE TREATMENT OF PANCREATIC CANCER Beverley G Fosh Finelli,MD,JD; Truman Sasaki, MD; Yolanda Becker, MD., The Program for MBChB, J Guy Finch MBChB, Addan Anthony MBBS, Karen K Riches MBBS, Advanced Lapareacopic Surgery, Washington Hospital Center, Washington, Guy J Maddem PhD MS, Departments of Surgery and Pathology, The Queen D.C. and The DMsion of Transplantation, University of Wisconsin, Madison, Elizabeth Hospftal, Adelaide, South Australia Wl Objective Of Study In pancreatic cancer the majority of patients are offered pal- Introduction: Rhabdomyolysis is a rare and potentially devastating compli- liative treatment, usually in the form of a surgical bypass to alleviate symptoms. No ablative techniques are currently employed to either treat or palliate pancre- cation. Although it has been descnbed in urologic, vascular and orthopedic atic cancer, although there are recent reports of radiofrequency ablation in the surgery, it has not been repoded following laparoscopic surgery. porcine pancreas. Electrolysis is the delivery of a direct current between an Case 1: A 35 y.o. man underwent hand-assisted left donor nephrectomy in anode and cathode to induce Iocaiised necrosis, The aim of this study was to right lateral decubitus position. The oparatJve time was about 6 hrs; blood assess the long-term effects of electrolytic pancreatic ablation in the porcine loss was 150 ml. He complained of dght mid-back pain upon awakening and model had an 8-cm firm area at the site of pain. At 35 hours he developed fever, worsening pain and dark unne (myoglobinuna). Treatment for rhabdomyoly- Description of Methods sis was begun. The serum CPK was 2,651,256 IU/L. Serum creaUnine Eiectrelysts was delivered to the head of pancreas in nine healthy pigs. Each reached 2.5 mg/dl. He was discharged on POD 8 and at 2 months had com- pig received 150 Coulombs (amps x seconds). The pancreas and other pletely recovered. organs were hawested at 2 weeks (n--3), 4 weeks (n--3), and 8 weeks (n--3) to Case 2: A 27 y.o. man underwent uneventful laparoscopic donor nephrec- assess long-term responses. A histological score for pancreatic injury was tomy in the right lateral decubitus position. The operative time was about 6 derived by analysis of sections with Haematoxylin and Eosin stains, and hours; blood loss was 100 ml. Upon awakening, the patient complained of immuno-fluorescence. severe right buttock pain and leg weakness. Myoglobinuria was found and the serum CPK was 54,260 IU/l_ Compartment pressure was elevated (31- Results Eight pigs survived the procedure and gained weight. One pig died of a perfo- mm hg). Treatment was begun. The creatinine reached 1.9 mg/ml. He was rated bowel 2 days post procedure. Pancreatic duct dilation was noted in all discharged home on POD 4. At 6 months he still had numbness of the dght surviving pigs and was due to fibrotic obstruction at the site of the electrelytic thigh and scrotum and had developed reflex sympathetic dystrophy. lesion. There were no fistulas or pseudocysts. The histology of the area ablat- Discussion: Rhabdomyolysis following surgery can result from vascular ed showed fibrosis and some chronic inflammatory changes. The pancreatic compromise due to prolonged pressure on immobilized muscle. Long oper- histological score was not related to the length of time following electrolysis. ative times and decubitus positioning predispose to this condition. The rarity There was no histological evidence of any other end-organ injury related to the of this complication can lead to difficulty in diagnosis. Immediate postopera- procedure. tive pain in an area remote from the surgical site should trigger a strong sus- picion of this diagnosis. Prompt diagnosis and aggressive hydration and Conclusions alkalization will usually prevent permanent kidney damage. Fasciotomy is Other than iccaiised pancreatic duct obstruction, there were no other long-term needed in some cases. complications of pancreatic electrolysis. In humans, malignant pancreatic Conclusions: Rhabdomyolysis can occur after prolonged laparoscopic obstrucl~n would be a pre-existing cond~on. There was no evidence of sys- surgery, especially in decubitus position. Careful positioning, shortened temic effects of the procedure. Excluding methodological problems, electroly- operative times and heightened awareness can limit the occurrence and sis appears to be an effective ablative technique for the palliative treatment of severity of this complication. pancrea~ carcinoma. The application of electrolysis as a minimally invask'e technique is now being explored. S124

INVESTIGATIONOF THE SHORT-TERM EFFECTS OF ELECTROLYSIS A LAPAROSCOPICCURRICULUM WITH SKILLS TRAININGIMPROVES AS A NOVEL TREATMENT FOR PANCREATIC CANCER Beverley G Fosh RESIDENT PERFORMANCEON SKILLS ASSESSMENT. Dennis L. MBChB, J Guy Finch MBChB, Adrien Anthony MBBS, Karen Riches MBBS, Fowler. M.D. and Nancy J. Hogle, B.S.N. Dept. of Surgery, Allegheny Guy J Maddern PhD MS, Departments of Surgery and Pathology, The Queen Elizabeth Hospital,Adelaide, South Australia General Hospital, Pittsburgh, PA.

Objective Of Study Teaching laparoscopioskills in the operating room significantlylengthens This study aims to investigate the short-term local and systemic effects of OR time and has the potentialto cause complicationsthat cannot easily be producing an electrolyticlesion in the head of the pancreas gland in a porcine corrected laparoscopically. Despite this, there is no proven method to teach model. laparoscopicskills outside the operating room, and there is no established Pencreatic cancer is a biologically aggressive disease with only 15-20% of patients suitable for a "curative" surgical resection. This, combined with the method to assess laparoscopicskills other than the somewhat subjective poor 5 year survival figures indicates that aitemative palliative methods for evaluation of a mentor. symptom relief should be explored. Electrolysis is a novel ablative technique. Eight residents (4 beginning as PGY-1 and 4 beginning as PGY-2) A direct current (DC) delivered via electrodes inserted into tissue generates participated in a laparoscopiccurriculum consisting of 16 sessions during a chemicals that are locally cytotoxic. It is effective end reproducible,with neg- 2-year period. Each session included a didactic portion and a lab portion. ligible thermal effect end has the potential to be delivered endoscopically. Some didactic sessionswere dedicated to technique, but most were about Descriptionof Methods procedures. Somelab sessionswere dedicated to techniques such as 22 pigs underwent a laparotomy and electrolysis to the head of the pancreas tying, but most were about specific surgical procedures. Skills were of between 50 to 200 Coulombs (amps x seconds). Blood samples were assessed at the beginningof the curriculum and at the end of each year for obtained pre end post-electrolysis.All animals were killed at 72 hours. "tissue two years. The previously reported skills tests measured both speed and samples were histologicallyanalysed. accuracy in each of 7 different laparoscopictechniques, includingcutting, Results clipping, suturing, and tying (Fded, et al., McGill Univ., Monb'eal). Two pigs died of complications. Electrolysis produced volumes of necrosis in All residents improvedtheir skills assessment scores each year. The the pancreas in a linear dose-related manner. Histology showed inflammation mean scores at each interval were analyzed with paired t-tests. The was Iocalisedto the electrolytic lesion. Serology revealed a transient rise in average score for each level of resident improved significantly. amylase, leukocytesand CRP, which was not dose-related. Level ScoresFall '98 Scores Spring'99 ScoresSpring '00 p PGY-1 310 988 1159 .005 Conclusions Electrolysis produced necrosis in the pancreas in a reproducibledose-depen- PGY-2 904 1357 1458 .006 dent manner. Systemic effects were only observed at the highest doses of Residents who participatedin a laparoscopiccurriculum with skills training electrolysis. This technique shows promise as a palliative treatment for significantly improvedtheir skills assessment scores. This type of training patients with non-resectablepancreatic tumours and has the potential to be has the potential to improve performance in the operating room. applied as a minimally invasivetechnique.

LAPAROSCOPIC ASSISTED COLONOSCOPIC POLYPECTOMY: LEFT UPPER QUADRANT VERESS NEEDLE PUNCTURE FOR THE TEXAS ENDOSURGERY EXPERIENCE MORRIS E. FRANKLIN CREATION OF PNEUMOPERITONEUM: INmAL EXPERIENCE WITH MD, J.ARTURO ALMEIDA MD, EDUARDO PARRA-DAVILA MD, 776 PATIENTS Joseph A. Franklin, MD; James A. Young, MD; Cadyle DANIEL ABREGO MD, JOSE A.DIAZ, JORGE BALLI MD, TEXPS Dunshee, MD, MBA; Melvin S. Swanson, Ph.D.; William H.H. Chapman, III, ENDOSURGERY INSTITUTION. San Antonio, Texas MD, FACS; Kenneth G. MacDonald, Jr., MD, FACS., Section of GI Surgery, Dept. of Surgery, Brody School of Medicine at East Carolina University, INTRODUCTION:We present a technique combining colonoscopy Greenville, NC and laparoscopy to remove troublesome polyps without the need for segmental resections. Obesity and prior abdominal surgery once excluded patients from METHODS: From May 1990 to September 1999 laparoscopic moni- laparoscopy because of complications related to pneumoperitoneum cre- tored colonic polypectomies were performed in 47 patients with a total ation. Veress needle puncture at Palmer's point, located in the mid-axillary of 60 polyps being removed. All polyps undergo immediate frozen line 3crn inferior to the subcostal arch, is advocated to decrease insuffiation section analysis. If the pathological evaluation indicates malignancy complications in these patients. This series characterizes both safety end then a segmental resection may be performed, otherwise the patients efficacy of left upper quadrant (LUQ) Veress needle puncture end provides are decompressed and fed within a short period of time prior to dis- the largest study of this technique in general surgery patients. charge. Retrospective chart analysis was performed from January 1997 to RESULTS: The polyps were located most commonly in the ascend- January 2000. Patient demographics, operative diagnoses, technique of ing colon (18 polyps), transverse colon (12 polyps), and cecum (12 pneumoperitoneum, and complications related to creation of pneumoped- polyps). The most common histopathologic diagnosis was tubulo-vil- toneum were evaluated using frequency distribution end means. Ious adenoma in 28 polyps followed by villous adenoma in 11 polyps. 776 laparoscopic procedures were performed on 764 patients during the In three cases histopathologic diagnosis revealed malignancy necessi- study period. Ages ranged from 7-92 years; 62.1% of patients were female, tating segmental resection (1 low anterior resection, 2 right hemicolec- 37.9% were male. 62 patients (7.9%) were excluded due to prior LUQ tomies), which were performed laparoscopically. Patients received a instrumentation, patient disease, or surgeon preference; Paimer's point was liquid diet within 6 hrs, were discharged in an average of 21 hours and theoretically useable in 714 patients (92.1%). Obesity was observed in 172 retumed to full activity most commonly within days. The only compli- patients (24.1%); prior abdominal surgery was appreciated in 136 additional cation presented in this group of patients was an umbilical port sero- patients (19.1%). Technical failure occurred in 3 of 714 (0.42%). Major ma. Virtually all patients (97%) behaved as if only a colonoscopy was complications (i.e., requiring operative intervention) occurred in 2 of 711 performed. Pain at the trocar sites was managed with Acetaminophen patients (0.28%)-serosal bowel injury (n=l) end carbon dioxide embolus 600mg P.O. as needed, (n=l). Minor complications were identified in 5 of 711 patients (0.70%) but CONCLUSION: Laparoscopic monitored colonoscopic polypectomy required no operative intervention-needle perforation of liver, stomach, or allows patients to undergo removal of colonic polyps without a seg- omentum. No patient died or required conversion to laparotomy because of mental resection. This less invasive procedure yields recovery times the technique of pneumoperitoneum. similar to that of colonosoopy alone and, the potential complications of LUQ puncture for establishment of pneumoperitoneum is safe end well a segmental resection are avoided. All polyps are examined by frozen tolerated in a diverse general surgery population. Because of the favorable section and if a malignancy is encountered a laparoscopic resection complication rate, the general surgery division at this institution uses can be performed. Palmer's point almost exclusively. S125

LAPAROSCOPIC NON ANATOMICAL HEPATECTOMY IN A CANINE BOWEL OBSTRUCTION AFTER LAPAROSCOPIC GASTRIC MODEL BYPASS FOR MORBID OBESITY EIdo E Frezza MD, Sayeed Eldo E. Frezza MD, ~na Raldt MS, Sayeed Ikramuddin MD, William Gourash Ikramuddin MD, Michael Federle* MD, William Gourash CRNP, James Luketich MD, Philip Schauer MD., Minimally Invasive Surgery CRNT, MSN, Philip Schauer MD, Minimaly Invasive Surgery Center, University of Pittsburgh Center and Radiology* Department, University of Pittsburgh The purpose of this study was to establish an animal model for laparoscopic hepatectomy and determine feasibility and safety. Bowel obstruction resulting from internal hernias are a recognized Methods.Two groups of ten female dogs (mean weight 20kg) underwent but rare complication of open Roux-en-Y gastric bypass. This laparoscopic non-anatomic resection of approximately 500 of the total liver study describes our experience with bowel obstruction following mass.Group I was evaluated for 48 hours postoperatively to assess for the laparoscopic approach to Gastric bypass. immediate postoperative complications.Group II was evaluated for 14 days Methods. We reviewed our experience with postoperative bowel postoperatively to assess for longer-term complications.At the end of the obstruction in 405 patients who underwent LRYGBP between July observation period, animals were euthanized.Low-pressure pneumoperi- 1997 and August 2000. toneum (6mHg) was used.A variety of dissection and hemostatic techniques were employed including endoscopic stapling and bipolar electrocautery. Results. Eight patients in the series (2%) developed a postopera- Laparoscopic ultrasound was employed for major vessel identification.The tive bowel obstruction requiring operative management. Their liver specimen was extracted through an approximately 7-cm mcision and mean BMI was 46 (range: 38-65) and the average age was 45 weighed. For Group II animals, a drain was placed to assess for postopera- (range: 29-56). Five occurred in the early postoperative period the bile leak. and 3 occurred late (> 3 months). Internal hernias through Results.In group I, 3 animals developed a pneumothorax requiring premature mesenteric defects (4) were the most common cause followed by euthanasia while the other 7 survived the 48 hours observation period.No obstruction at the entero-enterostomy (3), and adhesions (1). In 6 significant pedoperattve bleeding occurred.The mean EBL was 66 ml.The patients the obstruction was managed laparoscopically (1 conver- mean postoperative Hct was 36%.1n group II, the mean EBL was 70 mI.The mean postoperative Hct remained stable between 35% (POD1) and 37.5% sion) and two patients underwent exploratory laparotomy. In all (POD10).Mean glucose (mg%) remained stable between 118 and 130 at 1 cases the obstructions were successfully managed without requir- and 5 days.One biliary leak at a resection site was confirmed (10%).Total ing bowel resection. In two cases the entero-enterostomy Bilirubin remained in normal range in all animals except two (one associated required revision. All patients recovered uneventfully, except for with a bile leak the other unknown cause).Mean GOT (UI/L) and GPT (UI/L) one patient who eventually succumbed to a pulmonary embolus. peaked at 1675 and 1279 respectively but retumed to near normal levels by Conclusion. Internal hernias appear to be a significant cause of POD 10.There was no evidence of pulmonary embolism in either group. bowel obstructions after laparoscopic gastric bypass. They devel- Conclusion.Laparoscopic non-anatomic hepatectomy in a canine model is op because bowel herniates through mesenteric defects resulting feasible with minimal perioperatlve bleeding and a relatively low rate of bile from creation of the Roux-limb. Secure, suture closure of these leak using currently available dissectnon and hemostasis techniques.The canine model appears to be helpful in evaluating resection methods prior to defects should be performed before completing the operation in use in humans despite anatomic differences with human liver anatomy. order to prevent intemal hernias and subsequent bowel obstruction.

MEDIAL RETROPERITONEAL APPROACH FOR LAPARO- CHANGES IN COAGULATIVE FIBRINOLYTIC SYSTEM AFTER THO- SCOPIC- ASSISTED COLECTOMY FOR COLON CANCER RACOSCOPIC ESOPHAGECTOMY AND TRANSTHORAClC Masaki Fukunaga,M.D., Akio Kidokoro,M.D., Toshiaki Iba,M.D., ESOPHAGECTOMY Tetsu Fukunaga M.D., Akio Kidokoro M.D., Masaki Kazuyoshi Sugiyama,M.D., Tetsu Fukunaga,M.D., Shoichi Fuse,M.D., Fukunaga M.D., Kumhiko Nagakari M.D., Seiichiro Yoshikawa M.D., Kunihiko Nagakari,M.D., Masaru Suda M.D., Seiichirou Department of Surgery, Urayasu Hospital of Juntendo University, School ot Yosikawa,M.D., Nobuyoshi Aihara,M.D., Department of Medicine CHIBA, JAPAN Surgery,Juntendo Urayasu Hospital, Juntendo University ,Urayasu, Changes in the coagulative flbdnolytic system after major operation arG Japan known to reflect the degree of surgical trauma, and to be involved in post. operative organ failure. We have conducted a comparative study to exam. Laparoscopic- assisted colectomy has been common in the treat- ine whether the postoperative coagulative fibrinolytic system differs ir ment for colon cancer. However, it can be difficult -especially for cases of thracoscopic esophagectomy and the conventional transthorack advanced colon cancer to perform lymph node dissection including esophagectomy with radical lymph nodes resection. regional blood vessels (D3 dissection)via laparoscopy. There are [Methods] three main approaches to D3 dissection: lateral, medial, and retroperi- Subjects for the study were 15 patients who underwent radical thoraco toneal. The purpose of this study is to evaluate the appropriate scopic esophagectomy (thoracoscopy group) and 15 patients who under approach to perform D3 dissection. We chose the medial approach went radical transthoracic esophagectomy (thoracotomy group) for thoraci( with early retroperitoneal mobilization from medial to lateral ( medial esophageal cancer. In each subject, platelet count, prothrombin time acthi retroperitoneal approach ; MRA). The advantages of MRA are the ty (PT), activated partial thromboplastin time (APTr), TAT, PIC, D-dimer, t ease and safety of mobilizing the mesecolon from the retroperi- PA and PAl-1 were measured before and immediately after the operation toneum, the ease of utilizing the rotation technique for D3 lymph node and on the 1st, 3rd and 7th P.O.D. [Results] dissection and its consonance with the no touch isolation technique. 1 .Platelet count decreased postoperatively in beth groups, with a more sig Of the 217 patients reviwed, the ilnitial 50 cases were excluded for nificant decline seen in the thoracotomy group (3POD 12.6 vs 16.8103/pl). this study, six of the initial group were converted to open surgery, for 2.Coagulation function was enhanced postoperatively in both groups; in 81 lateral approach was used. (There were no conversions in this terms of observed changes in TAT, aggregation was enhanced for a Ionge group.), and for 86 MRA was indicated. Only one case was convert- peded in the thoracotomy group (3POD 33.2 vs 47.8 ng/ml). ed to open surgery, and that for reason of massive adhesion. There 3.Fibdnolytic function was enhanced postoperatively in both groups; no dit were no intra-operative complications related to this procedure. ferencas in the extent of fibrinolytic function were seen between the tw, Operating time for MRA is shorter than that of lateral approach. There groups. was no significant difference in blood loss between the two groups. [Conclusions] Incidences of post-operative complications for MRA were less than for Postoperative enhancement of coagulative function was less marked iJ those of the lateral approach. patients who underwent thoracosoopic esophagectomy than in those wh, We conclude that the medial approach with early retroperitoneal underwent transthoracic esophagectomy. Changes in the postoperath, mobilization( MRA ) is a safe a~d feasible technique for performing coagulation system suggested that thoracosoopic esophagectomy cause lymph node dissection, including regional blood vessels, for advanced less trauma to subjects than transthoracic esophagectomy. colon cancer. $126

ACQUIRING LAPAROSCOPICINTRACORPOREAL KNOTTING LAPAROSCOPIC MANAGEMENT OF OBSTRUCTIVE JAUN- TECHNIQUES-EVALUATION IN A CENTRAL EUROPEAN COUNTRY DICE IN AN ARGENTINEAN RURAL HOSPITAL Alex Gandsas, Istvan Gal, M.D.. Ph,~),1 Gergely Csaky, M.D., Ph.D.z, Gy6rgy Weber, M.D., MD1; Fernando Telleria, MD2 and Jorge E. Lenzi, MD2, 1- Ph.D.3, Zoitan Szabo, Ph.D. ~.lDepartment of Surgery, Bugat Pal University Department of Surgery, University of Kentucky, Lexington., 2- Hospital, Gy6ngy6s, 2Department of Surgery, County Hospital, Miskotc, Department of Surgery, iMEC, Junin, Argentina. 3Departmentof Surgery, UniversityMedical School of P6cs, Hungary,4M.O.E.T. Institute, San Francisco, CA, USA Percutaneous transhepatic intervention with or without endo- Acquiring the sldils for laparnscopicsuturing and knottingtechniques can be a scopic management is not universally available in developing considered a prerequisite to learning advanced laparoscopic procedures. countries to treat patients suffering from obstructive jaundice. We Although disposable mechanical devices are available to simplify the tissue report the experience at a rural hospital in Argentina, using a mini- approximationtask for surgeons, their use is associatedwith higher operating mally-invasive approach to provide adequate long term biliary costs, and they are not universallyapplicable. The purpose of our study was to drainage using several types of biliary-enteric bypass procedures. evaluate and compare in the acquisitionof intracorporealknot tying techniques From October 1993 to July 2000 Forty-three patients (24 using reusableinstruments in two groups of surgeons. The skills of 17 specialists females and 19 males, aged 60-96 years) underwent one of the and 12 residents, ranging in age from 26-57 years of age, were compared. following procedures: choledocoduodenostomy 34 (79%); hepati- Hands-on training workshops on advanced laparoscopic procedures were cojejunostomy 7 (16%); chotecystojejunostomy 1 (2%) and hepati- conducting, ranging from 1.5 to 2 days (15-20 hours) in length. After each coduodenostomy 1 (2%). All surgical procedures were indicated surgeon had practiced the knordng techniques three times, their performance for: choledocholithiasis 20(47%), pancreatic cancer 14 (33%), bile limes were measured for tying a simple fiat knot; the number of erroneous duct cancer 3 (7%), gallbladder cancer 3 (7%), revision of previous movementswere also noted and evaluated.The averagetime for creating a fiat choledocoduodenostomy 1 (2%); lymphoma 1 (2%) or chronic pan- knot d~fered significantly in the group of specialists who had an average creatitis 1 (2%). performance time of 58.8 seconds (range of 7-100 seconds), whereas the Thirty seven procedures were successfully completed laparo- residents group averaged 15 seconds (range of 6-29 seconds). The mean scopically. Six conversions were required for: cancer of gallblad- number of erroneous movements corresponded to the average performance der and pancreas, bleeding and technical difficulties. Operative lime: 3.4 (0-9) in the group of specialists and 1.08 (0-3) in the resident's group. time averaged 156 +/- 10 minutes. The mean postoperative hospi- Followingthe first round of evaluations,the participantscontinued to practicetheir tal stay was 7 +/- 2 days. Post operative complications included slu'lis. On the second day, creating a complete knot (simple square knot, with a bile leak (3), wound dehiscence (1), intestinal perforation (1), ente- third opposingfiat knot) was the next task. The averageperformance time for the rocutaneous fistula (1) and infection (2). There were 5 deaths dur- specialists was 178.8 seconds (range of 65-230 seconds) and in the resident's ing the immediate post op period due to bleeding and sepsis. group: 143.5 seconds (range of 97-205 seconds). The mean number of Laparoscopic biliary-enteric bypass is an alternative and feasi- erroneous movements were similar in both groups: 5 (0-9) and 4.9 (2-12) ble approach to provide an adequate drainage of the biliary system respectively. The authors conclude that the acquisition of laparoscopic when percutaneous and/or endoscopic techniques are not avail- instracorporeol knot tying techniques is dependent on practice rather than able. When applied to debilitated patients carrying a malignant dis- whetherthe surgeonis in trainingor not. ease, the psychological burden of carrying an external drainage with its side effects can be spared.

GASTRIC REMNANT CARCINOMA: RE-EVALUATION OF MINIMALLY INVASlVE DIRECT TRANSDUODENAL BIUARY STENT- SCREENING ENDOSCOPY Christopher J. Gannon, M.D., Brett ING FOR PANCREATIC CANCER Sashidhar V Ganta M.D., Seth Engbrecht, M.D., Lena M. Napolitano, M.D., Barbara L. Bass, M.D., Gendler M.D., Geredo Magana M.D., Madhu Rangraj M.D., Department Department of Surgery, University of Maryland School of Medicine and of Surgery, Department of Gastroenterology, Sound Shore Medical Baltimore VA Medical Center, Baltimore, Maryland Center, New Rochelle, New York

Objective: Gastric remnant oarcinoma (GRC) after resection for peptic Recently biliary endoprostheses assumed significant role in palliation of ulcer disease is an uncommon entity that is potentially cured by surgical obstructive jaundice in pancreatic cancer patients. ERCP and PTC being intervention. A recent case of advanced GRC prompted a review of the the usual mutes, we present a novel and effective approach for this unfor- role of screening endoscopy in this population. tunate group in the event of failure with using these traditional methods. To Case: A 67-year-old male presented with complaints of chronic post- date this method is not reported in litereture. prandial pain in the epigastric region. The patient had undergone a vago- Two weeks after ERCP and stent exchange, an 80-year-old female pre- tomy, antrectomy, and loop gastrojejunostomy for peptic ulcer disease 25 sented with abdominal pain, vomiting, fever and jaundice for four days. years prior. Abdominal CT revealed markedly thickened walls of the gas- She was diagnosed with pancreatic cancer six months ago and under- tric remnant with infiltration of the adjacent fat planes. An esophagogas- went ERCP with stent placement. Endoscopic stenting on this admission troscopy demonstrated erythematous, friable remnant mucosa. Gastric was unsuccessful secondary to proximal duodenal obstruction. Patient biopsies revealed invasive adenocarcinoma. At laparotomy a large tumor underwent laparoscopic Gastro Jejunostomy and direct Trans duodenal mass involving the gastric remnant and the antecolic loop gastrojejunos- biliary wall-stent placement successfully. Open duodenotomy was per- tomy was identified. Further exploration revealed a firm nodule in the left formed and a metal stent was deployed directly through the previous lobe of the liver and several small nodules on the diaphragm and the papillotomy into the CBD, without endoscopy. Her biliary and gastric outlet lesser omentum. Biopsies confirmed metastatic adenocarcinoma at all obstructions were palliated effectively as evidenced by symptom relief and sites. Curative resection was abandoned. objective data. She was tolerating diet by post-operetive day two. Discussion: GRC typically presents more than 20 years after the initial However, 17 days later she finally succumbed to the disease. gastric procedure and has a history of poor survival rates. With Randomized studies suggested that endoprostheses are as effective as increased use of diagnostic endoscopy, GRC has been detected at earli- surgical bypass in relieving jaundice, but late complications secondary to er stages. Recent cohort studies demonstrate that GRC has similar sur- stent occlusion are common and a significant source of morbidity. The vival rates after stage stratification when compared with primary proximal advent of expendable metal stents allow placement of conduits with much gastric carcinoma. The incidence ratio of GRC in patients with resection larger lumen, thereby significantly increasing median stent patency. (273 for benign disease increases from 1.4 for the 5-20 year postoperative vs. 126. days, David's et al.) ERCP and PTC are the traditional approach- interval to 3.9 from 21-40 years and finally to 7.3 from 40-45 years after es used to place the biliary stents. However, in some patients either surgery. approach may not be feasible and these patients have miserable death. Conclusion: The increased incidence of GRC in later decades (>20 approach we described may be of help to properly selected years) after operation in conjunction with decreasing numbers of patients The some suggests that screening endoscopy should be considered on a 2-5 year patients. The authors suggest this innovative approach as an aitemative in select- basis in this population. Furthermore, any endoscopy undertaken in post- gastrectomy patients should include biopsy of the gastric remnant ed patients. The technique could be further refined to avoid duodenotomy, because early GRC can often have a normal mucosal surface appear and attendant morbidity. S127

THE USE OF NEEDLESCOPIC INSTRUMENTATION IN LAPARO- LAPAROSCOPIC NISSEN FUNDOPLICATIONLEADS TO OVERCORREC- SCOPIC PROCEDURES DOES NOT INCREASE SURGICAL TIME TION OF VECTORVOLUME IN A PiG MODEL OF GASTROESOPHAGEAL GARCIA-RUIZ ANTONIO M.D., CHAVEZ-RODRIGUEZ JUAN JOSE REFLUX. Kanm A. Gawad, M,D,, Christian Rempf, Robin Wachowiak, Chri- M.D., HAGERMAN GONZALO M.D., LOPEZ LETICIA M.D., SUBSEC- stian Bloechle, M.D.,PhD., Jakob R. Izbicki, M.D., PhD., Department of Sur- CION DE CIRUGIA DE MINIMA INVASION , HOSPITALCENTRAL MILl- gery, UniversityHospital Eppendorf, Hamburg, Germany. TAR Laparoscopic treatment of gastroesophagealreflux disease (GERD) INTRODUCTION: Preliminary reports on the use of needlescopic tech- has become very popular over the past years. Several techniqes of total or niques had advocated increased surgical time in comparison with conven- partial fundoplicationare applied not knowingwhat the mechanismsof func- tional laparoscopic operations. After formal laparoscopic training we have tion really are. The purpose of this study was to elucidatethese mechanisms used needlescopic instrumentation (diameter <3.3 ram) for a variety of in an experimentalmodel. laparoscopic procedures. Twentyfour pigs of the german landrace were included. Vectonrolume AIM: To determine if the use of needlescopic instrumentation increases was assessed by repetetive (x4) 6-channelwater pedused rapid-pullthreugh operative time compared to standard laparoscopic techniques. manometry performed in apnoea and without the use of muscle relaxation. STUDY DESIGN: Prospective, longitudinal,comparative, non-randomized. Gastreesophageal reflux was induced by open cardiomyotomy. Sufficiency EXCLUSION CRITERIA: BMI > 26, perforated inflammatoryprocess. METHODS: From Aug 1999 to Aug 2000, we have performed a total of 127 was confirmed and perforation excluded by esophagogastroscopy.Animals laparoscopic procedures (38 using needlescopic instrumentation). were randomly allocated to receive 360~ (Nissen type), 270~ posterior (Tou. According to selectioncriteria we have the following results: pet type) or 180" anterior (Dor type) fundoplicationsperformed laparoscopi- cally 2-3 days alter myotomy. Manornetry was performed at baseline, 2 days Needlescopic Cholecistectomy n=14 Mean Time(MT)= 64.74 post myotomy, 10 days and 60 days post fundoplication.Statistical evalua- Laparoscopic Cholecistectomy n=23 MT=49.38 p=0.0001 Needlescopic tion of differences was tested by using the paired t-test, All values are provi- Nissen n=11 MT=96.36 Laparoscopic Nissen n=38 MT=87.76 p=0.1156 ded as mean. Needlescopic Appendectomy n--6 MT=55.83 LaparoscopicAppendectomy Pigs had a median weight of 56.8 (48.4-65.2) kg at entry, 57.35 (48- n---6 MT--40.83 p----0.0488Needlescopic Heller n=2 MT 147.5 Laparoscopic 67.1) kg after myotomy and 70.1 (62-81.4) kg at the end of the study. Maxi- Heller n= 6 MT=135.83 p=O.4058 and one Needlescopic Splenectomy mal (15.8 vs. 10.8 mmHg) and mean (9.5 vs. 6.8 mmHg) sphincterpressure was performed in 80 mins. as well as vectorvolume (1977 vs. 823 mmHg2*cm) were significantly (p<0.05) reduced by myotomy. All three different procedures led to a signifi- we have not converted any needlescopic procedure to laparoscopic nor cant increase of all these parameters with Nissen fundoplicationshowing the conventional open surgery and we have had no postoperative complica- most excessive increase in maximal pressure (34.9 vs. 78.9 mmHg) and tions in the needlescopicgroup after a 10-month follow up. vectorvolume compared to postmyotomy values (915 vs 5014 mmHg2*cm) CONCLUSION: The use of needlescopic instruments has many appli- cations in laparoscopic general practice. In selected cases and for as well as normalvalues (1977 vs 5014 mmHg2*cm). experienced surgical teams, their use does not result in longer opera- The overcon'ectionof vectorvolume as well as maximal sphincterpres- tive time(clinically significant) as compared to standard laparoscopic sure by 360~ (Nissen type) fundoplicationassessed by rapid pullthroughma- techniques. nometry in this experimentalmodel may be an explanationfor the increased percentage of dysphagia followingthis procedure in the clinical setting.

ENTEROSCOPIC TREATMENT OF EARLY POSTOPERATIVE A MODEL FOR EVALUATION OF LAPAROSCOPIC SKILLS: IS THERE BOWEL OBSTRUCTION Keith S. Gersin MD, Jeffrey L. Ponsky CORRELATION TO LEVEL OF TRAINING? Gabriela A. Ghitulescu,M.D., MD, Robert D. Fanelli MD Department of Surgery, University of Anna M. Derossis, M.D., Uane S. Feldman, M.D., Donna Stanbridge, R.N., Cincinnati, Department of Surgery, Cleveland Clinic Foundation, Gerald M. Fried, M.D. Centre for Minimally Invasive Surgery, McGil Department of Surgery, Berkshire Medical Center University, Montreal, Canada

Early postoperative small bowel obstruction (EPSBO) occurs Performance of basic laparoscopic skills has been measured objectivel~ in nearly 1% of patients undergoing laparotomy and has a mor- and scored in a trainer box with a video-endoscopic optical system. ,~ tality rate exceeding 17%. Nasogastric (NG) decompression is series of structured tasks has been previously developed and described successful in 78% of patients. Repeat laparotomy has been rec- along with an objective scoring system. The performance scores of al ommended when obstruction does not resolve after 14 days of subjects evaluatedto date were related to level of training. NG decompression. We report 4 patients with EPSBO treated One hundred and forty nine subjects were tested performing ; successfully with push enteroscopy after failed NG decompres- laparoscopic tasks (peg transfers, pattern cutting, clip and divide, use of sion. Methods: Four patients who failed NG decompression ligating loop, mesh fixation, suturing with intraoorporeal and extracorporea underwent push enteroscopy instead of repeat laparotomy. knots). Performancewas measured using a scoring system that rewards( EPSBO was diagnosed if obstruction lasting more than 14 days both speed and precision. Student's t test was used to evaluate difference,, developed after initial resolution of postoperative ileus or high between junior (PGY 1,2,3) and senior (PGY 4,5, fellows, attendin( NG output persisted for 21 days in the absence of prolonged surgeons) participants. Data were analyzed by linear regression to asses,, ileus or sepsis. Small bowel series or CT was utilized when radi- the relationshipof performance to level of training for each task. ographic assessment was necessary. The Olympus SIF 100 There was a significant difference between the performance of junior vs push enteroscope was introduced with an overtube using topical senior participants, and good correlation between level of training an( anesthesia and intravenous sedation. After maximal insertion, P.errfaOs~nancle* for ea~h tesk3,(Data 4r,e mea~SD).l (*~.0001,7:'p<=-.OoO~t~;, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy and the patients Junior 1175.-67131r 74.+21 59-J:38275-J:781189~152 142:t:80 988333 followed clinically. Flatus, defecation, and tolerance of diet Senior 173+46170-~53 78+20 955:30 332i-67 358.t:117 2005:80 1409+-29; defined resolution of EPSBO. Results: EPSBO resolved 24-36 r .5 .39 .25 .51 .48 .56 .39 .62 hours following enteroscopy and all patients were discharged on Analysis of all participantswho have been evaluated with the laparoscopiq general diets 48 hours after return of bowel function. skills model has shown that there is correlation between level of training anq Readmission has not been necessary during 12-24 month fol- performance on all seven tasks, thus showing construct validity. Basi~ low-up. Conclusions: Our experience suggests that push laparoscopic skills models such as this one can become useful in th~ enteroscopy is successful in treating EPSBO and should be con- evaluation and improvement of technical skill in trainees and practicin! sidered prior to re-operation. Repeat laparotomy may not be surgeons. necessary and push enteroscopy may reduce patient morbidity, cost, and hospital lengths of stay associated with this uncommon surgical complication. S128

A MODEL FOR EVALUATION OF LAPAROSCOPIC SKILLS: IS THERE DIAGNOSTIC AND THERAPEUTIC LAPAROSCOPY FOR TRAUMA. A EXTERNAL VAUDITY? Gabdela A. Ghitulescu, M.D., Anna M. Derossis, TECHNIQUE OF SAFE AND SYSTEMATIC EXPLORATION Piotr J. M.D., Liane S. Feldman, M.D., Donna Stanbridge, R.N., Gerald M. Fried, Gorecki M.D., Daniel Cottam M.D., George Angus M.D., Gerald Shaftan M.D. Centre for Minimally Invasive Surgery, McGill University, Montreal, M.D. Department of Surgery, Nassau University Hospital, East Meadow, Canada New York Laparoscopy has a limited role in the evaluation of stable trauma patients. A video-endoscopic optical system and trainer box have been used to The main concems addressed in the literature are the potential for missed devise a serias of skill testing tasks, along with an objective scoring system. visceral injury and its limited role for therapeutic applications. We present Seventy surgeons and residents at our institution were compared to seventy a simple technique for the systematic exploration of the abdomen for sus- nine subjects from other institutions. pected intraabdominal injury using a series of three consecutive trauma One hundred and forty nine individuals were tested performing 7 patients (two penetrating, one blunt), over a six month period at a level one laparoscopic tasks (peg transfers, pettem cutting, clip and divide, use of a trauma center. ligating loop, mesh fixation, suturing with intracorporeal and extracorporeal All patients underwent complete exploration of the abdominal cavity knots). Performance was measured using a scoring system that accounted through three 5-mm ports. The first port was placed in the umbilicus for the for both speed and precision. Student's t test was used to evaluate camera and the second and third ports were located in the dght upper and differences between subjects at the host(H) institution and at outside left lower paramedian area for instrumentation. A 30-degree laparoscope institutions(NH), controlling for level of training. was utilized for all diagnostic and therapeutic explorations. The proce- At the junior(Jr) level (PGY 1,2, 3), there was a difference between the two dures started with the inspection of the pelvic organs, followed by running groups for tasks 1 and 5, where non-host subjects performed better. There of the small bowel from the ileocecal valve to the ligament of Treitz. Inspection of the colon, liver, stomach, spleen, diaphragm, and lesser sac was no difference in performance at the senior(Sr) level (PGY 4,5, fellows, was performed. Each of the presented patients was found to have a signifi- attending surgeons). cant injury traditionally requiring therapeutic laparotomy. Additional ports Data are mean values + standard deviation for retraction were used as needed once injuries were identified. Task 1 2 3 4 5 6 7 Total Therapeutic procedures consisted of sutudng an intrapedtoneal bladder H Jr 83i~o4 128_+5875+1E 57+40 258+8~= 183+163 132:1:77 917:1:360 rupture, draining of a lacerated tail of the pancreas, and obtaining hemosta- NH Jr 159-J:4413EL-50 74:1:2E;62:t:36 297i63! 196:1:141 154:t:84 1076.+.279 sis of an actively bleeding penetrating wound to the left lobe and caudate p 0 .53 .81 .63 .02 .71 .25 .03 lobe of the liver. All patients experienced a prompt and uncomplicated recovery with no missed injudes and a mean hospital stay of 3.3 days. H Sr 160-J:4~180+-36 30+-2;!102:1:23 332:1:73364+123 202:t:69 1419-~.266 We conclude that the presented laparoscopic technique enables system- NH Sr 181+4:164i-62 78+_1,r 91~:33 334i-64 356+115 200-J:88 1404+318 atic exploration of the abdomen, which follows the principles of open explo- p .07 .16 .70 .13 .92 .79 .93 .83 ration. The role of laparoscopy in the management of stable trauma This data provides evidence for external validity in inanimate testing of patients is likely to increase as more surgeons acquire advanced laparo- laparoscopic skills. scopic skills. A modem prospective study is needed to determine the role of therapeutic laparoscopy in stable trauma patients.

VIDEO-ENDOSCOPIC TREATMENT OF HEPATIC AND LAPAROSCOPIC TREATMENT OF COMPLICATED DUODENAL LUNG HYDATID DISEASE Vladimir Grubnik M.D, Ph.D., ULCERS Sergey Chetverikov M.D., Ph.D., Pushpendra Sharma M.D., YURI GRUBNIK M.D. Ph.D, VLADIMIR GRUBNIK M.D. Ph.D., PUSHPEN- Sabri A. Nidary, Department of Surgery, Odessa State Medical DRA SHARMA M.D., VLADIMIR KARLUGA M.D., VLADIMIR FOMENKO M.D. University, Odessa,Ukraine Dept. of surgery, Odessa State Medical University, Odessa, Ukraine

Introduction: For the aim to reduce the occurrence we pro- Introduction: Conservative treatment of the ulCerdisease is not so effective posed some improvements in laparoscopic treatment of in Ukraine like in Western Europe due to social and economical situations. hydatid cysts of liver. Operative treatment of duodenal ulcer disease is still economically feasible Methods and procedures: For the last 7 years, 59 patients in Eastem Europe. with one or more hydatid cysts of the liver were treated laparo- Methods and procedures: Laparoscopic operation were performed in 149 scopicaly. In 9 patients co-existing cysts were observed in the patients for management of complicated peptic duodenal ulcer disease. lungs. The laparoscopic procedure was performed with the Indications for operation were: bleeding in 97 patients, perforation in 36 patients, stenosis in 8 patients. In patients with bleeding, vagotomy was per- help of 3 or 4 trocars. The abdominal cavity was filled with formed after successful endoscopic hemostasis. Taylors procedure - poste- CO2 at 10-12 mm Hg pressure. Special needle was used to rior trunk vagotomy and anterior seromyotomy was performed in 82 aspirate the hydatid fluid and germicide solution was injected patients. In 69 patients anterior seromyotomy was performed by contact Nd- into the cyst cavity. Endocyst and the daughter cysts were YAG laser, which was more effective than seromyotomy by scissors. In 15 aspirated and removed with the use of endoscopic bags. The patients Gomez-Ferrer procedure - postedor trunk vagotomy and resec~on endoscope was advanced into the cyst cavity to check. In 32 of the lesser curve by stapler was performed. In 36 cases with perforation, patients (I group) we used Nd YAG laser at the power 20-30 19 patients were operated by intracorporal suturing of the perforated ulcer, W to coagulate the cyst cavity. In 27 patients (11 group) the 9 patients by omental patch to the perforation defect. Taylor's vagotomy and cavity was irrigated with scolocidal fluid and saline solution. 7 sutudng of the ulcer defect was performed in 8 cases. In category of patients with stenosis, 4 patients were operated by bilateral posterior truncal patients with co-existing hydatid cysts in the lungs were oper- vagotomy with gestroenterostomy.In 3 cases we performed Taylor's vagoto- ated thoracoscopicaly and 2 by thoracotomy. my and pyloroduodenoplasty. In one case Taylor's operation and balloon Results: Minor complications were observed in 2 (6.3%) dilatation of the duodenum were performed. patients from the I group and in 7 (27%) from the II group. Results: Postoperative mortality was zero. Complications were observed Temporary bile leakage was observed only in 5 (15.8%) in 12 cases. Conversion was performed in 6 cases. Analysing the results of patients from the II group. There were no deaths, major com- 4 years of post-operative observations, 90 % of patients were graded as plications and conversion to open surgery in any of the Visick I or II, 3.8 % were Visick III and 6.2% was considered as Visick IV. groups. Follow-up time ranged from 6 months to 6 years. In 2 Conclusions: Our experience shows that laparoscopic vagotomy by Taylor (7.4%) patients from the II group recurrence was observed. and Gomez-Ferrer procedures are adequate operations in conditions of Conclusions: The use of laser coagulation of the cyst cavity successful eradication of Helicobacter pylori. Lapamscopic procedures can be performed successfully in patients with complicated duodenal peptic improves the results of laparoscopic treatment of hepatic ulcers. hydatid disease. $129

LIQUID PHASE GASTRIC EMPTYING IN COLONIC ANASTO- DOES ENDOTHELIN-1 PLAY ROLE IN POSTOIPERATIVE MOSES AT DIFFERENT SITES Omer Gunal, M.D., Berrak (~.Yegen INTRAPERITONEAL ADHESION FORMATION BY REGULATING M.D., PhD.*., Department of Surgery, D0zce School of Medicine, THE INTESTINAL BLOOD FLOW? Abant Izzet Baysal University, DUZCE.TURKEY. Department of (3met G0naI,M.D.,Y0ksel Arykan,M.D.,Mustafa Deniz*, Berrak Physiology, Marmara University Medical Faculty. IstanbuLTURKEY (~.Yegen*,M.D.PhD., Department of General Surgery, D0zce School of Medicine, Abant Yzzet Baysal University, DOZCE,TURKEY.Departmentof Gastric emptying (GE)plays a crucial role when determining the Physiology*,Marmarauniversity, school of Medicine.YSTANBUL, TURKEY. oral feeding time after surgery. Current study was done to evaluate the effect of colonic anastomosis which has been done at different Pathogenesis of postoperativeintraperitoneal adhesion formation is still being a subject of investigation. Local peritonealischemia is one of the parts of the colon on gastric emptying. factors that is responsiblefor the postoperativeintraperitoneal adhesion for- 42 Adult 200-250 g weighed Wistar-Aibino rats were divided in to mation. The current study was plannedto investigatethe role of ET-1 as a six groups. Control (Group-I; n=7) group did not undergo operation. potent vasoconstrictor agent in the local peritoneal ischemia and subse- Sham groups underwent midline laparatomy and GE measurement quent peritonealadhesion formation. 28 Adult Wistar Albino rats weighed was done on postoperative 1st (Group-2; n=7 )and 10th (Group-3; 200-230 g weredivided to four groups. Control group (Group-I; n=7) did n=7)days. Group-4 and 5 underwent rectum and ascending colon not undergoan operation.In adhesion anastomosis respectively, and subjected to the gastric emptying test group (Group-2; n=7),1x1 cm peritoneal patch excision from the right on first potoperative day. Group-6 and 7 underwent same operations abdominal wall and caecal abrasion were done as the"adhesion model respectively, and subjected to the gastric emptying test on post- operation".Sham group (Group-3; n=7) had only laparatomy. After "adhe- operative 10th day. Liquid gastric emptying test has been performed sion modeloperation" treatment group (Group-A; n=7) receiveda non-selec- by using the methyl cellulose phenol red method. tive ET-1 receptorblocker Bosenthan(30 mg/kg) intraperitoneally,once a On postoperative 1st day, gasrtic emptying rate were 34,9+-1.5 % day for five days. Intestinalblood flow throughthe superiormesenteric artery and 50.9+-5.2 % in rectum and ascending colon anastomosis was measuredby dopplerultrasound, at postoperativetenth day. Adhesion groups respectively. GE in rectum anastomosis was significantly less scores of the groupswere calculated. (49.9+-7.8 %) than the ascending colon anastomosis (72.5+-2.1%) Mean intestinal blood flow was significantly increased in adhesion group on postoperative 10th day. GE rate in Sham group was similar to the (81.9+-5.6 ml/100g) when compared to Group-1 (65.5+-1.2 ml/100g). control group on postoperative 10th day. Bosenthan caused a significantdecrease (44.3+-6.9 ml/100g) in intestinal Rectum or ascending colon anastomosis causes a significant blood flow when comparedto group-1 and 2. Sham group (62.2+-1ml/100g) decrease in liquid gastric emptying on early postoperative period. had similar blood flow level with the control group (65.5+-1.2 ml/100g). This delay persists even on the postoperative 10th day in rectum Adhesion scores were similar in adhesion and besenthangroups. Sham anastomosis but not in the ascending colon anastomosis. group had nearlyno adhesion. Non-selective blockadeof ET-1 has no effect on intraperitonealadhesion Anastomosis at diferent sites on the colon causes different gastric formation. Adhesion formation increases the intestinal blood flow. Chronic emptying rates. intraperitonealETA and ETB receptor blockade causes a decrease in the blood flow of adhesionformed intestinal tissue.

DELAYED LIQUID PHASE GASTRIC EMPTYING RATE BY LAPARDSCOPICNISSEN FUNDOPUCATION WITHOUT AN INDWELLING COLORECTAL DISTENSION CAN BE REVERSED BY ESTROGEN DILATOR. C)mer G0nal*,M.D.,Ayhan Bozkurt, Ph.D, Berrak GuptaM, Yuh J, ChenP. Departmentsof Surgery,Huron and RobinsonMemorial (~.Yegen,M.D.,Ph.D. Department of General Surgery, Duzce School of Medicine, Abant Hospitals, Clevelandand Ravena,Ohio. Yzzet Baysa University, Duzce, Turkey, Department of Physiology, Although passinga largeesophageal dilator is a safetechnique in open School of Medicine, Marmara University, Istanbul, Turkey fundoplication,the samemay not be assumedfor the laparoscopicoperation, Colorectal distension that can be occurred in many surgical clim- since the loweresophagus is unsupportedduring per oralinsertion of the dilator. cal situations may affect the gastric motility. Gastric emptying rate is an important measure in the evaluation of gastric motility. The latrogenicperforation occurs in as high as 3%. We tested the hypothesisthat purpose of this study was to investigate the effect of different good fundopticationcan be performedwithout a dilatorin a consecutiveseries of modes of rectal distension and estrogen on gastric emptying rate. 32 Male 200-250 g weighed Wistar-AIbino rats were divided to 35 patients(Group I), usingsimple precautionary measures, such as routinely three groups. Group-1 (n=8) subjected to gastric emptying test visualizinga 0.5-1 an space between the fundic wrap and ~'e esophagusupoil without undergoing any operation. Group-2 (n=8) has been applied to painless colorectal distension for one hour. Group-3 lifting the wrap. The results, comparedwith a consecutiveseries of (n=8) subjected to painfull colorectal distension for one hour. bougie-assistedwrap (group II), weresimilar, the follow-upbeing 100% in both: Group-4 (n=8) has been pretreated with 17 beta estradiol ben- zoate (20 microgram/kg/day s.c.) for five days before painful rectal Group I (n=35) GroupII (n=71) distension. Colorectal distension has been created by indwellig a Esophageal tear 0 1 number six foley catheter through the rectum 2 cm above the anal verge. Pain stimuli was determined according to electromyograph- Pneumothorax 1 1 ic measurement from the abdominal muscles. Gastric emptying Conversionto open 0 2 test has been performed by the methyl cellulose phenol red Dilationrequired 2 4 method. Gastric emptying rate was found 72.1+-3.5 % in Group-1. Revisionfor reflux 1 1 Colorectal distension decreased the gastric emptying rate to Ventral hernia 0 1 62.6+-3.5 % (n.q.s) while the painfull colorectal distension caused a more decrease in gastric empying rate 48+-6.3 % (p<0.01). Totalcomplications 4 g Group-4 gastric emptying rate increased even above control lev- We concludethat a floppyfundoplication can be performedwithout an els (80.5+-4.9 %). Painful rectal distension causes significant inhibition of gastric indwelling dilator~ resultssimilar to the conventionaltechnique. emptying rate. This inhibition can be reversed by estrogen therapy. S130

VALIDATION OF INANIMATE LAPAROSCOPIC SKILLS TESTING LAPAROSCOPIC HERNIORRHAPHY OF EXTERNAL USING RESIDENCY IN-TRAINING EVALUATIONS SE Haqarty, MD, SUPRAVESICAL HERNIA; A CASE REPORT Masanobu AM Derossis, MD, LS Feldman, MD, GA Ghitulescu, MD, D Hagiike M.D., Kinihiko Izuishi M.D., Hisashi Usuki M.D., Stanbddge, RN, GM Fried, MD. Centre for Minimally Invasive Takashi Maeba M.D., Hajime Maeta M.D., Department of Surgery, McGill University, Montreal, Canada. Surgery, Kagawa Medical University, Kagawa, Japan

Objective: Technical skills of residents have traditionally been External supravesical hernia is very rare, and its diagnosis is evaluated using subjective In-Training Evaluation Reports (ITERs). difficult. We report a case of external supravesical hernia which An objective model for assessment of fundamental laparoscopic was diagnosed and repaired by laparoscopic technique. skills has been developed (FLS). This model measures skill at A 76-year-old male with history of right inguinal herniorrhaphy performing 7 tasks: 1) peg transfer 2) cutting 3) clipping 4) endoloop and proximal gastrectomy admitted our hospital with complaint 5) mesh fixation 6) intra-corporeal and 7) extra-corporeal knot tying. of mass and pain in the right groin. Physical examination The goal of the current study was to assess if residents with high showed a thumb-tip-size mass in right inguinal lesion. The ITERs would also have high FLS scores. Method: Technical skill as graded in the ITER was compared in a blinded fashion to FLS scores mass was easily released into peritoneal cavity by hand. In for 50 residents. The proportion of superior ITERs during the year in addition, we find a hernia defect in the left groin. We diagnosed which the resident was assessed by the FLS was calculated. The bilateral inguinal hernia. Laparoscopic herniorraphy (transab- median proportion of superior evaluations for the whole group was dominal preperitoneal repair) was scheduled. Under laparo- 33%. Residents were divided into two groups: high ITER (>33% scopic examination, a hernia defect was observed in the right superior) or low ITER (<33% superior). Students' t test was used to supravesical fossa. The size of hernia defect was 1.0 cm in compare FLS scores between the two groups. Results: Residents diameter. We covered widely hernia defect with polypropylene with high ITERs performed significantly better than those with low mesh and fixed to preperitoneal layer. Left inguinal hernia ITERs in tasks of peg transfer, cutting, intra- and extracorporeal knot defect was also covered by mesh to strengthen the fragile part. tying (see below). Conclusion: Residents with higher skills in vivo, as Postoperative course was uneventful. assessed by the in-training evaluations, also perform better in the Laparoscopy is a useful diagnostic tool in the evaluation of FLS skills model. groin mass. It enables the surgeon to visualize and define (HIGH=high ITER group, LOW=low ITER group, data is presented as accurately a variety of hernia defects. In addition, it is a signifi- mean • standard deviation) cant repairing tool of hernia defect. It has been reported that supravesical hernia was caused by extensive fragility of Task n 1" 2* 3 4 5 6* 7* abdominal wall structures provoked by the previous operation HIGH 21 84-1-74 124• 74::1:20 70• 267::1:89 216::1:148 138:1:80 or increasing age. Therefore, to repair the hernia defect, it LOW 28 145!-50 177:t:34 86• 92:1:36284:t:100 365+127 184+73 might be important that the defect is covered widely. p .0018 .0009 .0710 .0513 .5391 .0005 .0396 Laparoscopic technique should be applied to external supravesical hernia.

ESOPHAGEAL MYOTOMY IN AN OPOSSUM MODEL LAPAROSCOPIC DOR VS. TOUPET FUNDOPUCATION FOLLOWING Valerie J. Halpin, MD, Chandra Prakash, MD*, Laura Harolan, BSN*, Donna ESOPHAGEAL MYOTOMY IN AN OPOSSUM MODEL Valerie J. HalDin. R. Luttmann, RN, Thomas A Meininger, Ray E. Clouse, MD*, Nathaniel J. MD. Chandra Prakash, MD," Laura Haroian, BSN,* Donna R. Luttmann, RN, Soper, MO Thomas A. Melninger, Ray E. Clouse, MD,* Nathaniel J. Soper, MD Department of Surgery and Institute for Minimally Invasive Surgery, Department of Surgery and Institute for Minimally Invasive Surgery, *Division of Gastroenterology, Washington University, SL Louis, Missouri. *Division of Gest~oentemlogy,Washington University, SL Louis, Mlssoud. The role of fundopllcation following esophageal myotomy for Didelphis virginianls, the North American opossum, has esophageal achalasia remains controversial. There are proponents for both anterior musculature and motility similar to humans and potential to be a useful (Dor) and posterior (Toupet) partial fundoplication. The purpose of this model to evaluate surgical treatment of gastroesophageal reflux. The study was to compare anterior to posterior fundoplicaUons following purpose of this study was to assess the effect of esophageal myotomy on esophageal myotomy in an opossum model. lower esophagealsphincter (LES) function. Laparoscopic esophageal myotomy was performed in 8 animals. Successful laparoscopic esophageal myotomy was performed in 6 Laparoscopic fundoplication was performed 3 weeks post-myotomy (4 Dor, animals. Manemetry data were obtained preoperatively and post-myotomy 4 Toupet). Manometry data were obtained preoperatively, post-myotomy, in awake animals using a 21-lumen perfusad transoral catheter. These data and post-fundoplication in awake animals using a 21-lumen perfused transoral catheter. These data were analyzed using a computerized were analyzed using a computedzed acquisition and display system capable acquisition and display system capable of generating 3-dimensional of generating 3-dimansional topographic plots. topographic plots. Immediately following sacrifice LES competence :v3: There was a significant redu~on in LES post-deglutitive contraction assessed by measuring in situ gastric pressure at the point of esophageal pressure and a trend for reduction in LES basal pressure. Therewere no reflux during gastric infusion with saline. significant chan! as in the residual LES pressure or peristaltic parameters. There was no significant difference between Dor and Toupet in Pressures are ex }ressed as mean + standard deviation. restoration of LES basal or post-deglutitive contraction pressure. The LES Pressures Basal Contraction Residual Toupet significantly increased the residual pressure compared to the Dor (mmHg) (mmHg) (mmHg) (15.45 vs. 6.35 mmHg, p<0.02). At sacrifice the Toupet group refluxed at a Preoperative t8.8 + 8.4 69.8 + 9.4 4.66 +_4.75 significantly lower gastric pressure compared to the Dor group (5.5 vs. 35 mmHg, p<0.005), Postoperative 10.5 + 5.4 45.6 ~ 19.0 5.03 + 1.61 In vivo manometric pressures following Dor and Toupet P = .067 P< 0.03 P = .861 fundoplicaUon did not predict in situ anatomic reflux in this animal model. In the opossum, esophageal myotomy diminishes LES pressures Further studies are warranted to determine the antireflux mechanisms of but does not abolish its function completely, perhaps due to crural partial fundoplication, espedally following myotomy, influences. Further manipulation of the LES complex may be necessary to develop a satisfactory reflux model. S131

PNEUMOPERITONEUM DOES NOT INFLUENCE TROCAR SITE COMPARISON OF ROBOT VERSUS HUMAN LAPAROSCOPIC CAMERA IMPLANTATION DURING TUMOR MANIPULATION IN A SOUD TUMOR CONTROL: IMPACT ON SURGEON EFFICIENCY E(~ Hamilton, M,0., MODEL Valerie J. HalDin, MD. Robert K UndenNeed,MD, Dan Ye, GV Kondraske, Ph.D., CA Fischer, B.S., ST Tesfay, R.N., DJ Scott, M.D., MD,PhD, Daniel H. Cooper, BA, Mark Wright, Suzanne M. Hickerson, BS, R Teneja, RJ Brown, B.S., DB Jones, M.D. Southwestern Center for William C. Connett,'PhD, Judith M. ConneR, PhD, James W. Fleshman, MD. Minimally Invasive Surgery, Department of Surgery, UT Southwestern Department of Surgery, Washington University, SL Louis, Missouri. Medical Center, Dallas, Texas The purpose of this study was to assess tumor implantation at Surgical robot assistance is being used to perform a wide range of abdominal wall wounds following surgical manipulation of a solid intra- abdominal tumor in the presence of pneumoparitoneum. laparoscopic procedures. Previous reports suggest robot-assisted camera GW-39 human colon cancer cell suspension (0.1 ml of 50% v/v; 3.35 control (RACC) may be superior to a human camera driver in terms of overall x 107 cells) was injected into the omentum of golden Syrian hamsters quality of the view, directional precision, as well as long-term cost savings. through a midline incision. At 2 weeks the omental tumor was harvested and We hypothesize that use of RACC results in increased surgeon efficiency the animals were randomized to one of eight groups: bivalve(At, crush(B), because of increased economy of motion and decreased operative time. epithelial stripping(C), or complete excision without manipulation(D); each Twenty pigs (n= 20) were randomized to undergo laparoscopic Nissen with and without pneumoperitoneum. Four 5-ram trocars were inserted fundoplication with either a human or voice-controlled, AESOP 2000 robot- through the anterior abdominal wall, the manipulated tumor was reinserted assisted camera system (Computer Motion, Goleta, CA). The operative through the midline, swept through all four quadrants, and removed. The procedure was standardized for all animals. Operative time was recorded midline incision was closed and pneumoperitoneum at 7 mmHg was separately for dissection and suture phases. maintained for 10 minutes. Tumor implantation at trocar sites and midline Data were recorded as Mean + standard deviation. Analysis was wound Incisionswere documented grossly and histologically 7 weeks later. performed by T-test. Tumor manipulation increased implantation at trocar sites (p<0.001) Camera Driver and midline incisions (p<0.001). Pneumoperitoneum did not increase tumor implantation at trocar sites (p=0.gg3) or midline incisions (p=0.886). Human (n: 10~ AESOP(n: 10) Group A+B+C D Dissection Phase (minutes) 23,4 (t. 7.4) 22.2 ~. 7.1) p= NS Wound location Mldline Trocar Mldtine Trocar Suture Phase (minutes) 24.7 ~ 4.2) 25.7 (+ 8.1) p= NS Pneumo- 77% 53% 45% 9% peritoneum (103/133) (2811530) (20/44) (151176) We conclude that robot-assisted camera control is comparable to a human No pneumo- 77% 49% 51% 10% camera driver in terms of time to perform key parts of a laparoscopic Nissen peritoneum - (101/132) (2611528) (21141) (161164) fundoplication. Robot-assisted camera control demonstrated no objective Tumor Implanlolionat ttocar sites Is due to spillage of tumor dudng benefit using this measure. Economy of motion, as a component of manipulation and not to pneumopedtoneum itself. performance, requires further data analysis.

DA VINCI-ASSISTED TOTALLY ENDOSCOPIC PROCEDURES IN THE IMPACT OF CO2 AND HEUUM INSUFFLATION ON CARDIORESPIRA- ABDOMINAL SURGERY Makoto Hashizume, MD, PhD, Keizo Sugimachi, TORY PARAMETERS DURING PROLONGED PNEUMOPERITONEUM MD, PhD, Mitsuo Shimada, MD, Modmasa Tomikawa, MD, Youichi Ikeda, Eric J. Hazebroek MD1, Jack J. Haltsma MD2, Ewout W. Steyerberg PhD3, MD, Ikuo Takahashi, MD, Ryou Abe, MD, Fusashi Koga, MD, Shinichiro Ron W.F. de Bruin PhD1, Richard L. Marquet PhD1, Nicole D. Bouvy MD Maehara, MD and Shouzou Konishi, MD, Department of Disaster and PhD1, Burckhard Lachmann PhD2, H. Jaap Bonier MD PhD1, 1Dept. of Emergency Medicine and Department of Surgery and Science, Graduate Surgery, University Hospital Rotterdam-Dijkzigt, 2Dept. of Anesthesiology School of Medical Sciences, Kyushu University, Fukuoka, Japan and 3Dept. of Public Health, Erasmus University Rotterdam, The Netherlands Objective of the study: For complex minimally invasive procedures to become more widely adopted by surgeons, significant improvements must Rodents are often used to investigate local and systemic effects of laparm be made in the operating evironment. Robotic and computer.assisted sys- scopic surgery. Since the purpose of experimental studies is to extrapolate tems are making exceptional progress in the field of minimally invasive car- experimental findings to daily practice, knowledge of cardiorespiratory diac surgery. However, the efficacy of these procedures has not been changes in animals exposed to pneumoperitoneum is essential. The objec- demonstrated as dramatically in general surgery as in cardiac surgery. We tive of this study is to determine the impact of CO2 and helium insufflation on report the techniques of our first experiences performing complete total endo- arterial pH, pCO2, 1:)O2,blood pressure and respiratory rate during prolonged scopic procedures in patients with colon cancer, gastric cancer, splenic pneumoperitoneum in the spontaneously breathing raL tumor, esophageal hiatal hernia assisted by the da Vinci system. 5 groups of 6 rats were exposed to intraperitoneal CO2 insufflaton (6 and Methods: From July to September 2000 the computer enhanced surgical 12 mmHg), helium insufflation (6 and 12 mmHg) or abdominal wall lift (ges- system, da Vinci was successfully used in ten patients who underwent totally less control) during 120 minutes. A cannula was placed in a carotid artery for endoscopic surgery. The operative procedures were ileocaecal resection in blood pressure monitoring and drawing blood samples. Before insufflation, one patient with early colon cancer, distal gastrectomy in two patients with baseline measurements of mean artedal pressure (MAP), respiratory rate early gestfic cancer, splenectomy in two patients with malignant tumor and and arterial pH, pCO2 and pO2 were determined. Blood gases were idiopathic thromcytopenic purpura, cholecystectomy in two patients, inguinal obtained at 5, 15, 30, 60, 90 and 120 minutes during pneumoperitoneum. hemiorrhaphy in two patients, and repair of the esophageal hiatal hemia in MAP and respiratory rate were recorded every 15 minutes. Statistical analy- one patient. The anastomoses were performed in the functional anastomosis sis was performed with a repeated measures ANOVA test (p < 0.05 is signifi- for the colon and in a manual fashion for the stomach assisted by the da cant). Vinci system. Hemostasis was done with an electrocautery and ligatures of CO2 insufflation (6 and 12 mmHg) directly caused a decrease in pH (p< the vessels. 0.001) and an increase in pCO2 (p= 0.01) compared to both helium groups Preliminary results: All procedures were successfully performed. There and the gesless control group. Acidosis and hypercapnia were not influenced were no major intraoperative complications. There was no transfer to open by intra-abdominal pressure. Abdominal gas insuffialJon caused a significant surgery. The operative time of the robotic surgery was still longer in all increase in respiratory rate (p= 0.036), independent of type of gas. CO2 patients than that of the conventional endoscopic procedures. The anasto- insuffiation at 12 mmHg increased MAP (13= 0.006) during 30 minutes, but moses were more precise and easier w=th the Endo-Wdst of the da Vinci than after this, no influence of gas type or insufflation pressure on bleod pressure those in the conventional surgery. could be detected. Conclusion: This technological innovabon should help surgeons overcome Abdominal CO2 insuffiation resulted in acidosis and hypercapnia, indepen- various difficulties in order to perform more precise, safer and less minimally dent of the intra-abdominal pressure. Helium insufflation can prevent the invasive abdominal surgery in the coming era. Occurrence of respiratory acidosis during prolonged pneumoperitoneum in the spontaneously breathing rat. S132

LAPAROSCOPIC RESECTION OF DUODENAL TUMORS B. Todd THORACOSCOPIC AND LAPAROSCOPC SURGERY FOR THO- Heniford, MD, Sharon L. Goldstein, MD, Brent D. Matthews, MD, RACIC ESOPHAGEAL CANCER Masayuki Higashino M.D., Shinya Kent W. Kercher, MD, Frederick L. Greene, MD., Department of Tanimura M.D., Yosuke Fukunaga M.D., Harushi Osugi M.D., Osaka Surgery, Carolinas Medical Center, Charlotte, NC City General Hospital, Department of Gastroenterological Surgery, Osaka, Japan The duodenum's size, retroperitoneal location, close proximity to vital structures, and limited disease states has resulted in few One hundred and fourteen esophageal cancer cases have undergone reported laparoscopic operations on this organ. The purpose of this thoracoscopic and/or laparoscopic surgery for these 5 years in our insti- study was to review our experience with laparoecopic resection of tutional hospitals. Noting cases since 1997 when a laparoscopic tech- duodenal masses. nique for the abdominal procedure was introduced, we have performed All cases were prospectively followed from 7/96 to 9/00. Seven 34 open surgery, 26 thoracoscopic and laparoscopic (TL Group), 28 tho- patients presented with duodenal masses. Four were found sec- racoscopic and laparotomy (T Group), and 24 laparoscopic and thoraco- ondary to leeding; 3 were incidentally discovered. All patients tomy (L Group) surgery for this disease, meaning recent increase of the underwent laparoscopic surgery. There were 3 females and 4 laparoscopic cases. Above 3 thoracoscopic and/or laparoscopic groups males with an average age of 55 years (36-66 years). Pathology were compared with 80 conventional open surgery cases (C Group) included 2 lipomas, 2 stromal tumors, and 3 adenomatous polyps. which were performed before introduction of the thoracoecopic tech- Two were in the first portion of the duodenum and 5 were in the sec- nique. Results: The 3 major complications after surgery, pulmonary ond. All lesions were removed with the aid of an endoscope to troubles, anastomotic insufficiency, and recurrent laryngeal nerve palsy, localize the tumor. Three lesions were resected full thickness and 2 were 7%, 4%, and 24% respectively in TL group, 23%, 5%, and 23% were enucleated. Two required 5-7 cm incisions after laparoscopic respectively in T group, 8%, 0%, and 12% respectively in L group, and mobilizatiGn to remove them due to their proximity to the ampulla; 16%, 3%, and 16% respectively in C group. This summarized that the the others required 4 trocars. Laparoscopic closure of the duode- recurrent laryngeal nerve palsy is higher in the thoracoscopic surgery num was performed with interrupted, intracorporeal sutures. In than in thoracotomy procedure and that the pulmonary troubles are addition to the duodenal resections, 2 cholecystectomies with lower in the laparoscopic surgery than in laparotomy procedure. Mean cholangiogram (to assess the ampulla following resection) and a number of nodes dissected, mean duration of the operation, and mean Nissen fundoplication were performed. Average hospital stay was blood loss were not differ among those 4 groups. As far as postopera- 4.4 days (3-7 days). There were no complications and no deaths. tive respiratory function was concerned, the reduction of percentage of With an average of 6 months of follow-up, there has been no docu- the vital capacity was lower in the T group than in thoracotomy cases, mented recurrence or complication. resulting a better tolerance of the exercise. Conclusion: Although the Laparoscopic resection of duodenal tumors is safe and feasible. laparoscopic and thoracotomy surgery' was the best procedure among Endoscopic-assistance is extremely helpful to localize the tumor these groups in terms of the postoperative complications, distant respi- and determine its relationship to the ampulla. Even when open ratory function was the most maintained in the T group. This implied resection is required, laparoscopic assistance can limit the laparoto- that if the ratio of recurrent laryngeal nerve palsy had been reduced the my incision. thoracoscopic and laparoscopic surgery would be the best procedure for the esophageal cancer.

LAPAROSCOPICCHOLEDOCHOTOMY AND REPAIR USINGZEUS ROBOTIC-ASSISTED SURGERY IMPROVES TIME AND ACCURACY OF ROBOTIC TECHNOLOGY. Celes~QM. Hollend~,MD, Michael J. Torma, ADVANCED LAPAROSCOPIC TASKS PERFORMED BY SURGICAL RES- MD, Laramie N. Dixey, RN, Department of Surgery, LouisianaState IDENTS Santiago Horgan M.D., Marcia I. Edison Ph.D., Daniel Vanuno M.D., Jose Universit7 Health Sciences Center.Shreveportand BiomedicalResearch Cintron M.D., W. Scott Helton M.D., Minimally Invasive Surgery Center, Foundation,Shreveport, Louisiana Division of General Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois The purpose of this study was to determine the feasibility of performing longitudinalcholedochotomy and repair with ZEUS robotic technology. Robotic assisted surgery is projected to accelerate the learning curve for Methods: 20-30 kg pigs were operated on by 2 surgeons =n this non- advanced laparoscopicsurgery, but little data exists to support this contention. survivor protocol. The control group underwent laparoscopiclongitudinal This study tested the hypothesis that novice surgeons would learn advanced choledochotomywith repair (n=10, 5 per surgeon). The experimentalgroup laparoscopicskills more quickly using a robotic assisted surgical system than using conventionaltwo-handed laparoscopic surgical techniques. unde~ventthe same procedure using ZEUS robotic assistance (n=10, 5 per Twelve surgical residents (PGY1 - PGY5) participatedin the initial study. Each surgeon). Times for anesthesia, robotic set-up, and anastomosiswere resident was given a brief orientationto the DaVinci(tm) Surgical System and measured along with technical complications. was given standardized instructions to perform 2 simple two-handed laparo- Results: scopic tasks. Task 1 was transferring 10 lifesavers out of a box onto a nail Anesthesia Anastomosis Set-up Complications using the non-dominanthand while holding a 30-degree camera with the dom- (minutes) (minutes) (minutes) inant hand. Task 2 was passing a needle through 9 keyhole pins placed in an t-test p=0.007 p=0.04 p=0.0004 p=0.008 S pattern. Each resident was given 5 minutes to practice these tasks with both standard laparoscopic needle drivers and with the DaVinci (tm) Surgical Control n=10 128~2 79+41 3=+3.3 9 (n=7) System. After the practice session, each subject performed these tasks using ZEUS n=10 235+91 140+73 12+5 4 (n--4) the robot and using conventional two-handed laparoscopic technique. Complications: Control group: leak-3, 50o Y, narrowing-2, common duct injury- Subjects were scored using a standardizedassessment tool based on accura- 1, liver/stomachinjury-I, conversion to open-l, back wall sutured-l. ZEUS cy and time. group:leak-2,back wall injury-2. We sought to determine whether there were significantdifferences in resident Condusion: ZEUS robotic assisted longitudinalcholedochotomy and performance of the tasks using paired T-tests and chi-square analysis. Results repair is technically feas~le. Significant differences in anesthesiaand for Task I showed no significantdifference in time or accuracy (13< 0.05). The number of residents completing Task 2 was significantlyhigher using the robot anastomosistimes likely represent the learning curve, since current (9/12) versus using conventional two-handed lapamscopic technique (2/12)(p anastomotictimes are 70-90 minutes for a robotic end-to-endanastomosis. <0.001). Accuracy was also significan~ improved on Task 2 when the robot Set-up times are inherently longer for ZEUS. Additionally,back wall injuries was used. in the ZEUS group were eliminated once scissors were used instead of a We conclude that for learning speed and accuracy of simple surgical tasks, scalpel. The highly signiticant difference in complicationrates markedly robotic surgical assistance is at least as good as conventional laparoscopic favors robotic assistance. Survivor studies are needed to further validate techniques. However, for complex tasks, both speed and accuracy are these results. Nonetheless,ZEUS robotic technology offers the promise of enhanced by the DaVinci(tm) Surgical System. These findings suggest that expandingapplications in advanced iaparoscopicsurgery. robotic surgery will accelerate the learning and performance curve for advanced laparoscopic skills. $133

LIVER METASTASES ARE LESS ESTABLISHED AFTER LIVER METASTASES ARE LESS ESTABLISHED AFTER GASLESS LAPAROSCOPY THAN AFTER CO2 PNEU- GASLESS LAPAROSCOPY THAN AFTER CARBON MOPERITONEUM AND LAPAROSCOPY IN A MOUSE DIOXIDE PNEUMOPERITONEUM AND LAPAROSCOPY MODEL Takanobu Hoshino, M.D., Hideyuki Ishida, M.D., IN A MOUSE MODEL Takanobu Hoshino, M.D., Hideyuki Ikuya Takeuchi, M.D., Masaru Yokoyama, M.D., Hiroshi Ishida, M.D., Ikuya Takeuchi, M.D., Masaru Yokoyama, Okita, N.D., Daijo Hashimoto, M.D., Department of Surgery, M.D., Hiroshi Okita, N.D., Daijo Hashimoto, M.D. Saitama Medical Center, Saitama Medical School Department of Surgery, Saitama Medical Center, Saitama Medical School, Kawagoe, Saitama, Japan Background: Although the liver is the most frequent site of recurrence after conventional open surgery for colorectal Background: Although the liver is the most frequent site of cancer, the effect of laparoscopic procedures with or with- recurrence after conventional open surgery for colorectal out gas insufflation on the development of liver metastases cancer, the effect of laparoscopic procedures with or with- is largely unknown. Methods: Male BALB/C mice inoculated out gas insufflation on the development of liver metastases intraportally with colon 26 cells were randomized to under- is largely unknown. Methods: Male BALB/C mice inoculated go CO2 pneumoperitoneum (n=14), abdominal wall lifting intraportally with Colon 26 cells were randomized to under- (n=14), full laparotomy (n=12), or to serve as controls with- go carbon dioxide pneumoperitoneum (n=14), abdominal out any procedures other than tumor inoculation (n=13). wall lifting (n=14), full laparotomy (n=12), or to serve as Results: The growth of liver metastases 14 days after controls without any procedures other than tumor inocula- surgery was enhanced following full laparotomy (P<0.01) tion (n=13). Results: The growth of liver metastases 14 and pneumoperitoneum (P<0.01) as compared with that in days after surgery was enhanced following full laparotomy the control, while there was no difference in the growth of (P<0.01) and pneumoperitoneum (P<0.01) as compared liver metastases between abdominal wall lifting and the with that in the control, while there was no difference in the control (P=0.99). Conclusions: These results suggest that growth of liver metastases between abdominal wall lifting the defense against liver metastasis is better preserved fol- and the control (P=0.99). Conclusions: These results sug- lowing the gasless procedure than following laparotomy gest that the defense against liver metastasis is better pre- and CO2 pneumoperitoneum in this animal model. served following the gasless procedure than following laparotomy and carbon dioxide pneumoperitoneum in this animal model.

LAPAROSCOPIC PARTIAL ADRENALECTOMY Ibrahim LAPAROSCOPIC HARVESTING OF OMENTUM FOR USE AS M. Ibrahim M.D., Fred Silvestri M.D., Department of A PEDICLE OR MICROVASCULAR FLAP Ibrahim M. Ibrahim, Surgery, Section of Laparoscopy, Englewood Hospital M.D., Fred Silvestri, M.D., William Boss, M.D., Department of and Medical Center, Englewood, N.J. Surgery, Section of Laparoscopy, and Department of Plastic Surgery, Englewood Hospital and Medical Center, Englewood, Total adrenalectomy performed laparoscopically may N.J. become the standard for the treatment of benign adrenal tumors. On the other hand, partial adrenalectomy is infre- Omental Transposition is a recognized but infrequently employed quently performed, reserved for the patient cohort at risk for procedure for providing vascularized tissue to heal infected sites, iatrogenic Addison's disease were total adrenalectomy to improve the milieu for poorly vascularized tissue or to provide cov- be carried out.This includes patients with a single adrenal erage for an exposed prosthesis. gland, bilateral disease and the multiple endocrine neoplas- The challange of chronically non healing wounds in two elderly tic syndromes. We recently treated a patient by partial patients form the basis of this report. In both cases, the omentum adrenalectomy in order to preserve paired organs, an indi- was harvested laparoscopically and used in one instance as an cation we believe to be appropriate in a young person. This omental pedicle flap to cover an infected stemal wound. In another type of operation can be performed effectively, safely and patient, the omentum was used as a free flap to cover a large indeed was easier than total resection. Laparoscopy affords pretibial, post radiation wound. This procedure required microvas- superior visualization of anatomy. Mobilization and dissec- cular technique. The wounds in both patients healed within few tion of the adrenal is facilitated by the delicate laparoscopic weeks with full skin coverage. instruments that reach deep into the recesses of the The omentum can be harvested laparoscopically by dividing its retroperitoneum. Clearly long term followup studies are attachment to the greater curvature of the stomach with an har- necessary, but we believe that adrenal preserving proce- monic scalpel, care being taken to avoid injury to the gastroepi- dures deserve serious consideration in selected cases. ploic arcade. Detachmment from the spleen is performed with rel- (A two minute video accompanies the presentation). ative ease including separation from the abdominal wall and colon. The free flap method requires dissection of the gastroepiploic ves- sels as they originate from the posterior gastroduodenal vessel. Division at this level enables the subsequent anastomosis to the donor vessels. Laparoscopic harvesting of the omentum is technically nonde- manding and minimally traumatic. It obviates the need for laparo- tomy and espeQally the need for complicated muscle flaps that are associated with significant morbidities, S134

ENDOSCOPIC THYROIDECTOMY: PATIENT SELECTION, TECH- LAPAROSCOPIC FUNDOPLICATION IS THE APPROPRIATE NIQUE, AND PRELIMINARY RESULTS William B Inabnet, Ill, MD and SURGICAL MANAGEMENT FOR PATIENTS WITH BARRETT'S Michel Gagner, MD, Mount Sinai Medical Center, New York NY ESOPHAGUS OR A LARGE HIATAL HERNIA K Irsh~d MD,LS.Faldman MD,S.Mayrand MD,D.Stanbridgo RN, Objectives: Conventional thyroidectomy is performed through a cervi- G.M.Fried MD, McGill University Health Center, Division of General cal incision, necessitating myocutaneous flaps to gain access to the thy- Surgery, Montreal, Canada. roid gland. The aim of this study was to report our initial experience with endoscopic thyroidectomy, a new minimally invasive technique for thyroid excision. Objective: Barrett's esophagus (BE) and hiatai hamias (HH) have been Methods: Between Sept 1998 and July 2000, 22 patients underwent associated with advanced gastro-esophageel reflux disease (GERD) and short endoscopic thyroidectomy. Exclusion criteria included patients with nod- esophagus. The aim of this study was to examine the objective and subjective ules greater than 3cm, muitinodular goiter, Graves disease, or malignan- results of patients with BE and large HH who undergo laparoscopic cy. There were 20 females and 2 males with a mean age of 42 years fundoplication (LF) without any esophageal elongation. Methods: From January (17-66 years). Indications for surgery included follicular neoplasm (n=9), 1995 to May 2000, 65 consecutive patients underwent LF. BE was present in 25 indeterminate cytology (n=7), recurrent thyroid cyst (n=2), HQrthle cell end a large HH (>5 cm on barium swallow) was present in 17 patients. All neoplasm (n=l), and toxic thyroid nodule (n--3). Endoscopic thyroidecto- patients underwent preoperative manometry and endoscopy with biopsy, 95% my was performed with CO2 insuffiation utilizing 4 trocars (1 X 10mm, 1 underwent 24-hr pH testing and 75% underwent badurn swallow. A GERD X 5ram, and 2 X 3mm trocars). A combination of titanium clips and ultra- specific quality of life (QOL) questionnaire (Velanovitch et al.) was completed by sonic energy were used for hemostasis. The specimen was placed in a 88% of patients. Post-opsrative evaluation included manometry and 24-hr pH small bag for extraction. Results: Nineteen of 22 cases were completed endoscopically with a studies at 3 months and QOL assessment at 3,6,12,24 months. Results: mean operating time of 200 minutes (100-330 min). Operative proce- Pre-op Post~p Pre.op Post-op Pre-op QOL at dures included left thyroid iobectomy (n=10), left subtotal thyroidectomy LESP LESP % % QOL~ 2 years 1 (n=2), right thyroid Iobectomy (n--4), right subtotal thyroidectomy (n=2), mmHg I mmHg I pH<&01 pH<4.0 t and isthmusectomy (n--4). There were no major complications, but 3 o to 45 (severe) patients developed mild hypercarbia. Final pathology yielded a diagnosis +BE 7.54 17.2 18.4 1.4 23.3 0.8 of follicular adenoma (n=13), HQrthle cell adenoma (n=l), oncocytic ade- -BE 7.50 17.1 11.4 1.3 23.4 0.2 noma (n=l), thyroid cyst (n=l), multinodular goiter (n--4), and papillary thyroid carcinoma (n=2). One of the patients with papillary carcinoma LHH 5.4 14.5 17.7 1.,4 27.7 1.0 underwent open completion thyroidectomy without evidence of residual SHH 8.2 18.7 12.4 1.2 22.2 0.3 disease. All patients were highly satisfied with their cosmetic result. (p

A MODEL FOR EVALUATION OF LAPAROSCOPIC SKILLS: DOES IT LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR A YOUNG MAN WITH SUPERIOR MESENTERIC ARTERY SYNDROME JR REFLECT IMPROVEMENT OVER RESIDENCY TRAINING ? Isaacson MD, GS Smith MD, GL Falk MD, Department of Kashif Irshed MD, Gab~la GhitulascuMD, Liane S. Faldman MD, Anna Endosurgery/Upper GI Surgery, Concord Hospital, University of Sydney, Derossis MD, Donna Stanbridge RN, Gerald M. Fried MD NSW, Australia Centre for Minimally Invasive Surgery, MOGill University, Montreal, Canada INTRODUCTION: Superior mesentedc artery syndrome is a rare disor- der most commonly affecting young adults. The clinical picture of chronic Laperoscopicskill can be measuredobjectively in a simulatorusing the FLS vascular compression of the third portion of the duodenum usually pre- program (Fundamentalsof Laperosc~ic Surgery). Skillsere assessed in a sents with intermittent fullness and bloating after meals, vomiting, and trainer box with a video-endoscopicoptical system. The purposeof this study weight loss. Conservative treatment includes nasogastric tube decom- was to evaluatewhether the FLS scores reflect improvement in laperoscepic pression, prokinetic agents, and postprandial positioning. If these fall, the operation of choice is duodenojejunostomy. Laparosoopic duodenoje- skills expectedto occur during residencytraining. junostomy for SMA syndrome was first described by Gersin and Heniford Eighteen general sa-gical residentswere asked to complete seven tasks at in 1998. We report a case of SMA syndrome treated definitively by laparosoopic duodenojejunostomy and provide medium-term (one year) lrensfering(1"1), patten outing (12), dipl~ng and d'rviding('1"3), plating a fellow-up. PROCEDURE: The patient, a thin 31-year-old male diag- nosed with SMA syndrome, had failed medical management. He was ligaling loop(T4), mesh placementand Exation(T5), inlracorparealknot tying prepared for surgery. A stapled side-to-side duedenojejunostomy was (T6), and extracorl:x~eatknot tying 0"7). Each task was assigneda score created to the third portion of the duodenum through the transverse based on precision and timing. Residentswere first evaluated at a mean time meseoolon using three five millimeter and one twelve millimeter ports. of Z1 yasrs into their rasidency lralning and again at 3.S ye=s, giving a mean RESULTS: The patient was discharged home four days postoperatively interval of 1.8 years. The paired t-test was used to compare performanceof eating and drinking without pain. He subsequently had a weight gain from 50kg to 62kg over the next several months; however, he continued each subjectat the two differentlimes in their training. Results: to have intermittent periumbilical pain, which he desoribes as "50%" of the preoperative level. A gastrcecopy performed at about nine months PG IT T21T31T4 Tsl 8 17 postoperatively showed a new diagnosis (not seen on preoperative gas- 2.1199 144 I 78 I 74 2491248 161 10s3 troscopy)of Barrett's esophagus confirmed by biopsy. The gastrosoopy showed the anastomosis to be widely patent. He has been provided some further relief of symptoms with the addition of a proton pump p I o.o131o.o191o. I o. 1 inhibitor and a prokinetic agent. CONCLUSION: Laparoscopic duode- Performanceoverall and for each task (except 1"5) improved significantly nojejunostomy provides a minimally invasive surgical altemative to the over the follow-up period. The simulatoris a valid tool for assessing patient, while not sacrificing the technique of the original open procedure. The procedure can provide symptomatic relief, but long-term follow-up is laperoscopicskill and for evaluating residents'progress over their training. crucial for this difficult set of patients. S135

SPREAD OF INTRAPERITONEAL TUMOR CELLS FOL- METHOD OF VIDEOTHORACOSCOPIC PARASTERNAL LYMPHADIS- LOWING CARBON DIOXIDE PNEUMOPERITONEUM SECTION IN BREAST CANCER DIAGNOSE AND TREATMENT Artur H. Hideyuki Ishida, M.D., Masaru Yokoyama M.D., Nobuo Ismagilov M.D., Eugine I. Sigal, PhD., Rinat G. Hamidullin M.D., Albert M. Murata, M.D., Ikuya Takeuchi, M.D., Daijo Hashimoto, Guimranov M.D., Hasan M. Gubaidullin M.D., Department of Breast M.D.,Yasuo Idezuki, M.D, Department of Surgery, Saitama Surgery, Kazan Republic Oncology Center, Kazan, Russia Medical Center, Saitama Medical SchooI,Kawagoe, Saitama, In our clinic we developed a technique of performing videothoracoscop- Japan ic parastemal lymphadenectomy (VTS PLAE). The operation is fulfilled through the use of general anesthesia with the separate intubation ot bronchi. With the appropriate surgery performed on the mammary land Background: The influence of pneumoperitoneum with carbon and axillary collector 3 thoracoports are introdeuced into the pleural cavit~ dioxide on intraperitoneal tumor cells remains controversial. in the following way: along the medioolavicular and medioaxial lines in th~ This experimental study was performed to investigate the 5th intercostal space and along the anterior axillary line in 4th intercosta spread of intraperitoneal tumor cells following carbon dioxide space. Pulmonary ventilation is dis-connected from the operation side pneumoperitoneum in rats. The effects of different insufflation thoracoscope and manipulators are introduced into the pleural cavity. Th~ pressures were also examined. Methods:Male Donryu rats parietal pleura is dissected in parallel with intemai vessels using electr~ weighing 180-220g were intraperitoneally injected with surgical retractor (from the level of the 1st inter-costal space down to th~ 5X1000000 ascites hepatoma AH 130 cells and randomized 4th intercostal space). After mobilization the internal breast vessels ar~ to 4 groups: Group A (n=14) and Group B (n=15) received clipped and resected, the fat with lymph nodes are sepa-rated and th( CO2 pneumoperitoneum at 5 mmHg and 10 mmHg for 30 preparation is removed. The pleural cavity is drained up to 2 days. min, respectively; Group C(n=15) underwent a xipho-pubic 20 cadavers were used to study the adequacy of VTS PLAE volume laparotomy for 30 min; and Group D (n=15) underwent trocar Simultaneously VTS PLAE from one side and a traditional (open) lyn placement alone for 30 min. Survival times and frequency of phade-nectomy from the other side were performed followed by the exam trocar site implantation (for Groups of A, B, and D)at autopsy ination of lymph nodes number. In the course of the experiment with car davers histologi-cal assay of the preparation removed the average num were evaluated. Results: The median survival (days) was 17.0 ber of parastemal lymph nodes was 2.5+-0,56 and 2,3+-0,3) by VT,r in Group A, 15.5 in Group B, 15.5 in Group C, and 32.5 in PLAE and traditional (open) method, respectively (P>0,1). It reveals th, Group D (P<0.05). The frequency of trocar site implantation full value of VTS PLAE. was 57% in Group A, 53% in Group B, and 46% in Group D Parastemal lymph nodes metastases were observed in 53 (19.9%) c (NS). Conclusions: These results suggests that, compared 266 patients (control group) with the isolated affection of the parastem.~ with the sham-treatment, pneumoperitoneum with carbon col-lector in 2 (2,17~ of them (the axillary collector being not alfected1 dioxide may not fascilitate port site metastasis, regardless of Frequecy of metastatic lesion in parastemal lymph nodes depending o= the pressure of insufflation. However, similar to full laparoto- localization of a tumor in breast has the following indecies: maximun my, pneumoperitoneum with carbon dioxide may promote the number of lymfatic nodes metastatic lesion took place in cases of tumc spread of tumor cells. localization on the border of lower quadrants (3 Dun of 8 37.5%).

DOES SMOKE FROM LAPAROSCOPY CONTAIN INFECTIVE VIRUS? THE IMPACTOF CARBONDIOXIDE ON MONOCYTE-MACROPHAGECYTOTOXICITY Patrick G. Jackson. M.D.*. Alberto R. Iglesias, MD, Donald R. Czemlach, PetdckG. Jackson,M.(~.*, Donald R. Czemiach,MD, AlbertoR. Iglesias,MD, StephenR.T, MDI Stephen R.T. Evans, MD, Patricia S. Latham, MD' Department of Evans,MD, PatriciaS. Lath~, MD' Depa~mentof Surger/and'Pathology, George Surgery and' Pathology, George Washington University, Washington, D.C., WashingtonUniversity, Washington, D.C., and *Depa~r~mtof Su~r/, Massachusetts and *Department of Surgery, Massachusetts General Hospital, Boston, MA GeneralHospital, Boston, MA

During laparoscopic surgery, a smoke plume is commonly expelled into the Pentonealmacrephoges derive from monocytes, and thekfunctions include pbegocytosis, operating room in order to improve clarityo(field. Elactrosurgical smoke has cytoldnesecrelJon, and cytotolddty.When exposedto C02,macroldtages demonstrate been shown to contain at least viral particles, but not necessarily infective impairedadJvity. The goalsof this studywere to detemlinethe impactof humanmacrephar virus. The goal of this study was to determine the presence of infective virus on peritonealtumor growth, and the significanceof C02-inducedhuman macrophage in the smoke generated during laparoscopic dissection. suppressionon tumorimpaantadon. Twelve Sprague-Dawiey rats were injected intraperitoneally with 10(5) A humanmonocyte-macrophage cell line, THP-1, and a humancolon cancer cell line, plaque-forming-units of MAV-1 or the same volume of complete media. One LS174T,were cultured for 2 hoursin ei~r 100%or 5% C02.Sixty ~yntc ratswere divki~ week after inoculation, half of both the viral and media-only rats were into 6 groupsof 10 arimaiseach, injected intraperitoneally with media or cellsas subjected to pneumoperitoneum without eiectrocautery. The remaining half below,and housedlor 2 weeks.AI necropsy,all tumornodules were counted by a blinded of each group underwent laparoscopy with electrocautery,of the spleen. obse~,erand confirmedb~ a blindedpathdi Pneumoperitoneum was expelled into chambers containing confluent plates Complete' THP.1cells THP-1cells LS174Tcells LS174Tcells of mouse kidney(RAG) cells. All plates were then cultured for 1 week, and Media exposedto exposedto exposedto exposedto plaques counted. Viramia was confirmed by culture of plasma samples from 5% 002 100% C~ 5*/, C02 5% C02 infected rats at the time of surgery. A reference curve for plaque formation Group 1 X X was created by aerosolization of dilutions of a known viral concentration. Group2 X X Aerosolized standard concentrations of virus created dose-dependent Group3 X X plaque formation in confluent RAG cells. Aerosolization of virus free media Group4 X X over confluent RAG cells did not induce plaque formation. Viremia was Group 5 X X present only in rats injected with virus only. All injected rats were viremic. Group6 X X Laparoscopy with or without electrocautery did not induce plaque formation Group 1 and 2 ratsshowed no nodulefotmalJon. Group 3 ratsdeveloped 3.9 (• tumo As shown by this study, aerosolized MAV-t virus is indeed infective to RAG nodules.Group 4 ratsdeveloped 4.1 (• nodules.Group 5 ratshad 6.3 (4- 0.6) nodules; kidney cells. However, no viable virus was isolated from either the smoke group6 ratshad 6.6 (4- 0.7) tumornodules. Rats injected with THP-1 cellsand LS174Tcell plume or pneumoperitoneum alone. Even in viremic rats, smoke generated had lewernodules t~ ratsinjected with LS174Tceils alone (,o<0.01 for all comparisons). during electrocautery does not contain viable adenovirus. While this finding Ca~oondioxide exposure did not impairthe monocyte.macrophagecyto0dc activity. As th suggests that electrosurgical smoke does not pose an occupational threat, it Fesa~e of THP.1 significantlyreduced tumor nodule formation, the monocyte-macrophag is unclear if the study can be extrapolated to other viridae. mayplay an importantrole in suweillanceagainst neoplastic ceils. $136

GIANT HERNIAS WITH LOSS OF DOMAIN: A CASE SERIES. ANTONI LAPAROSCOPIC EXPLORATION FOR PANCREATIC INJURY. JURKIEWlCZ, M.D., CORRADO P. MARINI, M.D., JOHN MCNELIS, M.D., Robert Kalimi, M.D., Piotr J. Gorecki, M.D., L.D. George Angus, M.D., DEPARTMENT OF SURGERY, LONG ISLAND JEWISH MEDICAL CENTER, and Gerald W. Shaftan, M.D. Department of Surgery, Nassau County NEW HYDE PARK, N. Y. Medical Center, East Meadow, New York.

Giant hernias with a loss of intra-abdominai domain are infrequently The use of laparoscopy as either a diagnostic or therapeutic tool in encountered. However, the incidence may be increasing because of the trauma patient has been debated in the literature. In this report we immigration from areas of the world with fewer medical resources. Successful describe a patient with penetrating injury to the pancreas who was management of these difficult hernias require awareness of potential treated laparoscopically. complications and management options. Three uniquely different cases of giant hernia are presented. Case 1 was a 60 year old white man with a long- standing giant inguinoscrotal hernia who presented with signs of partial bowel A 34-year-old female was admitted with a stab wound to the lower obstruction. Pneumoperitoneumwas established with a single lumen catheter back. CT scan of the abdomen revealed minimal haziness of the tissue to a pressure of 15 to 20 mm Hg for two weeks in order to re-establish intra- planes in the region of the tail of the pancreas and the splenic hilum. abdominal domain prior to hernia repair. Repair was then accomplished During laparoscopic exploration a 5 mm ultrasonic dissector was used through a groin incision after omentectomy. His preoperative course was to transect the gastrocolic and gastrosplenic ligaments allowing complicated by pulmonary emboli requiring anticoagulation and vena cava exposure of the pancreas. On exploration a 5-mm laceration in the tail filter. Case 2 was a 70 year old Russian female who presented with a of the pancreas was noted which was surrounded by an area of complete bowel obstruction seoonoary to a giant incisional hernia. Loss of fibrinous exudates. Pancreatic duct injury was not suspected based on domain was managed with a midline incision and a large madex mesh placed the location and degree of the injury. Posterior wall of the stomach and without tension to span the gap between fascial edges. Despite this, the the gastroesophageal junction were examined and did not reveal patient developed abdominal compartment syndrome requiring ventilator evidence of perforation. A closed suction drain was placed in the support for two weeks. Case 3 was a 60 year old Indian female with a long- retropancreatic space and another at the splenic hilum. Postoperatively standing giant incisionai hernia and intermittent bowel obstruction. Loss of domain was managed at surgery with a long midline incision and construction the patient recovered uneventfully, and was discharged on the eighth of a temporary silo using the patients redundant skin. The patients postoperative day tolerating a regular diet. postoperative course was uncomplicated and hernia repair was successfully completed several weeks later when intra-abdominal domain was re- In this report we present a case of a stable patient with an injury to established by the pressure created by the silo. the pancreas, who underwent laparoscopic exploration. The area of Patients with giant hernias with loss of domain can be difficult to manage. pancreatic injury was assessed and drainage was achieved The potential complications and some management strategies and surgical laparoscepically. We suggest that with increasing experience, selected options are illustrated in this series of three cases presenting to our hospital pancreatic injuries may safely be treated laparoscopically in the stable between 1997 and 2000. trauma patient.

MICROWAVE COAGULATION THERAPY FOR HEPATOCELLULAR LAPAROSCOPICDONOR NEPHRECTOMY AND RECIPIENT OUTCOMES CARCINOMA m A PREUMINARY REPORT OF THE FIRST US TRIAL AT A COMMUNITY HOSPITAL LeonV. Kalz. M.D.. Ashutosh KauI, M.D., KetuI T Kato, MD, S Tamura, MD, N Yamashiki, MD, J Casillas,MD, D Levi, MD, Chauhan, B.S., Mark Dreeel)sch,B.S., Sluart R. Geffner, M.D., Department of M Berho,MD, T Seki,MD, E Schiff,MD, A Tzakis,MD, Divisions of Surgery, Sabt Barnabas Meckal Center, LJv~geton,New Jersey. Transplantation, Immunopathology and Hepatology, University of Miami, School of Medicine, Miami, Florida, Department of Surgery II, Osaka Laparoecopicdonor nephrectomyhas been ut~zed in Univel~y Hospitalswith University Medical School, Osaka, Japan, and Third Department of Medicine, excellentresults. The purpose of ~ study was to criticallyanalyze our results Kansai Medcal College, Osaka, Japan Ioparcecopicdonor nephreotomydone at a community hospital with a busy transplant center. Objective: To assess the safety and efficacy of microwave coagulation ther- We did a r~o~e study of our rrst 35 laperco~pic donor nophrecton~es apy (MCT) for hepatocellular carcinoma (HCC) in patients awaiting liver and compared ~em with 52 open donor nephrectomiesdone during ~ same transplant (OL'r). Background: Control of tumor growth while waiting for OLT period. Si~cence of any changeswas tested using Student'st-teat is ~ly important for patients with HCC. MCT is an ablabve therapy devel- independentva~bles. oped in Japan. For more than a decade it has been used routinely in the Comparisonof laparcecol~Oversus open technique revealed a dgr~cant management of HCC. We applied this technology to OLT candidates with difference in e~matad blood ]osa (59 co vs. 132 c=), Iongthof stay (3.11 days vs. localized HCC. This is a preliminary report of the first US trial of MCT. 5.12 clap) and'dme to resump~onof solid (aet (123 days vs. 2.4 days) (P<0.01). Patients and Methods: A microwave generator (Microtaze| AZWELL.Inc, There was no signiicant difference in total operating room time (245 vs. 189 Osaka, Japan) with specialized probes (16G-22G needle) was used in the mino), intraopera~e inUavenousfluid used (3040 co vs. 3431 co) and study. Seventeen OLT candidates have been enrolled in the study (mean age inlraopereUveudne output (425 ccvs. 512 cc). Thare was no ddference in the 56.2 years). All patients were cirrhotic secondary to hepatitis C (n=12), donor preoperativeand postopera'~ BUN a~ crea~nine(P>O.05). There was a hepatitis B (n---3), and cryptogenic (n=2). Their Child's scores were:Child A difference in redpient creatbino level at the 2" postoperativeday, 3-month and 6 (n=7), B (n=9), and C (n=l). 15 patients had a single lesion and two had month (ai P

COMPARISONOF LAPAROSCOPICAND OPENLYMPHOCELE DRAINAGE LAPAROSCOPIC SURGERY FOR THE PATIENT WITH AshutoshKaul, M.D, LeonV. Katz, M.D., ElaineDressbach, B.S, Erin L Vermeulen, HIGH-RISK PAC, Mark Drassbach,B.S, StuartR. Geffner, M.D., Departmentof Surgery,Saint Michihiro Kawada M.D.,Hiedo Yamada M.D. and Yasunaga BarnabasMedical Center, livingston, New Jersey. Okazaki M.D. Department of Surgery, Sakura National Hospital, Chiba, Japan Laparoscopicdrainage of lymphoceleafter renal transplantshas bean doneat UniversityHospitals with excellentresults. The purposeof this studywas to critically OBJECTIVE: Laparoscopic surgeries for cholecystolithiasi- analyzeour resultswith laparoscopiclymphocele drainage at a communityhospital with a sis,early gastric cancer and colorectal cancer have come to be busytransplant center. Significanceof any changeswas tested usingStudent's t-test with so popular in Japan. Thus controversy continues to surround independentvariables the use of laparoscopic resection in cases of the patients with Between March 1993 and August1999 we did 852renaltransplants and 113 of these high risk. To determine the amount of the invasion for the developedsymptoma~c lymphoceles requiring operative drainage (13.7%). Laparoscopic laparoscopic surgery, we assess if laparoscopic surgery may drainagewas attemptedin 39 and was suocessfulin 29 cases.Comparison was made given to the high risk patients. with 60 opencases doneat the same time. Our averageoperating time was 59 rainsfor METHOD: Between 1984 and August 2000, 928 Patients laparoscopiccases, 66 mins. for convertedcases and 72 min. for open cases. Our underwent iaparoscopic surgery, of whom 25 patients with renal dysfunction or renal failure in Sakura National Hospital. averageblood loss was 26 cc in laparoscopicand 65 cc in open.The average RESULT: Laparoscopic surgery was performed in 1 case of postoperativestay was 2.3 daysin laparoscopiccases and 5 days in open cases. laparoscopic assisted distal gastrectomy, 8 cases of cholecys- Comparisonwas also donebetween laparoscopic and open casesduring the same tectomy, 1 case of surgery for the transverse colon cancer, 1 period for complications,reoccurranca and changein creatininein postoperativeperiod. case of left hemicolectomy, 5 cases of low anterior resection, Our averagefollow up was 22 months. 5 case of colostomy. The surgical mean time was required 176 Even thoughwe were still in the earlylearning period of doinglaparoscopic minutes(60-402). The average of serum Cre was 4.01mg/dl, lymphocehdrainage our patientshad a better cosmeticresult, lost less blood BUN was 28mg/dl and K was 4.01mEq/l. None of the critical and were dischargedhome sooner. Though laparoscopic skills are requiredour complication was found in the surgical period. data suggeststhat withadequate training community hospitals with busy CONCLUSION: Within this prospective study, laparoscopic transplantcenters may be able to offerthis procedure.Laparoscopic drainage of techniques were as safe as conventional surgical techniques if lymphocehresults in minimaldisability and acceptablecomplication rates. we operate them safer and quicker with laparoscopic instru- Therefore laparnscopicdrainage should be consideredas primarytreatment for ments. It may be safer way for the patients who need opera- all patientswith symptomatic post-transplant lymphoceles even in community tions suffering from other disease like renal dysfunction as centers. high risk, and wider we can expand the operative indications for the high risk cases.

LAPAROSCOPIC REPAIR OF THE VENTRAL INClSIONAL HERNIA WITH POLYPROPYLENE MESH: EARLY EXPERIENCE LAPAROSCOPIC CHOI T.13OCHOLITHOTOMY OF A TEACHING INSTITUTION Kaz~, Tsuyosld Takahashi, Kouski Sato, Muneki George B. Kazantsev M.D., James P. Dorman M.D., Department of Yoskida, Ken Shimada, Kouji Itabashi, Akira Kakita. Surgery, University of Texas Health Science Center, and Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas Department of Surgery Kitasato University School of Medicine, Japan Introduction. Although safety and technical feasibility of laparo- scopic ventral incisional hernia (VIH) repair with a PTFE mesh have been documented, difficulty handling and high cost are among the There are any treatment to remove chohdocholithiasis. In the drawbacks of PTFE grafts. Polypropylene (PP) mesh is less costly first choice, we remove chohdocholithiasis by endoscopic and easier to handle laparoscopicaly, but the fear of adhesions duodenal papilla vater sphincterotomy(EST). If we could remove restricts its use. Here we present early results of laparoscopic VIH repair with PP mesh, performed at a teaching institution. stones comphtely by EST, after some days laparoscopic Methods. Between July of 1998 and August of 2000, a total of 35 cholecystectomy was performed. And if we could not remove by patients underwent laparoscopic VIH repair with PP mesh. Patients EST, laparoscopic cholecystectomy and choledochotomy were were accrued in a prospective fashion. Mean age was 54.1 years (range 38-80). Obesity was common: mean BMI of 33.9 kg/m2 performed to remove stones. Before in these choledochotomy (range 23.4-55.1). All procedures were done by PGY III-V level resi- cases, we detained T-tube in the common bile duct(CBD) in dents with direct supervision of a faculty member. Mesh was secured laparoscopicaUy and T-tube drain were induced to in place with a hernia stapler and transcutaneous sutures. Omentum was always positioned to cover underlying loops of bowel. Patients extracorporation. were followed in clinic at frequent intervals. Recently we choose the method of p~mary closure of CBD Results. No conversions were necessary. Average time of surgery without T-tube drain after chohdocholithotomy. This procedure was 132 min (range 60-300). Defects ranged from 4 to 270 cm2 in size, mean 44.9 cm2; average mesh size was 237 cm2 (range 25- is explained, dissec~on of CBD, cutting 10ram in length of CBD, 760 cm2). Two small serosal lacerations occurred (repaired intracor- and CBD closure is interrupted sutured using 5-0 absorbable porealy). Median length of stay was 2 days (range 0-12); one patient had prolonged ileus. Seromas of the hernia sac were observed in 9 thred after choledocholithotomy. patients (26.4%), but only one required aspiration. One hernia Complication cases were one stricture of CBD and one bile recurred (2.9%); there were no wound or mesh infections. Mean fol- abscess. Two cases were recoverd. low up was 6.3 months (range 1-17 months). Conclusion. Preliminary results indicate that laparoscopic VIH The advantage of the primary closure will be able to reduce the repair with PP mesh is a safe and effective procedure as document- hospital days after operation and cost benefit. However the ed by low rate of recurrence and no infections. The technique is eas- disadvantage of this procedure have techical difficulty and some ily learned by residents with appropriate supervision. Further accrual of patients with careful follow up is antictpated. complications. S138

HAND-ASSISTED LAPAROSCOPIC AORTOBIFEMORAL MINIMALLY-INVASIVE MANAGEMENT OF PARAESOPHAGEAL HER- BYPASS VERSUS TRADITIONAL AORTOBIFEMORAL BYPASS NIATION IN THE HIGH-RISK SURGICAL PATIENT Kent W. Kercher MD, FOR OCCLUSIVE DISEASE Kent Kercher MD, Elias Arous MD, Brant D. Matthews MD, Sharon L. Goldstein MD, Robed T. Yavorski MD, John Kelly MD, Karen Gallagher RN, Demetrius Litwin MD, Jeffrey L. Ponsky, Ronald F. Sing DO, B. Todd Heniford MD Department of Department of Surgery, University of Massachusetts Medical General Surgery, Carolinas Medical Center, Charlotte, North Carolina, and School, Worcester, MA The Cleveland Clinic, Cleveland Ohio Traditional management of symptomatic gastric volvulus involves hernia Aortobifemoral bypass grafting is the treatment of choice for reduction, hiatai closure, and an antireflux procedure or gastropexy. patients with symptomatic aortoiliac occlusive disease. Yet, tradi- However, patients with paraesophageal hemiation and multiple comorbidi- tional operative exposure through a midline laparotomy incision car- ties may not tolerate formal operative repair. Endoscopic or laparoscopic- ries significant morbidity. The authors compare operative and assisted endoscopic reduction and fixation of the stomach may provide a patient outcomes following hand-assisted laparoscopic aortob- minimally-invasive treatment altemative in this setting. ifemoral bypass (LABF) and open aortobifemoral bypass (OABF). A sedes of six high-surgical-risk patients presenting with symptomatic An initial series of patients who underwent hand-assisted laparo- intrathoracic herniation of the stomach were managed with flexible scopic aortobifemoral bypass grafting (n=8) were compared to a endoscopy with or without laparoscopy. simultaneous cohort of patients treated w~th standard open bypass All patients presented with symptoms of chronic gastric volvulus, includ- (n=10). The two groups were similar with respect to age, weight, ing inability to eat, weight loss, regurgitation, and chest pain. Diagnoses and gender. Operative parameters, clinical outcomes, and compli- were confirmed by barium swallow and upper endoscopy. Average patient cations were compared. age was 78.7 years (72-84). Each was deemed high risk for definitive repair due to pre-existing coronary artery disease and at least two additional med- Hand-assisted LABF was successfully performed in all eight ical comorbidities (atrial fibrillation, congestive heart failure, diabetes melli- cases attempted. There was no difference in operative time tus, and/or hypertension). Paraesophageal hernia reduction and intra- between the laparoscopic and open groups (234 vs 206 min, abdominal fixation of the stomach was achieved in all cases using flexible p=0.99). Mean blood loss was comparable (562 mL [LABF] vs 756 upper endoscopy and double percutaneous endoscopic gsstrostomy tube mL [OABF], p=0.56). There were no conversions. Time to resump- insertion. Laparcecopic assistance for reduction and gastropexy was utilized tion of oral intake (1.8 vs 4.7 days, p=.001), and length of stay (3.8 in 4 cases. Mean operative time was 33 minutes (28-40). Average LOS was vs 6.3 days, p=.0004) were significantly shorter in the laparoscopic 1.4 days (0-2). One patient developed a superficial PEG infection. Three versus the open group. There was one late death in the laparo- have reflux symptoms managed medically. All resumed normal oral intake scopic group related to pre-existing cardiac disease. and achieved weight gain at mean follow-up of 4.8 months (1-7). Hand-assisted laparoscopic aortobifemoral bypass is a safe and Our patients with symptomatic paraesophageai hemiation necessitated technically feasible procedure. When compared with the traditional intervention to alleviate weight loss and chest pain and to avoid the compli- cations of gastric ischemia and strangulation. In the high-risk elderly patient, open operation, this technique may result in shorter hospitalization, endoscopic reduction and percutaneous gastrostomy with selective laparm more rapid return of bowel function, and an earlier return to activity. scopic assistance may provide effective palliation with minimal morbidity.

ACHALASIA FOLLOWING FUNDOPLICATION LAPAROSCOPIC ADHESIOLYSIS AND PLACEMENT OF SEPRAFILM: A Leana Khaitan, MD, Jonathan A. Cohen, MD, William O. Richards, MD NOVEL APPROACH TO PATIENTS WITH INTRACTABLE ABDOMINAL Department of Surgery, Vanderbilt University Medical Center, Nashville, "IN PAIN Leena Khaitan, MD, Jonathan A. Cohen, MD, William O. Richards, MD Backqround: Achalasia is a motility disorder of the esophagus characterized by Department of Surgery, VanderbUt University Medical Center, Nashville, TN esophageal apadstaisis and non-relaxation of the lower esophageal sphincter. It Backqround: It is controversial whether or not abdominal adhesions cause is unclear whether achalasia may develop secondary to a funddonal distal pain. Repeated operative treatment of these patients exacerbates adhesion obstruction such as a tight fundoplicetion (FP), or whether the FP may unmask formation following each procedure. Seprafilm (Germ/me, Tucker, GA), a undiagnosed achalasia. bioresorbable membrane, has been shown to significantly decrease Materials and Methods: Four patients who had previously undergone Niesen postoperative adhesion formation. We reviewed our experience with fundoplication were referred to our institution for evaluation of severe dysphagia laparoscopic adhesiolysis and Seprafilm placement in this difficult population. and a diagnosis of secondary achalasia. Only one patient had undergone pre- Materials and Methods: Nine consecutive patients underwent laparoscopic operative manometry, which revealed normal peristalsis. The remaining three adhesiolysis and placement of Seprafilm for chronic abdominal pain patients had undergone fundoplication based upon symptoms and esophagram secondary to adhesions between July 1, 1998 and July 30, 2000. There alone. Three of the patients had had multiple previous lower esophageal were 8 females and 1 male. Patients had previously undergone an average procedures. After developing dysphagia, all undenvent esophagram and upper of 5.2 abdominal procedures, of which 2 were for lysis of adhesions. All endoscopy. Three patients then underwent reversal of the Nissen FP and patients suffered from intractable abdominal pain for at least 4 months prior to procedure. Five patients had radiographic evidence of, or previous reconstructionwith a Toupet FP. admission for bowel obstruction. Results: All four patients had low amplitude (~=33.5 mmHg), apedstaltic Results: Two patients were converted to an open procedure due to very contractions with a nnn-relaxing, norm=l amplitude LES (~= 21 5 mmHg). dense adhesions. Eight of the nine patients report excellent results (off all Barium esophagram and endoscopy were consistent with achalasia. narcotic pain medications) from their procedure at an average of 9.4 month Intraoparetive findings in the three patients who unden~ent takedown of the FP follow-up. The one complication occurred in a patient who was converted to and revision to a Toupet FP were noted to have a wrap 92 cm in length or one an open procedure. This patient's postoperative course was complicated by that was too tight. While these 3 patients experienced relief immediately after an abdominal abscess and an enterocutanaous ~tule. She remains on surgery, all of the 3 patients have developed recurrent dysphagia months later. narcotics for abdominal pain. All other patients report complete resolution of One of these patients continues to undergo dilations and another has since had their preoperative abdominal pain. Most patients report that their pain the Toupat FP taken down. resolved almost immediately post-operatively allowing early resumption of Conclusions: Achalasia discovered following FP is a clinical conundrum. Such activities of daily living. Average hospital stay was 2 days for all patients. cases confirm the recommendation for routine preoperative esophageal Those who had a completely laparoscopic procedure were hospitalized for manomaW. These cases also highlight the technical considerations of FP, less than one day. including division of all the short gastric vessels, performing the wrap over a Conclusion: Patients who suffer from chronic, intractable abdominal pain as large bougie, and creating a short, loose wrap. Our exparience indicates that a result of adhesions from previous abdominal procedures benefit from a repeat dilations and FP revision may be inadequate therapy. Complete combination of meticulous laparoscopic adhesiolysis and placement of takedown of the FP and anti-acid medication may be a durable option in treating Seprafilm. This approach provides excellent relief of pain and interrupts the these patients with findings of achalesia after fundoplica~n. cycle of repeated operative procedures to lyse adhesions. S139

A VAUDATED ANIMAL MODEL FOR ACHALASlA, Ye~hodhanS. Khaianchee. THE INFLUENCE OF DIFFERENT VASODILATATORIC AGENTS ON M.D., Blair A. Jobe, M.D., David R. Urbach, M.D., Roger Van Andel, Ph.D., Luke PORTAL VENOUS BLOOD FLOW DURING LAPAROSCOPIC CO2- Kinzie, R.N., Paul D. Hansen, M.D., Lee L. Swanstrom, M.D. Minimally Invasive INSUFFLATION Surgery Departx~nt, Legacy Health System, Portland, Oregon. Zun-Gon Kim, M.D., Elif Sanli, M.D., Thomas Schmandra, M.D., *Lukas Achalasia, though a rare disease, represents significantpatient morbidity. A Kr~henb0hl, Carsten N. Gutt, Department of General and Vascular validated reproducibleanimal model is necessary to investigatethe etiology and Surgery, Johann Wolfgang Goethe-University, Frankfurt/Main, Gemlany * Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, potential treatments of the disease for humans. Previousanimal models of Switzerland achaiasiahave not been completelyvalidated using all of the manometric, radiographicand histopathologiccdteda establishedfor achalasia.We present Recent experimental and clinical studies suggest that laparoscopic CO2- definitivevalidation of an animal achalssia model with manometric, radiographic insufflation reduces macro- and microperfusion in splanchnic organs and and histopathologiccriteria. portal venous blood flow (PBF). Doparnine was found to increase PBF by In 12 opossums (Diedelphisvirginia) partial obstrudJonwas created at the level preportal vasodilatation and endothelin-1 (ET-1) receptor blockade might of gastro-esophagealjunction using a one-centimeterwide Gore-Texband. Water diminishing PBF by ET-1 dependant portal venous vasoconstriction. The perused manomeW and contrast esophagogram were performed before and at current study investigates changes on portal venous blood flow during four weeks after banding. After final assessment animals were euthanisedand CO2-1aparoscopy using different intraabdominal pressures and application histologicevaluation of esophaguswas done under light microscope,Manometric of different vasodilatatoric agents. values are expressedas medians (range). Statistical differences are assessed 15 male WAG/Rij rats were randomized into 3 groups to obtain CO2- using the Wilcoxon Rank Sum test. laparoscopy and low-dose doparnine infusion (n---5), selective ET-l-antago- nist (JKC 302) infusion (n--5) or sodium chlodd infusion as control (n--5). A A non-relaxinglower esophageal sphincter (LES) was demonstrated in seven PE-50 cannula was inserted into the intemal jugular veine for drug apply animals (median percent relaxation of LES decreased from 106.2 (92.9-129.7)to and a Doppler ultrasound probe was placed around the portal vein. 36.2 (0-55). Five animals developed amotile achalasiademonstrated by a Following an equilibration time of 30min PBF was measured during lAP of decrease in the mean body amplitude from 112.5 (88.8-145.5) mmHg to 28.7 (8- 2mmHg, 4mmHg, 6rnmHg, 8mmHg, 10mmHg and 12mmHg. Data were 35.7) mmHg0 (p< 0.01). Contrast esophagogram showed a classic bird's beak analyzed by Kruskal-Wallis, Dunn and Holm test. deformity and histologic evaluation demonstrated degenerationof the ganglion Increased lAP lead to a linear decrease of portal venous blood flow (PBF) cells in the Auerbach's plexus. Two animals developed a vigorous vadety of in the sodium chlorid control group. The application of ET-l-antagonist achalasiacharactedzed by simultaneousand repetitivecontractions of high (JKC 302) and low-dose dopamine infusion significantly improved PBF amplitude. Achalasia could not be demonstrated in one animal, and four animals when compared to sodium chlorid controls (p<0.05). No significant differ- died. ences were found comparing PBF during ET-1 and dopemine application This representsvalidation of an accurate model of human achelasia based on (p>0.05). Pharmacological vasodilatation of the splanchnic organs restores portal physiology,radiographic characteristics, manometnc findings and histopathology. venous blood flow (PBF) reduction during laparoscopic CO2-insufflation This model will be useful for investigatingthe etiology and potentialtreatments of whereas sodium infusion shows no effect. Whether improved hepatic per- achelasiain human beings. fusion may have beneficial effects on the liver function needs further inves- tigation.

IMPACT OF CO2-EXPOSURE ON THE EXPRESSION OF LAPAROSCOPIC ASSISTED COLECTOMY FOR COLON CANCER. Mich~ TUMOR-ASSOCIATED MOLECULES IN DIFFERENT CUL- Kobayashi. M.D.. Ken Okamoto, M.D., Tom A,ndo M.D., Naoshige Tohch~a M.D TURED TUMOR CELL LINES Zun-Gon Kim, M.D., Christoph Kimio Matsuura, M.D., Keijiro Araki, M.D., Satoru Tamura, M.D.,* Department o Mehl, M.D., Matthias Lorenz, M.D., Carsten N. Gutt, M.D., Surgery and Internal Medcine*, Kochi Medical School, Nankoku, Kochi. Department of General and Vascular Surgery, Johann Wolfgang Goethe-University, Frankfurt/Main, Germany Laparoscop~cas.~ed cdiectomy (LAG) is now one of the surgical modal~desfo colon neoplasm. However,there is a discussion tt~ LAC should not be al~e~ Recent clinical and experimental data propose laparoscopic for advanced cases because of the port site recurrence. From Janua~ 1997 tr CO2-insufflation to enhance proliferation and metastatic potential December 1999, our indicat~ of the LAC was adenoma and cancer with mucesa of different gastrointestinal tumor cell lines. But the pathophysio- or submucoeal invasion (F'rst period). After the inves~on of these cases, logical mechanisms for these findings are still unknown. E- have changed it to the Dukes A cases (Second pedod). In this study, we review~ Cadherin, I-CAM1, I-CAM2 and CD44 are cell surface molecules, our LAC cases of both pedods. which are involved in the metastatic process, invasivness and Twenty-~vecases (cancer; 21, aderloma; 4) underwent LAC for adenoma anq behaviour of different tumor cell lines. Therefore the aim of the early colon cancer from January 1997 to December 1999 in our departmenl current study was to analyze the influence of CO2-exposure on Twelve cases undenvent endoscopic rese(~on following LAC. Seventeen case the expression of tumor-associated cell adhesion molecules of underwent magnified colonoscopy (MC) to observe the surface slructure of th different cultured tumor cells. tumor (pit pattern) to diagnose the depth of cancer invasion. There were t~ Two colon cancer cell lines, CX-2 (human colon carcinoma, cases with muscular invasion and 2 cases with subeeresal invasion, without U metastasis histologically. However,no cases showed recurrenceso far. n=80) and CC-531 (rat colon carcinoma, n=30) were exposed for Alter we have become to be able to perform D2 dissection ,se~ely,we ha~ 60 rain to a CO2-environment at 6 mmHg. Control groups were changed its indicationas Dukes A from January 2000. We performed CT scan f( exposed 60 min to room air. The expression of E-Cadherin, I- the diagnesis of the T and N factors. Our policis are as foliows: 1) Try to perforr CAM1, I-CAM2 and CD44 was measured directly, 12 h, 24 h, 48 MC for eerty cases to grope for the possibilityof the endoscopic mucesal resediJor h and 72 h after CO2-exposure by flow-cytometry. Data were 2) If the Laparoscop~cobsavat~ reveals the tumor shows seroeal exposure, w analyzed by Wilcoxon-Mann-Whitney u-test. convert to the conventional laparotomy. 3) Even If we accomplish the D Expression of E-Cadhefin significantly decreased, while expres- dissecl~ laparoscopically,we convert to the taparotomy for further LN diss~o sion of I-CAM1, I-CAM2 and CD44 significantly increased after for the cases, which the frozen section of N1 and/or N2 LN shows canc( exposure to CO2-insuffiation, when compared to room air con- metastasis. In the second period, wepedormedLACin9ceses. Threecase trols (p<0.05). were subrnucosal invasion without LN metastasis. The cases, which ShONe The current study demonstrates CO2-exposure to alter the muscular and subseroealinvasion, were I and 5 cases, respectively. One cas expression of tumor-associated molecules in cultured colorectal showed N1 posith~ by histologicalexamination alter o~. cancer cells. Whether decreased E-Cadherin expression and Some insMutes have presented that the same grade of the LN dissec~on a increased I-CAM1, I-CAM2 and CD44 expression due to CO2- convent~nel laparotomy can be done. However, we performed only D insufflation might promote the metastatic potential of colorectal dissection taparoscopically. For this reason, our indicationof the LAC is Dukes, malignancies in-vivo needs further investigations. at present. The diagnoses by CT scan for T and N factors preoperat~ely an intraoperalNe frozen section for N factor are very importanL S 140

NORMAL SUPRAPANCREATIC AND PERIPORTAL LYMPH NODES Suprapubic approach: A novel access for laparoscop/c appendectomy ARE LARGER THAN ONE CENTIMETER BY LAPAROSCOPIC ULTRA- 0 Kollmar M.D., K Z'graggen M.D., BM Buchholz, MK Schilling M.D. SOUND EVALUATION Amy J. Koler, MD, Michael C. lilly, MD, Maudce E. Department of Visceral and Transplantation Surgery, Inselspital, University Arregui, MD, Department of Surgery, St. Vincent Hospital, Indianapolis, IN of Bern, Switzedand

OBJECTIVES: Laparoscopic ultrasound is being used to assess The cosmetic result is one argument in favor of laparoscopic over open resectability of gi malignancies. Lymph node size greater than 1 cm is a cri- appendectomy. To further improve that cosmetic result we developed a tarion for abnormal. This is not the case with penportal and suprapancreatic laparoscopic access to the abdominal cavity through two suprapubic lymph nodes. To date, the echo characteristics and size of these nodes incisions placed in the line of the pubic hair. Patients: We compared operative characteristic, outcome and patient preference of three different have not been described. We will define the laparoscopic ultrasound accesses to the abdominal cavity for laparoscopic appendectomy in a appearance of normal penportal and suprapancreatic lymph nodes. retrospective study. Furthermore 24 healthy female persons were asked METHODS: This is a prospective study of 21 patients with chronic acal- about their preferred procedure in regaKI to the cosmetic result. Results: culous cholecystitis or cholellthiasis. Each underwent elective laparoscopic Between 111997 and 08/2000, 149 patients underwent laparoscepic cholecystectomy with intraoperative ultrasound. Length and width mea- appendectomy and were assigned to either one technique (see fig. 1). surements were taken of pedportal and suprapancreatic lymph nodes in both a longitudinal and transverse direction. The length to width ratio of each node was calculated. Shape and echo textures were characterized. RESULTS: All measurements given in centimeters. SUPRAPANC MEAN RANGE STANDARD DEVIATION long length 1.57 0.55-3.11 + - 0.62 long width 0.49 0.25-1.26 + - 0.25 trans length 1.53 0.84-2.94 + - 0.57 trans width 0.48 0.21-1.17 + - 0.23 Fi,qure 1 PERIPORTAL long length 1.78 0.85-2.68 + - 0.52 technique 3 long width 0.50 0.27-1.04 + - 0.17 27" 24" 98 trans length 1.68 0.87-2.53 + - 0.45 =emale/ male 19/8 17/7 73125 trens width 0.52 0.22-0.95 + - 0.20 ~9e 30,0• 31,2• 28~3:1:11~6 Four lymph nodes had a L/W ratio < 2, and thus were considered to be :)perationtime (rain) 64,7 + 26,0 52T3+ 17f0 62r4+ 23~8 round (9.5%). All others were described as being oblong. All of the lymph ~ospital stay (days) 3,5 + 1,2 3,8 + 1,6 3,7 + 1,4 nodes were noted to have a hyperechoic center, surrounded by a thin, I method (%) 10% hypoechoic rim. 24/24 (100%) healthy interviewees preferred technique 2. CONCLUSION: The average size of periportal and suprapancreatic Discussion: Operation time and hospital stay were similar between all lymph nodes is greater than 1 cm. For these nodes, size of greater than 1 techniques. The cosmetic result of technique 1 and 2 were supedor to cm should not be used as a criterion for malignancy. technique 3. Patients and healthy interviewees preferred technique 2 over technique 1 and 3.

TRAINING OF LAPAROSCOPIC SUTURING SKILLS USING A NEW A PITFALL OF ENDOTIP. Fnm~ Ku~ni+hi M_D. Yoshincd Kwoda, COMPUTER-BASED VIRTUAL REALITY SIMULATOR (MIST) PRO- M.D.,Takmbi Urush/hara~.D., Kouhei Ishiytms,M.D., Nodaki Tokumom, M.D., VIDES COMPARABLE RESULTS TO AN ESTABLISHED PELVIC TRAINER SYSTEM Shanu N. Kothari, M.D. Brian J. Kaplan, M.D.,Edc J. Masayuki Shisbida,M.D., Depaunent of Surgery, Onomichi General Hospi~, DeMada, M.D, "timothy J. Broderick, M.D. Sue Clary, R.N. and Ronald C. Onomichi c~y, J apart Merrell, M.D., Department of Surgery and Center for Minimally Invasive Surgery, Medical College of Virginia Campus of Virginia Commonwealth [INTRODUCTION] We have experienceda caseof panpeitonidsdue to damqe University, Richmond, VA of the smal/imest/we by Eado TIP. We report aboutk. [CASE] The p~e~ was Objectives: The Yale Lapamscopic Skills Course utilizes pelvic trainer skills 46yea-s old female. Jamm'y llth 19991apaosmpic hysterectomywas peffomed. to improve performance in lapamscopic suturing (Amh Surg 1997;132:200- The patient compldned asthma on the secound day post operatively.But she 204). The Minimally Invasive Surgery Trainer (MIST, VP Medical R, London) could e~ Tl~rd day Uesu was co~'smed by abdominal x-p. Fourth day abdominal is a new computer-based virtual reality simulator for training, but the MIST has not been validated against standard training systems including the Yale Skills umdemess was seen.Freeairwas seeaby sb~x-p.CT showed us freedrmd Course. We hypothesized that the MIST would be equally effective to the Yale asdtes. We disgnosedit panpedto.m!ds. So m~ old'on wu done. Skills in training for laparoscopic suturing. [OPI~TIVE FINDINGS] Inthesbdom/nal cav/tytherewasaplenty ofydlow Methods: 24 of 29 enrolled 3rd year medical students completed the study. dight ascitestlntwas thou~tfow o~of the i~estimd fluid.We recked two They received detailed instruction in laparoscopic knot tying. Each student perfontions in the mesentedc borderof small int~e. Pandeto~s was dueto was given 6 attempts to tie a knot (3 throws, 600 second limit). Students were then randomized to train on the MIST for 5 sessions (6 skills/session) or the refute of the msll iwn~ Therefore we pedomed dr~e, ~ected ruptured Yale Skills for 5 sessions (3 skills/session) over a 5 day penod. Upon comple- sma//imetim~ and made a store,, of me small intestine. Soon alter opermon we tion of training, all students were evaluated by a test consisting of 6 additional reviewed the video of the previous lapm'oscopichysterectomy, confirmed that it attempts to tie a laparoscopic knot. Improvement within groups 'was assessed could be/mposslbleto make a dam~e 'tosmal/ intestineby dm mmipulzion of by paired t-test, while percentage improvement from baseline between groups was assessed using ANOVA. hysterectomy.Fimd/y we could confinnthe raptureand leakof~ fluidby Results: 11 students completed training on the pelvic trainer and 13 on the EndoTIP/nsertion ass ~ttroc~. Pint emergency apron/on two dsyslater,the MIST, Total knot tying time (mean +- SD) decreased significantly in the pelvic Imi~t have fallen to endotoY;m~. We have done blcod dialysis to remove endotoxin trainer group from 443 +- 135 to 311 +- 137 seconds (p

OUTCOMES OF REPAIR PROCEDURES FOR PATIENTS WITH BILE IS THERE A NEED FOR A FORMALLAPAROSCOPIC TRAINING PROGRAM DURING A DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY GENERALSURGERY RESIDENCY? Karen Kwong, M,D., Terrence Liu, M.D., DavidMercer, Toshiomi Kusano, M.D., Ph.D., Tsutomu Isa, M.D., Ph.D., Hiroshi Miyazato, M.D., Ph.D., Yoshihiro Muto, M.D.,Ph.D., Masato Furukawa, M.D., Universityof Texas-H0ust0nMedical School, Houston, Texas. M.D., Ph.D.* First Department of Surgery, Faculty of Medicine, University of the The acquisilJ0nof lapar0sc0picskills and knowledge is an important componentof all Ryukyus. surgical kaining programs. M0~t programs do not have a formal laparosc0picIraining Department of Surgery, Nagasaki Chuo National Hospital*. program and acquisitionof knowledgeis based on that reeiden~soperative expenence. II was our hypothesisthat our residentshad not acquiredsufficient knowledge in lapar0scopI Laparoscopic cholecystectomy is associated with a higher incidence of bile duct injury than open cholecystectomy. This study evaluated the out- despite'adequate' case numbers. comes of repair procedures for bile duct injury dudng laparoscopic chole- Methods: A proctored45-multiple choice queelJ0n tapareso0pic exam, usingthe SAGE~ cystectomy. Manualas a source,was givento all residents(n=39) at the beginningof the year. None0 A retrospective study of 14 patients with a median age of 49 years who the residentsstudied for the exam. Thus, it representedtheir current level of kn0~edge suffered bile duct injury during elective laparoscopic cholecystectomy Examswere graded,c0~ect scores grouped by PG year, and scorescompared by ~0-taile( over 8 years were reviewed. The main outcome of the repair procedure student'sT-Test (Table). was assessed using the records abstracted for demographic information, postoperative clinical data. n Mean SD Range A diagnosis of bile duct injury was made during surgery in 9 patients, PG1 15 22.4 4.5 (13-29) and after surgery in 5 patients. Thirteen patients suffered an injury to the PG2 7 23.9 2,5 (21-27) common bile duct, while the remaining one patient to the right hepatic PG3 6 26.5 3,5 (22-31) duct. As for the degree of injury, 9 patients had their bile ducts transect- PCA 6 30.2 2.6 (27-33) ed, 4 patients had a partial bile duct injury, 1 patient had a clipping. Four PG5 5 30.0 2.4 (27-33) out of 7 patients undergoing duct-to-duct anastomosis and one with an Results: end-to-side choledocoduodenostomy developed biliary stricture from 6 to None of the PG years scored higher than 73%. There was no differeno 15 month after repair surgery. These patients consequently underwent betweenPG1 and PG2 years(p=0.43). Therewas a trendtoward signilicance between PG hepaticojejunostomies as a second procedure. Primary closure in 3 and PG3 years (p=0.06). Signilicantdifferences were noted when PG2 residentswet patients for a partial injury, hepaticojejunostomy in 2 patients and 1 compared to PG4 or PG5's (p=0.0009 and p=0.001) respectively. PGI's versus PG4 an patient with removal of the clip all showed smooth postoperative course. PG5'swere als0 significantly different (p=0.00083 and p=0.002). In conclusion, hepaticojejunostomy offers satisfactory results for bile Conclusions:Our dataindicate that our residentshave a knowledgedeficit in laparoscop duct injury during laparoscopic cholecystectomy, even after previous interventions have failed. In cases of duct-to-duct anastomosis for bile when that knowledgeis acquiredthrough an operativeexperience. Althoughour residenl duct transection, the use of a long-term indwelling stents might be neces- increasedtheir knov~L-~je over time in the program, our data suggestthat implementaSon sary, a formal laparescopickaining program would be beneficialin our GeneralSurgery Resident and suspectthat other programs would benefit as well. (Sponsoredby Ethicon).

LAPAROSCOPIC TOTAL EXTRAPERITONEAL (TEP) INGUINAL RENAL ABLATION: AN IN VITRO COMPARISON OF CURRENTL~ HERNIA REPAIR - BEATING THE LEARNING CURVE PAWANINDRA AVAILABLE ELECTRICAL TISSUE MORCELLATORS Jaim~ LAL MS, FRCS(Ed), FRCS(Glasg), R K KAJLA,JAGDISH CHANDER Landman M.D., William C. Collyer M.D., Ephrem Olweny B.S., Cassic MS, V K RAMTEKE MS., THE DEPARTMENT OF SURGERY, Andrecni M.D., Elspeth McDougall M.D., and Ralph V. Clayman M.D. MAULANA AZAD MEDICAL COLLEGE & ASOCIATED LOK NAYAK Wahington University, Division of Urology, St. Louis, MO HOSPITAL, NEW DELHI, INDIA Morcellation with the high speed electrical laparoscopic (HSEL) mor While Lichenstein tension free repair is now regarded as the gold stan- cellator (Cook Urological Inc., Spencer, IN) in an impermeable dard in open hernia repair, Laparoscopic TEP repair has gained ground nylon/plastic sack (LapSac, Cook Urological Inc., Spencer, IN) ha.' in the last few years as it is less invasive and preserves the "peritoneal remained unchanged since its inception nearly a decade ago. Sacl sanctlty".lt however, has a longer and steeper learning curve due to the deployment and specimen entrapment remain relatively difficult an{ "inside out anatomical view", to which the surgeon =s not accustomed. morcellatlon with this device is expensive and relatively slow. As such Also, the standard teaching is that any laparoscopic procedure should be a copy of the basic open operation. While it has been true for cholecys- in an effort to facilitate specimen entrapment and moroellation, w~ tectomy and other intraabdominal procedures, ut is not so for inguinal her- adapted two currently available electrical morcellators (Steiner gyneco nia where the above repair is not done in the routine surgical practice. No logical morcellator from Karl Storz Inc., Culver City, CA and the electri wonder, the steep learning curves and initial complications! We suggest a cal prostate morcallator (EPM) from Coherent, Inc., Sturbridge, MA) fo simplified model and protocol for resolving this unpleasant situation. renal morcellation, and compared them to the HSEL morcellator. All morcellation was performed through a simulated abdominal wa METHOD: In our center, we perform the open prepedtoneal operation under direct laparoscopic vision. Ten porcine kidneys were ablate popularized by Stoppa initially, on one side only to familiarize the surgeon with each of the following techniques: 1.) HSEL morceUation in with the anatomy of the pre-peritoneal space. All the anatomical land- LapSac, 2.) HSEL morcellation in a fluid filled LapSac, 3.) Steiner tool marks are to be noted carefully. A minimum of 10 such operations would cellation in an insufflated Endocatch sack (U.S. Surgical Inc., Norwal~ be required to enable the surgeon with better insight into this CT), and 4.) EPM morcellation in a fluid filled Endocatch sack. A medi anatomy.The same procedure is then to be repeated in the laparoscopic fled laparoscopic trocar was constructed and applied for Steiner an, operation. We have found the learning curve far less steep as the anato- EPM morcellation. Time to complete moroellation, morcellation produ( my is now very familiar. In case of bleeding or excessive pneumoped- size, and entrapment sack integrity were evaluated for each techniqu{ toneum, the procedure should be converted to open Stoppa operation, Cost data for each morcellator is also presented. which the laparoscopic surgeon performs in open surgery, rather than Morcellatlon times for Steiner, HSEL dry, HSEL wet, and EPM roD1 TAPP. This enables the complication to be identified and noted for future. cellatlon were 6.0, 15.9, 14.7, and 26.0 minutes respectively. Fragmer We feel that this practice would make the learning curve for laparescopic sizes for these morcellators were 2.97, 0.65, 0.62, and 0.013 gram., TEP less steep and also decrease the incidence of initial complications. It respectively. A single entrapment sack perforation at the neck of th would also give added confidence in dealing with structures in this space sack, was documented in a LapSac during routine HSEL morcellation. where the anatomy has an "inside out view" which the surgeon now finds much more familiar, having routinely performed the "open equivalent" of the same operation. S142

COMPARISON OF THE LIGASURE SYSTEM, TITANIUM CLIPS, LAPAROSCOPIC MANAGEMENT OF GIANT PARAESOPHAGEAL ENDO-GIA STAPLER AND SUTURES FOR LAPAROSCOPIC HERNIATION VASCULAR CONTROL IN A PORCINE MODEL Jaime Landman Rodney J. Landreneau, M.D., Richard H. Maley, Jr., M.D., Robert J. M.D., Kurt Kerbl M.D., Cassio Andreoni M.D., William Collyer M.D., Keenan, M.D., Paul McKesey, M.D., "13bethaS. Santucci, R.N., Robin Ephrem Olweny B.S., Chandru Sundaram M.D., and Ralph V. Clayman S. Macherey, R.N, Department of General Thoracic Surgery, Allegheny M.D., Washington University Division of Urology, St. Louis, Missouri General Hospital, Pittsburgh, PA

Our goal was to assess the utility and define appropriate usage para- Introduction: The anatomic distortion and technical difficulty inherent meters of the 5-mm laparossopic UgaSure system for vascular control with repair of giant paraeeophagealhemiation have limited the use of of small and medium sized vessels during laparoscopic surgery. laparoscopic approaches for the correction of these disorders. Twenty-five domestic pigs were divided into four groups. In groups 1 Materials and Methods: Since 5/1994, we have performed laparoscopic and 2 in situ bursting pressures were used to compare the LigaSure repair of paraesophageal hiatal hemias in 94 patients. Mean age was system to titanium clips and Endo-GIA staples for control of arterial and 62+-14 and 62%(58/94) were women. Pre and post operative mano- venous structures of varying sizes. In group 3 the LigaSure system metric and prolonged pH testing were obtained on 31/94 (33%) was compared to standard bipolar energy for vascular control. In group patients. Ufestyle improvement and severity of heartbum/regurgitation 4 in vivo laparoscopic application of the LigaSure system was evaluat- and dysphagia were assessed on a 1-10 scale preoperatively and at 6- ed. 12 months postoperatively. Principles of repair included: reduction of The LigaSure system with the 5-mm laparoscopic device was able the hemia, excision of the sac, crural approximation, and fundoplication to reliably seal arteries up to 6-mm and veins up to 12-mm in diameter over a 54Fr bougie (Nissen-72, Toupet-22). with supraphysiologic bursting pressures. The Ligasure device was Results: Operative time was 157+- 53 minutes. Length of stay was deployed twice at two overlapping sites on each vessel. Thirteen arter- 2.7+-1.9 days. There were no mortalities. Conversion to Aopen@ ies with diameters of 6-mm or less were evaluated with a mean burst- repair was required in one patient (due to adhesions). Paired t tests pressure of 662 mmHg (range 363 to 1985 mmHg). Eleven veins with comparisons of mean preoperative to mean 6-12 month scores diameters s 12-mm were evaluated with a mean burst pressure of 233 showed significant improvement: lifestyle 6.9 to 8.1(p=0.001), heart- mmHg (range 63 to 440 mmHg). Standard bipolar energy was less bum/regurgitation 8.2 to 0.1(p=0.001), dysphagia 4.1 to 0.3(p=0.001). reliable, and vessel sealing could not be accurately assessed prior to Differences in pre and post operative manometric findings were not sig- vessel division due to local thermal tissue damage. nificant; however, significant improvement in pH scores (15.0 to 2.1% The UgaSure system is a viable option for laparoscopic manage- of time pH less than 4) was seen in those patients tested (p=0.001). ment of vascular structures within well-defined parameters. Arteries up Conclusions: Our experience suggests that laparoscopic repair of giant to 6-ram and veins up to 12-mm are reliably sealed with supraphysio- paraesophageal hiatal hernias is a viable alternative to Aopen@ surgi- logic bursting pressures. However, safe application of the system cal approaches. Thoracic surgeons interested in the management of 1requires meticulous technique. this complex process should become familiar with these minimally inva- sive techniques.

A PROSPECTIVE TRIAL OF ANALGESIA FOLLOWING ENDOSCOPIC LAPAROSCOPIC ANTI-REFLUX SURGERY IN THE LUNG EXTRAPERRONEAL INGUINAL HERNIOPLASTY: LOCAL WOUND TRANSPLASPLANT POPULATION Christine L Lau, MD; Scott M Palmer, INFILTRATION VERSUS EXTRAPERITONEAL INSTILLATION OF MD; Theodore N Pappes, MD; R Duane Davis, MD; Ross L McMahon, BUPWACAINE. Hun9 Lau, M.D., Nivdtti G. Patil, M.D., Francis Lee, M.D., MD; and Steve Eubanks, MD, Departments of Surgery & Medicine, Duke University Medical Center, Durham, NC. Wai K Yuen, M.D., Departmentof Surgery, Universityof Hong Kong Medical Center, Hong Kong SAR, China Background: Lung transplantation has emerged as a viable therapeutic option for patients with a vadety of endstage pulmonary diseases. As Exlmperitoneelinstillation of bupivacaine has been shown to be superior to immediate posttransplant surgical outcomes have improved, the greatest placebofor postoperativeanalgesia following endoscopic extraperitoneel limitation of lung transplantation remains chronic allograft dysfunction. inguinalhemioplasly. The objective of the present study is to compare the Gastroesophageal reflux disease (GERD) with resultant aspiration has efficacy of postopara~e analgesia by local wound infiltrationand instillationof been implicated as a potential contributing factor in allograft dysfunction. the extraperitoneelspace with bupivacaine. GERD is prevalent in end-stage lung disease patients, and even higher in From 1 September 1999 to 2 June 2000, a total of 100 consecutivepatients, patients after transplantation. This review reports the safety of lapraoscop- who underwentunilateral endoscopicextraperitoneel inguinal hemioplasties, ic fundoplication surgery for the treatment of GERD in lung transplant were randomizedto receive eider local wound infiltrationwith 10ml of 0.25% patients. bupivacaine(Group I, n=50) or instillation of the extmperitonealspace with Methods: Eighteen of the 292 lung transplants performed at Duke 40ml of 0.25% bupivacaineafter placement of mesh (Group II, n=50). Daily University Medical Center underwent anti-reflux surgery for documented postoperativepain was assessed by visual analogue pain score, on a scale severe GERD. The safety and benefits of laparoscopic fundoplications in from 0 to 10, at rest and upon coughing. Total amount of oral analgesic this population was evaluated. consumed and clinical outcomes of the two groups ware compared. Results: The anti-reflux surgeries included 13 laparoscopic nissen fundopli- The demographicfeatures and types of hernia were comparable.Table 1 cations and 4 laparoscopic toupets. Two of the 18 patients have reported shows the mean pain scores at rest and upon coughing of the 2 groups recurrence of GERD symptoms (11%), however, 24-hour pH testing was normal in all patients. Two other patients reported minor GI complaints (P=ns). The mean number of oral analgesic tablets consumedwere 3 in both postoperatively (nausea, bloating). There were no deaths or intraoperative groups (P=ns). During follow-up, asympatomaticgroin collection was more complications from the anti-reflux surgery. After fundoplication surgery 12 common in group II (n=4) than group I (n=2) (P=ns). of the 18 patients showed measured improvement in pulmonary function The authors conclude that extmperitoneel instillation of bupivacainedid not (67%). Conversion was necessary in one patient (5.6%), due to extensive bestow any eddibonalpain relief compared to local wound infiltrationwith adhesions. bupivacaine. Conclusions: GERD occurs commonly in the posttransplant lung popula- Table 1. Postoperativepain scoresat rest and uponcoughing. tion. Laparoscopic fundoplication surgery canbe performed safely with Pain scoreat rest Pain scoreupon coughing minimal morbidity and mortality. In addition to resolution of reflux symp- PostopDays Group I GroupII Group I Group II toms, improvement in pulmonary function may be seen in this population Day 0 2.3 2.6 4.5 4.7 after fundoplication. Lung transplant patients with severe GERD should be Day I 1.4 1.8 4.5 4.3 strongly considered for anti-rallux surgery. Day 2 1.8 2.5 3.9 4.8 S 143

TECHNICAL ASPECTS OF LAPAROSCOPIC TOTAL EXTRACORPORAL SHOCK-WAVE LITHOTRIPSY (ESWL) FOR ABDOMINAL COLECYOMY David M. Lauter MD, Eric J SYMPTOMATIC CHOLEDOCHOLITHIASIS IN THE ELDERLY Froines MD, Michael Theobold MD, and Lex Mottl MD, Group Avraham Lebenthal M.D., Dov Wengrower M.D., Eran Goldin M.D., Health Cooperative of Puget Sound, Seattle, WA Dov Pode M.D., Petachia Reissman M.D., Sergey Lyass M.D., Departments of Surgery, Gastroenterology and Urology. Hadassah Controversy exists around the role and appropriate indica- Hebrew University Medical Center, Ein-Karem, Jerusalem, Israel tions for laparoscopic assisted colon resection. We present in detail our technique for laparoscopic assisted total colectomy, Introduction: The majority of common bile duct (CBD) stones can developed during 185 consecutive laparoscopic colon surg- be cleared successfully by ERCP. Large stones, un-retrievable eries, including 14 total colectomies. The procedure is per- from CBD by usual endoscopic methods, are usually approached formed with the patient in a modified lithotomy position using surgically. Open CBD exploration carries a relatively high morbidity two 12 mm ports and three 5mm ports. Instrumentation and mortality rate in elderly patients. Recent reports showed that a includes a 10 mm 30 degree scope, harmonic scalpel, 5 mm combination of ERCP and ESWL might be an alternative approach bowel graspers, and 5 mm flexible retractors for exposure of to this problem. the distal rectum. Operative strategy is sequential mobilization Objective: The aim of this study was to asses the feasibility of of the entire large intestine from distal to proximal colon is fol- ESWL in combination with ERCP in clearing large stones from lowed by intracorporeal mesenteric division going from distal to CBD in elderly patients. proximal. Specifics of patient positioning, surgeon and assis- Methods: Patients with symptomatic choledocholithiasis in whom tant positioning, and technical pitfalls are presented for each ERCP failed to retrieve stones from CBD were referred for ESWL. sequence of mobilization and mesenteric division of the differ- All patients had severe co-morbid conditions, which precluded safe ent segments of the large intestine. Technical pitfalls with spe- surgical procedure. After ESWL the patients undenNent repeated cific solutions include splenic flexure mobilzation and distal rec- ERCP until complete removal of stones. tal dissection. Specimen removal is performed through either a Results: Five patients with mean age of 70 y. ( range 65-72) were 5 cm suprapubic incision, a mini-Pfannensteil incision, or an included in the study. A total of 17 ERCP and 6 ESWL were per- ileostomy site, depending on the exact procedure performed. formed. There was no morbidity and mortality after the procedures. Standard anastomotic techniques are used as indicated. In all patients the CBD was completely cleared of stones. The Retrospective review of our 14 cases demonstrated a 7% patients were followed for 86-24 months (mean 46) and remained (1/14) conversion rate and a mean operative time of 185 min- asymptomatic. utes. We conclude that laparoscopic assisted total colectomy Conclusion: Elderly patients with CBD stones that are not can be performed with acceptable operative times by GI tract extractable by ERCP may be successfully treated with ESWL fol- surgeons with advanced laparoscopic skills and appropriate lowed by endoscopic removal of fragments. This approach appears OR and OR team resources. to be a safe alternative to surgical common bile duct exploration.

COMPARING 5 V. 10 MM PORTS IN LAPAROSCOPIC NISSEN CAN SURGERYIMPROVE THE QUALITYOF LIFE FOR ASTHMA FUNDOPLICATION. Philip L Leggett, M.D., Charles O. Bissell. M.D.. The PATIENTSWITH GASTROESOPHAGEALREFLUX? Philip L Leggett, M.D, Universityof Texas- Houston Health Science Center (HNMC), Houston, TX. Hesham Atwa, M.D, The Universityof Texas-HoustonHealth Sdence Center Advantages of laparoscopic surgery include shortened hospital stay, (HNMC),I-husto~, TX. decreased post-operetivepain and earlier retum to activity.Studies have indicated that these benefits are realized in laparoscopic Nissen FiReen million Americanssuffer fi'omasthma, one proposedetiology of asthma is flJndopiication. A Medline review of the literature revealed no studies GERD. This study demonslratesthe effect of laparoscupir N'men funduplic=ionon investigating whether minimizing port size in laparoscopic Nissen [undoplicatton would augmentthese benefits. thesymptoms, frequency of m~cation and ovcnllquality of life in asthma pstimts, A prospective, randomized study was conducted from December, 1999 to Lap~oscopicNissen ~doplicalion was performed on 231 patientsl~ueen May, 2000. Fody patientsware randomized to undergo laparoscopic Nissen Januay 1997 and August 2000. Twmty five patimts were diagnosedwith asthma. sith either 5 mm ports or 10 mm ports. Data was collected for operetive Telephone iatervicw~ performedwith all asthma patient~ Lime, length of hospitalization, analgesic use while hospitalized, number of Asthma was idmtified in 25/231 palients(10%). Six patientsw~e excluded. analgesictablets used as an outpatient,time required to leavethe home and return to baselineactivities as well as post-operativepain. Fisher'sexact or had asthma as children which resolved sponmeously and three were lost to follow chi-square methods and Student'st-test ware used for statisticalanalysis. up.Follow up was performedon 22/25patients (8~A). Follow up time was 1-44 Twenty patients under,vent laparoscopic Nissen with 5 mm ports and 20 months(mean23.4). Five patients were on bronchodllatorsas needed and 12 used ~h 10 mm ports. The operative time (47.3 v. 48.7 rain,/7= 0.826) and bronchodilatorson a regu1~ basis. F~ two percent of patients were oil steroids length of hospitalization (1.2 v. 1.2 days, p=0.728) was similar for the two preq~nfively and 58% weretither s~n inthe omergmcyroom or admittedto the :lroups. Although not statisticallydifferent, the 5 mm group required fewer :loses of intramuscular analgesics (2.8 v. 3.4, p= 0.423) but more doses of hospital for their asthma symptoms.No change in asthma symptomswas noticed in 9ral analgesics (1.5 v. 1.1,/7= 0.346) while hospitalized. Once discharged 36.8% and 63% showed either improvementor marked ~aprovementin their from the hospital,the 5 mm group showed trends toward benefiting from the symptoms.Forty two percent had either disemtinued or decreasedtheir smaller ports in terms of the number of analgesictablets consumed (11.6 v. bronchedilatortherapy. Sixty four~ctat have decreasedor discontinuedtheir 16.0, p= 0.352), duration of analgesicuse (4.4 v. 5.5 days, p= 0.391), time to steroid therapy. Sixty eight percent of patients showed an improvementin the qualit leavethe home (3.2 v. 4.4 days, p= 0.151), time to return to baseline activity {8.6 v. 21.5 days,p= 0.103), and post-operetivepain (4.9 v. 5.8, p= 0.403). of life in relationto their asthma symptoms. Although statisticaldifference was not seen, the 5 mm group did show Ore'results indicatean improvementin the quality oflife in relation to the aaluna '.rends indicatingthat they benefitedfrom the smallerport size. Trends symptomswith decrease in the f~qumcy and dosage of medicationsin asthma ncluded decreased post-operativepain, reduced outpatientanalgesic use, patients with GERD followingI~eroscopic Nissen ~duplicatim. and earlierreturn to baselineactivity. S144

ULTRASOUND OF THE INGUINAL FLOOR TO EVALUATE A NEW APPROACH TO TRANSANAL ENDOSCOPIC MICRO- HERNIAS Michael C. Lilly, M.D., Maurice E. Arregui, M.D., SURGERY: ULTRASONIC DISSECTION AND THE STORZ OPERATION Departments of Surgery, St. Vincent Hospital and Health Care RECTOSCOPE Center, Indianapolis, IN, Keesler Medical Center, KeeslerAFB, MS Marco Maria Lirici-, MD, Massimiliano Di Paola, MD, Cnstiano GS Huscher, MD Department of Surgery, San Giovanni Hospital, Rome, italy Purpose: To evaluate the utility of ultrasound in the diagnosis of inguinal hernias and obscure groin pain. Transenal endoscopic microsurgery is an effective procedure for treatment Methods: A prospective evaluation of 65 consecutive groin of large sessile adenomas and early cancers of the rectum that allows a pre- explorations performed subsequent to percutaneous ultrasound cise full thickness resection of lesions under optical magnification. examination. Patients were examined in an office setting, including Unfortunately, TEM needs dedicated and rather expansive instruments and a history and physical, and then an ultrasound of the inguinal equipment. Other limits of the original procedure described by Buess are: region was performed. Ultrasound was performed by the staff sur- high skill demanding closure of the defect with running sutures secured by geon and fellows. Patients were then taken to surgery for either a silver clips, and control of bleeding especially in lesions located in the mild rectum. laparoscopic or open hernia repair. A comparison was made -Objective of the study-. The technical characteristics of the Storz operation between the pre-operative and operative findings to determine the rectoscope required the development of a slightly different procedure. utility of groin ultrasound. Definition of indications and contraindications and cost-effectivenese evaiua- Results: 41 patients presenting with symptoms of groin pain or fion of the procedure were the main objectives. palpable groin bulge were evaluated with ultrasound of the groin. -Methods/technique-. Ultrasonically activated 5 millimetres, curved blade 24 of the patients went on to have bilateral repairs, thus making the scissors are emploied for dissection and coagulation. Full thickness resec- study group consist of 65 groins. 50 laparoscopic and 15 open her- tion with adequate margin of clearance or simple mucosectomy or partial nia repairs were performed. This included 19 groins without hernia thickness resection may be performed. Closure of the tissue defect is by physical exam, and 46 with a palpable hernia. Overall, ultra- accomplished by interrupted 3-0 PDS sutures secured by extracorpereal slipknots. sound was utilized to correctly identify the type of hernia (direct vs -Preliminary results-. Ten TEM have been performed according to the above indirect) in 87.7%. In the 19 that there was not a palpable bulge, mentioned technique with the following indications: 4 adenomas, 4 ca in ultrasound identified a protrusion (hernia or lipoma) in 17. Two of situ/T1 tumours, 2 "1"2 rectal cancers. Patients with T2 cancers underwent these were false positives, and the 2 negative ultrasound exams preoperative chemoradiation or postoperative radiation therapy. Follow-up were false negatives. Thus the accuracy of ultrasound to identify ranged 24-1 months. No recurrences were observed. One complication pathology in the evaluation of a groin without a palpable bulge was occurred in a patient with adenoma: a bleending on postoperative day 6 that 79%. The overall accuracy of ultrasound in identifying a herniation required new rectal suturing. was 94%. -Conclusion/Expectation-. Compared to the original technique, TEM with the Conclusions: Ultrasound is a useful adjunct in the evaluation of Storz rectoscope and ultrasonic dissection is indicated only for tumours located up to 15 cm from the anal verge, the dissection is less fine. Despite the groin for hernia, and can be performed by surgeons. the complication described, coagulation is optimal and US scissors allow working in a pretty bloodless field. Overall costs are lower.

PEDIATRICLAPARO~OPIC NEPI~OUP.ETEP~CTOMY FACILITATES RECONSTRUCTIVE DETERMINING AN APPROPRIATE THRESHOLD FOR REFERRAL TO SURGERYFOR COMPLII~ GENITOURINARY ANOMALIIr.q. SURGERY FOR GASTROESOPHAGEAL REFLUX DISEASE Jean Y. Uu, Dould ~ Uu. M.D.Pb.D. D~ Mm-~M.D~ and Je=ep&Ortenbery~ M=D. CldMre|'s H~ of MD, Samuel RG Finlayson, MD MPH, William S. Laycock, MD MS, Richard I. NewOdemm ud La~um Sl=e UsiverttlySdlod of Medleh~New Orlem~ Lo~a.t Rothstein, MD, Ted I_ Trus, MD, Heiko Pohl, MD, John D. Birkmeyer, MD, VA Outcomes Group, VA Hospital, White River Junction, ~ Department of Baekgrmmd: Renal dysplasia may be associated with lower urinary tract malformations Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; or =3ntndatenl urcteral anomalies Traditional managemmt of throe complex urinary Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH tract anomalies otim requires abladw as well as recmssz'uctiw surgery. In the past, repair at the =une setting involved debilitating wide and/or separate incisions. For Background: Referral to surgery is usually reserved for gastroesophageal marginally functional renal ~mits,wr have adopted the technique oflaparosc~ic reflux disease (GERD) patients with poor quality of life despite medical thera- nephroummamny (LN) in associmim with reconsm~w surgery for complex py. However, an appropriate quality of life threshold for referral is not well- r m~my tract =omli~ established. M=tlNds: Eight children (7 boys and I girl) with an avenge age of 4 years (range: 6 Objective: To determine what quality of life threshold for medically-managed patients would justify laparoscopic fundoplication to optimize long-term out- mos.-12 yrs.) underwent LN with cmcomitant cmtralatml or lower urinary tract comes. surgery, predominantly for recu~et =riB=7 tract infecti0mor bladder dysfunction. LN Methods and procedures: Decision analysis using a Markov model to simu- was indicated due to dysplasia associated with postorior urethral valves, umeral ectopia, late long-term health outcomes after laparoscopic fundoplication or continua- urctero~e or multicy=ic kidney. LN was perf=~=/through three 5-ram trochar tion of dally prescription medication over 10 years. Peer reviewed publications sirra, with the majority of tissue and ~ dissection using a 5-mm harmonic scalpel. were located with a MEDLINE search for English-language articles for adult Specimm rmricvtl and low~ ='inm7 tract rs~nslructm (ure~ocystoplas~y. 2, saninal patients since 1994 to obtain probability estimates for the model. Health-relat- ed quality of life was represented in the model by utilities between 0 and 1.0, vesicle cyst excisim. 2, or uret='ocel=tomy- 1) were ac=mplished through a small where 0 represents death and 1.0 represents freedom from disease. The suprapub~ m in five children. Nephrectomy specimens were removed through base case analysis assumed a cohort of otherwise healthy patients with typi- l~t sitm in thr~ elher chikkm. Childrm wae studiai for safety of surgay, cal GERD symptoms who require daily medication. pastq~erative recover, rmolutiml ofsymlXoms,and r results. Results: Surgery is associated with better long term quality of life if the utility LN was perfumed =~=mfidly and safdy in spit= of more extrusive with medical treatment is below 0.99. For medically treated patients with a perinephric h'br=is in some easm. Opmt/ve times averaged 64 minutes (range 45 - 92 utility of 0.90 (equivalent to the health state of mild angina), surgery confers a min.) fur the LN ~ P.~overy wm uniformly imevenffuland parenteral analgesics benefit of 0.64 quai~ adjusted life years (QALY) over continuing medical treat- ment. For scores of 0.82 (equivalent to the health state of chronic colitis), the were unne~sm'y~pmt-opm~ve day2 in allcasm. T~etodisdmrge averaged I.$ benefit of surgery is 1.18 QAI_Y. Sensitivity analysis shows these results to be days (hinge, I-3 d.) and no dd,ty~l cmnplimtions wzre identifi=d. Functional and relatively insensitive to reasonable variations in baseline risks of surgical mor- emmet results~ mmkkr~l ~cellmt in all cases, with the e~ceptioa of one patient tality, surgical failure, and re-operation. who had pmistmt voiding ~unaioa following acisl'on of a massive uraaoccele. Conclusions: Based on cumentestimates of morbidity and mortality for laparo- Coar 121 mhancmthe aqiml mmganag of complex urinmytractanoma/ies scopic fundoplication, this model suggests that surgery would benefit patients requiring B~0mm~o=y ~1 hams r=covw/. Debilitm/ng wick and/or separate with even modest decrements in quality of life on medical therapy. Explicit incisions requinM to add~ tl~s= widdy sepm~d anmnalim at the same setting can quantification of utility scores for GERD patients should be considered to aid thus I~ avoided. clinical decision making. $145

WHICHLAPAROSCOPIC OPERATIONS ARE THE FASTESTGROWING IN A RANDOMIZED TRIAL OF HERMES-ASSISTED VERSUS NON- RESIDENCYPROGRAMS? HERMES-ASSISTED FOR LAPAROSCOPIC ANTI-REFLUX Lo, P; AhmedN; Chung R S. Departmentof Surgery, Hutou Hospital, Cleveland SURGERY James D. Luketich, M.D., Percival O. Buenaventura, M.D., ClinicHealth System,Cleveland, Ohio44112. Neil A. Chdstie, M.D., Sean C. Grondin, M.D., Kathryn E. Lovas, B.S., Susan A. Churma, R.D., Philip R. Schauer, M.D. , The Section of Laparoscopicoperations continueto increase in popularitybut the extent has not Thoracic Surgery and The Minimally Invasive Surgery Center, University been studied quantitatively. The growth can be expressed as the rate of change of of Pittsburgh Medical Center Health System, Pittsburgh, PA the proportion of laparoscopicvs the correspondingopen operation, ifa complete set of statistics have been kept. Fromthe National ResidontOperation Statistic, Advances in robotic technology, including voice-activation of operating collected by ACGME, we tracked the proportion oflaparescopicvs open operations room equipment, are being introduced into the clinical practice of surgery done by residents overthe past four years, includingthe total operationsperformed. but few reports have objectively evaluated their impact. This study was Results: (N= total number of proceduresrepotted; fraction=laparoscopic/ total) designed to assess the impact of the HERMES Voice-Activated system on operating room efficiency and user satisfaction. 1995 1999 growth (A ~ Cholccystect N 82493 89057 +1.99%* This was a prospective randomized tdal of patients undergoing laparo- Fraction 0.637 0.827 +7.45%* scopic anti-reflux surgery performed by expedenced minimally invasive Nisson N 6188 9060 +11.6%* general and thoracic surgeons. Patients were randomized to HERMES- Fraction 0.223 0.392 +18.9%** assisted or standard operating room procedure. Variables of interest Appendectomy N 35077 35262 +0.13% were circulating nurse's time spent adjusting devices that are currently Fraction 0.130 0.187 +10.75%* voice-controlled by HERMES, potential operating room cost savings, number of interruptions to adjust devices, and surgeon and nurse satis- Hernia Repair N 56182 54610 -7.0% faction (on scale of 1-10). Fraction 0.065 0.118 +20.38%** Colectomy N 36395 44145 +5.32%* A total of 30 cases were randomized and performed by one of 2 sup Fraction 0.024 0.032 +8.25%* geons. In the non-HERMES cases, nurses were interrupted for laparo- * p<0.005; ** p<0.0001, t-tests performedon slop= of plot: number vs year. soopic device adjustments on average 15.3 times per case which led to a The total number of operations increased in three of the five listed operations, but statistically significant time advantage for HERMES-assisted cases the laparoscopicproportion increasedin all, though at diffcront rates. The largest (p=0.03). Average satisfaction scores for HERMES vs. non-HERMES growth ratesare in laparoscopicgroin hernia repair (+20.3$'/dyr) and Nisson cases for nurses were 9.2 and 5.3 (p<0.001), and for surgeons 9.0 and 5.1 (p<0.001). fundoplication(+lS.tP/dyr), with appendectomy,colectomy, and cholecystcctomy also showingsubstantial growth..lust as laparo~opic cholecystectomygrew rapidly The HERMES voice-activated system eliminated 15 physician directed in the first half of the past decade, laparoscopicNissan fundoplicatiouand hernia nursing interruptions to adjust surgically related devices per case and repair are enjoyingthe fastest growth currently in residencyprograms. reduced operating time by approximately 5 minutes per case. There was a marked user preference for HERMES voice-activation for both sur- geons and nurses due smoother interruption-free environment.

BILATERAL LAPAROSCOPIC ADRENALECTOMY - INITIAL UNIQUE FEATURES OF LAPAROSCOPIC CHOLECYSTECTOMY IN EXPERIENCE THALASSEMIA PATIENTS RAN KA'I'Z M.D., LYASS SERGEY M.D., ADA Sergey Lyass M.D., David J. Gross M.D., David Hazzan M.D., Ben GOLDFARB M.D., MICHAEL MUGGIA-SULLAM M.D., ZVI GIMMON M.D., Glazer M.D., Petachia Reissman M.D., Dept. of Surgery & DEPT. OF SURGERY & HEMATOLOGY. HADASSAH UNIVERSITY MED- Endocrinology. Hadassah Hebrew University Medical Center, Jerusalem, ICAL CENTER, JERUSALEM, iSRAEL Israel Objective: Hemolysis and multiple blood transfusions are the well-known Introduction: Laparoscopic adrenalectomy (I.A) is rapidly becoming reasons for a high incidence of symptomatic gallstones in thalassemic the preferred approach to adrenal neoplasms, both benign and malig- patients. This prospective study was designed to assess the feasibility and nant. While the indications for unilateral LA are quite evident, in case of safety of laparoscopic cholecystectomy (LC) in this group of patients. Methods and Patients: Thalassemic patients who underwent LC in our insti- bilateral adrenal disease there is not enough data in the literature to sup- tution from 1996 to 2000 were evaluated. Data analysis included patients' port or condemn synchronous laparosoopic removal of both adrenals. age and gender, indication for chotecystectomy, comorbid condition, intraop- Objective: To assess the outcome of bilateral LA and compare it with erative findings, morbidity, blood loss, conversion to open surgery, and length the outcome of unilateral procedure. of postoperative stay. Patients & Methods: All patients who underwent LA between 1996 and Results: There were 8 patients with thalassemia (2 patients with major and 2000 were evaluated. Data analysis included patients' age and gender, 6 with intermedia) who underwent elective LC. Indications for cholecystecto. histological diagnosis, comorbid condition, length of procedure, morbidity, my were biliary colic in 6 patients, previous gallstone pancreatitis and acute blood loss, conversion to open surgery, and length of postoperative stay. cholecysbtis each in 1 patient. Previous open splenectomy was performed in Results: Between 1996 and 2000 years 54 patients underwent LA, 7 of 6 patients. The following features were common and unique for all the them - bilateral in one session (4 male, 3 female, with the age range patients: from 20 to 77 years). The indications for bilateral adrenalectomy were * Stgnificant hepatomegaly decreases the potential intra-abdominal space bilateral pheochromocytoma in 4 patients, Cushing syndrome in 1 that requires lower than usual trocar placement. patients, Cushing disease in 1 patient and 1 patient had Cushing disease * Cirrhotic, hemosiderotic and firm liver does not allow safe and sufficient with bilateral adrenal hyperplasia secondary to ectopic ACTH production. cephalad retraction of gallbladder. The procedure was usually done first from the right side, and, after repo- * Lack of adhesions in spite of previous open splenectomy. sitioning of the patients, was followed by left adrenalectomy. The mean * Cystic lymph node is significantly enlarged. operative time was 6 hours, but in the last 3 cases it was less than 4 * The thalassemic patients usually have hemoslderin cardiomyopathy, which hours. The conversion rate was 14% (n=l), compared to 6.4% in unilat- increases the risk of anesthesia and post.operative care. eral procedures. This one case of conversion was due to technical prob- * The inherent jaundice of thalassemic patients does not necessarily require intra-operative cholangiography unless it is not associated with bile duct lems after one side was already removed laparoscopically. There was no dilatation. peostoperativemorbidity, one patient received blood (1 unit) pedoperative- No procedure was converted to open and there was no morbidity. ly. The mean length of postoperative hospital stay was 6.8 days, while Conclusion: To allow safe LC in patients with thalassemia the surgeon after unilateral adrenalectomy the patients stayed at the hospital less should be familiar ~ some unique features in this specific group of patients. than 4 days. In spite of high prevalence of cholelithiasis in thalassemic patients we recom- Conclusion: According to this initial expedence bilateral synchronous mend to perform LC only in symptomatic patients, unless it is not associated laparoscopic adrenalectomy is technically feasible, safe, and associated with laparoscopic splenectomy. with relatively short hospital stay. S146

LAPAROSOCPIC ENUCLEATION OF PANCREATIC INSULINOMA - THE LAPAROSCOPIC DISTAL PANCREATECTOMY FOR INSUUNOMA. IMPORTANCE OF INTRA-OPERATIVE ULTRASOUND Sergey Lyase M.D., Mahon D, Allen E, Heyburn P, Rhodes M., Norfolk & Norwich David J. Gross M.D., Ben Glazer M.D., Richard Lederman M.D., Petachia Health Care NHS Trust, UK. Reissman M.D., Dept. of Surgery, Radiology & Endocrinology.Hadassah Hebrew University Medical Center, Ein-Karem, Jerusalem, israel Aims:A review of our experience of laparoscopic distal pancrea- tectomy. Introduction: Despite modem imaging preoperative localization of pancreatic Patients & Methods: insulinorna may be difficult making surgical management in such patients chal- lenging. Intraoperativeultrasound (IOU) was shown to be effectivefor tumor local- Three cases of pancreatic insulinoma were referred to us ization and excluding synchronous pancreatic tumors during open surgery. The between July 1996 and March 2000. Patients had pre-operative recent development and growing experience with laparoscopic ultrasound (LUS) radiological investigations and we then proceeded to perform made this medality useful in the laparoscopic management of pancreatic insulino- laparoscopic distal pancreatectomy. Intra-operative ultrasound was ma. We present two cases of pancreatic insulinoma demonstrating the impor- used for final Iocalisation and dissection was performed with a har- tance of LUS. monic scalpel. The tail of the pancreas was excised by a linear cut- Case 1. A 28 year old female with a one year history of hypoglycemia, the ter/stapler and removed in an endoscopic bag retrieval system. endocrine evaluation confirmed the diagnosis of insulinoma. The preoperative imaging including spiral CT scan and endoscopic ultrasound (EU) failed to local- Results: ize a tumor. The patient was explored laparoscopically,at that time, however, LUS All three patients made a swift recovery, became normoglycaemic was not available to us. In spite of thorough laparoscopic exploration of the entire and suffered no major complications. One patient underwent a pancreas, includingthe uncinate process, the tumor was not found. The operation planned laparoscopic splenectomy at the same time as the distal was converted, and conventional IOU revealed a 15 mm tumor in the head of the pancreatectomy. pancreas under the surface, which was successfully enucleated. Case 2. A 44 year old male was evaluated for recurrent episodes of dizziness Op ]3me Blood loss Hospital stay and fainting. Biochemical tests revealed h=gh endogenous levels of insulin. (minutes) (ml) (nights) PreoperativeCT scan and EU failed to localize a tumor in the pancreas. Laparoscopic exploration of the pan- 148 300 5 creas including LUS revealed a 20 mm solid lesion in the tail of the pancreas adjacent to the splenic vein, no additional tumors were noted. Successful enucle- 85 100 6 ation of the tumor was concluded laparoscopically. The pathological diagnosis 80 1800 3 confirmed insulinoma and the hypoglycem;a resolved completely in both patients after surgery. Conclusions: Conclusion. The development of the LUS has made pancreatic insulir.oma Definitive treatment of pancreatic insuiinoma is by excision of the amenable for laparoscopic management. LUS is crucial for both tumor localiza- turnout. Traditionally this has required a major laparotomy not at all tion as well as exclusion of potentfal synchronous lesions. Although technically in keeping with the size of the turnout itself, however, a laparoscop- challenging laparosoopicenucleabon of pancreatic insulinoma is feasible. ic approach would appear to be perfectly feasible and offers obvi- ous advantages to the patient.

HAND-ASSISTED LAPAROSCOPIC TOTAL GASTRECTOMY LAPAROSCOPY-ASSISTED SURGERY FOR COLORECTAL NEO- (HALTG) FOR EARLY GASTRIC CANCER Minoru Matsuda, MD. PLASM IS JUSTIFIABLE REGARDLESS OF THE ADVANCED AGE PhD*., K. Onodera*, Y. Kino*, T. Asama*, T. Munakata*, S. Kasai*, Hiroyoshi Matsuoka,MD., Tadahiko Masaki,MD.,PhD., Toshiyuki K. Kato** , Second Department of Surtery, Asahikawa Medical Mori,MD.,PhD., Masanobu Nakashima,MD.,PhD., Masanori Sugiyama, College, Asahikawa, Hokkaido, Japan* Departertment of MD.,PhD., Yataka Atomi,MD.,PhD, The First Department of Surgery, Kyorin University, Tokyo, Japan Endoscopic Surgery, Pippu Clinic, Pippu, Hokkaido, Japan** PURPOSE : The aim of this retrospective study was to confirm the feasi- Introduction: We present the operative technique and the advan- bility of laparoscopy-assisted surgery (I_AS) for colorectal neoplasm in geri- tage of hand-assisted laparoscopic total gastrectomy for early gas- atric patients. tric cancer.Patients: We performed this operation to two patients (a PATIENTS AND METHODS : During May 1995 to April 2000, 74 patients 57-year-old man and a 70-year-old man). The indication of HALTD with colorectal neoplasm underwent I.AS in our hospital. Fourteen patients is limited to the early gastric cancers with submucosal invasion were older than or equal to 75 years old (the aged group), and the remain- (TI: UICC) at U region of the stomach. Operative procedure: One ing 60 patients were younger than 75 years old (the non-aged group). During the same study periods, 46 patients with colorectal neoplasm older 10mm and Three 5 mm trocars were inserted to the abdominal than or equal to 75 years old underwent open surgery(OS group). Patients cavity. Then a 3 inches upper midline abdominal incision was made demographic features were compared between LAS-aged group and LAS- to set up the HandPo~_ (Smith & Nephew Inc. USA). The left gas- non-aged group (STUDY 1), and between LAS-aged group and OS-aged troepiploic and short gastric vessels were dissected using laparo- group (STUDY 2). scopic coagulating shears (LCS_, Ethicon Inc.). The left gastric A p-value less than 0.05 was accepted as statistical significance. artery was clipped and dissected. The anterior and posterior vagus RESULTS : In STUDY 1, neither patients gender, histroy of previous nerves were dissected preserving hepatic and antropyloric branch. abdominal surgery, operative time, amount of hemorrhage, conversion rate The esophagus was divided, then stomach was pulled out from the to laparotomy nor preoperative and postoperative complications such as hypertension, diabetic, ischemic heart disease, or respiratory disease were HandPort site. After a 25mm anvil head (ILS_, Ethicon Inc.) was statistically significant between beth groups. Futhermore, amount of postop- inserted into esophagus, the regional lymph nodes located along erative analgesics, postoberative oral resumption, duration of hospital stay, the right gastroepiploic artery, the right gastric artery, the common recurrence rates were not significantly different. hepatic artery and the celiac artery were dissected under the direct In STUDY 2, the mean operative time of the LAS group was significentiy vision through the abdominal incision. Total gastrectomy was fol- longer than that of the OS group ( 273 min vs. 188 min : p = 0.015 ). Mean lowed by the reconstruction of the Roux-en-Y method using ILS_. blood loss of the I.AS group was significantly less than that of the OS group Results: The mean operating time was 363.5 min. These patients ( 110 ml vs. 192 ml : p = 0.005 ). None of the remaining factors related to the were able to walk on the 1st postoperative day and take a meal on preoperative and postoperative complications and recurrence were signifi- 5th postoperative day. The mean postoperative hospital stay was cantly different between the two groups. However postoperative oral resumption( p = 0.05 ) and duration of the hospital stay ( p = 0.057 ) tended 16 days. Conclusion: This novel technique is available for minimal- to be earlier in the I_AS group than in the OS group. ly invasive surgery for the early gastric cancer. CONCLUSIONS : Laparoscopy-assisted surgery is an adequate treatment for colorectai neoplasm even in geriatric patients. SI4?

OPTIMAL TEACHING ENVIRONMENT FOR LAPAROSCOPIC VEN- A MODEL FOR ASSESSMENT OF ADHESIONS UTILIZING MINI- TRAL HERNIORRHAPHY B. Todd Heniford, MD, Brent D. Matthews, MD, LAPAROSCOPY Charles L. Backus, DO, Kent W. Kercher, MD, Bill Teel, PhD, Frederick L. Brent D. Matthews, MD, Broc L. Pratt, MD, Charles L. Backus, DO, Ronald F. Greene, MD, Ronald F. Sing, DO, Department of General Surgery, Sing, DO, Kent W. Kercher. MD, Sharon L. Goldstein, MD, B. Todd Heniford, Carolinas Medical Center, Charlotte, North Carolina MD Department of General Surgery, Carolinas Medical Center, Charlotte, North The introduction of labaroscopic techniques after residency training has Carolina created a new teaching paradigm focusing on laparoscopic workshops with animate course training and limited preceptor instruction. The purpose of The purpose of this study was to assess the safety and cost savings of using this study was to test the benefit of an animate course and evaluate the role repetitive mini-laparoscopy (2 mm) to evaluate the evolution of adhesion for- of proctoring in learning to perform laparoscopic ventral hernia repair mation after the intraperitoneal placement of various prosthetic biomaterials in (LVHR). the New Zealand white rabbit model. Attending surgeons who had taken a 1-day course to learn LVHR (n = 59) Polypropylene and polytetrafluoroethylene mesh were randomly placed were polled to determine their previous experience with laparoscopy and mtraperitonealin 44 New Zealand white rabbits. The peritoneum was left intact with LVHR since the course. The course included lectures, operative to simulate laparoscopic ventral hernia repair, Mini-laparoscopic evaluations videos, and an animal lab. were performed at 1, 3, 9, and 16 weeks. Evaluations were videotaped for Forty-eight (81.4%) attending surgeons taking the course responded. A p blinded analysis. Adhesion formation was scored using a modified Diamond value < 0.05 was considered significant. Thirty-two (66.7%) surgeons had scale. performed 179 LVHR (mean 5.6) since the course at a mean follow-up of Four rabbits had anesthestic complications and died prior to mesh place- 130.5 days. There were no statistically significant differences between the ment. Forty rabbits tolerated the mini-laparoscopic evaluations without compli- groups performing and not performing LVHR regarding academic]private cations. After the 16 weeks and 4 complete mini-laparoscopic evaluations, the rabbits were sacrificed and tissue in-growth was evaluated histologically.Cost practice (1::}=O.8)or opportunities to perform VHR (p=0.6). Fifteen (31.3%) savings using 40 rabbits with repeated mini-laparoscopic evaluation instead of surgeons were proctored (in their own hospital OR) by the lead author. 160 rabbits undergoing necropsy at 1, 3, 9, or 16 week intervals is summa- Thirteen (86.7%) of the proctored surgeons have performed a LVHR com- rized in Table 1. Total cost savings was $14,720.00. In addition, the study was pared to 19 (57.6%) of the 33 surgeons taking the course without a proc- completed in 16 weeks instead of 36 weeks because of housing restraints in tored intervention (p=0.05). Surgeons who had performed laparoscopic our vivarium. inguinal hernia repair, Nissen fundoplication, and common bile duct explo- ration were much more likely to perform LVHR (80%) after the course Table 1 (p<0.0001). Surgeons performing laparoscopic cholecystectomy only were Category Purchasing Housing OR Charges PostoperativeCharges less likely to perform LVHR (42%), nearing statistical significance (p=O.08). Savings $ 7200.00 $ 560.00 $ 2640.00 $ 2400.00 Surgeons with prior advanced laparoscopic surgery experience are more likely to perform LVHR after participating in a l--day course with an animate Necropsy Total lab. Surgeons precepted in their own OR were also more likely to perform $1920.00 $14720.00 LVHR. Participation in an animate lab and a precepted experience may determine the future performance of advanced laparoscopic surgery. This model for assessment of adhesions utilizing mini-laparoscopy is safe, cost-effective, time efficient and limited the number of animals needed for the experiment.

LAPAROSCOPIC CHOLECYSTECTOMY IS AN APPROPRIATE EFFECTS OF FLUOROSCEIN DYE DOSAGE AND PNEUMOPERITONEUM TREATMENT FOR ACUTE GANGRENOUS CHOLECYSTITIS. PRESSURE IN THE LAPAROSCOPIC EVALUATION OF INTESTINAL Alexander Matz, M.D., Arkadi Ischakov, M.D., Ilan Charuzi, M.D., Ofer ISCHEMIA USING ULTRAVIOLET LIGHT IN THE PORCINE MODEL. James J. McGinty, Jr., M.D., Nancy J. Hogle, B.S.N., Dennis L. Fowler, M.D., Landau, M.D., Shlomo Kyzer, M.D., Department of Surgery 'B', E. Department of Surgery, AlleghenyGeneral Hospital, Pittsburgh,PA. Wolfson Medical Center, Holon, Israel. Sodium fluoroscein administered IV and observed with an ultraviolet (UV) The role of laparoscopic cholecystect0my (LC) as the treatment of acute light is a preferred technique to determine intestinal viabdity intraoperatively cholecystitis is well established. However, controversy persists about via laparetomy. However, the use of fluorescein and UV light with laparoscopic visualization has not been well defined. This study compares whether LC is the treatment of choice for gangrenous cholecystitis. We the visualization of the fluorescence laparoscopically using different undertook the present retrospective study in order to determine the results intraperitoneal pressures and different doses of fluorescein. of LC on patients operated for gangrenous cholecystiUsas compared to the Sixteen 25 kg pigs were divided into eight groups of two pigs each. Four results on those undergoing LC for acute cholecystitiswithout gangrene. groups had a pneumoperitoneum of 7 mmHg, and four groups had a The study included 231 patients who had undergone LC for acute pneumoperitoneum of 14 mmHg. Alter devascularizing a 10-15 cm segment of small bowel, two filters (Kad Storz Endoscopy, Culver City, CA) were cholecystitis. The diagnosis of gangrenous cholecystitis was made only placed, one between the light source and the light cable to filter all but UV according to the histopathological report. Various variables, such as light, and one between the laparoscope and the camera to filter all but duration of preoperative symptoms conversion rate, intraoperative and fluorescent frequency. One group receiving each pressure was given either 5 postoperative complications, duration of the procedure and length of rag, 10 rag, 15 rag, or 20 mg per kg of fluorescein. Videotape and digital still images were made to determine if the different pneumopedtoneum pressure,, hospital stay, were analyzed. or fiuoroscein dosages affected visualization of viable and ischemic bowel. The group of 231 patients consisted of 147 cases with various forms of In all cases, viable tissue and intestine were visualized as fluorescent, whik acute cholecystitiswithout gangrene (Group A) and 84 cases with gangrene the ischemic segment was a darkened silhouette against the fluorescent (Group B). The two groups were similar in demographic attributes and tissue. There were no differences noted between the groups with different clinical characteristics except for the presence of more men among the pneumoperitoneum pressures when using the same fluoroscein dose. However, visualization was better with the intermediate doses (10 rng/kg and patients in Group B. The conversion rates in Group A and B were 3.4% and 15 mg/kg) than with the lowest or highest dose. 2.3%, respectively (P=0.9017). There were no significant differences The pressure of the pneumopefitoneum (up to 14 mmHg) does not interfen between the groups regarding the length of surgery, incidence of intra- and with laparoscopic visualization of ischemic intestine using fluoroscein and U~, postoperative complications and duration of hospital stay. light in the porcine model. Optimal doses of fluoroscein are 10 mg/kg or 15 The intraoperative findings of gangrenous cholecystitis do not increase mg/kg. This technique using these doses and pressures has potential to assi the chance of conversion or occurrence of intra- or postoperative in the evaluation of patients suspected of having mesenteric ischemia. complications. $148

COMPUTER ENHANCED "ROBOTIC" TELESURGERY: INITIAL LATE OUTCOMES OF DIAGNOSTIC LAPAROSCOPY FOR CHRONIC EXPERIENCE IN FOREGUT SURGERY W. Scott Melvin, MD, ABDOMINAL PAIN Elizabeth A. Mittendorf, M.D. and Raymond P. Bradley J. Needlaman, MD, Kevin R. Krause MD, Carol Scheider, BA, Onders, M.D., Department of Surgery, University Hospitals of Cleveland, RN, Randall K. Wolf, MD, Robed E. Michler, MD, E. Christopher Case Western Reserve University School of Medicine, Cleveland, Ohio Ellison, MD. Department of Surgery, The Ohio State University, Columbus, Ohio Introduction: In order to determine the utility of performing diagnostic laparosoopy in patients with chronic abdominal pain, this study was per- New technologic advances have changed the way surgeons interact formed to evaluate long-term outcomes in patients undergoing this proce- dure. with their patients in the operating room. Computer enhanced Methods: A retrospective review was performed of patients undergoing telesurgery allows remote control manipulation of multi-articulated intra- laparosoopic procedures between July, 1997 and July, 2000. Those corporeal instruments. The daVinci tm Surgical System (Intuitive undergoing diagnostic laparoscopy for chronic pain were identified and Surgical, Inc., Mountain View, CA, USA) was approved for general sur- length of time with pain, number of diagnostic studies performed, intraop- gical use this year and we have employed it for the treatment of disor- erative findings, interventions, pathology, and long-term follow-up were ders of the upper gastrointestinal tract. We prospectively collected determined. patient data to evaluate the safety and efficacy of the device. Results: Of 1308 laparoscopic procedures performed, 70 (5%) were Seventeen cases were done that included 10 anti-reflux operations, 4 for the evaluation of chronic abdominal pain. There were 61 women and Heller myotomies, 1 distal pancreateotomy/splenectomy, 1 diagnostic 9 men with an average age of 42 years. The average length of time with laparoscopy, and 1 esophagectomy with transthoracic esophagogas- pain was 74 weeks (range 8-260) and the average number of studies trostomy. There were 8 females and 9 males with an average age of performed prior to surgical referral was 3.3. 53 (76%) patients had their 45.7 years and weight of 182 Ibs. The average operative time was procedures performed as outpatients with the remainder admitted for 178.6 minutes with a range of 88 - 458 minutes and the average robot observation status. The average length of operative time was 70 min- time was 90.4 minutes with a range of 16 - 185 minutes. We generally utes, no cases required conversion to an open procedure and no compli- used 2 operative ports, 1 camera port and 1 or 2 assistant ports. There cations occurred. Findings included adhesions in 39, a hernia in 13, were no conversions due to device failure. There were no major compli- adhesions from the appendix to adjacent structures in 6, appendiceal cations. pathology in 5, endometdosis in 3 and gallbladder pathology in 2. 10 Computer enhanced robotic telesurgery is a safe and effective patients had no obvious pathology. At the time of their initial postopera- tive visit, 75.7% reported their pain to be gone or improved. After an method of treatment for a vadety of disorders of the proximal gastroin- average follow-up of 74 weeks, 28.8% noted recurrence of their symp- testinal system. The advantages of three-dimensional imaging, scaled toms therefore 66.7% had long-term pain relief. No patient experienced hand motions and intracorporeal articulation allow complex tasks to be any long-term complications and all reported satisfaction with their proce- performed. Devices and procedures that are currently available remain dure. under development. Further advances and studies will define the true Conclusions: Diagnostic laparosoopy can be performed safely, fre- role of "robots" in the operating room. quently on an outpatient basis, with good long-term results in patients with chronic abdominal pain.

CHRONIC RIGHT LOWER QUADRANT PAIN: LONG-TERM RESULTS ADVANCED LAPAROSCOPIC SURGERY TRAINING COURSE: AFTER LAPAROSCOPIC APPENDECTOMY Elizabeth A. Mittendorf, IMPACT ON SURGICAL SKILL AND THE CUNICAL PRACTICE PAT- M.D. and Raymond R Onders, M.D., Department of Surgery, University TERNS Toshiyuki Mori M.D., Hiroshi Shimoi, M.D., Tadahiko Masaki, M.D., Hospitals of Cleveland, Case Western Reserve University School of Masanod Sugiyama, M.D., Yutaka Atomi, M.D., Department of Surgery I, Medicine, Cleveland, Ohio School of Medicine, Kyorin University, Tokyo, Japan Introduction: The purpose of this study was to evaluate the utility of laparoscopic appendectomy in patients with chronic right lower quadrant Background: Advance laparescopic courses, highlighting suturing skill, (RLQ) pain in whom preoperative imaging failed to identify an etiology. are needed for surgeons who routinely perform laparosoopic cholecystec- Methods: A retrospective review was performed of patients undergoing tomy before they start new demanding procedures. This study is conduct- diagnostic laparosoopy for chronic pain between July, 1997 and June, ed to assess the impact of the advanced laparescopic course on laparo- 2000. Length of time with pain, number of diagnostic studies performed, scopic surgical skill and the clinical practice pattern of the participants. preoperath,e exam, intraoperative findings, pathology, postoperative pain Method: A survey was mailed to all eighty one participants of our advanced status and long-term follow-up were determined. laparosoopic courses, regarding suture techniques employed at the time of Results: Of 70 patients undergoing diagnostic laparoscopy for chronic questionnaire, procedures performed in the clinical practice. The course pain, 21 subjectively localized their pain to the RLQ. 15 (71%) had repro- consists of three half days, covedng sutudng practice, suture-closure of ducible pain on exam. The average lengt~ of time with pain was 64 weeks duodenal perforation, Nissen fundoplication, and nephrectomy. Results (range 8-200) and the average number of diagnostic studies performed Twenty-eight out of eighty-one participants responded the survey was 4. Intraoperative findings included adhesions in 5, adhesions from the (Response rate 34.6%). Acquisition or improvement of suturing skill was appendix to adjacent structures in 5, a thickened appendix in 4 and an noted in 15 (53.6%). As a result, twenty-two surgeons are able to tie knots appendiceal mass, inflamed gallbladder and endometriosis in one each. 4 laparosoopicelly (78.6%), seventeen surgeons intracorporeally (60.7%) and had no obvious pathology. All 21 patients had an appendectomy per- five surgeons extracorporeally (17.9%). Nine surgeons started laparoscop- formed, 13 also had extensive adhesiolysis. Pathology revealed findings ic closure of perforated ulcer after the courses (32.1%). Skill acquis~ion or consistent with chronic appendicitis in 9, a feoal~ in 2, 1 appendix with improvement in suturing was noticed in all. Seven surgeons started CBD inflammatory exudate and 1 with endometriosis. 7 were normal. exploration after the courses (25~176Suturing skill of these surgeons at the Intraoperative appearance of the appendix did not correlate with pathologic course was none in all, and intracorporeal knot tying in all at the survey. diagnosis. At an average follow-up of 51 weeks, 17 have had resolution of F'Ne surgeons started laparosoopic splanectomy after the course (17.9"/.). their pain including all those with abnormal pathology except for the patient Sutudng skiU of these surgeons at the course was none in all, and intracor- with fibrinous exudate who reports no change in his symptoms. 2 patients, poreal knot tying in all at the survey. No relation was found between skill both with pathologically normal appendices had early improvement but acquisition and the profile of respondents, including age, experience in have subsequently experienced recurrence. general or laparoscopic surgery. Conclusion Advance laparoscopic course Conclusions: Diagnostic laparosoopy has a role in the treatment of has a tremendous impact not only on surgical skill, but on the clinical prac- patients with chronic RLQ pain. The intraoperative appearance of the tice patterns. Surgeons who have learned suturing skill in the course tend appendix is unreliable in determining disease therefore all patients should to start more demanding procedures after thaL undergo appendectomy. Pathologic findings are predictive of long-term success in symptom relief. S149

MUSCLE ABILITY AFTER LAPAROSCOPIC HERNIOPLASTY VERSUS CLOSUREOF CUTANEOUSLAPAROSCOPIC WOUNDS CONVENTIONAL REPAIR Nobuo Murata. M,D., Y. Makita, M.D., A. Odaka, USINGBUTIL-2-ClANOACRYLATE. C.,.lyI.M. Muto. M.D., S. UIIo,M.D., M.D., H. tshida, M.D., K.$himomura, M.D., K. Takahashi,M.D., D. Hashimoto, F. Pettar,Jti, M.D., L. Esposlto,M.D., G. Verrengia,M.D., V. Schiavone,M.D. - Video Surgical OperativeUnit - ClinicePinata Grande - CastelVoitumo (CE) - ITALY M.D., Y. Idezuki, M .D. Department of Surgery and Rehbilifation, Saitama Medical Center, Saltama, JAPAN In our s~cture we courrentiy use butil-2-cianoacrylatafor repadng cutaneous laparoscopicaccess. We obtainvery goodresults. In the timeof minHnvasivesurgery is very importantgood results aboutdcatTizzation of surgical wounds. Is't necessary a It has been reported that laparoscopic hemioplasty (LH) yields reduced good "rostitutJo ed integrum 9 for littJe cutaneous laparoscopic access. Wounds postopertive disability of exercise. However, no comparative data on muscle cicatfizzabonis very difficultresult of many reec'dor~of connectiveand epifelialtessue strength after LH and conventional repair (CR) have been collected. The aim that make function twice. In the connective tessue, after an ini~l inflammatory of this study was to compare the strength of muscles related to the operation essudativerases, we obtainmoltiplication of fibroblesteand endotatialceils. Dudngfirst by muscle testing after LH and after CR. 24 hourswe havecollageno whose production is highdudng first weekof dcatdzzation. Dudng fifth/sixt~ days we see formationof neevascoladzatJonof new tessue. Epitetlal Twenty-sevan patients with primary inguinal hernias were randomly tessue makes function that give reparationof wounds in third days. Maturationof new divided into 2 groups according to surgical procedure: 14 patients were treated tessue givesfunctional e rnorphologicproperty of epidermids.At eightsday we obtaina with LH (a preperifoneal technique) and 13 w{th CR (an itiopubio tract repair r that has less resistance,but after few months it takes good rasistence. technique). Two types of muscle testing around the inguinal region by manual Cutaneous cicab'izzationdepends from general and local factors: costitution,age of examination and using a musculator were performed pdor to and 1 week after patient;,coagulopathologies, nutriztonal factors; inflammation,venous or artarialdeficit; ilia operat;or,. temperature,kind, large,idratation of wounds. Wounds suturegives best dcetrizzation for first intention and it'lo importantfor a good aestheticand fundJonal results. For There were no significant differences in muscle strength in the muscles suture we can use suture, adhesivesubstance and methaliicagraphes. All suturegives around the inguinal region, except the iliopsoas muscle, between the 2 extra bodyresction. This reactionmakes a not gooddcelzizzation for ischemicreaction procedures. The muscle strength of the iliopsoas muscle was reduced in 6 of tessue. In our private s~ctura, accreditate with italian S.S., we use b~'l.2. patients in the CR group but in none of the patients in the LJ-I group by manual cianoacrylatafor reparing cutaneous laparoscopicaccess, a fluid tessutal adhesive examination. The muscle strength of the iliopscas muscle by the musculator substance that in 10 seconds give pollmedzzationwith good tollerability, no was 48.5 + 27.4 kg (mean + SD) in the LH group and 41.8 + 22.1 kg in the oncogeneeis, and spontaneouselimination with cutaneous rechange.We use this adhesive substance in 37 cases of patients operatedusin laparoscopicaccess. For CR group before the operation. It was 50.5+27.0 kg in the LH group and 32.5 every patients we make 4 cutaneous access and we use butil-2-danoacJytatefor :1:21.0 kg in the CR group I week after the operation. There was a significant reparing100 cutaneouswounds. We ~'eaReda~omeo wounds,above Langer tines, of difference in the decrease in muscle strength in the iliopsoas muscle after the 5 to 20 ram. After suturing understandingplanes, we put adhesivesubstance on the operation between the 2 groups. wounds, with ster]l streepsabove tha wounds.We removethe stedl sfzeepsalter 10 In conclusion, since the muscle strength of the iliopscas muscle did not postoperativedays. reduce after LH, we suggest that this procedure is more useful than CR, in We obtaingood dcetdzzation with goodfunctional and aestheticresults. In only 4 cases we obtainednot good linearwounds, one deiscence,and one granulomas.We don't terms of muscle strength. obtain ipertrophicevolution of wounds repair.We can say that we obtainedvery good aestethlo and functional results using butii-2-cianoacrylatedosing cutaneous laparoscopicaccess and, very important, patients don't go to removesuture.

EFFECT OF HEATED AND HUMIDIFIED GAS ON POSTOPERATIVE PAIN EFFECTIVENESS OF LAPAROSCOPIC ADHESIOLYSIS AFTER LAPARO$COPIC NI$SEN FUNDOPMCATION: A RANDOMIZED ASSESSED BY SECOND-LOOK LAPAROSCOPY D. Nio, STUDY. Ninh T. Nauven. MD, GabrieUa Furdui, MD, Franco Canet, Steven W.A.Bemelman, A. Peters, F.W. Janssen, M.S. Dunker, J. Ringers, D.J. Lee, BS, Bruce M. Wolfe, MD, UC Davis Medical Center, Sacramento, CA. Gouma, Departments of Surgery and Gynaecology, Academic Medical Center, Amsterdam and Leiden University Medical Center, The Heated and humidified gas has been shown to reduce intraoperative Netherlands hypothermia, The aim of this study was to compare the effect of heated and humidified COz insufflation versus room temperature CO2 insuffiation on Postoperative adhesions may cause infertility, bowel obstruction and intraoperative urine output and postoperative pain. chronic abdominal pain. Adhesions can be classified as 9 de novo " Twenty patients undergoing leparoscopio Nissen fundoplication were adhesions developed at the area of dissection (type a) or outside the randomized to receive either room temperature CO2 insufflation (group 1, area of dissection (type Ib), and reformed adhesions (type II). It is n=10) or heated and humidified CO2 insuffiation (group 2, n=10). An external unknown how effective laparoscopic adhesiolysis is with respect to" de warming device was used intraoperatively in both groups. Core temperature, novo ' and reformed adhesions. The objective of this study is to asses~ abdominal temperature, volume of gas delivered, in~'aoperative urine output, the effectiveness of laparoscopic adhesiolysis assessed by seconC look laparoscopy. and number of lens fogging episodes were recorded. Postoperative pain was From January to November 1998 16 patients (14 women, 2 men) witl" evaluated on day 1 by a visual analog scale (VAS) and narcotic requirements chronic abdominal pain were included. Mean age was 42.8 year., were recorded. (range 32-66). Mean number of laparotomies was 4.4 (range 1-7). Priol There was no difference between groups for age, operative time, and volume to laparoscopic lysis, adhesions were assessed using a modification o' of gas delivered. No postoperative complications occurred in either group. the American Fertility Society (AFS) model. In addition the area of th~ Temperature Group Baseline 0.5 hour 1 hour 1.5 hour organs covered with adhesions was measured using a calibratec Core 1 35.7 • 0.5 35.9 • 0.6 36.1 • 0.5 36.0 ~ 0.6 laparoscopic probe. Next all adhesions were lysed taparoscopicatly (~ 2 35.9 ~ 0.4 36.0 • 0.5 36.2 • 0.4 36.3 • 0.3 Four to ten weeks after laparoscopic adhesiolysis patients had a sec Abdominal 1 35.6 • 0.7 35.7 • 0.7 35.4 + 0.7 35.1 • 0.5 ond look laparoscopy to evaluate de novo and reformed adhesions (=C) 2 35.7 _+0.5 35.9 • 0.6 35.7 • 0.5 35.9• 0.6* Efficacy parameters were number of adhesions, number of involve( Data are given as mean:1: SD. *p < 0.05 versus group 1 (repeated-maesuresANOVA). organs, and total area. Statistical analysis was done using the statisti Compared to baseline value, core temperature remained stable in both groups. cal package of SPSS 9-0 for Windows. Abdominal temperature decreased by 0.5 ~ in group 1 but increased by 0.2 In one patient a" de novo" type la adhesion was found during secon( ~ in group 2. There was no significant difference for VAS, urine output, look laparoscopy. A significant reduction of adhesions was found affe narcotic requirements, and number of lens fogging episodes between groups. laparoscopic adhesiolysis in number of adhesions (50%, 5.9 to 2.9) Laparoscopic tundoplication with room temperature C02 insufflation did not number of involved organs (50%, 8.7 to 4.4), and total area (25%, 9; result in significant core temperature changes. Heated and humidified CO2 cm2 to 69 cm2). insuffiation during laperoscopic fundoplication minimized the reduction of In conclusion, despite a certain effectiveness of laparoscopic adhesioly intreabdominal temperature but did not enhance intraoperative urine output or sis, more than half of the lysed adhesions reform. The laparoscopi~ reduce postoperative pain compared to room temperature CO2 insuffiation. approach is associated with a low incidence of de novo adhesions. S150

EFFICIENCY OF MANUAL VERSUS ROBOTIC (ZEUS) ASSISTED CLINICAL APPLICATION OF 3D CT ANGIOGRAPHY FOR LAPARO- LAPAROSCOPIC SURGERY IN THE PERFORMANCE OF STAN- SCOPIC COLORECTAL SURGERY: OUR PREUMINARY EXPERIENCE DARDIZED TASK: A RANDOMIZED STUDY D. Nio, W.A.Bemelman, Kanji Nishiguchi M.D., Junji Okuda M.D., Masao Toyoda M.D., Shinsyo R. Kuenzler, K. den Boer, D.J. Gouma, T.M. van Gulik, Departments of Morita M.D., Tetsuhisa Yamamoto M.D., Keitaro Tanaka M.D., Hiroshi Surgery and Surgical research, Academic Medical Center, Amsterdam, Kawasaki M.D., Soyu Lee M.D., Nobuhiko Tanigawa M.D., Department of The Netherlands General and Gastreenterological surgery, Osaka Medical College, Osaka, Japan Several robotic arms have been developed to assist in laparoscopic surgery. It is not known how efficient robotically assisted laparoscopic Introduction: The purpose of the study was to examine the role of three surgery is as compared to manual laparoscopic surgery. The objective of dimensional (3D) helical CT angiography as an adjunct to laparoscopic this study is to compare the surgical performance of manual and roboti- surgery for colonic carcinomas. For the resection of sigmoid and upper rectal (:ally assisted laparoscopic surgery. carcinomas using laparoscopic techniques, we routinely perform lymph node Twenty medical students without any surgical experience were random- dissection around root of IMA with preserving the left colic artery. In add~on, ized to perform a set of laparosoopic tasks either manually or robotically for right sided colon carcinomas, we perform lymph node dissection exposing assisted (ZEUS) to evaluate the efficiency of a set of basic endoscopic what we call the surgical trunk (superior mesenteric vein). For either of these movements: dropping beads in receptacles, running a 25 cm rope, cap- procedures to be performed safely, vascular anatomy becomes an important ping a hypodermic needle, suture and laparoscopic cholecystectomy on issue. It is our opinion that accurate preoperative assessment of this vascular a cadaver liver. All exercises were recorded on videotape for later time anatomy aids the surgeon in performing a safer operation. motion analysis. A quantitative time-motion analysis was carried out to Methods: The 3D helical CT angiograms of 5 patients were examined (3 evaluate the speed of skill performance and the number of actions. left sided carcinomas, 2 right sided). The radiographic images were com- pared with intraoperative findings. Primary efficacy parameters were total time and total amount of actions Results: For left sided cancers, we were able to accurately visualize the left required to finish the several tasks. Statistical analysis was done using colic artery as well as ascertain its relationship to sigmoidal branches using the statistical package of SPSS 9-0 for Windows. the 3D helical CT for all three patients. For both patients with right sided carci- The time required to complete the dropping beads exercise and the nomas, we were able to assess branches of the superior mesenteric artery laparoscopic cholecystectomy was significant longer when done roboti- as well as determine the presence (or absence) of a right colic artery. These cally assisted (p---0.001 and p=0.05). Picking up the beads, grasping the findings were not only confirmed intraoperatively, but knowledge of this rope and picking up either the needle or cap were tasks that required less anatomy actually facilitated the operative dissection of these difficult regions. actions to complete when performed robotically assisted (p=0.011, Conclusion: Our preliminary experience with the 3D helical CT angiography p=0.030 and p=0.015). Both beads and rope were more frequently is that it can accurately determine the surgical vascular anatomy important in dropped unintentionally in the manual performed exercises (p=0.031 and the treatment for both left sided and right sided carcinomas. With further p=O.O24). improvements in imaging quality of the 3D helical CT, it is likely that this will In conclusion, robetically assisted laparoscopic surgery requires more replace standard contrast angiography in the preoperative setting, and may time, but actions can be performed more precise as compared to manual play an important part in the preopera~e planning of cancer operations. laparoscopic surgery.

LAPAROSCOPIC NISSEN FUNDOPLICATION WITHOUT A BOUGIE: SYMPTOMATIC AND PHYSIOLOGIC OUTCOMES AFTER OUTCOMES ANALYSIS Yuri W. Novitsky, M.D., Kent W. Kercher, M.D., OPERATIVE TREATMENT FOR EXTRAESOPHAGEAL REFLUX John J. Kelly, M.D., Karen A. Gallagher, R.N., Vinetta M. Hussey, A.N.P., Brant K. Oelschtager M.D., Thomas R. Eubanks D.O., Dmitry and Demetrius E.M. Utwin, M.D., Department of Surgery, University of Oleynikov M.D., and Carlos A. Pellegrini M.D., University of M~_ss Medical School, Worcester, MA Washington, Department of Surgery, Seattle, Washington Background: Esophageal intubation with a beugie during LaDaroscopic Nissen Fundoplication (LNF) is used to gauge cah'ber of hiatal closure and Pharyngeal pH monitoring has recently been used to identify patients prevent an excessively tight wrap. Intraoperative gastric and esophageal with extraesophageal symptoms induced by gastroesophageal reflux. perforations by the bougie have been well documented. We report the We employed this method of acid detection to evaluate patients with results of LNF performed without a beugie at our institution. respiratory symptoms prior to and after laparoscopic Nissen fundopli- Design: Retrospective review of 52 consecutive patients who underwent cation. LNF without a bougie at a tertiary care hospital with a mean follow-up of METHODS: Twelve patients underwent symptom evaluation, 10.9+-7.8 (1-28) months. esophageal manometry and 24 hour pH monitoring with a pharyngeal Materials and Methods: Presenting symptoms included heartbum (86~ probe before and after laparoscopic Nissen fundoplication. Episodes regurgitation (50%), epigastricJchest pain (48%), respiratory symptoms of pharyngeal acid exposure were considered abnormal if the pH (15%) and dysphagia (12%). Sliding hiatal hernia was present in 28 (54%) dropped below 4, occurred simultaneously with esophageal acidifica- patients, esophegitis in 27 (52%) and Barrett's esophagus in 11 (21%) patients. Percent of time with pH<4 was 10.8+-6.8% (2-33%). Mean rest- tion, and occurred outside meal times and a one hour postprandial ing LES pressure was 13.9+-8.9 (5-40) mmHg. Mean distal esophageal period. Continuous data was analyzed using student t-tast and ordi- amplitude was 72.6+-38.2 (21-200) mmHg. At operation, all short gastric nal data using a one-tailed Wilcoxon Ranks Sum test. vessels were divided, the crura were reapproximated, and a loose 360 RESULTS: Symptoms of aspiration, laryngeal irritation, and heartburn degree fundoplication was performed without a beugie. were improved by operative treatment (p<0.05).The LES pressure Results: In the immediate postopera~e period, 29 patients (56%) com- before and after operative intervention was 13mmHg and 18mmHg, plained of mild, 5 (9.6%) of moderate and 2 (3.8%) of severe dysphagia. respectively (p=0.09). There was a significant change in both upright Average duration of early dysphagia was 4.5+-2.1 (2-8) weeks. Dysphagia (7.0% to 1.0%) and total (4.9% to 0.6%) percent time acid exposure resolved in 50/52 patients w~in 8 weeks. Persistent dysphagia was found in the distal esophagus after operative treatment. Pharyngeal acid in 2 patients (3.8%). One of them had severe preoperative dysphagia that reflux episodes were decreased from 4.7 to 0.7 episodes/24hr, was improved after LNF. One patient was successfully treated with esophageal dilatation at 8 weeks postoperatively. 15 patients (29%) had (p=0.t5). transient gas bloat with average duration of 6.5+-5.6 (2-24) weeks. Mild CONCLUSIONS: Operative treatment of GERD is effective at control- persistent reflux was noted in 7 patients (13.5%) with 6 requiring daily med- ling subjective and objective measurements of extraesophageal ications. reflux. The use of pharyngeal pH monitoring may help in selecting Conclusion: LNF performed without beugie offers a safe and effective which patients with respiratory symptoms will benefit from antireflux therapy for GERD. While avoiding the potential risks of gastric and procedures. esophageal injury, in the experienced hands it provides low rates of postop- erative dysphagia and reflux recurrence. S15I

REDUCTION OF LAPAROTOMY ASSOCIATED LUNG METASTASES TECHNIQUE AND RESULTS OF LAPAROSCOPY ASSISTED DISTAL AFTER PERIOPERATIVE FLT3 UGAND ADMINISTRATION IN A MURINE AND TOTAL GASTRECTOMY FOR TREATMENT OF GASTRIC CANCER MODEL Yasunaga-Okazaki,M.D., Hideo-Yamada, M.D., Michihiro-Kawada, M.D. Anthony On, MD; Joseph Carter, MD; Peer Wildbrett, BS; George Stapleton, Department of Surgery, Sakura National Hospital, Sakura, Japan BS; Zishan Asi, BA; G Bhagat, MD; Emina Huang, MD; Marc Bessler, MD; Robert Fine, MD; Richard L Whelan, MD, Columbia University's College of Background: The use of laparoscopic curative resection for gastric cancer is Physicians & Surgeons, New York, N.Y. growing,and Laparoscopy- assisted distal gastrectomy (LADG) has been gradually accepted for the treatment of early and advanced gastric cancer Object~e: It has been establishedthat laparotomy is associated w~h postopera- located in the body and antrum of the stomach. The patient with gastric cancer tive immuncsuppreesion, increased tumor cell proliferation, and an increased located in upper part of the stomach was treated by open total gastrectomy. incidence of pulmonary metastases(mets) when compared to So, we applied the double stapling technique of gastric bypass for morbid obe- anestheeia(anesth.)alone. This study's goal was to determine the impact of peri- sity to these patients.(Hand assisted laparoscopic total gastrectomy : HALTG) op administration of Fit3 ligand, a precursor that acts synergist=cally with Patients:From Jan. 1999 to Sep. 2000, LADG for gastric cancer limited to GMCSF, on the incidence of lung mete after laparotomy or anesth, alone. the submucosa ('1"1) and located in the body or antrum of the stomach were ~: A murine pulmonary metastasis model was utilized. Six week old NJ performed to 19 patients. From Sep. 2000. HALTG was performed to one mice(n=70) were randomized to 4 groups: 1) anesth, control(AC), 2) anesth. patient with early gastric cancer located in cardia of stomach control plus FIt3(ACFIB), 3) sham lapa~(OP), or 4) sham laparotomy plus Operative of LADG:Dissection and divide of the left gastric and right gastric FIt3(OPRt3). Groups 2 & 4 received daily intmparitoneal(IP)injections of 10mcg arteries and veins, the left and right gastrcepiploic arteries and veins and D1 Fit3 in saline with 1% ~ serum albumin(MSA) for 5 days prior and 7 days lymphadenectomy were performed under the pneumoperitoneum. Dissection alter surgery. Groups I & 3 received similar IP injectionsof saline with 1% MSA. of lymph node 7, 8a, 9, and 11th and resection of stomach with stapled end-t(> On r day of surgery, tail vein injeclkx~ of 1.5 x 10"5 Ta3Ha meuse mammary end anastomoses were performed via a minilaparotomy through an incision carcinoma cells were given to all mice. Alter 14 days, the mice were sacrificed 5-7 cm long in the epigastric area. and the lung.Mmd~eaexcised en bloc after injecting the trachea with Incr=aink. Operation of HALTG:Operative methods are almost same as LADG, ant The lungs were later immersed in Feket's solution to bleach lhe tumor nodules. resection of stomach and reconstruction are different. After the stomach is Surface mets were counted by a blinded observer. Results: The OPRt3 sub- complete mobilized the gastroesophageal junction is cut off by way of the lin, group had significantly fewer lung meta(38) then the non-treated Open sub- ear stapler. We have employed the esophagus as a conduit to introduce th( group(166,p=0.021 vs OPFIt3). The same was true for the AC subgroups( anvil of the stapling device into the stomach. The reconstruction is created a~ ACFIt3, 10 vs. AC, 50, p=0.001). As noted earlier,more lung mets were noted in a Roux en Y esophago- jejunostomy performed by a circular stapler. These the OP (166) than in the AC group(50) (1:)==0.048).Histolegic analysis of Fit3 methods are performed by hand assisted. treated mice revealed increased numbers of antigen presenting cells surround- Result:The mean operative time of LADG were 142(97-219)min The mear ing the tumors compared to controls. Conclusions: Laparotomy(vs AC) was blood loss were 150 ml. There were no severe early postoperative complica again associatedwith an increased number of lung roots. Periop Fit3 treatment, tions. presumablyvia up-regulationof ceU-medzatedimmunity, significantly red~ ~he Conclusion:We conclude that these laparoscopic procedures are curative number of lung rnets after either anesth, alone or laparotomy. Further studies LADG and HALTG is expected to become more widely adopted as a treat examiningthe role of periop imrnu~lation in the setting of cancer seem to ment for gastric cancer and may change the surgical treatment for patien~ be indicated. with gastric cancer.

LAPAROSCOPIC COLORECTAL CANCER SURGERY IN 129 OFFICE ULTRASOUND BY GENERAL SURGEONS AIDS PATIENT CARE PATIENTS AND MANAGEMENT Junji Okuda, M.D., Maseo Toyoda, M.D., Shinsho Mofita, M.D., Tetsuhisa Michelle M Olson. MD and Keith N Apelgren, MD Yamamoto, M.D., Keitaro Tanaka, M.D., Kanji Nishiguchi, M.D., H!roshi Department of Surgery, Michigan State University, East Lansing, Michigan Kawasaki, M.D., Hirokazu Okano, M.D., Nobuhiko Tanigawa, M.D., Department of General & Gastroenterological Surgery, Osaka Medical General surgeons utilize ultrasound (US) in caring for patients with breast College, Takatsuki-City, Osaka, Japan or thyroid problems and in the setting of traumatic injury. In the office setting, this technique can be a valuable adjunct to physical examination as well as The purpose of this study was to demonstrate our indication and surgical needle aspiration or biopsy. The purpose of this abstract is to illustrate the procedure of laparoscopic curative surgery for coloreotal cancer and to utility of this technique in the management of a variety of office surgical evaluate its efficacy. problems. Based on our clinicopathological analyses of conventinally resected col- Over the previous 2 years, the 7.5 or 10 MHz US probe has been used to orotal cancers at our department, we've applied laparoscopic bowel resec- le physical examination in many patientsr inc ludin9 me following: tion with paracolic lympadenectomy(D1) to mucosal('lqs) cancer difficult to be resected endoscopleally, with paracolic and intermediate lymphedenec- Patient Problem Ultrasound Finding Outcome tomy(D2) to elevated type of submucosal(T1) cancer, and with additional CS Soft tissue mass, Vague density 4.1 US guided core lymphedenectomy around the origin of major vessels(D3) to depressed i left lilac crest cm deep biopsy done type of T1 cancer as well as T2,T3 cancer, located in the colon or rectum. EM Left groin mass s/p Cystic mass US guided EMR appears to be the optimal medality even for large mucosal tumors. lymph node biopsy drainage of.semma However, in case the tumor could not be resented completely by EMR i WD Rectus hematoma Mixed-density Operative drainage including piecemeal fashion, laparoscopic-assisted bowel resection with mass, scant fluid D1, especially using micro-instruments(2mm in size), might be feasible not JO Foreign body in Localization Easy removal only of curative intent but also for better quality of life. The conventional foot oncologic principles can be maintained in laparoscopic surgery using i WP Bullet fragment in Localization Easy removal laparoscopic type of "No-touch isolation technique", which could lead to beck, 2 mos later prevent the port site recurrence. MJ Neck mass near Solid lesion Needle biopsy in Through August 2000, we did laparoscopic resection on 129 cases mandible office (D1:25, D2:41, D3:63). With respect to adequate resection with lym- As we have gained experience, we find more uses for US in the office phadenectomy, laparoscopic surgery was comparable with open surgery. setting. The technique aids accurate and complete aspiration of a cystic in a laparoscopic group, blood loss was less and first flatus was passed earlier. The overall morbidity rate and mortality rate after lapasroscopic mass and accurate placement of a biopsy needle. Based on our experience surgery were 11.6% (major:6.2%, minor:5.4%) and 0%. The mean follow- with the above patients and others, we conclude that general surgeons up time is 25 months. Recurrence was identified in three patients with should become competent in office uttrasonography and utilize the techniqul Stage Ill cancer (liver metastasis:2, peritoneal seeding:l). There have been more often. no local or port site recurrences so far. In conclusion, laparoscopic surgery could play a signiFy.antrole in the treatment of colorectal cancer. $152

LAPAROSCOPIC MANAGEMENT FOR ENTERAL BLEEDING Hiroaki A LAPAROSCOPIC FOREGUT DISORDER PROGRAM Omori,M.D.,Hiroshi Asahi,M.D.*,Yoshihiro Inoue,M.D.,Takashi INCREASES SURGICAL RESIDENTS' EXPERIENCE IN Irinoda,M.D.,and Kazuyoshi Saito,M.D., Critical Care and Emergency Center and Departmentof Surgery I*, Iwate Medical University, Morioka, FLEXIBLE UPPER ENDOSCOPY Raymond P. Onders Japan M.D., Department of Surgery, University Hospitals of Cleveland and Case Western Reserve University School of Introductionand purpose: Enteral bleeding is a relativerare condition Medicine, Cleveland, Ohio among lower G.I. bleedingand is usuallyaccompanied with massivebleed- ing requiring transfusion, because it takes a long time to make accurate Background: There is some concern that the endoscopic diagnosis.Therefore prompt urgent diagnosisand therapy are neededand open surgery is usuallynecessary. However,several papers regardingwith training of surgical residents has been decreasing or being laparoscopicresection of Mecksi's diverticulumor.bleeding tumor of small performed by non-surgeons. The aim of this study is to see bowel were recently reported. In this study, we assessed the outcome of if the addition of a laparoscopic foregut disorder program enteral bleeding retrospectivelyand evaluated indication of laparoscopic increases surgical residents' exposure to upper endoscopy. managementfor enteralbleeding. Methods: The setting is the division of general surgery in Patients and results: Patients who had accurate diagnoses of enteral one of three training hospitals for a university based surgi- bleeding preoperativelywere 5 cases from January 1997 to August 2000. All had emergencyarteriography in which 3 had extravasationof contrast cal residency. A five-year retrospective review from 1995- media and I had tumor stain. One case with no abnormalfindings in arteri- 2000 of billing and operative procedures done by the divi- ography had tube enterography and a big enteral diverticulumwas sion was performed. The first two years were compared to detected. Each diagnosisof 5 cases is Meckers diverticulum, leiomyoma, the last three years after the division began a laparoscopic enteral mural aneurysm, lilac pseudo-aneurysm related retroperitoneal foregut disorder program with specifically trained faculty. abscess, and Crohn's disease. Open surgery was selected for 2 cases Results: From 1995-1997 the division averaged 56 flexi- (lilac aneurysm and Crohn) who had poor conditions due to shock and laparoscopicsurgery was selected in the other. It was difficult for detecting ble upper endoscopic procedures. From 1997 to 2000 the bleeding site in case with enteral mural aneurysm and convertedto open division averaged 158 procedures a year. This is a 180% surgery. On the other hands, it was easy for detecting each lesions in increase. During the same time period there was only an cases with Meckers diverticulum and leiomyoma and wedge resection of increase of 50% in the number of colonoscopies. Surgical ileum and partial enterotomywere done by laparoscopy-assistedfashion, residents are involved in all of the division's operative pro- respectively. Each operativetime was 70 and 100 minutes and oral intake cedures. was started at 3POD and 6POD, respectively.Two cases required open Conclusions: The development of a minimally invasive surgery and 1 case with conversionwere obliged to have artificial ventila- tion for ARDS. foregut disorder program can increase resident's experi- Condusion: It was concludedthat Meckers diverticulumand benigntumor ence and training in flexible upper endoscopy. There has of small intestine without shock were good candidates of laparoscopic been no decrease in referrals for foregut procedures even managementfor enteralbleeding. with the increased surgical endoscopic practice.

LAPAROSCOPIC VERSUS OPEN SPLENECTOMIES IN THE NEW ROBOT-ASSISTED LAPAROSCOPIC ANTI-REFLUX SURGERY Soji MILUNEUM: SHOULD OPEN SPLENECTOMIES STILL BE DONE? Ozawa, M.D., Toshiharu Furukawa, M.D., Masahiro Ohgarni, M.D., Go Raymond P. Onders M.D., John J. Jasper M.D., Department of Wakabayashi, M.D., Masaki Kitajima, M.D., Department of Surgery, Surgery, University Hospitals of Cleveland and Case Westem Reserve School of Medicine, Keio University,Tokyo, Japan University, Cleveland, Ohio Recently "master-slave" robot systems for endoscopic surgery have Background: Laparoscopic splenectomy (LS) is rapidly becoming the been developed. We have been using the da Vinci Surgical System procedure of choice for surgical correction of hematologic disease (Intuitive Surgical, Inc.), which consists of a surgeon's console, a patient- side cart, a high - performance vision system, and proprietary instru- refractory to medical management. This study was undertaken to com- ments, since March, 2000. The purpose of this study was to clarify its pare operative time, blood loss, length of stay and morbidity for patients clinical usefulness. undergoing open splenectomy (OS) vs LS for hematologic disorders at We performed 14 operations for benign diseases with the da Vinci a single institutionat the dawn of a new millenium. Surgical System. We used it for anti-reflux surgery in 6 cases because Methods: In the last 30 months of the 1990's, 20 patients underwent many suturing steps are required for laparoscopic Nissen fundoplication LS and 20 patients underwent OS for treatment of hematologic disor- (4 ders with decision for the type of surgery based only on the referral pat- cases) and laparoscopio Heller and Dor procedure (2 cases). After tem and insurance status of the patient. laparoscopic mobilization of the lower esophagus and the gastric fundus Results: The two groups were comparable in indications (40% for ITP or Heller procedure, the patient-side cart of the da Vinci Surgical System in each group), age (59 for LS, 48 for OS), ASA classification (2.7 for was placed on the left side of the patient, and a 3D camera and LS, 2.5 for OS) and splenic weight (482 g for LS and 5,33 for OS). The EndoWrists, which are proprietaryinstruments, were set up to it. postoperativehospital stay was significantly longer for OS patients than The entire suturing step (Nissen / Dor fundoplication)was successful- for LS patients (7.3 +- 1.0 days vs 2.5 +- 0.4 days, p < 0.0001). The ly performedusing the da Vinci Surgical System in all patients. The aver- operative time was shorter for OS than for LS (159 +- 14 min vs 169 +- age time (183 seconds) required to tie 4 knots in one suture with the da 10.5 min, p=. 75). Blood loss was leas for LS than for OS (382 +- 116 Vinci was slightly shorter than without the da Vinci (195 seconds). It took 15 minutes to set up the da Vinci Surgical System. It was very easy to ml vs 477 +- 107 ml, p=. 55). One of the patients who underwent LS insert a needle into the crural structure, the stomach, and the esophagus, required conversion to open surgery (5%). Accessory spleens were not only in the proper direction but to the proper depth, and it was also found in two OS patients (10%) and two LS patients (10%). One com- very easy to tie knots. There was no morbidity or mortality related to this plicationwas observed in the OS group (5%), none in the LS group. procedure. Conclusions: For similar groups of patients the laparoscopic tech- In conclusion, surgery with the da Vinci Surgical System was feasible, nique affords patients a decreased hospital stay, a reduction in blood safe, and useful. If a wide variety of instruments, including an ultrasoni- loss and comparable operating times. There is also improved cosme- cally activated scalpel and a wide view 3D camera, were available,and if sis and more rapid convalescence. Patients should be informed of the feedback of tactile sensation were provided, it would be a much more option of laparoscopic splenectomy to make a true informed decision promising system. prior to surgery. $153

NEEDLESCOPIC FUNDOPLICATION David E. Pace M.D., Patrick LAPAROSCOPIC SPLENECTOMY: DOES THE TRAINING OF M. Chiasson M.D., Joseph Mamazza M.D., Christopher M. Schlachta LAPAROSCOPIC FELLOWS AFFECT OUTCOMES? David E. Pace M.D., Eric C. Poulin M.D., The University of Toronto Centre for M.D., Patrick M. Chiasson M.D., Christopher M. Schlachta M.D., Minimally Invasive Surgery, Toronto, Ontario, Canada Joseph Mamazza M.D., Eric C. Poulin M.D., The University of Toronto Centre for Minimally Invasive Surgery, Toronto, Ontario, Canada Interest has grown in reducing the size of laparoscopic instruments. The purpose of this study is to compare the short term outcomes of The training of surgeons and residents in laparoscopic surgery has needlescopic fundoplication with conventional laparescopic fundoplica- become an important issue. The purpose of this study is to determine tion. if the training of a laparoscopic fellow affects outcomes in patients Between January lg9g and June 2OO0, thirty eight needlescopic fun- undergoing laparoscopic splenectomy. doplications (using instruments 3 mm or less in diameter) were per- Data was obtained from a prospectively collected computer data- formed by three surgeons. Short term outcomes of these patients base of patients who underwent laparoscopic splenectomy by one of were compared to a matched cohort of patients who had undergone three surgeons from August 1994 to November 1999. Outcomes of conventional laparoscopJc fundoplication. Statistical analysis was per- the last 25 cases, which were performed by fellows under supervision, formed using the student's t test and Fisher's exact test where appro- were compared to 25 cases performed by surgeons just prior to the priate. introduction of fellows. These surgeons had already performed over 20 Patient age, weight, gender, and the number of patients who had laparoscopic splenectomies. Patients with spleens larger than 20 cm previous abdominal surgery were similar between groups. The aver- were excluded from the study. Statistical analysis was performed using age operative time (127 vs 143 min, p--0.13), average blood loss (48 the student's t test and the Fisher exact test. vs ,54 ml, p=0.30), and average length of hospital stay (1 .S vs 1.8 Patient age, gender, preoperative platelet count, and splenic size days, p=0.10) were non-significantly shorter for the needlescopic were similar between groups. Average operative time (151 min vs 178 group. There were no significant differences in intra-operative (5.1% vs min, p=0.055), average blood loss (214 ml vs 162 ml, p=0.40), intra 2.6%, p=l.0) complications. Conversion to open laparotomy did not operative complication rate (15% vs 10%, p=1.0), need for transfusion (8% vs 12%, p=-1.0), conversion rate (4% vs 0%, 10=1.0), length of hos- occur in either group while two needlescopic cases were transformed pital stay (3.3 days vs 2.5 days, p=O.13), and post operative complica- to laparoscopy because of body weight and habitus. Postoperatively, tion rate (4% vs 8%, p=-1.0) were similar between cases done by staff there were no significant differences in rates of early dysphagia (7.9% surgeons and cases done by fellows under supervision. There was vs 7.9%), heartbum (0% vs 2.6%, p=l.0), bloating (13.2% vs 5.3%, one death in the last 25 cases done and no deaths in the other group 10=0.43), or other complicaUons (5.3% vs 5.3%) between groups. of 25 cases. There was a non-significant trend towards longer opera- This series suggests that there is no disadvantage to performing tive time and shorter hospital stay in cases done by fellows. needlescopic fundoplication with the cosmetic benefit of smaller inci- Laparoscopic fellows can safely and effectively perform laparoscopic sions. splenectomy under the supervision of an experienced laparoscopic surgeon.

RESULTS OF PNEUMATIC PAPILLA DILATATION DURING RESULTS OF LAPAROSCOPIC ADJUSTABLE SILICONE GASTRIC LAPAROSCOPIC CBD EXPLORATION FOR DUCTAL STONES. Alessandro BANDING (LASGB) FOR MORBID OBESITY. Alessandro M Pacanini. Md, M Paganini, MD, PhD, FACS, Francesco Fellctottl, MD, Andrea Tambudni, PhD, FACS, Francesco Fdidot~, MD, MacioGuerded, MD, Andrea Tamburini, MD, Mark> Guerrieri, MD, Roberl~o Campagnacci, MD, Ernanude Lezoche, MD, Emanuele Lez~he, MD, FACS. Ctinica di Patdogia Chirurgica, MD. Clinica di Patdogia Chirurgica, University of Ancona, Italy. Universityof Ancona, Italy.

In patients with mu~ple CBD stones undergoing laparoecopic CBD LASGB is a noninvesivesimide and reversiblegest~c re~dve procedure exploration, pneumatic papilla dilatation may be performed after Illhottipey to for the treatment of morbid obedty which avoids problems of stoma size facilitate removal of stone fragments. Aim of the present study is to evaluate encountered with nonadjustablegastric banding. Aim of this study is to report the results of pneuma~ papilla dilatation dunng single stage labaroscopic the results of laparoscopic adjustable gastric banding for the treatment of treatment of gallbladder and ductal stones. morbid ol~ty. From January 1991 to August 2000, 2894 patients unden~ent From June lgg5 to August 2000, 63 patients (11 males, 52 females, mean laparescoplc chdecyste~y at our institution. Associated age 37.4 years, age range 19-56 years) undehvent LASGB for morbid obesity choladochdil~ads was present in in 301 cases (10.4%). A successful at our l~on. Mean Body Mass Index (BMI) was 44.5 Kg/m2, (range 35.1- laparoscopir CBD exploration was performed in 297 cases (98.6%). We 63.1), and preoperativeasaodatnd morbiditywere: hypercholesterolemia(2), divided the patients in two groups: Group A (42 pa~ente, 11 males, 31 diabetes (2), choldithiar~s (7), esteo-a~ropathy (14), hyper~nsion (6) and females, mean age 53.3 years, range 12-87 years), palJen= undenNent endocnne d~o~em (3). papilla dilatation after CBD exploration; Group B (25g paints, 100 males, No batlantwas convertedto open surgery. Mean operativetime was 131.4 159 females, mean age 64.2 years, range 23-94 years) patients did not min. (range80.270 min). Major comprca~onswere an esophageal perforation undergo papilla dilation. in 1 case (1.6%), requiring reobara~on on postoperativeday 1, and severe Group A GroupB P arythmiafollowed by sudden de~t in a 45 years old male pa~entwith setvera Tra~choledochotomy expl. 33/g 138/95 obsltuctJve respiratoryinsuffciency and hypertensionwho died 12 hours after Transcystic/T.tube drainage 11/9 74/92 an uneventful operation for respiratory failure. All remaining patents were Hyp~mylasamla 8 (19~) 0 p<0.001 ambulating freely and were assuming a semisolid diet within 24 houls after Other minor complica~ona 2 (4.8%) 13 (5.1%) 1:=0.874 the opera~n. Subcutaneous pert and banding complicalJons requiring Major complications 2 (5.4%) 7 (2.7%) p=0.742 recperatJon were observed in 11 (18%) and 3 (5%) cases, respac~ely, and Mortality 1 (2.4%) 0 p=0.326 included: port denubitus of the sldn (1), port deconnec'don from the .~licone Residual stones 2 (4.8%) 12 (4.7%) I)=0.763 tube (2), port disl~aceme~t(8), banding displacement(2) and dilatalJonof the Reourrsntsfonea 2 (4.8%) 3 (1.1%) 10=0.352 gastzic pouch (1), requiring band recnoval in the latter three patients. At an Air.ugh in Group A we observed a significant higher incidence of average follow-up of 33.9 months (range 7-62 mon~a) mean BMI decreased hyperamilasemia as compared to Group B, no statistical difference exists to 27.7 Kg/m2 (range 20.9-35.8 Kg/m2). between group= in terms of morbidity, mo~ity, residual and recurrent CBD On the base of tt~ above mentioned resultswe conclude q~tatLASGB for stones. We cor~ude that pneuma~c papilla dilata'don during laparoscopic the ~eatment of morbid obedty in selected patients is feasible, safe and explot~on of the CBD is a safe and effective procedure. effeddve in obtaining prolongedweight reduction Sl54

A NEW COMPOSITE MESH FOR LAPAROSCOPIC REPAIR OF A HYPOXIC PNEUMOPERITONEUM INITIATES THE METASTATIC PARAESOPHAGEAL HERNIAS Tom Paluch, MD, Mark Milford, MD, CASCADE IN COLON CANCER CELLS ParaskevasK ParaskevaFRCS, Mark Schumacher, MD, and Mike Clar, MD, Kaiser Foundation Medical David Peck PhD,/Era Da'zJ FRCSI Imparial College School of Medicine, St Center, San Diego Mary's Hospital London, United Kingdom.

Laparoscopic techniques are now widely accepted for the repair of Tumour cells when rendered hypoxic have an enhanced abllibj to form Type II, or paraesophageal hiatal hernia. Initial enthusiasm was tem- metastases. The carbon dioxide (C02) pneumopedtoneum used in pered by a recurrence rate higher than that seen in open surgery. We laparo~___opicsurgery as v,~tl as alternative gases such as Helium (He) cause report the use of a bi-component or composite mesh for repair of Type hypoxic conditions. The metastat~ process begins when tumour cells detach II hiatal hernias. and migrate. These interactions are underthe control of several families of From 1994 to 2000, 52 patients (27 female, 25 male) aged 36 - 88 yrs adhesion molecules particularly the cadherins and integdns, and a number of underwent primary laparoscopic repair of a paraesophageal hemia. All proteolyt~cenzymes such as the urokinase plasminogan activator (uPA). underwent sac excision, primary crural re-approximation, mesh repair, and fundoplication with fixation of the wrap to the diaphragm and mesh. The changes in expression of components of the metas~c ~ in Repair in the first 22 patients utilized a simple polypropylene mesh fixed human colon cancer cells when exposed to CO= and He to the esophageal hiatus with silk suture and the endoscopic hernia sta- pneumoparitoneums were examined. The human colonic cancer cells pling device. Since early 1997. all repairs utilized a composite mesh SW1222 were exposed to an in vitro pr~umopadto~um of Air (control), CO2 developed by the authors which is composed of a 'darted' PTFE teflon or He at 3 mmHg for 4 hours at 3TC. Cells were then detached and cuff secured to the nee-hiatus with polypropylene suture. The mesh incubated wi~ primary antibodies against, E-Cadherin, CD44, uPA receptor was then secured to the hiatus and the fundoplication secured to the (uPAR) and I~1 integrin, a secondary FITC-anti-mouse IgG was addedto the hiatus and diaphragm in the same manner as in the first 22 patients. cells that were analysed for surface receptor expression by flow cytometry The groups were similar with respect to mean age, BMI, and ASA (FACScan, Becton Dickinson). The results are the mean fluorescent Intensity class. There were no significant differences operating time, complica- expres____~Jasa percentage of the conlz'oland standard enor of ti'zemean. tion rate, or LOS between those repaired with simple mesh -vs- those I E-Cad n l IS1 9 I repaired with composite mesh. There were no conversions or I C02 44%+/- 3" I 80%+/'1" 200%+/-7* I 80%*/-0.5 esophageal leaks in either group. There were 4 recurrences in the I He 68 %+/-2* group repaired with simple mesh. There were no recurrences in the I composite mesh group. 1" = P < 0.05 vs Cont~, "= P < 0.01 vs Conbol (Dunnett) Preliminary results with the use of a composite mesh for repair of All of these receptors have pivotal roles within the process of metastasis paraesophageal hemias suggest a lower recurrence rate. Larger num- and these changes will enhance metas~c potential as a small change in bers of patients will be required to determine whether this diminution is expression has large functional significance. This could provide a statistically significant. mechanism to explain how viable tumour cells detach from a pdrnary and establish metastatic fed.

IMPROVEMENT IN THE LAPAROSCOPIC VIEW USING COMBINED LAPAROSCOPIC/ENDOSCOPIC APPROACH FOR HISTOGRAM EQUALIZATION A. Park M.D., W. Charash, M.D*., DUODENAL WEB RESECTION Eduardo Parra-Davila MD, J.Arturo Ph.D., M. Shaw, Ph.D., Depts. of Surgery, University of Kentucky and * Almeida MD, Morris E.Franklin MD, Jose Munoz MD, Jeffrey LGlass MD, Boston University Robert Michaelscn MD, TEXAS ENDOSURGERY, San Antonio, Texas

PURPOSE: Video images obtained during minimally invasive surgery Congenital duodenal obstruction is uncommon. In general the lesion suffer from limitations in illumination that result in color distortion and becomes evident in the newborn or in early years in life, although in a few degradation of image quality. Real time histogram equalization applied cases if may manifest in the adult pa~ent (20). We report a case of a 27 to the video signal can result in a better image. The subjective improve- year-old female with Down's syndrome and duodenal obstruction by a duo- ment in the image quality is correlated with an edge detection technique denal web in whom endoscopic treatment was not feasible. We review dif- to quantify the improvement. ferent treatment options for this rare anomaly and describe an innovative METHODS: Video of a laparoscopic procedure was obtained using approach by resecting the duodenal web utilizing laparoscopic endoluminal standard MIS equipment and was analyzed in real time using a digital surgery. signal processor. The signal was subjected to a histogram equalization Duodenal webs are the third leading cause of digestive tract obstruction in algorithm on the processor board and fed back to a monitor. The pro- childhood (3). Congenital duodenal obstructions are rare in the adult popu- cessing speed was fast enough so that the surgeons could detect no lation. delay between the processed view and the actual surgical scene. Duodenal webs account for less than 2% of the obstructions but the true Several images were captured in both processed and unprocessed incidence is difficult to estimate because more than half of the cases are form. The images were analyzed using a Sobel edge detection algo- reported later in life (11). Patients with Down's syndrome have an increase rithm and the increase in the number of edge pixels of each form was incidence of duodenal anomalies. computed. The increase in the edge pixels was compared to the subjec- Duodenal webs result from incomplete recanalization of the duodenum tive image quality. during the early weeks in life (2). Webs consist of mucosa and submucosa RESULTS: Twenty images were analyzed. In all cases histogram equal- and rarely have muscular layer (11). Most webs are proximally to the ization resulted in an improved image. The more dramatic the subjective ampulla of Vater (3). The reason why some of these congenital anomalies improvement in image quality, the greater the increase in the number of may only become manifest later in adult life is unexplained. Some suggest edge pixels detected, indicating that the subjective assessment of quali- that chronic inflammation with superimposed acute edema may suddenly ty was reflected in an increase in the number of features seen. The change a tight but asymptomatic lesion into an obstructing and sympto- results ranged from a 41% increase in edge pixels for images that were matic one. judged only slightly better in quality to over a 5400% increase in edge The role of endoscopy in the management of duodenal webs has been pixels where a dramatic increase in image quality was obtained.Detailed mainly diagnostic to confirm barium studies of the gastrointestinal tract. data will be presented as well as examples of the processed images. With the progress of technology and the increase ability of the endo- CONCLUSION: Histogram equalization of an image using a proprietary scopists techniques to cut and ablate the lesions are feasible. algorithm and digital signal processing results in an operative view The development of laparoscopic surgery has provided a different where features can be more easily discemed. The resulting clarity of the approach to gastrointestinal surgery. The improvement of lens and instru- operative image translates into subjective improvement of the surgical mentation has lead to the emergence of Laparoscopic Endoluminal experience. Surgery (LES). S155

LAPAROSCOPIC ESOPHAGOMYOTOMY FOR ACHALASIA COMPARISON OF LAPAROSCOPIC VERSUS LAPAROSCOPIC UTILIZING ULTRASONIC COAGULATION SHEARS Steven C. HAND-ASSISTED DONOR NEPHRECTOMY Emma J Patterson, MD, Patching, M.D.,Horacio Asbun, M.D., Helmuth Billy, M.D., Donald Michel Gagner, MD, Jonathan S. Bromberg, MD, Sandy Florman, MD, Waldrep, M.D., Department of Advanced Laparoscopic Surgery, Richard Knight, MD, Lewis Burrows, MD, and Michael Edye, MD., Divisions of Laparoscopic Surgery and Transplantation, Mount Sinai Sutter Medical Center, Sacramento, CA School of Medicine, New York, New York

Our center reports on 18 esophagomyotomies performed from Many transplant centers now prefer hand-assisted laparoscopic donor November 1996-August 2000; in all cases ultrasonic coagulation nephrectomy (HALDN) to the totally laparoscopic technique (LDN). shears were utilized in performing the esophageal myotomy. The Possible advantages of the hand-assisted technique include rapid manu- shears were used to develop the plane between the muscularis and al hemostasis and improved tactile sensation that facilitates dissection, the mucosa, then the device was applied to divide the muscular retraction, and exposure. Vascular control and extraction of the kidney may also be faster. layer. A Dot fundoplication was then performed in 17 patients. One This is a retrospective comparison of data from all LDN and HALDN at patient underwent a Toupet fundoplication. Intraoperative endoscop- Mount Sinai (MS) between October 1996 and April 2000. In June 1999 ic examination of the esophagus and the lower esophageal sphinc- the technique at MSH changed from LDN performed by one surgeon ter was used in all cases. (ME) to HALDN by another surgeon (MG). Results are as follows (mean + SE): 94.5% (17/18) of patients had complete resolution of their preopera- tive dysphagia. Patient ages range between 17-78 years. Outcome Laparoscopic (117) Hand-Assisted (40) Operating time (m) 257 +/- 5 184 +/- 0.2 * Complications included a small mucosal tear in one patient, treated Blood loss (ml) 286 +/- 33 108 +1- 15 * by laparoscopic suture repair at the original surgery. One patient Renal vascular bleed (%) 5.1 0 experienced persistent dysphagia requiring reoperation. One patient Conversion to open (%) 3.4 0 reported occasional postoperative heartburn. There has been no Warm ischemia time (s) 257 +/- 8 101 +/- 9* mortality. Average hospital stay is 2.3 days. There were no conver- LOS (days) 2.4 +/- 0.07 2.9 +/o 0.13 * sions to open surgery. 30-day graft survival (%) 94% 92.5% Median 30-d Creatinine 1.5 mg/dl 1.5 mg/dl Successful laparoscopic esophagomyotomy requires meticulous Hand-assisted laparescopic donor nephrectomy is associated with division of the muscularis and the lower esophageal sphincter. shorter operative times, less blood loss, shorter warm ischemia times Application of ultrasonic coagulation shears appears to be a safe (WIT), and slightly longer hospital stays. It is therefore beneficial to utilize and effective alternative to electrocautery myotomy, potentially the incision throughout the operation that is necessary for intact organ reducing the chance of electrothermal injury to the mucosal layer. removal. Longer follow-up is needed to assess whether the difference in WIT will have an effect on graft survival.

PATIENT OUTCOMES AFTER LAPAROSCOPIC HELLER MYOTOMY SALVAGE OF LEAKING RECTAL ANASTOMOSIS: THE ROLE OF WITH 45-DEGREE ANTERIOR FUNDOPLICATION Emma J LAPAROSCOPY Miguel Pera MD, Salva Delgado MD, Juan C. Gamia- Patterson, MD, Doron Katz, Marina Kurian, MD, Barry Salky, MD, Valdecasas MD, Antoni Castelis MD, Josep M. Pique MD, Manuel Pera MD, Mount Sinai Medical Center, New York, New York. Ernest Bombuy MD, Xavier Gonzaiez MD, Antonio M. Lacy MD., Service of Gastrointestinal Surgery. Institut de Malalties Digestives, Hospital Clinic, University of Barcelona, Spain Over recent years, laparoscopic Heller myotomy has become the standard treatment approach for achalasia. However, considerable The conventional management of a clinicel anastomotic leak with peritonitis controversy still exists regarding the addition of an antireflux procedure. is to take down the anastomosis with exteriorization of the proximal bowel The purpose of this study was to evaluate patient outcomes following end.However, salvage of leaking rectal anastomoses has been reported in laparoscopic Heller myotomy with a novel 45-degree anterior fundopti- some cases, with or without reoperation.Theaim here is to report our experi- cation. ence in the laparoscopic management of rectal anastomotic leaks.Between Sixty-two patients underwent laparoscopic Heller myotomy between August 1998 and August 2000,112 patients underwent treatment for rectal April, 1993 and July, 1999. There were 26 females and 36 males cencer.Mean age was 68.3 years (67 males/45 females).Fffty-eightpatients (56%), with a mean age of 46 years. Thirty patients (45%) had prior underwent preoperative radiotherapy.Surgicalprocedures included transanai excision in 13 patients (11.6%), rectal amputation in 17 cases treatment for achalasia. The preoperative mean resting LES pressure (15%),Hartmann operation in 10 patients (8.9%), and anterior rectal resection was 34.5 mm Hg. Using a standard five-port technique, a six centime- with anastomosis in 72 patients (64.3%).The celorectal anastomosis was ter anterior myotomy was performed, and the adequacy of the myoto- below 6 cm in 62 (86%) patiants.Allanastomosis were double-stapled except my was confirmed by intraoperative endoscopy. The anterior gastric 2 handsswn coloanal.Theoperation was performed laparoscopically-assisted fundus was sutured to the left edge of the myotomy. in 58 cases and open in 14 patients.Conversion rate in laparoscopy was The mean operating time was 112 minutes. There were three opera- 22.4%.Thirty loop ileostom~eswere done (41.6%).Among the 72 anasto- tive complications: one pneumothorax and two mucosal lacerations moses,10 clinical anastomotic dehiscenses occurred (13.8%).Five of these (3%) which were repaired laparoscopically. The mean postoperative 10 patients had a diverting stoma that minimized the symptoms.Conservstive length of stay was 34 hours, and all but four patients were discharged therapy was a success in 3 cases, and reoparation was necessary in the other 7 patients.Amongthe patients reoperated, the anastomosis was taken within 48 hours. At a mean follow-up of 25 months, 92% of patients down in only 2. Five patients with peritonitis were succesfully managed b~ were satisfied with the results of surgery: 84% were "very satisfied" and peritoneal lavage and creation of a diverting loop stoma using either sig- 8% were =somewhat satisfied". Good to excellent relief of dysphagia mold(2), or transverse colon(l) or ileum(2).Threa of these 5 cases had previ. (less than weekly symptoms) was achieved in 67% of patients. 86% of ous laparoscopic-assisted rectal resection and were reoperated by patients had less than weekly regurgitation, and 89% of patients had laparoscopy.No complications resulted from the use of laparoscopy in the less than weekly regurgitation. early postoperative period.There was no mortality.Four of the 5 divertin~ Laparosoopic myotomy with a 45 degree anterior fundoplication pro- stomas created to treat the leak were closed between 2 and 3 months afte vides good symptomatic relief of dysphagia. Medium-term follow-up reoperation.Saivage of anastomoses with a leak can be performed in the reveals that symptomatic reflux is uncommon. Correlation with objec- majority of cases (80%),and laparoscopy should become a therapeutic tive measures of reflux via 24-hour pH and manometry is still neces- option in patients who had previous laparosoopic rectal excision. sary. S156

A TECHNIQUE FOR GASTRIC INTUBATION IN PERCUTANEOUS PRACTICAL BENEFITS OF TELEMEDICINE S. Perretta, R. ENDOSCOPIC GASTROSTOMY PLACEMENT Paul E Perkowski, MD, Alan B Marr, MD, Department of Surgery, Louisiana State University Health Campegnacci, F. Feliciotti, A.M. Paganini, M. Guerrieri, A.Tamburini Sciences Center and Overton Brooks VA Medical Center, Shreveport, and E.Lezoche Istituto di Sdenze Chirurgiche Universit~ degli Studi di Louisiana Ancona. ITALY Ente Nazionale Idrocarburi (ENI). ITALY

OBJECTIVES Telemedicine has gained a wide acceptance dispelling the skepticism The majority of patients referred to surgeons or gastroenterologistsfor per- cutaneous endoscopic gastrostomy (PEG) tube placement are those with surroundig this new technological tool. Aim is to report a case in which malignancies of the aerodigestive tract, or disorders in swallowing. These telemedicine proved to be of practical benefit. disorders often make gastric intubation during PEG placement more difficult. A six years old female from Congo suffering from fatigue, dispnea and We present a technique to assist in re-intubatlon of the stomach during PEG mild precordial pain was referred to our telemedicine service (INCAS procedure. telemedicine project supported by Ente Nazionale Idrocarburi). Her METHODS We identified 34 patients referred to the General Surgery service for PEG symptoms had been underevaluated by the local doctor and treated as placement at the Veterans Affairs Medical Center. Each patient had a disor- chronic pulmonary infections. After worstening of the patient's der that may have potentially made gastric intubation difficult (e.g., stroke, conditions, the child was referred to the telemedicine service. Chest X- head and neck or esophageal cancer). The procedure was done under intra- Ray, EKG,and cardiac ultrasound were performed. The local venous sedation in most cases. The flexible video endoscope was inserted practitioner involved in the INCAS project suspected a cardiac atrial in standard fashion to begin the case. Difficult intubations were assisted with a nasogastrictubs used as a stent. The gastrostomy tubs was then placed septal defect (ASD). The exams were sent by satellite and terrestrial using the pre-assembledPonsky PEG kit. ISDN line to our Department and analized by a consultant cardiologist of Preparationswere made to pull the gastrostomy tube through the orophar- a pediatric cardiological Unit. Who confermed the presence of the atrial ynx and esophagus into the stomach using the guidewire. The snare, which septal defect liable to surgical treatment. In a very short time the child was still threaded through the gastroscope, was attached to the PEG tubs was transferred to our local Cardiologic Hospital. The ASD measuring button. The snare was then pulled into the stomach with the PEG tube, act- ing as a guidewire over which the gastroscope could be advanced back into 1,5 cm was repaired by a pericardial patch. The postoperative course the stomach. Correct PEG tube placement could then be confirmed prior to was uneventful and brillant. The patient was discharged after two weeks termination of the procedure. in excellent clinical conditions and repatriated. A four months follow up RESULTS shows the complete resolution of symptoms. The procedurewas successful in re-intubating the stomach with ease in all cases in which it was used during PEG placement. In each case it was felt Atrial septal defects are among the most common congenital cardiac that the techniquesaved time and potential morbidity to the patient. lesions and can be safely repaired by surgery. If underavaluated they CONCLUSIONS can lead to severe complications. In this case Telemedicine allowed to We suggest that this procedure may assist in percutaneous endoscopic easily diagnose and to successfully tret a clinical problem otherwise gastrostomy placement in patients with potential for more difficult gastric intu- difficult to manage in an african country breaking barriers related to bation due to near-obstructingmalignancies or disorders in swallowing. The technique could be done with less morbidity and faster operating times. distance and underdevelopmenL

LAPAROSCOPIC APPROACH TO THE MANAGEMENT LAPAROSCOPIC RYGB - SHOULD IT BE CONTRAINDICATED FOR THE OF TORSION OF APPENDICES EPIPLOICAE Yaron Perry SUPER OBESE? Richard Perugini, M.D., Kent Keroher, M.D., Demetrius M.D, Petachia Reissman MoD., Department of Surgery, I itwin, M.D., Stephen Baker, M.Sc., John Kelly, M.D., Department of Surgery, University of MassachusettsMedical School, Worcester, MA Hadassah Hebrew University Medical Center, Jerusalem, Israel Laparoscopic roux en-Y gastric bypass (LRYGB) is well recognized as an Appendices Epiploioae may be involved in several intraabdomi- effective therapy for the treatment of morbid obesity. The laparoscopic nal pathologic processes include torsion and primary inflamma- approach should lead to superior outcomes with respect to pain, recovery, tion. Clinical and biological features have a small specificity. and wound complications. However many centers reject patients for the laparoscopic approach who are super obese (BMI>50) or super/super obese (BMI>60) citing strict selection criteria. Since we felt this eliminates a sub- We are presenting here a 55 years old patient with right lower stantial subset of patients who would otherwise greatly benefit from the mini- quadrant abdominal pains, which started on the day of admis- really invasive approach, we performed our initial series of LRYGB without sion with temperature of 37.9c. using excessive BMI or weight as contraindications His past medical history was significant of Ischemic heart dis- ease and hyperlipidemia. We present a consecutive series of patients who underwent LRYGB from the inception of the program. None patients were selected for the open approach and all patients met routine NIH guidelines for surgical Veatment of On physical Exam He had right lower quadrant tendemess and the morbidly obese. Patients were then divided into Group I (BMI<50), and guarding. group II (BMI>50) and were compared with regards to time required for surgery, postoperativelength of stay, complication rate, need for readmission He was taken to the operating room and on exploratory and need for reoperation. Results were evaluated with two-tailed T-test laparoscopy he was found to have a torsion of cecal appendices (time of operation), Mann-Whitney U test (pest-operative length of stay), and epiploicae with necrosis at its tip and some reactive fluid sur- Fisher test (rate of complication)with significant p-value considered >0.05. round it. The appendix was mild hyperemic but not inflamed. LRYGB was attempted in 37 consecutive patients between 7/99 and 9/00. The appendices epiploicae was excised laparoscopically and The groups ranged in size from BMI of 42 to a BMI of 74, with 8 patients with appendectomy was done. BMI > 60. Conversion to open RYGB was necessary in 2 patients (both in Group II) due to splenic hemorrhage and to adhesions from prior attempted The patient had uneventful recovery and was discharged 24 LRYGB. The time required to perform LRYGB was similar between groups I hours after surgery. and II (mean+-st.dev.225+-77 rain. vs 228+-60 min.). Post-operativelength of stay (median, 25-75% equal 3 days, 3-4 vs 4 days, 3-4), major complica- tion rate (1/14 vs 3/23) and total complication rate (5/14 vs 8/23) were not dif- One of the differential diagnosis of acute appendicitis is torsion ferent between groups. of appendices epiploicae, in our case this pathology was treated laparoscopicelly with good outcome and with no complications. LRYG8 can be accomplished in super-obese patients without any increase The laparoscopic approach eases the diagnosis and the surgical in operative time, pest-operative length of stay, and comphcationrate. technique. S157

Evaluatiou of the Safety aud Efficacy of Early Chest Tube Removal After CONVERSION FROM LAPAROSCOPIC TO OPEN Video-Assisted Thorascopir Surgery (VATS). CHOLECYSTECTOMY AT A RURAL TEACHING HOSPITAL - StcvmW. Pe~ D.O.,P, obett Caccavale, M.D., J.P. Bocage,M. D., W. PeterGels, M.D. - A STABLE RATE Todd Petty, MD, Matthew Indeck, MD, Department of lkparane=of Surguy and Minimally lnvmive Training Cug=, St. Peter'sUniversity l.lmpital, Surgery, Geisinger Medical Center, Danville, PA New Bnmswick,New Jersey. Introduction: Chest tubes afer thoracic surgm'yhave traditionally resulted in Introduction prolonged hospital stay and morbidity. In this study we have designed a Laparoscopic cholecystectomy is recognized as the gold standard for mechanismto eliminateprolonged ches: tube drainage with the benefit of curly treatment of gallstone disease, and is now commonly a junior resident hospital discharge. Methods: From Javuary 1999 through July 2000, 245 case at teaching institutions. This study seeks to determine whether the consecutive patients refcn'~ for diagnostic and/or therapeuticlung resection conversion rate from laparoscopic to open cholecystectomy has changed underwentvideo-assisted tho'.ra.'scopic surgery (VATS) with lung resection. over the last 8 years at our institution. Patientswere placed in three ~agories for chest tube removaL 1) Removal within 1-2 hrs following surgery. 2) In hospital management of air leak with Methods This is a retrospective study of all patients undergoing laparoscopic removal of cbest tube prior to discharge. 3) Discharge home with chest cholecystectomy -- and those requiring conversion to an open procedure tube/Heimlich valve with removal as an outpatient. Chest tubes were removed - from January 1993 to August 2000 at Geisinger Hospital - a rural, refer- when there was no air leak, expansion of the lung was demonstrated, and drainage ral teaching hospital. These were then divided into two groups for com- was minimal. Results: Charts were available for review for 237 of the 245 panson - 1993 to 1996 (Group 1), and 1997 to August 2000 (Group 2). patients. This included 111 males and 126 females ranging from 16 to 89 years. Resections included 133 wedge resections, 16 segmental resections and 86 Results Iobectomies. The final pathology was benign in 97 cases and malignant in 140 During this time period, there were 1703 cholecystectomies initiated cases. Of the 235 patients, 126 had chest tubes removed within I-2 hours laparoscopicaUy, of which 100 required conversion to open. This is an following surgery. Eighty-fourpatients had chest tube managementwith removal overall conversion rate of 5.9%. Group 1 (n=814) had a conversion rate during their hospital stay. Twenty-seven patients had a persistent leak, which was of 6%. Group 2 (n=889) had a conversion rate of 5.7%. managed with chest tube/Heimlichvalve'as an outpatient. In group !, patients had an average length of stay of 1.2 days with only 4 patients requiring chest tube Conclusions reinsertion. The average hospital stay for patients in group 2 and 3 were 1.6 days The overall conversion rate of 6% falls well within reported rates in the lit- erature. The conversion rate has not significantly changed at our institu- and 1.7 days respectively. Conclusion: Clearly this data indicates that creative tion over this eight year period. Although the staff surgeons gain experi- and movstive managementof chest tubes following VATS lung resection allows ence with each procedure, the majority of these operations are per- an unprecedented shorter hospital stay. formed by the junior residents. As residents master this procedure, it is then passed down once again, and therefore a faidy constant conversion rate can be expected.

CHOLECYSTECTOMY: THE PATIENT IS TREATED BEST BY THE IS IT SAFE TO LEARN LAPAROSCOPIC COLON SURGERY (LAP) WITH TREATMENTMODAUTY THE SURGEONFEELS THE MOOr COMFORTABLE ILEOCOLIC RESECTIONSFOR CROHN'S DISEASE (CD)? Lis.aS. Porilz, WITH, PW. Plais'~r.Ph.D.G.C. Huitema,M.D.,J.J.GM. Gerritsan, Ph.D., W.BJ. M.D., Martin Fdedlich, M.D, and Helen MacRae, M.D., Department of Masttxx)m, Ph.D. Dept. Surgery, Medisch SpectnJm Twente, Enschedo, The Surgery, University of Toronto, Toronto, Ontario Nethedands. With concerns about port site recurrences and difficult Crohn's mesentery, Conventional cholecystectomy (CC) has been performedwith great it is recommended that one begin their LAP experience with benign, non- ~___,,':ce~__sfor overa cantury. Lapa~ cholecystectumy(LC), however,is now inflammatory cases. There ere very few such cases, making it difficult to generallyconsidered the gold standard.Still, in somerandomized controlled trials accrue experience. The following is a review of one surgeon's initial LAP experience with ileocol[c resection for CD. Methods: A retrospective review mini-choleoystectomy(Me) proved superior to LC. The discussion on what of all LAP ileocolectomies by a single surgeon without prior advanced vestment modality is best, may, therefore, not yet been considereddosed laparoscopic experiencewas done. The patients were divided into two equal dosed. CO, LC and MC are all being performed in our hospital, the method groups of 28 (1: 1/97-2/11/99,2: 2/17199-6/00),to compare eady and late chosenlargely depending on the surgeon'sexperience and preferanceand the experience. Results: patient'spreference and charactens~. We retrospectivelyanalyzed our results Group First 28 Second 28 in 419 patients (111m/308f, mean age: 53.4 • 15.4 years) electivety Age 31.4 • 2.03 31.3 • 2.3 cholecystoctomizedin the period 1994-1999. LC M.~ CC OR Time 166.4 • 8.58* 129.9 + 6.26* Number 57 89 273 LOS (days) 5.86 :t: 0.34 6,36 :t: 0.61 Mean operatingtime (min) 60+_.27 43+18~ 61:1:37 Inc (cm) 5.2 :!: 0.24 4.08 • Mean hospitalizationtime (day) 4.6.J:3.8= 4.7:1:1.9' 6.5• Conversion 28%= 4%= Minor complications(%) 1.1 6.7 9.8 means + standard error Major complication@(%) 1.1 2.2 2.2 *p

ENDOSCOPICEXTRAPERITONEAL REPAIR OF A GRYNFELI"r PORTAL VEIN THROMBOSIS: AN UNUSUAL COMPLICATION OF HERNIA. Ro(df R.Postema, H.D.t~ and HJaap Bonier, H.D. Ph.D.1, LAPAROSGOPIC CHOLECYSTEGTOMY. Ourania A. Preventza, M.D., Department of Surgew~ and PediabJcSurgery ~, UniversityHospital Rotterdam, Fahim A. Habib, M.D., Shun C. Young, M.D., David Penney, Ph.D., Rotterdam, The Netherlands. William Oppat, M.D., and Vijay K. Mittal, M.D. Departmentof Surgery, Providence Hospital & Medical Centers, Southfield, Michigan Lumbar herniasare uncommon.There are three types of lumbar hernia: Complications following laparoscopic cholecystectomy are encountered congenital, acquiredand Indsionalhernias. The acquired herniacan appear in infrequently due to the increasing proficiency in laparoscopic surgery. The two forms: the inferior (Petit) type and the supedor type, first described by occurrence of portal vein thrombosis following a laparoscopic Grynfeltt in 1866. We report a case of endoscopicextrapedtoneal repair of a cholecystectomy has not been previously described and forms the basis Grynfeltt hernia using a prostheticmesh graft. of this report. A 46 year old woman presentedwith a painful swellingin the le~ lumbar A 32-year old, healthy female on oral contraceptives underwent an region which had caused her Increasingdiscomfort over several months.The uneventful laparoscopic cholecystectomy for symptomatic gallbladder disease. Sequential compression devices and minMose-unfractionated diagnosis of Grynfeltt's herniawas made and she was operated upon. heparin were used prior to the procedure. The patient was discharged The patient was placed in a left sided decubltus position. Accasto the home on the first post-operative day without complaints. She returned extraperib:~l space was gained by Insertinga 10 mm inflatableballoon one week later with nausea, bloating, and diffuse abdominal pain. trocar Just antedor to t~ mldaxlllaryline between the twelfth rib and the Ultrasonography of the abdomen revealed thrombosis of the portal vein superior iliac crest through a muscle splitting incisioninto the extrapedtoneal and the superior mesenteric vein not seen in the preoperative ultrasound. space. Alter the balloontrocar had been removed a blunt tip trocar was Computed tomography of the abdomen and pelvis confirmed this finding Inserted and worldng space was maintained by Insuffiationof C02 to a and showed a wedge-shaped infarction of the right liver lobe. The patient pressure of 12 mm Hg. Usingtwo extra 5 mm trocars above and below the 10 was anticoagulated with intravenous heparin. An extensive coagulation work-up revealed elevation of the IgG anticerdiolipin antibody. A mm port In the mid-axillaryline the hernia could be reduced. A 6xll cm percutaneous ~'ans-hepatic portal vein thrombectomy was performed. A polypmpylenemesh graft was Introducedthrough the 10 mm trocar. The post-procedure duplex ultrasound of the abdomen demonstrated graft was tacked with 5 mm spiral rackers, avoiding bony sl~u~res and recannalization of the portal venous system with no flow voids. Anti- nerves. The three portsite openingswere sutured with 4-0 nonabsorbable coagulation therapy was continued and the patient was discharged home Interrupted sutures. OperalJveUme was 30 minutes with neglegibleblood therapeutic on oral warfarin and with resolution of her ileus. Ices. The patient could be dischargedthe next day afl:er requiringonly This case demonstrates an unusual complication of laparoscopic minimal analgesics,Two years after the operation she is doing well and there cholecystectomy. It may have resulted from the use of oral is no sign of recurrenceof the hernia. contraceptives, elevation of the IgG anticardiolipin antibody, unrecognized trauma, and was accentuated by the pneumoperitoneumgenerated for the This rare lumbar hernia which is prone to complicaUomoould safely be laparoscopic cholecystectomy. Our case report provides insight and treated In a minimallyInvasive manner using the extrapedtonealapproach. poses questions regarding peri-operative measures for This obviatesopening and dosing the peritoneumand can therefore reduce thromboprophylaxis in young females on oral contraceptives undergoing operative Ureaand possiblypostoperative complications. elective laparoscopic abdominal surgery.

LAPAROSCOPIC BILIOPANCREATIC DIVERSION WITH DUODENAL EEA STAPLER HEMORRHIODECTOMY: A NEW TECH- SWITCH: THE EARLY EXPERIENCE Theresa Quinn MD, Michel Gagner NIQUE OF EFFECTIVE REDUCTION OF HEMORRHIODAL MD, Christine Ren MD, John de Csepel MD, Subhash Kini MD, Paolo MUCOSAL PROLAPSE BY CIRCULAR SURGICAL STAPLER: Gentileschi MD, Daniel Herron MD, William Inabnet MD, Alfons Pomp MD., A CASE STUDY Prasanta Raj, MD FACS, Gregory Eason, Division of Laparoscopic Surgery, Mount Sinai School of Medicine, New MD, George Castillo, MD, Timothy Barnett, MD, Lavonne York, NY Urban, BA, Fairview Hospital - Department of Surgery - Cleveland Clinic Health System Biliopancreaticdiversion with duodenal switch (BPD/DS) is an excellent operation for weight reduction in the patient with super obesity (BMI [body The treatment of grade III or IV hemorrhoids can be a chal- mass index] > 50 kg/m2). The purpose of this study was to evaluate our lenging problem, especially in the face of circumferential anal experiencewith BPD/DS using a laparoscopic approach. mucosal prolapse. The use of standard techniques of hemor- We performed 62 laparoscopic BPD/DS at a single institutionover a one- rhoid repair in the face of mucosal prolapse may lead to recur- year period in 16 men and 46 women with a mean BMI of 57.3 kg/m2. The mean procedure length was 215 minutes, estimated blood loss 150 cc and rence and anal stricture. The ideal repair would restore near median hosp'aal stay 4 days (range, 3 - 200 days). Twenty-sixpercent of normal anatomic planes, maintain sphincter function and intact patients had previous abdominal surgery including two cases of failed sensation. bariatdc surgeries. Minor complications such as wound infection and ud- Proper anatomic repair can be performed by use of a circular nary retantion occurred in 14%. One patient required admission for dump- surgical stapler with minimal postoperative discomfort. Several ing and malnutrition. Major complications (6%) included anastomotic leak, details must be ensured to provide satisfactory repair: 1) suture staple line bleeding, Dv'r and splenic injury. There were three deaths (5~176 ligation of hemorrhoidal pedicles at their apex, 2) adequate dis- all of which occurred in patients with a BMI >60 kg/m2. Late complications section of the mucosa off the internal sphincter in the anal (5%) included incisional hemia and bowel obstruction. We calculated the canal, leaving the muscle intact, 3) placing the pursestring mean percent excess weight loss (-~SD) postoperatively:3 weeks: 15% +- such that the proximal dissected mucosa is centered properly 6 (39/62); 3 months: 33% +-11 (34/62); 6 months: 46% +-15 (19/62); 9 around the anvil of the stapler while incorporating the distal months: 60% +-18 (13/62); and 62% +-11 (4/62) at one year. Twelve of 23 internal sphincter, 4) firing the stapler above the perianal-ano- patients (52%) who had required medication for diabetes or hypertension dermal junction. were medication-free postoperatively. One operation was converted to an A satisfactory repair of mucosal prolapse and treatment of open procedure. No patient required a revision. hemorrhoidal disease can be obtained while reconstructing Laparoscopic BPD/DS is feasible and effective, and can be performed on anal anatomy with the circular-stapling device. This will main- patients with previous abdominal surgery. Half of the patients no longer tain normal sphincter function, intact sensation and because require medication for diabetes or hypertension. Mortality occurred in 3 of the anastomosis is above the dentate line should result in mini- 22 patients with a BMI > 60 kg/rn2. These patients may have a relative mal post-operative pain. contraindicationto laparoscopicBPD/DS. S159

LAPAROSCOPIC HERNIA REPAIR IN A COMMUNITY BASED VIDEO- RISK FACTORS OF GALLSTONE DISEASE IN THE LAPAROSCOPIC SCOPIC SURGICAL CENTER Chun (Chris) Rhim,BA, Charles Mixter, ERA. William Richardson, MD, Knstine Carter, MO, Boyd Helm, MD, Luts MD, S.D. Schwaitzberg, MD, Center for Videoscopic Surgery, Exeter Garcia, MD, Richard Chambers, MSPH, Bronya Keats, PhD; Alton Ochsner Hospital, Exeter, NH and the Department of Surgery, New England Medical Center/Tufts University School of Medicine, Boston, MA Medical Institutions and LSU Health Sciences Center, New Orleans, Louisiana. Objective: Repair of inguinal hernias by the laparoscopic methods has been somewhat controversial since the introduction. The aim of this study Introduction: Risk factors for gallstone disease are well known, but is to report a large case series of outpatient laparoscopic hernia repairs and have not been looked at recently with better ultrasound technology and in to evaluate the results in term of recurrence, conversion, complication and the laparoscopic era. retum to work. Methods: We compared a group of 100 consecutive patients who had Method: From May of 1991 to August of 2000, 483 patients (mean age of 45 years) with 633 inguinal hemias (455 males and 28 females) includ- undergone ultrasound showing no gallstones (NGS) to a group of 100 ing femoral and sliding hemies were operated upon in a community-based consecutive patients who had their gallbladder removed for gallstone videoscopic surgery center by a single surgeon using the Laparoscopic disease (GS). Data was obtained by questionnaire and chart review. Transabdominal Preperitoneal (TAP) method with a polypropylene mesh Ultrasound was performed for. al0dominal pain-58, cirrhosis.10, liver (no slit) onlay All cases were done in an outpatient basis. Complications, enzyme elevation-6, and other-19. Data is presented as mean+SD, and recurrences, conversion and return to work data were recorded. significancewas determined by independent T test or Chi squared test. Results: The laparoscopic TAP was successful in all 483 patients who underwent 633 hernia repairs, days There were 5 recurrences (0.8%) with Results: The mean age for the GS was 51 • 15.9 and for the NGS 50 • a mean follow up of 30 months. The overall complication rate per hernia 16 (p=NS). Fifty nine percent of GS were female and 52% of NGS were repair was 3.3%. There were 6 admissions after outpatient discharge female (p=NS). The body mass index was 32 • 8 for GS and 28 • 6 for (hematoma, postop bleeding requiring reoperation, pain, drug reaction, ure- NGS (p=0.013). Cholesterol in GS was 196 + 39 and in NGS 200 • 42 thral bleeding, urinary retention) 16 complications were managed on an (10=0.945). Cholesterol level greater than 200 also did not reach a outpatient basis (post-op bleeding (2), prolonged post-operative pain (6), significant difference betweenthe two groups. In GS, 74% were Caucasian hematomas (1), urinary retention (1), port-site hernia (1), balanitis (1), epi- didymitis (1), shoulder pain (1), infected mesh (1), and intestinal obstruc- and in NGS 64% were Caucasian (p=NS). Parity in GS was 2.6 • 2.1 and in tion (1)).The average Return to Work (RTW) was 7.5 (4.5-29)days. NGS 2.1 • 1.8 (p=NS). Menarche was 12 :i: 1 in GS and 12 :l: 1 in NGS "Sedentary light duty" patients had the shortest R'FW of 5.7 (1 -24) days (p=NS). 17 (24%) of GS breast-fed at least one child and 8 (12%) of NGS and "heavy labor" patients the longest with 9.4 days (1-36). (p=0.03). 37 (52%) of GS took oral contraceptivesfor more than a year and Conclusion: Laparoscopic TAP hernia repair method is associated with 17 (22%)of NGS (,o=0.0005). For GS primary relatives having gall bladder a low recurrence and complication rate with average return to work data surgery was 0.68:t:1 and for NGS was 0.35t0.6 (p=0.02). that compares favorably with open techniques reported. These data sug- Conclusion: Body mass index, breast-feeding, oral contraceptives,and gest that Laparoscopic TAPP hernia repair is suitable for both for unilateral and bilateral hernias. family history were risk factors identified for developing gallstones. Female sex and race were not significant dsk factors possibly due to selection bias. Cholesterol, padty and menarche contributed no nsk for gallstones.

THE HYPOXIC PNEUMOPERITONEUM MEDIATES INCREASED LAPAROSCOPIC LATERAL L4-L5 DISC EXPOSURE. Michael Rosen MD, MALIGNANT POTENTIAL VIA UP REGULATION OF MATRIX-METALLO- Fred Brody MD,IsadorLiebcrman MD.Cleveland Clinic Foundation, Cleveland,OH. PROTEINASE ACTIVITY P.F. Ridgway MB BCh MMedSc, A. Smith BSc, P. Ziprin MB BCh, D. Peck PhD, P.A. Paraskeva MB BS BSc, A. Darzi MD, The anterior laparoscopir approach requires precarious dissection around the lilac Academic Surgical Unit, Imperial College School of Medicine. St Mary's vessels to expose the IA-L5 level. Furthermore, a retroperituneal endoscopic Hospital London, UK. approach to the LA-L5 level requires a technically demanding dissection to access Background: Certain surgical strategies, including carbon dioxide (C02) the LS-SI disc space. A unique lateral laparoseopic approach to the LA-L5disc space insufflation in laparoscopy, have been demonstrated to induce a hypoxic allows concurrent access to the LS-SI space while avoiding major dissection around environment. Patients with hypoxic cancers have a worse prognosis than the iliac vessels. This paper describes this novel lateral approach and reviews the those with an adequate oxygen supply, particularly in head and neck can- initial clinical outcomes. cers and cervical tumours. The undelying mechanism has not been elucidat- Between January 1999 and April 2000, 5 patients underwent laparoscopic lateral ed. L4-L5 disc exposure at the Cleveland Clinic Foundation. All charts were reviewed Expression of Matdx-Metalloproteinases (MMPs) have been correlated with retrospectively. Mean value~standard deviation were determined for patient enhanced tumour aggression, we investigated the induction of MMPs in demographics and operative characteristics. A standard five port laparoscopic tumours in response to hypoxia. technique is used. The sigmoid colon is retracted medially with an endoloop. The Methods: Colonic (SW1222) and breast (MDA-MB231) adenocaminoma retroporitoncum is entered and the ureter and left lilac artery arc retracted medially cell lines were exposed to a hypoxic environment of helium or left in normal while the psoas is retracted laterally. Fluoroscopy delincatas the L4-L5 disc space growth conditions(Control).Media from cells was removed after exposure to allowing discectomy and cage insertion. Postoperatively, subjective patient normoxia, hypoxia, and reoxygenation for 24 hours after a 4 hour exposure to hypoxic conditions. Gelatin zymography was carried out to determine total satisfactionwas obtained and radiologic evidence of fusion was assessed. activity of MMP-9 and MMP-2. Activity of MMPs correlates with density of All 5 patients were males with a mean age of 47.4_+7 years and a BMI of 3_0!-6 the gel bands. Gel bands were analysed using densitometdcanalysis. kg/m~. Four patients had an L4-L5 and LS-SI fusion and one patient had an LA-L5 Results: The results are expressed as mean densitimetric readings and and L3-1A fusion. Mean operative time was 349~-32 minutes with a mean blood loss SEM (arbitrary Units) of 210+_74cc. There were no intraoperative complications, no convcrsious, and SW1222: postoperatively all patients were ~ on a clear liquid diet on POD#1. The mean CONTROL- 0* 0# length of stay was 3.4_+0.9 days. Patients returned to work in a mean of 12+7 weeks. HYPOXlA- 70 +/- 0.7* 51 +/- 0.6# All patients had evidence of fusion on their radiologic follow up. Four patients were MDA-MB231: pain free while one patient required intermittent narcotics at one year follow up. CONTROL- N/A* 27 +/-2# For multilevel fusions including the L4-L5 disc space, the lateral laparoscopic HYPOXlA- N/A* 44 +/-1.2#A exposure is a safe and efficacious procedure allowing simultaneous access to Key: MMP-2:* MMP-9:# multiple disc spaces while avoiding the sympathetic chain, ureter, and major vascular MDA-'~MMP 9 Control Vs Hypoxia - P < 0.05 structures. The lateral approach affords excellent exposure for accurate depioymen! Conclusions: These results indicate that oxygen levels play an important of the appropriate orthopedic hardware. role in malignant progression by virtue its effect on MMP expression and therefore the invasive capacity of tumour cells. SI60

LOW PRESSURE LAPAROSCOPY IS ASSOCIATED WITH LESS BEDSIDE LAPAROSCOPY IN THE ICU. Danny Rosin, M.D., Yael Haviv, INCREASE IN ICP AND LESS DECREASE IN RENAL BLOOD FLOW. M.D., Joseph Kuriansky, M.D., Eran Segal, M.D., Oscar Brasesco, M.D., Dannv Rosin M.D., Oscar Brasesco, M.D., Javier Varala, M.D., Arul Raul J. Rosenthal, M.D. ,Moshe Shabtai, M.D., Amram Ayalon, M.D., Chidembaram, M.D., Alan A. Saber, M.D., Seong You, M.D., Raul J. Department of Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida, Rosenthal, M.D., and Stephen M. Cohn, M.D. Department of Surgery, Department of Surgery B and Intensive Care Unit, Sheba Medical Center, Tel Cleveland Clinic Flodda, Fort Lauderdale, Florida, and Department of Hashomer, Israel. Surgery, University of Miami School of Medicine, Miami, Florida. Patients in the intensive care unit may suffer from life threatening Increased abdominal pressure is associated with both an elevation of the abdominal pathologies, which may necessitate a surgical intervention. intracranial pressure (ICP) and impaired renal function. These adverse Diagnosis may be difficult, as symptoms are often masked and physical effects are important in clinical situations, among which are severe examination is unreliable. Imaging studies are not accurate enough, and abdominal trauma and laparoscopic donor nephrectomy. It was hypothesized exploratory laparotomy carries a significant morbidity and mortality. The that the secondary elevation of intracranial pressure leads to release of unstable patient is difficult to mobilize to the imaging department or to the vasoconstrictors, which may affect renal function by decreasing the renal operating room. Bedside laparoscopy may overcome these diffcultJes. blood flow (RBF). We investigated the effect of using laparoscopy on We describe our initial experience with the use of bedside laparoscopy in simultaneous measurements of ICP and renal blood flow in a pig model. critical patients with suspected abdominal pathology. The procedure was 5 pigs were used. The abdominal pressure was gradually increased from baseline to 5, 15 and 25 mm Hg by insufflation of Nitrogen. ICP was performed in 4 patients, over a 4 months period, and successfully completed measured using a Camino 0"M) monitor, and RBF was measured using a ,n all four. Tne findings were. I) I,urbid ~uid consister,t w;U= a v;scus doppler probe placed on the renal artery. Results were analyzed using two- perforation in a patient with unexplained sepsis after cardiac surgery. 2) way ANOVA and paired t-test. sterile hemorrhagic fluid in a patient with malignancy and thrombotic No significant change from baseline was observed in ICP and RBF when thrombocytopenia purpura. 3) a retroperitoneal mass from which biopsies the abdominal pressure was 5 mm Hg (p=0.37 and 0.63, respectively). were taken in a patient with sudden respiratory failure. 4) abdominal However, both ICP and RBF were significantly affected by increasing the abscess in a patient after bowel resection for mesenteric embolism. None of abdominal pressure to 15 and 25 mm Hg (p<0.05L these patients had a laparotomy after the laparoscopy. Patient 1 and 4 died a Low pressure laparoscopy may reduce the adverse affects of few hours after the procedure from sepsis, and patients 2 and 3 dies several pneumoperitoneum. The mechanism may involve prevention of significant days later. elevation of ICP. It may be advisable to use low pressures in laparoscopic Bedside laparoscopy in the ICU is feasible, informative and accurate. It has donor nephrectomy, to reduce the incidence of graft malfunction. a role in diagnosing abdominal pathologies and planning further treatment, It may save the need for non-therapeutic laparotomy. Unfortunately, the prognosis in these patients is poor.

INITIAL RESULTS IN VIDEO ASSISTED THORACIC SURGERY USING LAPAROSCOPIC EXCISION OF A SYMPTOMATIC URACHAL CYST AN ELECTROTHERMAL BIPOLAR VESSEL SEALER. ~eyen S. IN AN INFANT Noel C. Sanchez, M.D., Harsh Grewal, M.D., Rothenbem. M.D.. John T. Bealer, M.D., Ned Cosgdff, M.D., The Hospital for Department of Surgery, University of Kansas School of Medicine- Infants and Children, Presbytedan SL Luke's Medical Center, Denver, Wichita, Wichita, Kansas Colorado. Introduction: The urachus is the obliterated allantois, and extends from the dome of the bladder to the umbilicus. Symptomatic urachal anom- Advanced thoracoacopic surgery requires a method of obtaining reliable alies are rare; a patent urachus has been observed in 2% of adult autop- hemestasis to ensure successful outcomes. The recent introduction of sies. However, these anomalies account for only 0.0015% of hospital bipolar vessel-sealing technology has made it possible to seal adedes and admissions. The diagnosis of symptomatic urachal anomalies requires a veins up to 7 mm in diameter safely and effectively through a 5 mm port. high index of suspicion. We report a unique case of laparoscopic exci- Chronic animal studies have demonstrated the effectiveness of the vessel- sion of a urachal cyst in a lO-month old boy. sealing device on both the pulmonary vasculature and pulmonary Methods: A lO-month old boy presented with a swollen, tender, and parenchyma. erythematous umbilicus. In addition, there was a tender supra-pubic From September 1999 to February 2000, 5 patients, ranging in age from mass. Incision and drainage of this 'urachal abscess' was performed through the umbilicus. A computed tomographic scan performed post- 11 months to 18 years, underwent video assisted lobe resections, (4 left lower Iobectemies, 1 dgM upper Iobectomy), using the bipolar vessel-sealing operatively revealed a tubular cystic structure in the antedor midline between the umbilicus and bladder, consistent with a urachal cyst. This system as an adjacent method for hemostasis and vessel occlusion. Major was excised laparoscopically four weeks later. Two 3-mm ports in the vessels that were effe<~lvaly sealed by the system include the infedor right and left upper abdomen, and one 5-mm port in the epigastrium pulmonary vein and branches of the main pulmonary admy. were used. The cyst was dissected off the abdominal wall with electro- An procedures were completed successfully without complication. There cautery and ligated with an endo-loop at its junction with the bladder. were no failures of the device to achieve hemostasls, and no apparent Post-operatively, he was dismissed the next day, and was asymptomatic injudes to surrounding tissues." In all procedures, the vessel-sealing device on follow-up. dissected tissue very well and there was no difference in surgical blood loss Conclusion: Traditionally, urachal anomalies have been treated by when compared to traditional techniques. Thoracescopy was performed open excision to prevent complications of infection and possible malig- nant change. This is associated with significant post-operative pain, completely through trocar sites using the 5 mm vessel-sealing device. Mini- morbid~, and prolonged convalescence. Laparoscopic excision mini- thoracotemy was not required in any of the cases. Spedmans were mizes the morbidity of definitive therapy and is cosmetically superior. morselized and brought out the 12 mm trocar site. Hospital stays ranged However, laparoscopy in young children and infants is not widely prac- ~rom 1to 3 days. ticed. Our case is unique in that laparoscopy was used for the definitive Iniial experience whh the laperoscopic bipolar vessel-sealing device in treatment of a symptomatic urachal cyst in an infant. In summary, we thoracoscopic surgery indicates that it is effective for dissecting and believe that laparoscopic excision of urachal anomalies can be safely permanently sealing vessels commonly encountered in thoracoscopic lung performed in infants and children. reseotlons. S161

ASSESSMENT OF HEPATIC METABOLIC RESPONSE IN RATS ADVANCES IN LAPAROSCOPIC CLIP DESIGN: THE PREFORMED CLIP AFTER LAPAROSCOPIC AND OPEN SURGERY Markus Sch&fer, S.D. Schwaitzberg MD, D Rifkin MD, W. A.Amold MD, R.J.Connolly, PhD M.D.1, Beate Richter, M.D.2, Carsten N. Gutt, M.D.2, Stephan Center for Minimally Invasive Surgery, Dept of Surgery, New England Kr&henbShl, M.D.1, Lukas Kr&henb0hl, M.D.1, Dep. of Visceral and Medical Center, Boston, MA Transplantation Surgery, University of Z(~rich, Switzerland 1, General and Vascular Surgery, Johann Wolfgang Goethe University, Frankfurt, Introduction: With over 600,000 laparoscopic cholecystectomies performed Germany 2 in the United States annually, it is easy to imagine that at least 2.5 million clips are applied and retained in patients each year for this procedure alone. Patient's stress response is an inevitable physiologic consequence of The most commonly applied ligating clip is the crush type clip delivered every surgical procedure, whereby it has been assumed, that through a 10mm application device. Almost universally, multiple clips are applied to the retained side of the cystic duct and artery, implying a lack of laparoscopy minimizes the surgical trauma and thus patient's stress surgeon confidence in the retention strength of any single clip. This concern response. The purpose of the current study was to assess the hepatic is borne out by the fact that the single greatest cause of bile leakage is clip metabolic response of diagnostic laparoscopy compared to open slippage. abdominal exploration in a small animal model. Method: Pre-formed, titanium spring ligation clips (Smm applicator), were Male Sprague-Dawley rats were randomized into 3 groups (n=28 tested for transverse and longitudinal holding force on simulated vessels each). Group A underwent a diagnostic laparoscopy (LS) using a CO2- and compared with published results for conventional crush clips from 2 pneumoperitoneum with a pressure of 6 mmHg. Animals of group B manufacturers (10mm applicator) and crush clips (5 mm applicator) had a 5 cm taparotomy (LP) and underwent open abdominal explo- Results: ration. Group C served as control group (CON) and animals only had Transverse holding force in Grams anesthesia. Animals were characterized by their body weights, daily 10mm crush clip A 235 food intakes, hepatic glycogen contents, activities of alkaline phos- 10mm crush clip B 185 phatase (AP), aspartate aminotransferase (AST), alanin aminotrans- 5mm crush clip A 206 ferase (AL'r), bilirubin, bile acids and glucose in plasma. 5mm preformed clip 566 Body weight gain and food intake did not differ among the 3 groups. Hepatic glycogen contents were significantly decreased after LS and Axial holding force in Grams LP compared to CON for 8 days postoperatively (-32%), whereas plas- 10mm crush clip A 416 ma glucose, bile acids and glucose remained unchanged. AST was 3-4 10mm crush clip B 488 fold increased after LS and LP compared to CON for 8 days postopera- 5mm crush clip A 279 tively. 5mm preformed clip 816 Both surgical interventions (LS and LP) induced a hepatic metabolic response which could be confirmed by a decreased glycogen content. Conclusion: The new clip design was found to demonstrate significantly better holding forces and significantly more consistent application than the Plasma glucose levels were maintained demonstrating that glucose crush clips with 25% of the crush clip falling below 147 grams and only 2% homeostasis is not severly altered. of the preformed clips removed with less than 409 grams of pulling force. This design may offer better protection against cystic duct bile leakage and clip slippage owing to patient activity or inconsistent clip application.

ADVANTAGES OF A STANDARDIZED LAPAROSCOPIC COLECTOMY A COMPARISONOF COSTS AND OUTCOMESAMONG PRIMARYAND FOR SIGMOID DIVERTICUUTIS. Anthony ~1. Sene(]ore.M.D.. Hans-Joachim REOPERATIVELAPAROSCOPIC FUNDOPLICATIONS= Duepree, M.D., Victor W. Fazio, M.D., Dept. of Colorectal Surgery, Minimal F. Serafini, MD, William Nlelds, MS, M. Bleomston, MD, E. Zervos, MD, M Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio. Murr, MD, M. Albdnk, MD, Eli Lemer, MD, A.S. Rosemurgy, MD. Department of Surgery, University of South Rorida, Tampa, FL. The indications for elective sigmoid colectomy for diverticulitis are deady defined however, lapamscopic sigmoidectomy has failed to become routine. The morbidity, efficacy, and costs of lapamscopic reoperative antireflux Concerns remain regarding prolonged operative times, extensive use of operations have not been established. This study compares cost and instrumentation, and limited reductions in hospitalisation. The purpose of this outcomes of laparoscopic reoperaUonsto initial antireffux procedures. report is to compare a standardized approach to laparoscopic sigmoid 30 consecutive patients undergoing laparoscopic fundoplication revisions were compared to 60 random patients undergoing primary laparoscopic colectomy to open colectomy for diverticular disease in one institution. fundoplication undertaken between 1995 and 1999. Patients were of similar All patients requiring elective stgmoid colectomy for sigmoid diverticulitis age (52ys + 18.3 vs 49ys • 15.0,1o=0.4)and severity of GERD (DeMeester from 3/1999-7/2000 were analysed. Data collection inctuded age, gender, score 31:1:10.6 vs 70:1: 64.1,p=0.4). Patient satisfaction was queried using type of procedure (LAP vs OPEN), estimated blood loss (EBL), length of scales (1 for worst, 10 for best) via written questionnaires that included relief hospital stay (LOS), intra- and postoperative complication, reedmission-rate from symptoms, need for antJreflux medications, and capability of returning (<30 days), and return of bowel function. The converted patients were to precp activities. Data are presented as mean • STD. included in the LAP group for calculations of OR time and LOS, based on Fundoplication was completed laparoscopically in 26 (86%) patients and intent to treat. Standardization of the instrumentation resulted in an increased in 60 (100%) patients undergoing revisional and primary fundoplicatJons. acquisition cost for instruments of $425.00 in the LAP group. Blood loss, hospital stays and costs are summarized in Table 1. No deaths A total o! 59 patients were eligible for evaluation (LAP:3 t/OPEN:28). There occurred, but with ravisional operations major morbidity (18%) resulted in were no significant differences between the groups with respect to age (LAP: prolonged hospitalization (10, 20, 28, 60, 90 days). At similar follow up (20 months • 14.6 vs 23 months :1: 17.9) (p=0.6), patients were more pleased 51.8• vs OPEN: 82.0~:1.8 years), M/F ratio (LAP 15118 vs OPEN 11/17), or zfter primary ft ndoplications(9 • 1.9 vs 6 +3.7) (p=0.0~)07). OR time (LAP: 109.3+7.3 vs OPEN:101.4• min). The LAP group had signi- Blood Ioss(ml) Hospital stay(days) Hospital Costs ($) ficanUy shorter lengths of stay (LAP: 3.2• vs OPEN: 6.3-/0.4 days), esti- Lap Redo 116+ 197.8 3 (2 - 90) 34~734:1:49,289.4 mated blood loss (LAP:148.0:I:20.4 vs OPEN: 280.~36,8 ml), and return of Lap Primary 41• 35.8 2 (1 - 21) 10,575:1:4238.5 bowel function (flatus: 2.481021 vs. 4.43~.78 days, bowel-movement: 3.4• P value 0.005 0.001 0.001 0.37 vs. 5.69• days). Conversion to open was required in 4 patients Longer hospital stays, increased morbidity, and higher hospital costs (12.9%) due to obesity, trocar.site bleeding or severe adhesions. Re-admis- occurred after recperative laparoscopic antireflux surgery. With extended sion occurred in 1 LAP (3.2%) patient for small bowel obstruction compared follow up, patients were less pleased after reoperative fundoplications to 3 OPEN patients (10.7%) however the difference was not statistically because of operative morbidity and recurrent symptoms. Revisional significant. operations are possible but with increased morbidity, increased cost, and The results indicate that a standardized approach to laparoscopic-assisted greater likelihood of symptom recurrence. resection for sigmoid diverticulitis reduces LOS, resource utilization, even with a low but acceptable conversion rate. S162

LAPAROSCOPIC CELIAC PLEXUS NEUROLYSIS IN A PATIENT WITH AN UNUSUAL LATE COMPLICATION OF LAPAROSCOPIC NISSEN INTRACTABLE PAIN ASSOCIATED WITH CHRONIC PANCREATmS FUNDOPLICATION: AN INTRAWRAP HERNIATION Thomas E. Serena, Thomas E. Serena, M.D., Warren General Hospital, Warren, Pennsylvania, M.D., Gary L. McAfoos, M.D., Warren General Hospital, Warren, Gannon University, Erie, Pennsylvania Pennsylvania

Background: We report a case of laparoscopic celiac ganglionectomy Background: We report an unusual complication of Nissen fundoplication with alcohol neurolysis of the celiac plexus. The disabling intractable pain occurring nearly two years postoperatively. In the past decade the treat- caused by chronic pancreatitis frustrates patients and physicians. Medical ment of gestroesophageal reflux disease (GERD) has been revolutionizeq therapy consists of addictive narcotic analgesics which do not have Ion- by minimally invasive surgery. Laparoscopic Nissen fundoplication provides gacting efficacy (1). Open abdominal procedures such as resection of the symptomatic relief in >90% of patients. In most series, postoperative corm celiac ganglion are associated with significant morbidity. These have been plications occur in <10% of patients (1-3). Mortality is infrequent. As the largely replaced by percutaneous techniques (2-4). However, there are also procedure becomes more commonplace one would expect to find previ- complications with percutaneous neurolysis and pain relief is not always ously unknown complications. achieved (5). More recently thoracoscopic splanchnicectomy has been pro- Case Report: The patient is a 38 year old Caucasian male with severe, posed as an alternative treatment, but requires a hospital stay of 3-5 days refractory GERD complicated by GERD-induced asthma. His past history (6). is remarkable for Ehlers-Danlos syndrome. Preoperative manometry Case Report: A 39 year old Caucasian male with intractable mid-epigas- revealed only a decreased LES pressure. His 24-hour pH studies demon- tric abdominal and back pain caused by alcoholic pancreatitis presented to strated a composite score of 48 on the Johnson-DeMeester Table. He my office in the early part of 1998. Not having had a drink in two years, he underwent an uneventful laparoscopic Nissen fundoplication in March of now feared he was becoming addicted to narcotic analgesics used to treat 1998 resulting in excellent relief of his GERD symptoms. Twenty-two his pain and was unable to work. He had not tolerated a previously months postoperatively the patient presented complaining of worsening attempted percutaneous procedure (neurolysis was not performed). We post-prandiai discomfort and [eft upper quadrant pain not relieved by nar- performed surgery in March 1998. We visualized the celiac plexus using a cotic analgesics. Ultrasound revealed a cystic mass in the area of the proxi- 10 mm. 30 degree laparoscope. The celiac ganglion was resected wi~ the mal stomach and distal esophagus containing both air and fluid. aid of the Harmonic scalpel (Ethicon, Cincinnati, OH). Alcohol neurolysis Percutaneous CT-guided aspiration of this collection was unsuccessful. was achieved using a modified laparoscopic needle passed through a 5 Upper GI endoscopy demonstrated no evidence of bleeding, obstruction or mm. port. Dehydrated Alcohol (American Regent Labs) was injected in the other abnormality. At surgical exploration we found that a portion of the area of the celiac plexus for therapeutic neurolysis. The procedure took greater curvature of the stomach which was not part of the wrap had herni- less than 30 minutes to complete and was uncomplicated. He was dis- ated between the esophagus and the fundoplication. This hemiated stom- charged on the day of surgery receiving almost immediate and complete ach was incarcerated in this intemal hernia. Two small perforations from pain relief. At his two year follow-up he had some mild abdominal discom- the CT-guided aspiration were repaired easily. The hernia was reduced and fort, but he was narcotic free and gainfully employed. the fundoplication redone. The patient did well and was discharged on the Conclusion: Laparoscopic celiac plexus neurolysis and/or celiac 9an- fifth postoperative day. At his six-month follow-up he was free of reflux glionectomy may be another option for selected patients with intractable symptoms. pain caused by chronic pancreatitis. Conclusion: As laparcscopic fundoplication is performed more frequently, we ex~ to see unique complications.

ESOPHAGEAL MANOMETRY PERFORMED BY SURGEONS AT A LAPAROSCOPY IN FULMINANT ULCERATIVE COLITIS Neal E. RURAL COMMUNITY HOSPITAL Thomas E. Serena, M.D., Sartaj Seymour, M.D., Robert L. Bell, M.D., Department of Surgery, Yale Ahmed, M.S., Gary L McAfoos, M.D. University School of Medicine

Background: Esophageal manometry can be performed by laparoscop- To establish the role of laparoscopy in the treatment of severely active ic surgeons. The popularity of laparoscopic Nissen fundoplicetion in the ulcerative colitis (UC), laparoscopic subtotal colectomy was undertaken treatment of esophageal reflux disease (GERD) has spread from acade- in 12 patients with pocdy controlled colitis on aggressive immunosup- mic centers to community hospitals. While most community hospital pressive therapy as a preliminary step to restorative proctectomy. operating rooms are outfitted with all the necessary equipment to perform Methods: Records of 12 patients who underwent laparosoopic subtotal these procedures, in many rural areas the necessary preoperative diag- celectomy with ileostomy were reviewed. Results: Courses of medical nostic studies are not available. It is considered the standard of care to therapy varied, but 9 patients were receiving inpatient treatment at the perform esophageal manometry on all patients considered for laparo- time of surgery, or had recently had inpatient treatment. 2 patients had scopic anti-reflux procedures (1,2). In our community esophageal failed cyclosporin treatment and had resumed prednisone (> 40 manometry could only be obtained at a tertiary center three hours distant. mg/day). Profound weight loss or biochemical evidence of malnutrition Methods: A solid state three channel manometry catheter (Sandhill was present in 9 patients (67=/o) and 6 (50%) were on TPN preopera- Scientific, Denver, CO) was used for all procedures. The data collection tively. 4-port access was used in all cases. Postoperative complica- and analysis were performed by the surgeon with the aid of Sandhill tions occurred in 3 cases (abscess, rectal bleeding, ileostomy diar- Scientific's Bioview computer software. rhea). Postoperative length of stay was 5.4 +/- 0.4 days compared to Results: We present the results of 79 esophageal manometries per- 8.8 +/- 1.8 days(p < 0.05) for a group of 6 patients who had undergone formed by laparosoopic surgeons at our institution between January 1998 open subtotal colectomy for the same indications. Systemic steroids and June 2000. The rnajority (77/79) of these studies were performed as were withdrawn in all patients, although 2 required hydrocortisone ene- part of the preoperative work-up for patients with GERD considering anti- mas for rectal disease. 11 patients underwent proctectomy and pelvic reflux surgery. The average time to complete the study was one hour with pouch construction within 4 months of the laparoscopic procedure. The times decreasing as experience with the procedure increased. 78% were first 3 patients had protective loop ileostomies, but the remaining 9 read as normal. 16% identified only a decreased lower esophageal patients did not. There were no anastamotic leaks, and all patients sphincter pressure. 4% were found to have achalasia and one patient have excellent pouch function at 1-24 month followup. Conclusions: had a motility disorder. Thirty patients subsequently underwent laparo- Laparoscopic subtotal colectomy with ileostomy is associated with early scopic anti-reflux procedures (90% Nissen fundoplications/10%o Toupet hospital discharge in acutely ill patients with UC. Relatively high mor- fundoplications). There have been no complications related to bidity is likely related to these patients' compromised status at the time esophageal motor dysfunction to date. of surgery. Subsequent pelvic pouch construction was facilitated by the Conclusion: Laparosoopic surgeons can safely perform preoperative absence of a large abdominal incision and of peritoneal adhesions. esophageal manometry studies in patients undergoing work-up for Laparoscopic subtotal colectomy, followed by proctectomy with pelvic laparoscopic anti-reflux procedures. This is particularly pertinent for sur- pouch construction an geons in rural communities in which these studies are not readily avail- d eliminat=on of ileostomy is an excellent alternative to conventional 2- able. and 3- staged surgical treatment of fulminant UC. S163

ULTRASONIC TROCAR-EVALUARION OF INFLUENCE ON CLINICAL EVALUATION OF COMMON BILE DUCT REPAIR BY TUMOR GROWTH Kazuvuki Shimomura MD. Yukio Fujino MD, TITANIUM CLIP Kazuvuki Shimomura MD. Yukio Fujino MD, Tsuyoshi Suzuki MD, Tomonori Ohsawa MD, Yasuo Idezuki MD, Masanobu Hosino MD, Deijo Hashimoto MD, Yesuo Idezuki MD, Department of Surgery, Saitama Medical Center, Saitama Department of Surgery, Saitama Medical Center, 8eiteme Medical School, Saltama, JAPAN Medical School, Saitama, JAPAN

Recently we developed ultrasonic (US) trocar for laperoscpic Recently common bile duct (CBD) exploration ieoften surgery to prevent complications at the time of insertion like performed laparoscopically. However suture repair of common abdominal wall bleeding or organ injury by its hemostatic and bile duct is sometimes difficult technically, and T-tube insertion forceless insertion as we previously reported. This time we tends to prolong hospital stay up to 3 weeks. In order to evaluated effect of US trocar on tumor growth at insertion site simplify closure technique of CBD and avoid T-tube insertion for in comparison with usual disposable trocar. (Method) Male shorter hospital stay, we applied VCS titanium clip to repair DomTu rats (n=30, body weight 200-250 gr) were used. Under CBD in clinical cases. We evaluated efficacy and safety of this intramuscular anesthesia, AH1 30 tumor cell (5 x 10(6)) were method. (Method) Before closing CBD, we performed injected into intraabdonminal space after 5 trocarswere intraoperative cholangiogram to neglect outflow obstruction of inserted. Pneumoperitoneum (30rain, 10mmHg)was maintained papilla Vater. After lithotripsy, we applied VCS clips ((~ 3ram) to in experimental group and just kept for 30rain without repair CBD. As we can expect pressure tolerance of clip- pneumoperitoneum (0mmHg) in control group. On POD 9, all repaired CBD up to 50 mmHg according to our preceded pig animals were killed for evaluation of port site tumor recurrence. experimatal data, we applied clips every 0.5 mm -,, 2ram. No (Results) Under 0 mmHg the rate of trocer site implantation was bile drainage was attempted to place. (Results) We have 4 10128 (35.7%) in US trocar, and 6126 (22.7%) in disposable clinical cases( 3 male, 1 female). Size of CBD exploration was 5 trocar, respectively. And under 10mmHg pneumoperitoneum, 10 ram, 10ram, 10mm and 20mm, respectively, mainly according to 136 (27.7%) in US trocar and 14/36(36.8%) in disposable trocar, the size of largest stone. And the number of applied VCS clip respectively. Between US trocar and disposable trocar, there was 10, 20, 10 and 10, respectively. Days of postoperative stay was no significant difference about the rate of tumor recurrence was 5, 3, 4, and 5. There was no bile leakage and CBD at tocar insertion site regardless of intraabdominal pressure. ( stanosis. Average period of observation was 2.5 months. ( Conclusions) Ultrasonic trocar did not enhanced tumor growth at Conclusions) VCS clip was useful to simplify CBD repair trocar insertion site in comparison of disposable trocar. technique and suggested possibility to reduce hospital stay as short as basic laparosccpic cholecystectomy.

CYSTIC FIBROSIS AND GASTROESOPHAGEALREFLUX DISEASE: LAPAROSCOPIC MANAGEMENTOF RECURRENTPOST TRAUMAT- CAN LAPAROSCOPIC NISSEN FUNDOPLICATIONREDUCE HOSPI- IC SPLENIC PSEUDOCYS-E CASE REPORT Jonathan Smith, MD, TAL RECIDIVISMAND PULMONARY MORBIDITY? T Shope, M.D., T CPT, MC; Anthony Laporta, MD, COL, MC; Department of General Singh, M.D. Departmentof Surgery and S Beagle, M.D., J Rosen, M.D. Surgery, EvansArmy Community Hospital, Fort Carson, Colorado Department of Medicine,Albany Medical Center, Departmentsof Surgery and Medicine,Albany, New York Introduction: Pseudocystsof the spleen are rare but usually arise after blunt abdominal trauma. The purpose of this review is to present the INTRODUCTION: GastroesophagealReflux Disease(GERD) is a com- case of a recurrent post traumatic splenic pseudocyst, three years after mon associated problem for Cystic Fibrosis (CF) patients. As the life initial injury, and its laparoscopicmanagement. expectancyfor patientswith CF lengthens, more of these patientswill be at Methods and Procedures: The patient is a 22 year old female who risk for the complicationsof the disease. Successful treatment of GERD three years prior to presentationto our facility, received blunt abdominal should reducemorbidity in CF patients. trauma during sports related activities. Three months after the initial OBJECTIVE: To evaluatethe impact of laparoscopicNissen fundoplica- injury, she developed a splenic pseudocyst, which was managed by lion (LNF) on hospitalizationrates and pulmonarycomplications of adult CF laparoscopic marsupialization. Three years later, she developed a large patientswith GERD. left upper quadrant mass, but was otherwise asymptomatic. A preopera- METHODS: A case series analysisof four adult patientswith CF and dec- tive CT was obtained which documented a 24 cm splenic cyst with signifi- urnentedGERD who underwentLNF was performed.Patients hospital and outpatientmedical records were evaluatedfor evidenceof pulmonarymor- cant mass effect. She then underwent laparoscopic exploration, cyst bidity and need for hospitalization. decompression, and splenic cystectomy. Several intraoperative pho- RESULTS: tographs were taken. 1600 cc of green fluid were obtained. A 7mm #Hospitalized #Hospitalizations SteroidUse Blake drain was placed within the cyst cavity and was discontinued on PulmonarySymptoms* post operative day 4. She also underwent CT on postoperativedays 1 PreL.NF** 3/4 8 4/4 Significant and 10, which did not demonstratecyst recurrence. Post LNF*** 2/4 5 1/4 Improved Uterature review shows that these cysts are rare. Most pseudocysts *Includes cough, dyspnea, and sinusitis. **In the year prior to their LNF. arise after splenic trauma from liquefaction of splenic hematomas. ***Follow-up 5-18 months. 4 Post LNF hospitalizationsand the need for Several treatment options exist to include percutaneousdrainage, marsu- Post LNF steroids were for 1 patient who had repeatedtechnical failures pialization,cystectomy, and spleneotomy. Extemal drainage and marsu- and documentedrecurrent reflux. For the periodswhen this patient did not pialization have an unacceptablerate of infection, bleeding, and reaccu- experience reflux symptoms, he did not require steroids. The remaining mulation, and are inadequate modalities of treatment. Splenic preserva- admission was for Aspergillus infection refractory to outpatient manage- tion is preferred, however splenectomy may be necessary for uncontrol- merit. lable hemorrhageor possible malignancy. Smallcysts may effectivelybe CONCLUSIONS: GERD is a common comorbidcondition in the CF pop- managed with percutaneous drainage, however, cystectomy is the pre- ulation. Recurrenttracheal acidification,and the resultantchronic inflamma- ferrod managementfor larger cysts. tion, which occurs with GERD, cause increasedpulmonary morbidity and Conclusions: Splenicpseudocysts are a rare complication of splenic need for increasedmedical care in this at risk population.Successful LNF trauma. We present the case of a recurrent posttraumatic splenic should eliminategastroesophageal reflux and thereforereduce pulmonary pseudecyst managed by laparascopic cystectomy. Severalmethods of morbidity and hospitalizationin adult CF patients. Further evaluationand treatment exist, however splenic preservationis preferred. long term follow-upis needed in this populationand should be in the pedi- atric population. S164

TASK DECOMPOSITION OF MINIMALLY INVAS1VE SURGERY LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER USING THREE FOR OBJECTIVE EVALUATION OF LAPAROSCOPIC SKILLS. TROCAR TECHNIQUE: OUR EXPERIENCE AND PRELIMINARY RESULTS Massimiliano Solazzo M.D. * Jacob Rosen Ph.D.A Blake HannafordPh.D. A, Massimiliano Solazzo M.D.; Paolo Marciano' M.D.; Roberto Fadani M.D.; Regina Paolo M.D.; Carlos PeUegrini M.D.; Francesco Pucoio M.D., 2 ~ SurgiceJ Mika N. SinananM.D., Ph.D. *, Dmitry OleynikovM.D. *, CarlosA. Department, Manerbio Hospital, Manerbio (BS), Italy; Center for Pellegrini M.D. * Videoendoscopic Surgery, University of Washington Medical Center, Seattle, 9Dcpamnent of Surgery, Box 356410, University of Washington Medical WA Center, SeaR]c,WA, USA ^Department of Electrical Engineering, Box 3.52500, University of INTRODUCTION: The aim of the current study was to assess the feasibility Washington, Seattle, WA, USA. and safety of laparoscopic colentomy for cure of left colon and rectal cancer, using a three trocar tenhnlque. MATERIALS AND METHODS: from June 1996 to July 2000, 24 patients Lapazoscopic skill evaluation of general surgery residents is usually a left colon and rectal cancer underwent complete laparoscopic or laparoscopic subjective process, carried out by senior surgeons in the operating room assisted colectomy using only three ports of entry instead of the 4 ports usually using fuzzy criteria. The aim of this study was to develop and assess an required. W'rth the patient in normal supine position a 10 mm. t]'coar is inserted objective laparoscopic surgical skill scale using Hidden Marker Models in the midline 3 cm above the umbilicus, a 10 mm trcoar is placed just above (HMM) basedon hapdc informations, tool/tissue interactionsand visual task the pubis, 2 cm on the left far from the midline and a 10 mm. tzocar is inserted decomposition. Eight subjects (six residents at different training levels: in the right midclavicular line just below the umbilicus. The patient is then placed in a full Trendelemburg posfdon, on the right flank, The assistant holds the cam- 2xR1, 2xR3, 2xR5 and two experts surgeons: 2xES) performed laparoscopic ere inserted through the trocar placed in the right midclavicular line, allowing the choleoystectomy on pigs following a specific 7 step protocol. During surgeon to perform the procedure autonomously by utilizing the remaining two surgery, they used an instrumented grasper equipped with force/torque if/r) ports. sensors able to measure forces and torques at the hand/tool interface and RESULTS: All the 24 procedures were completed laparoscopic~ly: 5 left colec- synchronized with a video of the operative maneuvers. Fourteen types of tomies, 7 sigmo=d resections, 11 anterior resections and 1 Hartmann's proce- tool/tissue interactions, each associated with unique F/r signatures, were dure. In 18 patients we completed a full laparoscopic colectomy with intracorpo- real anastomosis, whereas in the remaining 6 we performed extracorporeal defined from frame-by-frame video analysis. The statistical distances anastomosis. We used a 6 cm minilaparotomy for specimen retrieval. There between HMMs representing expert surgeons and residents were were no intraoperetive complications and 3 (12.5%) postoperative complica- significantly different. Major differences were: (i) F/T magnitudes (ii) tions requiring reoperation: 2 intestinal occlusions due to adhesions and 1 tool/tissue interactions used and transitions between them (iii) time intervals anastomotic fistula. The average number of lymph nodes harvested in resected in each tool/tissue interaction and overall completion time. The greatest specimens was 16 (range 6-26) and the mean distance of the tumor from mar- differencr in performaaco was between El and g3. Smaller changes were gins of resection was 9 cm (range 5.21). The average operative time was 180 min (range 120-240) and the mean hospital stay was 8.5 days (range 5.34). seen as expertise increased. This obJeCtive learning curve indicates that the CONCLUSIONS: Three trocar laparoscopic colectomy is a reliable and safe laparosoopic surgical residents acquire a major portion of their skill between technique in which most of the procedure is performed by one surgeon assist- the first and the third years of their 5 years of training. ed only by a camera operator. The use of only three trcoars decrease the risk of iatrogenic injuries.

THE ZEUSS SYSTEM IMPROVES PERFORMANCE OF COMPLEX LAPAROSCOPIC SPLENECTOMY FOR CHRONIC LAPAROSCOPIC SKILLS IRRESPECTIVE OF PRIOR TRAINING T. RELAPSING THROMBOTIC THROMBOCYTOPENIC Sweeney MD D. Rattner MD Department of Surgery Massachusetts PURPURA(TTP): LONG-TERM RESULTS Amir Szold, MD, General Hospital and the Harvard Center for Minimally Invasive Surgery Boaz Sagi, MD, Andre Keidar, MD, and Amiram Eldor, MD, Boston MA Endoscopic Surgery Service, Department of Surgery B' and INTRO: This study compares the performance of a set of standardized Department Hematology, Tel Aviv Sourasky Medical center surgical skill tests using conventional laparoscopic instruments (CLI) and a and the Sackler School of Medicine, Tel Aviv University, Tel robotic surgery system (RS)in subjects with differing surgical expertise. The Aviv, Israel effect of MIST Virtual Reality (VR) training and a 3 dimensional visual system on skill test performance are also examined. METHODS: 3 test cohorts were recruited: attending surgeons(n=12), general surgery residents(n=lO) and Objective: To test the efficacy and safety of laparoscopic medical students(n=10). Each subject performed a set of 4 tests: bead drop splenectomy (LS) for the treatment of the chronic relapsing into a container, object transfer, suture placement and intracorporeal knot tie. form of Thrombotic Thrombocytopenic Purpura (TTP). .Each test set was performed using CLI and the Zeus RS(Computer Motion Methods: We performed LS in nine patients with refracto- Inc, Goleta CA). RS test sets were performed with both a standard television ry or relapsing TTP. The operative as well as the early and monitor and a 3 dimensional visual system. Performance of each test was late post operative course and complications were record- assessed by both time and error rates. Residents and students, but not ed. attending surgeons were randomly assigned to receive VR training prior to Results: The mean duration of LS was 70 minutes (range performing the test set. A 2 tailed Hest was used for comparison of means of 35-180). There were no serious bleeding complications dur- paired samples. Significance was assumed at 10<0.05. RESULTS: 91% of ing or after surgery. Convalescence was rapid and the subjects completed all tests. Combined data from each test cohort mean hospital stay was 2.5 days (range 1-9). The patients demonstrated that CLI were faster and produced lower error rates than RS were followed up for a median of 29 months (range 1-60 for both bead drop and suture tests (p

PLACE OF LAPAROSCOPY IN GASTRIC AND DUODENAL THOFIACOSCOPIC ESOPHAGECTOMY IN THE ELDERLY. Masashi ULCER PERFORATION MANAGEMENT Hossein Takeh M.D., Harushi Osugi M.D., Hiroaki K]hoshita M.D., Masayuki Philippe Boute M.D., Patrick Philippart M.D., Patrick Emonts M.D., Higashino M.D." Second Department of Surge~/, Osaka City University Medical School, Department of Gastroenterological Surgery, Osaka City Pierre Mendes da Costa M.D., Department of Digestive and General Hospital" Laparoscopic Surgery, C.H.U. Brugmann, Brussels, Belgium We have reported that thoracoscoplc esophagectomy and The aim of this retrospective study is to evaluate the place of lymphadenectomy contributed to preserve pulmonary function (Surgical laparoscopy in gastric and duodenal ulcer (GDU) perforation man- Endosc, 11(2),p184,1997). Becauseesophageal cancer Is commonly seen in the elderly, feasibility of thoracosooplc surgery for elderly patients with agement. esophagealcancer was studied. From 1994 to 1999, 32 patients were admitted for GDU perforation. Twrdu patients with squamouscell carcinoma of the esophagusolder There were 20 males and 12 females. The mean age was 59 then 75 yearsold were subjected. All patients were fitted for our indicationsof years. 7 patients had received non steroidal anti inflammatory thoracosoo~ esophagectuny; 1) the patient is able to toleratethe singlelung ventilation, 2) no diffuse pleurel adhesion, 3) the esophageal lesion less then drugs(NSAI) and 3 others cortisone. 11 other patients have suf- T3. In 9 patients,the esophagectomyend medlastinal lymph node dissection fered from chronic GDU. All patient presented an acute abdomen were performed thoracoscoplcally(T group), and other 14 patients were done and 4 were shocked. 8 patients had ASA score 4 - 5 at operation. through right conventional thoraootomy (C group). CUnicopathologicel The perforation was gastric in 13 patients and duodenal in 19. Plain features and postoperativecourse In both groups were compared. There were no difference in age, gender, pathologicalstaging, locationof abdominal X ray failed in 50 % of cases but computed tomography tumor, preoj~,h-a.tive respiratory tundJoo (%VC, FEVI.0%, MVV%), Hugh- detected the pneumoperitoneum in all cases. 7 patients were treat- Jones classif'c,ation between two groups. Nine patients in C ~roup and 8 ed by laparotomy, 21 by laparoscopy (3 conversions) and 4 by patients in T group were associated with preoperative complication, such as Taylor procedure (nasogastric tube aspiration, H2 receptor antago- diabetes mellitus or hypertension. There were no significant difference in duration of intmthoracic procedure (C group ; 173 minute vs T group ; 204 nist and antibiotics). minutes) end amount of bi(xxI loss during intrathoracicprocedure (C group ; Mortality rate was 18.7 % (50 % in laparotomy group and 5.5 % in 208 g vs T group ; 231 g). The number of dissected rnediastinalnodes was laparoscopy group). The total morbidity rate was 43 % (50 % gen- 27 nodes and 31 nodes in C and T group, respectively. The changes of eral and 50 % local complications). The mean intensive care unit peripheral blood leukocyte count and C-reactive protein level were not stgnifcently difference during preoparatlon to two weeks after surgeryin two and hospital stay were respectively 4.6 and 16.6 days. groups. Therewas no hospital death related surgery. The most frequent The morbidity and mortality are both very high in GDU perfora- postoperativecomplication was pneumoniain both groups. The inddenceof tion with general peritonitis. The laparoscopic treatment of GDU postoper~ve complications was 64% end 56% in C and T ~roup, respectivdy, perforation is a feasible and safe procedure. In our experience, 64 which was not significantlydifferent. Accumulativesunnvel rate was 51% % of patients were treated successfully by laparoscopy with a very and 88% at I year after surgery, and 34% end 33% at 2 years after surgeryin C and T group, respectively. low mortality (5.5 %). Thoracoscopic esophagectomy was feasible for the elderly patients with esophagealcancer.

LAPAROSCOPIC STOMA CREATION: IS THERE A LEARNING ROBOTIC LAPAROSCOPIC SURGERY: EARLY LESSONS LEARNED CURVE? Mark A Talamini MD, Kurtis Campbell MD, Cathy Stanfield NP, Kazuo Takeuchi, MD, Brooke Gudand, MD, Oded Zmora, MD, Nelli Chandrakanth Are MD, The Johns Hopkins University School Of Mizrahi, MD, Seong You, MD, Lucia Oliveira, MD, Alon Pikarsky, MD, Medicine, Department Of Surgery Eric Weiss, MD, Juan Nogueras, MD, Steven Wexner, MD, Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida Robotic systems are now available and approved for use in the US for surgery below the diaphragm. The daVinci Robotic system offers signifi- The aim of this study was to compare our early to our latter experi- cant expansion and enhancement in the ability to perform minimally inva- ence with laparoscopic stoma formation. sive procedures by providing six degrees of freedom plus grasp in two We retrospectively reviewed all patients with laparoscopic diverting robotic wrists, motion scaling up to 5 to 1, tremor elimination, and stereo- stomas without intestinal resection from 1992 to 2000 who were then scopic high detail vision. After engaging the system, the surgeon sits at a divided into an Early Group: 1992-1996 and a Late Group: 1996-2000. console near, but physically separated from the patient, and controls the 73 patients of a mean age of 51 (22-89) years (37 females; 20 stereo-laparoscope, an energy source, and two robotic arms by means of males) were reviewed. 36 patients were in the early group and 37 in the a controller for each hand and foot pedals. Ten patients underwent robot- latter. 29(40%) patients had previous abdominal surgery. Average ic assisted laparoscopic surgery, consisting of 4 Nissen fundoplications,3 length of the procedure was 80 (30-330) minutes. 14 patients in the cholecystectomies, one exploratory laparoscopy, one laparoscopically early group had previous abdominal surgery and an average operative assisted bowel resection, and one Heller myotomy and Toupet fundopli- time of 117 minutes while 22 patients had no previous abdominal cation. There were no intra-operative complications. One patient was converted to open cholecystectomy due to extensive inflammation in the surgery and an operative time of 55 minutes. In the latter group, 15 right upper quadrant. One patient had a post-operative gastric leak from patients had previous abdominal surgery with an operative time of 94 the non-robotic portion of the procedure. Average time to engage the sys- minutes, and 22 patients had no prior abdominal surgery with an aver- tem during surgery was 7.4 min. (9.5 for lap Nissens) and average sys- age operative time of 77 minutes. 7 patients were converted to open tem time was 104 min. (132 for lap Nissens). In most cases, one or two laparotomy (5 in the early group due to extensive adhesions (n=3) and additional 5 mm auxiliary ports were used for additional retraction. In the intestinal injury (n=2); 2 in the latter group due to extensive adhesions). authors' judgment, 3 cases could not have been successfully completed 5 patients required reoperation (2 in the early group for intraabdominal laparcscopically without robotic assistance (extensive adhesiolysis nec- abscess and torsion and 3 in the latter group for lys=s of adhesions, tor- essary for bowel mobilization, difficult crural closure during laparoscopic sion, and trocar site hemorrhage). Length of hospitalization in the early Nissen, and ability to exhaustively examine the small bowel during group was 6.2 days and 8.2 days in the latter group (2 patients had an exploratory laparoscopy). Success with robotic laparoscopic surgery extended stay due to non-surgical conditions). depends upon existing experience in laparoscopic surgery, adequate Although conversion rates decreased with increasing experience, training regarding robotic technical issues, careful port placement, an operative time, length of stay, and complications requiring reoperation anesthesia team willing to accommodate the system, and team coordina- did not improve. Thus, laparoscopic stoma creation appears not to tion during procedures. Robotic systems expand the scope and difficulty have the steep leaming curve as other laparoscopic colorectal proce- of laparoscopic operations, and offer the future promise of at-distance dures. surgical intervention. $166

LAPAROSCOPIC GASTRECTOMY WITH REGIONAL LYMPH NODE SAFE AND EFFECTIVE LAPAROSCOPIC APPROACH FOR COLON DISSECTION FOR GASTRIC CANCER. Shinya Tanim~ra, M.D., Masayuki DIVERTICULITIS WITH DENSE ADHESION Keitaro Tanaka, M.D., Higashino, M.D., Yosuke Fukunaga, M.D., Department of JunjiOkuda, M.D., MasaoToyoda,M.D.,SinsyoMorita,M.D., Tetsuhisa Gastroanterological Surgery, Osaka City General Hospital, Osaka, Japan Yamamoto, M.D., Toshiyuki Tenjo, M.D. HiroshiKawasaki, M.D., KanjiNishiguchi, M.D., Hiroshi Okano, M.D., NobuhikoTanigawa, M.D., Department of General and Gastroenterological Surgery, Osaka Medical Recently a minimally invasive operation for gastric malignancies has College, Japan been advocated. Here we have performed laparoscopic gastrectomy with regional lymph node dissection using hand-assisted laperoscopic surgery In case of colon diverticulitis with dense adhesion, the medial aprcach, (HALS) on 83 cases of gastric cancer from March 1998 to August 2000; which means initial mesenteric dissection followed by mobilization of the distal gastrectomy in 78 cases, proximal gastrectomy in 2, and total bowel, appears to be useful for safe and easy identification of the ureter and gonadal vessels before mobilizing the inflamed bowel from the lateral gestrectomy in 3. The dissection of all group 1 and group 2 lymph nodes side. defined according to the general rules of the Japanese Research Society (Case 1) 72 y.o. male with both mid-rectal cancer and ascending colon for Gastdc Cancer was completely carded out in the distal gastrectomy diverticulitis. After laparoscopic rectal resection, we performed laparoscop- cases. Reconstruction after distal gastrectomy was made by Billreth 1 ic-assisted right colectomy for ascending colon diverticulitis. The right method in 67, and by Billroth 2 method in 11, respectively. Billroth 1 mesocolon was dissected from medial to lateral. The third portion of duode- reconstruction was applied intracorporeally to the former 29 cases using num was identified and swept free of the mesentery. After confirming right ureter and gonadal vessels, ileocolic vessels were divided. Despite dense the double stapling method with a conventional circular stapling device, and adhesion caused by diverticulitis, mobilization of dght colon was safely in the latter 38 cases 'the quadrilateral (square) stapling technique' with a accomplished without inadvertent injury of right ureter, gonadal vessels and laparescopic linear stapling device was employed to prevent postoperative duodenum. The inflamed bowel was resected extracorporeally and anasto- anastomotic bleeding and stanosis. The average duration of operation of mosis was created. 78 distal gastrectomy cases was 230 rain, which was significantly longer (Case 2) 68y.o male with sigmoid colon diverticulitis. We found the sig- than that of conventional open surgery. The average blood loss was 132 ml mold colon with dense inflammatory adhesion caused by diverticulitis, We incised the rectosigmoid mesocolon to the medial side of the inferior which was significantly less than that compared with an open gaslmctomy. mesentedc artery. Dissection proceeded medial to lateral. After sweeping Postoperative complications from anastomosis resulted in leakage in one down the gonadal vessels and ureter from the mesentery, the lateral patient, bleeding in one patient and stenosis in one patient; all attachment of sigmoid colon was detached laterally. The anal side of the complications were treated conservatively. Postoperative pedods of walking colon was transected with an endoscopic stapler. After completion of mobi- flatus, oral feeding, and discharge were 1.1 days, 2,7 days, 3.3 days, and lization, left colon was extracted from the left lower enlarged wound and the 13.7 days, respectively, which were all significantly sooner than those of oral side of the colon was resected outside. Anastomosis was performed conventional open gastrectomy patients. This technique is not only less intracorporeally using double stapling technique. Medial approach by laparosccpy is thought to be feasible for the ~eat- invasive, but similarly safe and curative compared to an open gastrectomy. ment of both side diverticulitis especially with dense adhesion.

HAND ASSISTED LAPAROSCOPIC SPLENECTOMY FOR COMPARISON OF LAPAROSCOPIC AND OPEN MANAGEMENT SPLENOMEGALY. A comparative analysis with conventional lap. OF PANCREATIC PSEUDOCYSTS Michael Tamoff, MD, Fred Brody, splenectomy. Eduardo M' Targarona, Carmen Balagu~, Gemma Cerd~n, MD, Michael Rosen, MD, Jeffrey Ponsky, MD, Department of General Juan Jose Espert, Antonio Lacy, Jose Visa, Manuel Tdas. Service of Surgery. Surgery and Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio Hosp. S Pau. UAB, and Hosp Clinic. Barcelona. Spain Currently, minimally invasive techniques are available for managing Laparoscopic splenectomy (LS) is an accepted technique for cases with pancreatic pseudocysts. Recent reports document successful treat- normal spleen but the difficulty of LS increases with splenomegaly. Recently, ment utilizing laparoscopic techniques. This study presents a compad- some devices have designed to assist laparescoplc procedures with the hand son of laparoscopic and open management of pancreatic pseudocysts inserted in the abdomen, while the pneumoperitoneum is maintained. This at a single institution. device permits to recover the tactile feeling and facilitate the mobilization and A retrospective review was performed of all patients undergoing oper- dissection of the organ. Finally, the organ is recovered through the ative treatment of a pancreatic pseudocyst between July, 1994 and mingaparotomy. Objective: To compare the immediate results of August, 2000 at the Cleveland Clinic Foundation. Patients requiring conventional LS and hand-assisted LS (HAt.S) in cases of splenomegaty. complex surgical management were excluded (n=25). Patient demo- graphics, intraoperative details and postoperative complications were Matsdal and Methods; Between FelP93 and sept-2000, 169 LS were determined for all patients. Wilcoxon rank-sum tests and Fisher's exact attempted in 2 surgical units. 48 cases had an enlarged spleen, with a final tests were used to compare the two groups. spleen weight 9 700 g. We compare the first 36 patients operated with Seven patients underwent laparoscopic intervention and twelve conventional LS (Group I, LS) with the last consecutive 12 patients patients underwent open decompression. The mean operative time approached by HALS (Group II. HALS). was 149.6 +- 49.5 minutes and 226.6 +- 103.2 minutes, and the mean Results: Group !, LE Grouo I1. HALS o length of stay was 8.6+- 3.1 days and 9.7 +- 9.0 days in the open and N 36 12 laparoscopic groups, respectively. The mean estimated blood loss in Age (y) 58 (19-82) 62(4476) ns the open and laparoscopy groups was 315.2 +- 325.8 cc and 183.6 +- Op t (min) 177 (95-300) 131(85-270) .009 230.1 cc, respectively. Comparison of these data revealed no signifi- cant differences. There have been no postoperative complications or Conversion 20% 7% ns recurrences in the open group. One patient in the laparoscopic group Transfusion 40% 25% ns suffered an anastamotic leak and was managed nonoperatively. One Morbidity 35% 7% ns patient in the laparoscopic group recurred 8 months postoperatively Stay 6.3 (3-14) 3.6 (2-7) 05 and underwent open cystjejunostomy. ReeperaUon 1/36 (3%) 1112 (7%) ns This study compares open and laparoscopic approaches in the treat- Spleen weight 1425 (700-3400) 1324(720-3100)ns ment of pancreatic pseudocysts. Failure to perform a wide cystgastros- Mortality 0 O tomy resulted in the single recurrence. As a result, we avoid a single Conclusion: HALS facilitates significantly the surgical maneuvers during LS, staple line technique and recommend a large resection of the posterior while keeping the advantages of a purely ]aparoscopic approach. gastric wall to ensure adequate patency. $167

AN OBJECTIVE ASSESSMENT OF THE IMPACT OF ADVANCED A MINIMALLYINVASIVE TECHNIQUE IN BARIATRIC SURGERY LAPAROSCOPIC FELLOWSHIP ON PERFORMING LAPAROSCOPIC CHOLECYSTECTOMY Michael Tamoff, MD, Fred Bredy, MD, Michael TV Taylor, M.D. Rosen, MD, Jennifer Maim, RN, Jeffrey Ponsky, MD, Department of BaylorCollege of Medidne General Surgery and MinimallyInvasive Surgery Center, ClevelandClinic St. Joseph Hospital Foundation, Cleveland,Ohio Houston, Texas Recent interest in pursuing minimally invasive fellowships has steadily increased. However, little data exists regarding the technical impact of A minimallyinvasive technique has been devised and tested for the these advanced fellowships. This study attempts to objectivelyquantitate performance of weight redudng surgery. The method of weight reduction is the technical impact of an advanced laparoscopic fellowship on surgical a modification of the bilio-pancreaticdiversion procedure described by performance. Scopinaro. A horizontal indsion about 4cm in length is made immediately A retrospectivereview of all laparoscopic cholecystectomiesperformed medial to the left costal margin. Accessto the stomach is easily achieved by two consecutive laparoscopic fellows at the Cleveland Clinic Foundation was performed. Patients were stratified by anesthesia class through this incision, as the stomach is the immediateposterior anatomical (ASA) and preoperative diagnosis (biliary colic or acute cholecystitis). relation. The greatercurvature of the stomach is deliveredinto the wound. Intraoperative details were recorded including skin to skin time (STS). From a point high on the greatercurvature, the stomach is stapled and The fellows performed a total of 77 laparoscopic cholecystectomieswith divided across its width using the 6cm Endoscopic GIA linearstapler/cutter, one staff surgeon. Initially,the relationship between STS and each of the thus completelydividing the stomach. A second horizontal incision about variables was assessed with Spearman rank-correlations to determine which variables were significantly related to STS based on univariate 4 an in length is made to the nght of the umbilicusand infenody lateralto the tests. Subsequently, stepwise multivariate regression analyses were per- rectus sheath. Thisincision allowsthe small bowel to be deliveredinto the formed to determinewhich variables were most relatedto STS. wound so that accurate measurementprior to stapling can be carried out. STS for procedures performed earlier in the year were longer based on Through this incisionthe small intestine and its mesenteryare divided250cm univariate analysis (p

COMPARISON OF TECHNIQUES OF CREATION OF GASTROJE- THE D~-.-NOSSOF CONG~Nn'~LESOPHAGEAL STENOSS BY JUNOSTOMY IN LAPAROSCOPIC ROUX-EN-Y GASTRIC ULTRASOUND SONOGRAF'~. :~z~T.~mm,..~: xa~o ~h~a, MD.', BYPASS FOR MORBID OBESITY Teixeira, M.D., Ashutosh Kaul, Kazurcci Fun.l~, MD.~, Sabine Ka~ M.D.~, Tattoo Eronoto, MDJ, Tsuyo~ M.D., Luis Jacome, M.D., Thomas Cerabona, M.D., Dominick Anuso, M.D., Dept. of Surgery, New York Medical College, Valhalla, N.Y. Takahashi,MD/, Akira~ M.D.~, G~ro Kamda, MD.~, ~Depem~ertof Sug~y,

Roux-en-y gastric bypass has been shown to an effective procedure Sa~r~ra Hosp~ g.a-~aw~.~r~ in the treatment of morbid obesity and laparoscopic Roux-en-Y gas- tric bypass (LRYGB) has been demonstrated to be a safe and effec- Cor~r~ ~ =a~ow(CES) ir~__,-~,__throe types of pJe'x~ =x',c~ tive altemafive. The creation of the Roux-en-Y gastro-jejunal anasto- namely ~d~cUord~ remna~ fi~mucular ~ and ~,,,;~,~,-,;,~ moses has remained an issue of contention with many alternative techniques and modifications reported in literature. The purpose of dartragn~ z s dmo~ 9 premem~ crB~noN~e ~ of CES at a pa~t We study was to critically analyze our experience of three different tech- pe~rmed per~ =~,~,,,~eal~ to ~reetan k~rt w~ CES ~er ~e ck~o~ niques of creation of the gastrojejunal anastomoses. bX~ ~=ound r (EUS). Three different techniques of creation of gastrojejunal anastomoses A 10~onCH~ Japanesegit p~ wi~ post~ ~al ~ili~ had a I-~ were compared. These included use of EEA stapler (29 cases); use ~ con0er~ e~=~W~ a~m a~d a~ ma~omW~m~e ~ r of Endo GIA stapler (20 cases) and hand sutured anastomotic tech- nique (23 cases). Brief description of different techniques will be pro- vided followed by a critical analysis of our results. Patients were stud- ~ reve~ed esq:t~eel dro.dar~-~ locad 18cm from arl indsor,lout led for intraoperative time, blood loss, complications, weight loss, 9as~ relax~ (GERD) v~s not noWcL EUS shov,~lg~e v~l of length of stay and wound problems. Significant differences were found in between these groups and they will be highlighted. not r my e~-,~ r GERD.md pressured'~e loweresopt',~_._ _ r ~ Hand sewn anastomoses required more advanced skills, took a ~ normalrungs B~oon ~ ~ d~e steno~salient ~ note~ec~z longer time but had better control of stoma size, lower wound infec- tion rates and avoided stapler costs. Endo GIA anastomoses were The paJert ~as cla~..:_,~._J as I-~v~nga lil~rnusoJarr type of CES, and more reproducible and took less time. Use of EEA resulted in higher ~-,~-,~rtsu~e;y. P-~ e~T,i'1~m co'6,med~he c~ d CES c~e ~o incidence of wound infection and has a potential for oral-pharyngeal and esophageal trauma. EUS ws ulJized~ cr~ ~ a ty10eor CES. Thiscase serves Io ~rnon~ale We believe that Hand Sutured anastomotic technique provides for a 9 at EUS rr~ be able not ody t~ da~x~e a type of CES, but abo ~o d§ m safe gastro-jejunostomy avoiding all problems asseQated with stapled anastomoses. It provides a better control of stomal size, avoids sta- ~rra~ ~r It may ~ p~_~'~ ~o ped~rms gxxacocq~ suge~ for CES, pler costs, eliminates the potential for oral-pharyngeal and v~d~ ~ dacron.____ of aty~eby EUS. esophageal trauma, and potentially decreases wound infection. S168

A COMPARISON OF T-TUBE INSERTION VERSUS THE FREQUENCY OF SPONTANEOUS PASSAGE OF BILE DUCT SUTURE CLOSURE FOLLOWING LAPAROSCOPIC BILE STONES AND RELATION TO CLINICAL PRESENTATION Sheena E. DUCT EXPLORATION Sheena E. Tranter, MB ChB, Tranter, MB. ChB., Michael H. Thompson, M.D., Department of Michael H. Thompson, M.D., Department of Surgery, Surgery, Southmead Hospital, Bristol, England Southmead Hospital, Bristol, England Little is known about the spontaneous passage of bile duct stones. The aim of this study is to determine the rate of spontaneous stone Exploration of the bile duct at open operation is conven- passage and relate it to the clinical presentation of the bile duct stone. tionally followed by insertion of a T-tube. The aim of this Prospectively collected data was studied on a total of 991 consecu- study is to compare the effectiveness of T-tube insertion tive patients undergoing laparoscopic cholecystec"tomy with or without with direct suture closure of the duct following laparoscopic laparoscopic common duct exploration (LCDE). Comparisons were exploration. made between 123 patients with common bile duct stones (CBDS); Comparison has been made between 29 patients under- 496 patients who had no previous or current evidence of duct stones and 372 patients who had good evidence of previous duct stones but going laparoscopic common bile duct exploration (LCDE) not present at the time of chloecystectomy.The evidence used for pre- with T-tube insertion and 43 patients in whom the duct was vious duct stones included a good history of jaundice, a raised serum directly sutured. All data were collected prospectively. amylase, abnormal pre-operative LF'F's and/or a dilated common bile Both groups were comparable in terms of age, sex, com- duct. We have assumed that this group underwent spontaneous pas- mon bile duct diameter and pre-operative LFT's. The use a sage of bile duct stones. T-tube was associated with a significantly higher incidence 49% of patients undergoing laparoscopic cholecystectomy had a his- of post-operative complications (32% vs 14%; p=0.001) tory of previous or current CBDS: 74% of these passed the ductal stones spontaneously prior to operation. Patients presenting with pan- including 5 cases (17%) of T-tube related complications and creatitis had an 82% chance of passing their stones spontaneously. 4 cases (14%) with retained stones requiring endoscopic Those presenting with jaundice had only a 58% chance of spontaneous sphincterotomy. The introduction of direct suture closure passage; the remainder in each group required LCDE or endoscopic resulted in a statistically significant reduction in hospital sphincterotomy (18%: p=0.001; and 42% NS respectively).All patients stay (5 vs 3 days; p=0.001). with cholangitis had CBDS at the time of operation. Direct suture closure of the bile duct is a safe and effec- The majodty of patients (almost 3 in 4) with CBDS pass their stones tive technique following LCDE resulting in a reduced inci- spontaneously. Four out of five patients with pancreatitis passed their dence of biliary morbidity and a shorter hospital stay. stones spontaneously, in contrast to patients with jaundice who were less likely to undergo spontaneous resolution. Cholangitis always implied the presence of duct stones.

THE VALUE OF LITHOTRIPSY DURING LAPAROSCOPIC MANAGEMENT OF BILE DUCT INJURY DURING AND AFTER REMOVAL OF COMMON BILE DUCT STONES Sheena E. LAPAROSCOPIC CHOLECYSTECTOMY. Konstantinos G. Tsalis M.D., Tranter, MB. ChB., Michael H. Thompson, M.D., Department of Emmanuil Ch. Chdstoforidis M.D., Charalampos A. Dimitriadis M.D., Surgery, Southmead Hospital, Bristol, England Dimitrios S. Botsios M.D., John D. Dadoukis M.D. D' Surgical Department, "G. Papanikoiaou" Hospital, /uistotelion University of Impacted bile duct stones are difficult to remove laparoscopi- Thessaloniki, Greece. cally. The aim of this study is to assess intra-operative endolu- minal lithotripsy as an adjunct to the management of difficult Bile duct injury is perhaps the most feared complication of laperoscopic common duct stones. cholecystectomy. The aim of the present investigationwas to analyze the Comparison has been made between 51 patients undergoing outcome of Isparescopicbiliary tract injury. laparoscopic common bile duct exploration (LCDE) without Twelve patients with bill duct injury after iaparoscopic cholecystectomy available lithotripsy (Group A) and 76 patients where it was were treated. Eight of them were referred to our institution for further used if required (Group B). All data were collected prospective- treatment. The follow-up was complete and focused on clinical outcome ly. and biochemical analysis. Group A patients experienced conversion to open operation Results: Five patients had minor biliary tract injury with leakage. In all in 12 cases (6 for gallbladder inflammation and 6 for impacted of them the biliary tract injury was recognised postoperatively.Two of stones) and post-operative sphincterotomy in 5 cases, result- these patients were managed by ERCP-stent placement. The other 3 ing in 31% failed LCDE's. In contrast, conversion was only patients underwent an open laparotomy and bile duct ligation. required in 11 cases when lithotripsy was available (Group B); Seven patients had major biliary tract injury. In two patients biliary 9 due to gallbladder inflammation, 1 due to bleeding from the injuries were identified at the time of laparoscopic cholecystectomy and cystic artery and 1 due to the large number of stone fragments the procedure was converted to a laparotomy. At the time of conversion produced by lithotripsy, too many for laparoscopic removal. primary suture repeire with T-tube drainage of the injured bile duct was There were no complications from the use of lithotripsy and performed. These patients developed stricture formation after 2 and 6 none of the cases in this Group required post-operative sphinc- months respectively and they were treated with a Roux-en-Y terotomy. The introduction of lithotripsy resulted in a statistically hepaticojejunostomy. In five additional patients, biliary tract injury was significant reduction in the failure rate of stone removal(31% to recognized postoperatively. In this group one patient died because of 9%; p<0.001) and a reduction in hospital stay (5.1 to 3.8 days; lately diagnosed biliary peritonitis. During a median follow-up time of 52 p<0.001). There was one missed stone in each group. months, neither clinical nor biochemical evidence of biliary disease has Lithotripsy is a safe and effective adjunct to the laparoscopic been found up to this writing. removal of common bile duct stones. Rates of conversion and sphincterotomy for failed laparoscopic duct clearance are sig- Laparoscopic biliary tract injury has a high morbidity and mortality rate. nificanUy reduced with a shorter hospital stay. Late recognition of the biliary tract injury remains a problem. $169

HAND-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY: LAPAROSCOPIC VENTRAL HERNIA REPAIR; INITIAL EXPERIENCE ASCENDING THE LEARNING CURVE Ruth vanDoorn MD, Willem Daniel G. Vanuno, M.D.,Ioannis Raftopoulos, M.D., Marcia Edison, Ph.D. Bemelman PhD, Laurens deWit PhD, Janto Surachno PhD, Cees Kox MD, Joubin Khorsand, M.D., Phil Lasky, M.D., Santiago Horgan, M.D., Olivier Busch PhD, Dirk Gouma PhD., Departments of surgery and nephrolo- Department of Surgery, University of Illinois at Chicago.Metropolitan gy, Academic Medical Center, Amsterdam, The Netherlands. Group Hospitals. Chicago, Ininois., Lutheran General Hospital, Chicago, Illinois, Illinois Masonic Medical Center. Chicago, Illinois Introduction Laparoscopic approach in live donor nephrectomy is gaining more acceptance. Potential advantages of laparoscopic donor nephrectomy Conventional repair of large ventral hernias is often associated with a (LDN) as compared to the open technique include rapid patient recovery, bet- ter cosmetic results and increased living donation. Crucial shortcomings are prolonged recovery time. The use of mesh has reduced the recurrence the learning curve. A longer operation and warm ischemia time may compro- rate, but the morbidity is still significant when wide fascial dissection and mize the graft function. The hand-assisted approach might exclude these dis- lysis of adhesions are required. The objective of this study is to investi- advantages. gate the efficiency of the laparoscopic approach in treating large ventral Methods Ten hand-assisted LDN of the right kidney were performed. hernias. Patients were postioned in the French position. Through a 7.5 cm We retrospectively reviewed the records of the first 50 laparoscopic Pfannenstiehl incision the cecum and ureter were mobilized. A 'handport' ventral hemia repairs done at two major community teaching hospitals (Omniport TM, Advanced Surgical Concepts, Co. Wtcklow, Ireland) was over the past 6 years. The size of the hemia defect ranged from 9 to 660 placed. Two 10-11 mm trocars were inserted subumbilical and in the epigas- cm2. The sample was divided into two groups based on the hernia size, tric region. A pneumoperitoneum (12 mmHg) was estabhshed. The right kid- using the mean of 114 cm2 as a cutoff between the groups. A one way ney was mobilized and the ureter was transected, followed by transection of analysis of variance (ANOVA) showed no statistically significant differ- the renal artery. The renal vein was transected by a vascular endostapler. ence (p<.05) in length of hospital stay, retum to normal activities, retum to The kidney was removed through the handport and was directly perfused. work and recurrence rate between the two groups, after a mean follow up Results The median age of the donor patients was 42 years (29 - 57) and of 17.5 months. However, the larger hemias required significantly longer the median body-mass-index was 22.4 (19.4 - 32.6). There were no conver- sions. Median operation and warm ischemia time were 140 minutes (120 - operative time (p<.02) and pain control medications (p<.047). 400 rain.) and 2.5 (1 - 4.5 min.) respectively. Blood loss was negligible. These results suggest that the size of the hernia, though a factor in the Postoperative morbidity included 1 unnary tract infection. One patient with a time needed to conduct the hemiorraphy and in the amount of pain med- long operation time (400 min.) suffered from femoral nerve neuralgy. All but ication needed in the post-operative period, does not have a significant one patient returned to a normal diet within 48 hours. Opiates were needed impact in the length of hospital stay, the time to reasume normal activities for a maximum of 48 hours. The median hospital stay was 8 days, due to the or early recurrence rate. .social relation between donor and recipient. There were no ureteral complica- These supports the fact that the laparoscopic approach minimizes the tions. In 1 recipient there was initial loss of graft function due to unknown significant difference in recovery time that we see when large ventral her- causes, which eventually required graft removal. In all other recipients the nias are approached with the open technique. Laparosoopic ventral graft func'donwas normal. hemiorraphy is an attractive altemive and should be strongly considered Conclusions Hand-assisted LDN significantly reduces operahon and warm for the repair of large ventral hernias. ischemia time even at the beginning of the learning curve.

PERCUTANEOUS CHOLECYSTOSTOMY IS AN EFFECTNE TREAT- CONVERGENCE OF QUALITY OF UFE OUTCOMES OF MENT FOR HIGH-RISK PATIENTS WITH ACUTE CHOLECYSTITIS. LAPAROSCOPE AND OPEN ANTIREFLUX OPERATIONS. Alex.~nder A.Vasiliev, M.D., Petr G. Kondratenko, M.D., M.Konkova M.D., Andrey F.Elin, M.D. Department of Hospital Surgery N= 2, Donetsk State Vic Velanovich, M.D.; Saroj K. Chowdhry, Aisha Violette, R.N. Medical University, UKRAINE. Department of Surgery, Henry Ford Hospital, Detroit, Michigan.

In elderly paints emergent cholecystectomy for acute cholecysttitis Ba..ckqround: Short term analysis of laparoscopic and open (AC) is a high risk procedure. Of 750 patients (range: 14-93 years) who antirel]ux surgery (ARS) have been shown to have equivalent underwent laparoscopic cholecystectorny, had acute cholecystitis; 476 (63,5%) of them aged over 60 years. This reports of our experiences of symptomatic symptom relief, but better quality of life (QL) percutaneus cholecystostomy (PCS) in the treatment of AC in a well defined outcomes in patients treated laparoscopically. However, no high.risk patient group. data exists comparing long- term QOL results. From October 1998 to July 2000 are 138 consecutive high-risk patients Methods: All patients treated with ARS from July 1996 to June underwentPCS by means of a transhepatic (n=130) or transperitoneal (n=8) access mute. In 112 patients (81%) ultrasound control was used for 2000 were interviewed for satisfaction, symptom seventy using puncture guidance, in the 18 (13%) - the procedures were performed under a standardized questionnaire and QOL using the generic QOL laparoscopic control, and 8 (6%) - underwent open dreinage procedure. instrument, the SF-36. Patients were divided into 3 groups:/, L,7~.: Eigth (6%) patients had acute severe medical problems, such as respiratory 1-2 yrs, and > 2 year follow-up. distress and cardiovascular shock. Ninety-one (66%) patients had chronic Results: A total of 144 ARS were done (107 laparoscopic, 37 severe underlying diseases. Ultrasound PCS was successful in 106 (95%) from 112 patients, 6 patients after unfortunate attempted ultrasound PCS open). There were no difference in satisfaction rate between omergency performed PCS under laparoscopic control. Ultrasound-signs of the lap and open group in any foUow-up period, nor were there gallbladder inflammation reduced on 3-4 days (96%). Three (2,1%) patients differences between follow-up period. Similady, there were no died from the evolution of their underlying diseases and 2 (1,4%) patients differences between groups nor follow-up pedods for symptom died from sepsis befor interval operation. Forty seven patients (34%) underwent interval cholecystectomy. Laparoscopyc cholecystectomy was severity. However, QOL scores were better in the lap patients attempted in 46 patients and was successful in 43, with 3 conversions to <1 yr follow up, but in the subsequent follow up pedod, these open cholenystectomy, differences appear to converge. Percutaneus cholecystostomy is a safe, effective trea~ent for high risl( Conclusion: Lap ARS produces similar improvement in >2 yrs. patients with AC. Cholecystostomy can be followed by laparoscopic However, the QOL advantage of lap ARS appears to be of cholecystectomy at later time if the patient's conditions permits or by expectant conservalJve management in patients who have a very high short duration. mortality risk with surgery. $170

LAPAROSCOPIC VERSUS OPEN PYLOROMYOTOMY: A THREE.DIMENSIONALCOMPUTERIZED AXIAL MANOMETRY (CAM) OF THE COMPARISON AND COST ANALYSIS Ashley H. Vernon, CANINELOWER ESOPHAGEALSPHINCTER WITH AND WrrHOUT M.D., William D. Hardin, M.D., Charles S. Baldwin, M.D., Walter FUNDOPLICATION. S. Cain, M.D, Keith E. Georgeson, M.D., Division of Pediatric Leonardo Ville=as,MD; MiguelGarcia-Oria, MD; RobertMcRae; Ross McMahon,MD; Sandhya Lagno, MD. PhD; Erik M Clary,DVM, MS; W. SteveEubanks, MD. Surgery, Department of Surgery, University of Alabama, Endosurgical ResearchGroup, Duke UniversityMedical Center, Durham, NC. Birmingham, Alabama Introduction Morphologicalcharact~zation of the surgically manipulated lower esophageal INTRODUCTION: Them have been numerous reports reflect- sphincter is important for understanding the treatment options for gastroesophagesl reflux ing early experience comparing laparoscopic and open disease (GERD). This study presents a reproducible extensive method of manomeUic pylommyotomy in the treatment of infantile hypertrophic pyloric evaluation using three-dimensional (3D) CAM imaging of the canine lower esophageal stenosis. We performed a retrospective study of 301 cases sphincter (LES), before and after fundoplication,performed in the awake dog. Materials and over the past 42 months. METHODS: From January, 1997 Methods: 6 dogs equipped with a cervical esophagnpoxyunderwent esophageal cannulatiun using the Seldmger technique. Control manometry with a 12Fr catheter containing 8 through July, 2000, 301 pylommyotomies were performed, 129 concentrically positioned channels was performed area" 24hs with the awake dog. The dogs lapamscopic and 172 open. Of the latter group, there were 148 were then divided in three treatment groups: Niasen fundoplication(n=2), Dor fundoplication performed through a right upper quadrant incision and 24 (n=2) and Heller myotomy (n=2). Manometric studies were repeated 4 weeks followingthe through a circum-umbilical incision. RESULTS: The groups main surgical procedure. Results: Vector volume(VV) was increased 105% with Nissen and were similar in terms of sex, age and weight. The procedure 250% with Dor fundoplication,reflectin~ increases in LES lengthand pressures. time was less for the lapamscopic group (23.4 mins) compared LES Length LES Mean LES Max LES to the open group (28.6 mins) (p--0.0001). The postoperative (cm) Pr.(mmH8) Pr.lmmHg) 3DVV(mm~) length of stay was shorter for the lapamscopic group (33.3 Control 2.24 26.6 64.1 6878.4 hours) compared to the open group (41.3 hours) (p=0.002); Nissen 3.15 33.1 83.9 14088 although this did not result in a cost benefit. The cost per Dor 2.50 49.9 113.1 24090 patient for the laparoscopic group was significantly higher than Hdler 1.75 6.78 31.1 415.5 for the open group, $4339 vemus $3886 (p=0.01). The compli- The 3D CAM morphologyof the fundoplicatienper manomet~c studies showed the presence cations were similar for both groups with five perforations in of a high-pressurezone posteriodyat the levelof the wrap in the Niss~ and on the fight in the lapamscopic group and four in the open group. CONCLU- Dor fundoplication. Hdler myotomy resulted in a reduction of LES pressures and vector SIONS: Laparoscopic pylommyotomy is equally safe and effec- volume. Conclusion: Manometric and 3D vectorvolume studies can be used to evaluatethe tive as open pylommyotomy in the treatment of hypertrophic morphologyof the LES and can providerecognizable patterns in variousfundoplication models pyloric stenosis. The lapamscopic procedure has obvious cos- and followinga Hellermyotomy. This information,in conjunctionwith patient symptomsand metic benefit, but the challenge now is to reduce cost. 24-hour pH studies, may provide a more thorough understanding of the efficacyand failure patterns of fundoplicationtechniques.

THE MANOMETRICCOMPONENTS OF THE LOWERESOPHAGEAL FIBRIN SEALING IN MINIMALLY INVASIVE SURGERY H:W. WACLAW- DOUBLE HUMP ICZEK, M.D., LandeskrankenanstaltenSalzburg ALEXANDER KLAUS, MD, FRANK RAISER, MD, JAMES M. SWAIN, MD, For the application of the two component sealant in minimal invasive RONALD A. HINDER, MD surgery a special adaptor for the trocar was designed in combinationwith a Mayo Clinic Jacksonville,Department of Surgery, 4500 San Pab[o Road, thin plastic catheter, which can be placed next to the wound surface which Jacksonville, 32224 FL has to be sealed.

Obiective of the study:The lower esophageal sphincter manometry of patients with Indicationsand Results: hiatal hernia often displays a double hump configuration. It seems that this is due to gastricbemiation above the high pressurezone of the crur~ This studyexamines this 1) FS (2 ml) was used in laparoscopic cholecystectomies (LC) when intra- manometric phenomenon in patients with hiatal bemia and relates it to the lower operativelydiffuse bleeding from the liver bed occurod and/or severe distur- bances of the blood coagulation in scope of liver cirrhosis, sepsis or acute esophageal antireflux barrier. acute choecystitis were observed. This method was necessary in 84 out of Methods: Manometric and 24-hour pH studies of 68 consecutive patients with 2.832 LC (4%). In only 3 of these cases a rebleeding occured which had to suspected gastroesophageal reflux disease were analyzed to obtain information be reoperated. regarding the double hump and acid reflux. Results: The findings of a manometric double hump correlated well with the presence 2) FS was also applied in very selected cases with liver (n-=2) and spleen of a hiatal hernia greater than 5cm. The mean pressure of the lower and upper high (n---3)traumas laparoscopically to achieve hemostasis. These lacerations pressure zones was 12.~1.3 mmHg and 16.0~1.4 mmHg respectively. The overall were then coated w~ a collagen fleece additionally. In none of of these patients postoperative complicationsoccured. length of the sphincter complex was greater in patients with a double hump (6.6:k0.3 vs. 4.3~.2, p<0.0001), but the length below the respiratory inversion point was 3) Another excellent indication for FS is the additional sealing of laparo- constant (2.5~.2 vs. 2.2_+0.1, p--0.2). Resting pressures at the respiratory inversion scop'r.~ly point were significantly lower (4.9i-0.9 mmHg) than those measured at either high sutured or stapled perforations and anastomoses of the gastrointestinal tract(i.e, perforated duodenal ulcer, bowel injuries, colon resection etc.) to pressure zone (12.~1.3 mmHg and 16.0-2:1.4mmHg). The location of the respiratory avoid postoperative insufficiency.The postop, leakage rate in our series inversion point was seen most commonly at the superior margin of the distal high amounted pressure zone. Double hump patients with a negative acid reflux score were found to 1.9 % (1/46). have higher pressures in the distal high pressure zone than patients with acid reflux. Conclusions: The two high pressure zones comprising the manometric double hump 4) Also in video assisted thoracic surgery (VATS) FS was used in patients represent the cmral and muscular components of the lower esophageal sphincter. suffering from recurrent pneumothorax in order to form adhesions of the Descriptive information regarding the double hump phenomenon is given, and the pleura after apical lung resections and so to avoid recurrences. In all these importance of the crural component of the lower esophageal sphinct~ in preventing cases (n=41) the FS method was sucassful. acid reflux is stressed. This information stresses the importance of crural closure Conclusion: during laparoscopic antireflux surgery. Rbrin sealing is a simple, safe and most effective method to achieve hemo- stasis and better wound healing also in minmal invasive surgery, The post- operative morbidityand mortalitycan be reduced. $171

TOTAL LAPAROSCOPIC RESECTION OF COMPLICATED HEPATIC LAPAROSCOPIC MESH RECONSTRUCTION OF SEVERE ABDOMI- VASCULAR TUMORS Donald J. Waldrep M.D., Helmuth T. Billy M.D., NAL WALL ATROPHY FOLLOWING OPEN ANTERIOR EXPOSURE Steven C. Patching M.D., Sacramento Advanced Laparoscopic Surgery FOR LUMBAR SPINE SURGERY Donald J. Waldrep M.D., Helmuth T. Associates, Sacramento, Califomia Billy M.D., Steven C. Patching M.D., Sacramento Advanced Laparoscopic Surgery Associates, Sacramento, California Introduction: Although minimally invasive surgical techniques have been described for hepatic resection, reports of laparoscopic excision of compli- Introduction: The benefit of employing minimally invasive surgical tech- cated hepatic vascular tumors are rare. We describe total laparoscopic niques to repair complicated abdominal wall hernias has been astab- resection of symptomatic hemangiomas in four patients, including an intra- fished. We present three patients referred for repair of severe unilateral hepatic 5 cm segment VIII lesion abutting the right hepatic vein and vena atrophy of the abdominal wall. We believe this is an as-yet-undescribed cava. complication of open anterior extraperitoneal exposure of the lumbar Methods and Procedures: Four females were referred for surgical resec- tion of symptomatic hemangiomas. The surgical team included two sur- spine. geons with extensive advanced laparoscopic experience. All patients Methods and Procedures: Three patients had recent lumbar spine underwent a total laparoscopic excision via a 4-trocar approach. surgery pdor to referral. All complained of subsequent left abdominal wall Results: All patients were female and ranged in age from 35 to 47 years. distention and pain. Abdominal wall mesh reinforcement was performed Preoperative symptoms of intermittent severe abdominal pain and nausea laparoscopically in each patient. were present from 3 to 16 months prior to referral. Surgical evaluation Results: Three females, ages 56, 60, and 76, underwent spine surgery included ultrasound, HIDA scan, esophagogastroduodenoscopy, CT, MRI, four, twelve, and five months prior to referral, respectively. Symptoms of and angiography. Involved segments included II/111,IV, V, and VIII. Tumor left abdominal distention and pain began three days to five months after size in greatest diameter ranged from 2 cm to 6 cm. All resections were spine instrumentation. Defects were 16 to 20 cm in the longest diameter. completed laparoscopically. The Pringle maneuver was performed in three A total laparoscopic 2- or 3-trocar technique using 3 mm or 5 mm, and 10 patients. Vascular isolation was completed for the segment VIII lesion by mm trocars was employed for mesh reinforcement of the left abdominal control of the intrahepatic right hepatic vein. Dissection was performed with wall. Operative time averaged 58 minutes (42 -70). Hospital stays were an ultrasonic aspirating device in one patient and harmonic shears in the 0, 1, and 3 days. There were no operative or postoperative complica- remaining three. Operative times ranged from 40 to 516 minutes. No tions. The patients have been followed for 3, 8, and 17 months. All patient underwent conversion to laparotomy. Estimated blood loss was less patients had resolution of preoperative symptoms, with no further than 50 cc in three patients and 1500 cc for resection of the segment VIII enlargement of the defect. One patient underwent laparoscopic explo- lesion. One cholecystectomy was performed. Hospitalization was 1, 3, 3, ration five months postoperatively, revealing complete incorporation of and 5 days, respectively. The only complication was a postoperative uri- the mesh by the peritoneum with no mesh migration. nary tract infection. Follow-up has ranged from 3 to 13 months. All patients Conclusions: Severe abdominal wall atrophy is a rare but disabling have had complete resolution of symptoms. complication of anterior extraperitoneal exposure of the lumbar spine. Conclusions: The well-established postoperative benefits of minimally Minimally invasive techniques provide an excellent altemative to tradition. invasive surgery may be achieved in total laparoscopic excision ot large al procedures, such as open mesh reconstruction or the use of muscle hepatic vascular tumors. flap transfer.

MICROLAPAROSCOPIC FUNDOPLICATION Donald J. Waldrep M.D., ACCURATE DETERMINATION OF INTACT SPLENIC WEIGHT BASED O1~ Helmuth T. Billy M.D., Steven C. Patching M.D., Sacramento Advanced MORCELLATED WEIGHT. R. Matthew Wal~h, M.D,, Bipan Chand, M.D., Laparoscopic Surgery Associates, Sacramento, California Jason Brodsky, M.D., Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, R. Todd Heniford, M.D., Carolinas Medical Introduction: Technical improvements in lapamscopic instrumentation Center, Charlotte, North Carolina. have allowed a progressive "rninimalization" of minimally invasive surgery. Microlaparoscopy is increasing in popularity for cholecystectomy because of the perceived benefits that include less pain and improved cosmetics. Comparisons of splenic size based on splenic weight is difficult after We present a series 38 consecutive laparoscopic fundoplications per- laparoscoplc splenectomy (LS) which results in a morceitated spedmen. Wq formed with 3 mm endosurgical instrumentation. report results of direct compedson of moroeliated and intact splenic wts. Methods and Procedures: Between February 1999 and August 2000, 38 Porcine spleens were harvested via a midline lapamtomy and an intact consecutive patients underwent laparoscopic fundoplication using a five- splenic wt obtained which served as the control. The spleen was then place( ~ocar approach (three 3 mm and two 5 ram). into an impermeable retrieval bag and returned to the peritoneal cavity. A Results: Of the 38 patients (23 male and 15 female) presented, 9 had a separate 10 mm indsion was made through which a utedne forceps history of previous abdominal surgery. Three-millimeter instrumentation mechanically morcellated the spleen. This design most faithfully recreates was employed except when limited by available technology (in the LUQ in the morceflation process at LS in humans. The aggregate wt. of the order to accommodate 5 mm harmonic shears and in the RUQ to accom- fragments was compared with intact splenic wt. Intact and morcellated wts. modate the 5 mm liver retractor). Procedures included Nissen fundoplica- were obtained from 58 porcine spleens. A linear regression analysis with tion in 34 patients, Toupet fundoplication in 3 (including one revision of a 95% prediction limits are given in Rgure 1. For a given morcellated wt. previous Nissen), and one esophagomyotomy with Dor fundoplication. In achieved at L$, an actual intact wt. can be determined by the following all antireflux procedures, the short gastric vessels were divided harmonical- ly, a beugie was employed, the crura approximated, and the wrap was formula: Intact wt. (gins) = morceliated wt. (gins) x 1.34 +44.92. sutured to the esophagus. Operative time averaged 110 minutes (55-145). No patient required conversion to standard laparoscopy or laparotomy. ~gure 1 Eight patients were discharged home from the recovery room, 27 were dis- charged the following morning, and 3 had hospitalizations of 2, 2, and 4 days. Pedoperative complication included reintubation in a patient with known pulmonary disease. All patients had resolution of their preoperative GERD symptoms. Functional complications of longer than 8 weeks includ- ed gas bloat in 2 patients and mild dysphagia in 1. Conclusions: Microlaparoscopic instrumentation allows fundoplication to be performed in a manner technically identical to standard fundoplication. The operative time and length of stay is comparable to or better than previ- ously published reports while providing identical outcomes. In summary, an intact splenic wt. can be accurately predicted by morceliated wt. These data allows for classification of splenic size based o= morcellated wt. S172

CURRENT INCIDENCE OF BILIARY TRACT LEAKS FOLLOWING BI-LEVEL POSITIVEAIRWAY PRESSUREFOR PERCUTANEOUS LAPAROSCPIC CHOLECYSTECTOMY. ENDOSCOPIC GASTROSTOMYTUBE PLACEMENT IN PATIENTSWITH Jeffrey L. Ponsky, M.D., Department of General Surgery, Cleveland Clinic AMYOTROPHIC LATERAL SCLEROSIS. Foundation, Cleveland. Department of General Surgery, Edk Pioro, M.D., Departmentof Neurology, ClevelandClinic Foundation, Cleveland,Ohio. Biliary leaks following laparoscopic cholecystectomy (LS) were felt to be the most common bitiary complication when the operation was introduced.. Amyotrophic lateral ,sclerosis(ALS) is a progressivedegenerative motor The current inddence and types of biliary leaks following LS performed by neuron diseasethat causes dysphagia and pulmonaryfailure. A expadenced surgeons is unknown and is the subject of this report. percutaneous endoscopic gastrostomy(PEG) tube may forestallpulmonary A prospective database is maintained of all biliary complications following failure from malnutrition. Bilevelpositive ailway pressure (BIPAP) is a device LS. From January, 1995 through July 2000 a total of 5 biliary leaks were that can support pulmonaryfunction during PEG insertionto avoid acute identified following a total of 1696 LS performed (incidence 0.3%). There respiratoryfailure. were two cystic duct leaks, two leaks from a duct of Luschka, and one was a From January, 1999 through July 2,000, 769 patientswith ALS were tiny lateral common duct leak presumed to be a thermal injury. The number evaluated at the ClevelandClinic, and 13 (2%) were referredfor PEG. There of LS has increased yeady since 1995 (183, 241,321,341, and 371, were 10 women and 3 men with a mean age of 64 (52-77) years. The mean duration of ALS symptoms was 26.7 ('/-72) months. The averageamount of respectively) with one leak occurring in 1998, two in 1999, and two in 2000. weight loss was 18.2 (0-33) pounds. Seven (54%) of patientswere on home Four of the five were operated for chronic cholecystitis, one for acute BIPAP. All receivedpulmonary function tests pdor to PEG; the mean FVC cholecystitis. The mean time of presentation was on the third post.operative was 127 (.41-2.2) liters, representing42 (25-68)% of predictedvolume. day (range 1-5 days) FEV.1 averaged0.92 (0.5-1.67) liters, which is 39.5 (17-54) % of predicted. Four patients were suspected to have a biliary injury due to persistent pain Pnor to endoscopy, all receivedtopical pharyngealanesthesia and and underwent computed tomography and biliary contrast studies. Two had intravenoussedation, Demero125.50mg and Versed 1-2rag.A complete collections amenable to percutaneous drainage, and all four had leak of EGD was performed in 12, and 10 (77%) had double endoscopy. The mean contrast at ERCP (3) or PTHC (1). Three of these patients were successfully length of time for procedure was 9.6 (5.13) minutes. The mean pre- treated with endobiliary stents. One patient failed stenting and required two procedure room air oxygensaturation was 95.5 (86-100)%. All received laperotemies for persistent intra.abdominal sepsis from which she supplemental oxygen (2.10 liters), BIPAP settings ranged from 6-25 cm H20 succumbed. The one remaining patient was explored for an acute abdomen end inspiratorypressure/2-5 cm H~O end inspiratorypressure. The lowest of the third postop day and the lateral common duct thermal injury was mean oxygensaturation during the pmcedurs was 92 (85.98)%. One patient treated successfully by T-tube insertion. had stndor post-procedure,none required intubation. At a meanfollow-up of In summary, blliary leaks are currently uncommon. The cause of the leak 8.3 (1.5-17) months, 8 (62%) have succumbed, all to respiratoryfailure at a is vadabie and not necessarily from the cystic duct stump. Control oftho mean of 8.5 months post-PEG. All had maintained or gained (2-61bs)weight. leak with drainage and stenting is crucial, yet may not ensure success. BIPAP is a useful adjunct to PEG placementin patientswith ALS and ma~ed pulmonarycompromise.

RETAINED GALLBLADDER/CYSTIC DUCT REMNANT CALCULI AS A TEP WITHOUT BALLOON DISSECTION OR MESH FIXATION CAUSE OF POST-CHOLECYSTECTOMY PAIN. R. Matthew Walsh, M.D., Carl J. Westcott, MD., Frank Chase, MD., Department of Surgery, Wake Jeffrey L Ponsky, M.D., Department of General Surgery, John Dumot, D.O., Forest University School of Medicine, Winston-Salem, NC. Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio. Laparoscopic hernia repair is cdtidzed on the basis of cost, operative times, and complications. OR times have been shown to decrease with Pain following cholecystectomy can be a diagnostic and therapeutic experience, and eliminating disposable equipment can bdng down expenses. dilemma. We reviewed our experience with calculi retained in gallbladder Presented is a senes of totally extra-pentoneal hernia repairs (TEP) and cystic duct remnants which present with recurrent biliary symptoms. performed without mesh fixation, or balloon dissection. These are compared Over the last six years, six patients have been referred for evaluation of to a group of traditional TEP repairs. Variables examined were direct OR recurrent biliary colic orjaundico. There were four men and two women cost, procedural times, and complications. ranging in age from 35 to 70 years. All six had biliary pain similar to 35 patients underwent a no tack-no balloon TEP. 42 TEP repairs by symptoms that preceded cholecystectomy, two had assodated jaundice and the same surgeon using mesh Exation and balloon dissection are used as a control group. There was no difference in over all OR times. Traditional TEP one pancreatitis. The time from cholecystectomy to onset of symptoms averaged 70 rain for unilateral and 76 rain for bilateral The experimental ranged from 14 months to 20 years (median of 8.5 yrs). Four had undergone group averaged 66 rain and 82 rain, respa~vely. There was a significant laparoscopic cholecystectomy and two open cholecystectomy; none having learning curve for manual prepedtoneal space creation as it relates to OR had an operative cholangiogram. Five of six had a diagnostic endoscopic times. Unilateral balloon-less OR times decreased from 83.1 rain for the first retrograde cholangiography (ERC) with obvious filling defects in the cystic 10 procedures to 63.7 rain (p=0. 03) for the last 10. Groin hemetoma, cord duct or gallbladder remnant. The final patient was diagnosed by swelling, recurrence rates, residual discomfort and conversion to TAPP did laparoscoplo ultrasound after eight negative radiographic exams. Three not differ between groups. Costs per case were significantly decreased in the underwent laparotomy and resection of a retained gallbladder and cystic experimental group. Recurring equipment costs for a bilateral repair duct. Two were treated with extracorporeal shock-wave lithotdpsy (ESWL) averaged $516 vs. $76, and unilateral repairs averaged $481 vs. $41. Total one of which also required endoscopic biliary Holmium laser lithctdpsy. One hospital savings for the experimental group (n=35) was $13,604 compared to patient underwent successful repeat laparoscopic cholecystectomy. There traditional TEP. were no treatment related complications. At a median follow-up of 11.5 TEP hernia repair expenditures can equal the cost of insufflation months, all have achieved complete stone clearance and are asymptomatic. tubing and Ititer over and above that of open mesh inguinal hemiorraphy. In summary, retained gallbladder and cystic duct calculi can be a source of Alter a short learning curve the proposed changes do not affect operative recurrent biliary pain, and an heightened suspldon may be required to make times or short term recurrence rates in these small groups. Complication the diagnosis. This entity can be prevented by accurate identification of the rates are not affected and the threat of stapler or tacker complication gallbladder.cystic duct junction at cholecystectomy and by routine use of avoided. cholangiography, A vadety of therapeutic options can be employed to obtain a successful outcome. S173

PERSISTANCE OF PNEUMOPERITONEUM AFTER CARNEY'S SYNDROME: LAPAROSCOPIC RESECTION OF A GAS- TRIC STROMAL TUMOR(GIST) IN A 17-YEAR OLD GIRL Jason Paul LAPAROSCOPIC SURGERY Wiltshire, M.D., Phillip D. Price, M.D., Department of Surgery, Mt. Warren D. Widmann, M.D., Elizabeth Teigen, M.D., Ned Carmel Medical Center, Columbus, Ohio Dykes, D.V.M.,, Lawrence Crist, M.D., Lauren= Willekes, Carney's syndrome is a rare condition consisting of M.D., $haun Calhoun, D.O., Eric H. Liu, M.D., Alycia Lungs leiomyomas/leiomyosarcomas of the stomach, pulmonary chondromas, Columbia Universe, College of Physicians and Surgi~ons, and adrenal paraganglionomas. A case is reported of a 17-year old girl 177 Ft. Washington Avenue, NY NY; Departmentsof Surgery suspected of Camey's syndrome who underwent laparoscopic resection of a gastric tumor. and Radiology, Universityof Medicine and Dentistryof New JS was admitted to our hospital with a severe anemia in February, Jersey, Morristown Memorial Hospital: 100 Madison Avenue, 1998. Extensive workup including colonoscopy, esophagogastroduo- Morristown, NJ denoscopy, and upper intestinal contrast studies revealed an ulcerated gastric mass which was histologically identified as a gastrointestinal stro- mal tumor after local laparoscopic resection. Further histologic evalua- This studywas performed to d=terminethe extent and tion by Mayo Clinic Pathology Department and J.A. Camey, M.D., con- firmed the uncertain malignant potential of the tumor consistent with the duration of pneumoperltoneumpost-laparoscopic surgery. syndrome. CT evaluation of the chest and abdomen revealed no evi- Five 140-150 lb. swine were studied alter standard dence of the tumor tdad. Consultation with the patient and family was laparoscopic and laparoscopicassisted cholecystectomy,and performed, at which time further surveillance was elected versus total open cholecystectomy. gastrectomy. The patient tolerated her initial procedure without incident and left the On plain film and CT imaging examination,there is little hospital on postoperative day 6. Regular endoscopic evaluation includ- remaining pneumoperitoneumby 36 hours postlaparoscopy. ing an endoscopic ultrasound of the stomach post-resection revealed no further evidence of recurrence at 24 months of follow-up. The time resolutionof pneumoperttoneumis expectedly Recurrence and malignancy is typical of Camey's syndrome GISTs. longer post open surgical procedures. They tend to occur in families and young women. Local resection is fol- Finding more than small amounts of pneurnoperitoneum lowed by local recurrence in the majodty. Total gastdc resection is the procedure of choice when the patient is known to have Camey's syn- greater than 36 hours after laparoscoplcand laparoscopic drome and develops a GIST or has a malignant GIST. Patients who are assisted proceduresis suggestive of a source otherthan at suspicion of Camey's syndrome with a gastric stromal tumor of uncer- residual CO2 pneumoperitoneume.g. bowel perforationor tain malignant potential are adequately resected locally with regular endoscopic follow-up and evaluations for the other components of the bowel =mstamotlc leakage. syndrome. Laparoscopic resection is effective and safe in this situation.

CORRELATIONBETWEEN ESOPHAGEALEXPOSURE TO ACID AND APPLICATION OF LAPAROSCOPIC COLECTOMY USING THE ESOPHAGEAL MOTILITY.Eleftherins S. Xenos, MD, Depadmentof Surgery,Lincoln RETROPERITONEAL SCOPY Yamada Hideo,M.D.,P_j, Ochiai County MernonalHospital, Troy, MO. Takenori,M.D.,,Q..j, Okazaki Yasunaga, M.D.,Pi, Michihiro Kawada Objso~ve:Factors that predisposeto gas~oescphagealreflux =nclude dacre~sed ,M.D.,P_i, 1) Dept. Of Surgery, Sakura national hospital, Chiba, Japan restingpressure of the loweresophageal sphincter( LES ), transientrelaxation of the ,1) 2 nd Dept. Of surgery, Chiba university, Chiba, Japan sphincter,abnormal esophageal acid clearance, dllatabon of the ga~oesophageal junc~on,delayed gastric emptying. Thisstudy evaluatedthe relationshipbetween Generally, it is thought that the technique of a laparoscopic colectomy esophagealacid expesure and manometricindicators of esophagealmotility. as the treatment for the colo-rectal cancer is difficult. Therefore, it takes Methodsand procedures:46 patientsunderwent esophageal manometry and 24- a long time at the operation time of a laparoscopic colectomy. To short- Iv pH testingfor evaluationof symptomssuggestive of reflux. Patientswith scisroderma, en the operation time and to assume a steady operation, we developed previoussurgery of the cardia,achalesia and esophagealstenosls were excluded. a laparoscopic colectomy which used the retroperitoneal scopy. The Medicationaffecting esophageal motility and gast~cacid production were discontinued 7 advantage of this technique is as follows. We can dissect the retroped. daysprior to the study. The esophagealmanomelr/study was performedusing the station toneum in a short time. We can obtain excellent view. And, we can see pull ~ough technique. LE$ pressureand length,percentage of penstaltic,hypotens~ve the blood vessel and ureter. We will show our operation method of and uncoordinatedswallows of the esophagealbody and, distal esophageal pedstals~ and anterior resection. We insert the scope into the abdominal cavity. And, waveamplitude were measured. The DeMeesterscore was usedto quant~teesophageal we observe the organs, liver, colon and others. Next, we insert the bal- acid exposureduring the 24-hrpH study. loon from a left side of abdomen to the retroperitoneum. We e~pand Results:17 patientshad DeMeosterscore<14.4 (group 1) =ndicatingphysiologic the balloon and expand the retroperitoneum. We remove the balloon. refluxand 29 patientshad De Meesterscore >14.4 (group 2) indicatingpathologic reflux. Next, we flow the carbon dioxide in to the retroperitoneum. And we do Therewas no differencebetween the ageand gendercharacteristics between these two retrepedtoneal scopy. We can see the dght and left common lilac artery, groups. Therewas no statis0callysignificant difference between the LES pressure(20-+15 the right and left ureter, Abdominal aorta, and IMA under the retropedto- mm Hg for group1Vs 15_+7mmHg for group2, p=0.19)and length(3_+1.3 crn for group 1 meal scopy. We are not disturbed view by other internal organs such Vs 3.3+1.2cm for group2, p=0.38).Similarly, the percentageof distalesophageal as small intestines and can see these vessels easily. Next, we inserl peristalticwaves was not differentbetween the two groups Patientswith pathologic reflux the scope into the abdominal cavity. Aorta and IMA can be easily had greaterpercentage of hypatensiveswallows (p=0.0017) and a greaterpercentage of observed by incising the retropedtoneum at the dght side of the meso- combinationof hypotensiveand uncoordinatedswallows (17_+25 % for group 1 Vs 32_+24% colon sigmoideum. We ligate and dissect IMA. Next, we dissect the left for group2, p=0.05). Alsothe amplitudeof the distalesophageal perista~ waveswas side of the retropedtoneum and cut the colon. We do anastomosis. smallerin the patientswith abnormalDeMeester score (8822 mmHg for group2 Vs Laparoscopic assisted colectomy is done to the cancer of Cecum, Ascending colon, and Tranverse colon. We have performed laparo- 116_.51 turn Hg for group1) but the differencedid not reachstatistical significance scopic colectomy for the colo-rectal cancers on 230 cases since 1994. (p-0.0a). The transition of the operation time is seen. The operation time has Conclusions: Pelientswith abnormalexposure of the esophogusto acidappear to have impairedmotility of the bodyof the esophaguswith fewer normal peristaltic been shortened by using the retroperitoneal scopy. Present operation swallowingwaves. They alsoexhibit smaller contraction amplitude of the distalesophagus. time is 120_}31 minutesin laparoscopic colectomy using retropedtoneaJ In this studyLES pressureand lengthwere not foundto be significantlydifferent between scopy. The postoperativus complication in this technique is not seen. Neither the hemorrhage nor the ureter trauma, etc. We will present the the two groups. technique of the taparoscopic colectomy and our results. S174

HAND-ASSISTED LAPAROSCOPIC SPLENECTOMY FOR SPLENIC EXPERIMENTAL ASSESSMENT OF AESOP, ENDOASSIST, TUMOR: A CASE REPORT. ~d~, Takushi Monden,M.D., IMAGTRAC AS SURGICAL CAMERA HOLDERS Yunus Mnsakatsu Kinuta,M.D., Yoshlaki Nak~mo,M.D., Takushi Tono,M.D., Shigeo Yavuz,M.D., Eirik Skogvoll*, M.D.,Ph.D., Brynjulf Ystgaard**, M.D., Matsui,M.D.,Takashi lwazawa,M.D., Toshiyuki Kanoh,M.D., Jun Okamura,M.D., Ronald Marvik, M.D., National Center for Advanced Laparoscopic Departmentof Surgery, NTT ~8,~stOsaka Hospital, Osaka, Japan Surgery, *Department of Pediatrics, **Department of Surgery, Trondheim University Hospital, Trondheim, Norway Splenic tumor, such as a hemangioma, lymphangioma, hamartoma, hemangic6areoma,malignant lymphoma, metastatic caranoma et al. is very rare and Surgical robots have been introduced to provide more precise and it is difficult to di~ preolm'atively whether it is malignant or not. The steady control of camera. We aimed to compare commemially available technique of hand-assistedlaparocoplc splenectomy (HAts) was dcvdct0ed mainly robotic camera holders Aesop (manual, voice and memory modes, for benign hematologic disease, such as idiopathic throm~nic purpura or Computer Motion,USA), Endoassist (Armstrong, England),lmagtrac heredit=y spherocytmis. We report a case of metastatic splenic tumor, rem~ by (Olympus, Japan) with the conventional human control. HALS. The patient is a 38-~r-old woman who undenvcuta hysterectomy,bilat~ A single examiner conducted the study in surgical training boxes with ~y, omentectomy by diagnosis of fight ovarian carcinoma(stage lllc) three standard laparoscopic equipment. Unear (upwards, downwards, side- yems ago. The solitary tumor formationof 3.0cm in the spleen was noticeablein a ways and diagonal) in and out, and complex three dimensional move- ments were assessed by using standardized distances and tests. The CT scan and MPJ. Ne/~r aacites, reU'Ol~-itoneallymph node swelling, nor other time required to achieve each task was measured assuming that the metastatic lesions was observed in the ixeolmmive examinations. HAtS was decided more precise and accurate the movements of the robot were, the short- to perform, becausewe could not diagnosewhether this tumor was malignant or not, er the time it would take to perform the tasks. Linear regression analy- ~mmy or metastatic, l.~oeroso~c p~edures were ped'ormed with the surgeon's sis and Mann-Whitney test with Bonferroni corecction was used left hand through the 7cm skin incision and lafamscopic coagulating shears. We ckl accordingly. not use the metal clips to cut the vessels. The splenic vessels were dividedusing In all type movements human control provided the best camera control. vascular stapl~ By the palpation of the left hand, the swollen regional lymph node In linear movements, Aesop manual control and Imagtrac were the was also n:sec~. The duration of surgery, and intra-operative blood loss was quickest among all; whereas voice and memory modes of Aesop and 178minutes, ~ 22g respactivdy. She could walk amend at the l'u'st post-operative Endoassist were relatively slower. Conceming in and out movements day, dischargeat the t0th post-opaneive day. The pathological diagnosis of splenic Imagtrac was the most effective and closest to human control (p<0.05). tumor aod the swdlen regional lymph node was metastatic serous papillary In complex three dimensional movements the memory mode of Aesop =leux:mcinuna from ovarian cancec The totally latxu'oscoplcsurgery, for splenic was supenor to other types (p<0.05) and it was followed by manual malignancies is now discussed to he a good indication or not, because the other control of Aesop and tmagtrac. malignant lesions including regional lymph node, pancreas and stomach =m not be The human control of the camera is still the best option regarding to dL,~c~__by only an inspection with lapsrow.opy. On the contra~, HALS is safe and a time required to achieve each movement; whereas the quality of vision good indication for splenic tumor, _beca_,_,_,_,~the 1~ resection of the malignant is poor due to movements of the scope. On the other hand, among the lesions may he expected by both the inspection with laparoscopy and ~pation of robotic systems the manual mode of Aesop and Imagtrac were efficient the tumor like a open surgery. and precise compared to the other robotic arms.

OUTCOME OF LAPAROSCOPIC COLORECTAL SEGMENTAL LAPAROSCOPIC COLORECTAL SURGERY: EARLY AND LA'I-FER RESECTIONS IN ELDERLY PATIENTS Seong Yeop You, M.D., Alon EXPERIENCE Pikarsky, M.D., Sung Won Chun, M.D., Pascal Gervaz, M.D., Eric G. Seong Yeop You, MD, Chien Yuh Yeh, MD, Sung Won Chun, MD, Pascal Weiss, M.D., Juan J. Nogueras, M.D., Anthony M. Vemava III, M.D., Gervaz, MD, Jonathan Efron, MD, Eric G. Weiss, MD, Juan J. Nogueras, Steven D. Wexner, M.D., Department of Colorectal Surgery, Cleveland MD, Anthony M. Vemava III, MD, Steven D. Wexner, MD, Departmentof Clinic Ronda, Fort Lauderdale, Flonda Colorectai Surgery, Cleveland Clinic Flonda, Fort Lauderdale,Flonda Background: Application of laparoscopic colorectal segmental resec- tions to elderly patients is steadily increasing. The aim of this study was Background: The aim of this study was to compare early and more to evaluate the outcome of laparoscopic colectomy in the elderly. recent results of laparoscopic colorectal surgery to assess any differ- Methods: All patients, who underwent laparoscopic-assistedsegmen- ences in indicationsor proceduresas well as any changes in results. tal resections between August 1991 and September 1999, were divided Methods: All patients who underwent elective laparoscopic colorectal into two chronological groups: below 65 years of age (Group I) and 65 surgery were prospectively entered in a laparoscopic database. Group 1 years and above (Group II). All operations were performed by one sur- included individuals operated upon between August 1991 and December geon. Statistical analysis was performed utilizing Fisher's Exact test for 1995 while Group II includedJanuary 1996 to September 1999. qualitative data, Mann-Whitney test for continuous non-parametricvari- Results: 364 patients underwent elective laparoscopicsurgery includ- ables, and Student t-test for continuous parametric variables; p value of ing 175 patients in Group I and 199 patients in Group I1. While them <0.05 was considered statistically significant. were no differences between the two groups relative to gender, patients Results: There were 88 patients in Group I and 101 in Group II. There in Group II were significantly older [50.3+19.5 (range 15-89) years; were no differences in gender between the two groups (10=0.15) and p<0.001]. In addiUon,significan T more patients in Group I than in Group the procedures were well stratified. Operations performed included dght II had undergone total abdominal colectomy or restorativeproctocolecto- hemicolectomy: 55 and 63, left hemicolectomy: 5 and 8, sigmoidecto- my (17% vs 2%;p<0.01) for either mucosal ulcerative colitis (19% vs my: 29 and 30 in Groups I and II, respectively.There was no difference 2%;p<0.01) or constipation (7% vs 2.5%;p<0.05). Conversely,the num- in the incidence of previous abdominal surgery between the two ber of patients who underwent nght hemicolectomy increased from groups. The most prevalent indications for surgery were neoplasia in Group I to Group II (24.5% vs 39.7~ mostly due to an increase Group I and Crohn's disease in Group I1. Significantly more patients in in terminal ileal Crohn's disease (18.8% vs 26.6%). Despite the fact that Group I1 than in Group I had higher (111and IV) ASA scores (19~ vs there was an increase from Group I to Group II in the number of patients 50%;p<0.0001). There were no statistical significances between the who had adhesions (25% vs 51%;p<0.001), the conversion rate two groups relative to the incidence of conversion (11% vs decreased (22% vs 14%;p<0.01) as did the intraoperativecomplication 15%;IO==0.52),intraoperative complications (6% vs 7%;p=0.77), postop- rate (16% vs 4.5%;p<0.01) and the operative time (181 vs 154 min; erative complications (37% vs 43%;p---0.66), operative times (169 vs p<0.01). 175 min.; 10=0.55),estimated blood loss (182 vs 213 ml; p--0.57), time Conclusion: Increasing experience in laparoscopic colorectal surgery to return of bowel function (4.2 vs 4.6 days; p=0.17), or length of hospi- may have lead to better case selection with the performanceof less total talization (6.8 vs 7.4 days; p=0.17). abdominal colectomias and restorative prectocolectomiesand more seg- Conclusion: Despite higher ASA scores in eldedy patients the out- mental nght colectomias. Thus, despite an increasing need to perform comes were comparable to those in younger patients. enterolys~s, both the conversion rate and the intraoperativecomplication rate decreased as did the operate time. $175

INITIAL PATIENT SERIES WITH A ROBOTIC ASSISTED LAPAROSCOPIC VS OPEN REPAIR OF INCISIONAL HERNIAS NISSEN FUNDOPLICATION James A Young, MD, William USING A MESH. H H Chapman, III, MD, Robert J Albrecht, MD, Victor B A CASE CONTROL STUDY Hans Zengerink MD, Bait Appeltans MD, Kim, MD, L Wiley Nifong, MD, W Randolph Chitwood, Jr, Henk ten Cate Hoedemaker MD Department of surgery, Academic Hospital Groningen,Groningen, The Netherlands MD, East Carolina University, The Brody School of Medicine, Department of Surgery, Greenville, North Introduction: Carolina Laparoscopic repair of incisionai hernias using a mesh is an attractive alternative to conventional open repair for larger defects. Many advan- Objective: The FDA has recently approved clinical use of tages are reported, but studies comparing the laparoscopicmethod with the da Vinci robot for general abdominal surgery. We will the open techniqueare rare. present results from our initial series of ten patients. Goal of this study was to prove these reported advantages. Methods: Methods: Patients with indications for elective Nissen fun- The first 25 laparoscopichernia repairs performed in our clinic were com- doplication were offered the option of a robotic procedure. pared with 25 historic controls that were operated using an open tech- Exclusion criteria included patients with large hiatal hernias, nique. Only open repairs using a pdmary closure of the hemia with a multiple prior abdominal surgeries, and severe dysmotility. madex onlay were used as controls. They were matched for age, sex, Operative times and details are compared to standard BMI and ASA status. The hernia sizes were comparable, as was theil laparoscopic Nissen fundoplication. operative history. Results: Results: Five patients have undergone Nissen fundoplica- Conversion to conventional repair was necessary in 2 patients of the tions using a robotic assisted technique, the remainder are laparoscopic group. In the laparoscopic group the mean operating time scheduled in the coming weeks. Robotic operative time was significantlylonger (93 min vs 72 min). On the other hand the mean averaged 1.4 hours (range 1.2 to 1.8 hours). To date, no hospital stay was significantlyshorter (6.1 vs 7,4 days; p=0.044). There conversions or complications have occurred in either group. were more short and long term complications in the open group. ThE Patient satisfaction has been high in each group. number of recurrences was higher in the open group (4 vs 1). Howevel Conclusions: Robotic Nissen fundoplication is a feasible the mean follow up in the laparoscopicgroup is only 9 months. Conclusions: alternative to the standard laparoscopic technique. We Our findings confirm the earlier mentioned advantages of the laparoscop. have found the robotic system easily understood and its ic approach. It also confirmsthe disadvantage of a longer mean operative operation quickly learned. While the optical system has time. Another problem concerns the much higher operative costs. Ou~ improvements over conventional laparoscopy, tactile feed- plan is to perform a prospective randomized study to compare these ; back is lacking. Continued development of computer assist- methods. In this study we will also compare whether the total costs of th~ ed technology and instrument refinement should improve laparoscopic repair are lower than of the open method due to a shortel the technique. hospital stay and a lower recurrence rate.

ENHANCED ADHESION OF TUMOUR CELLS TO MESOTHELIUM INTRAOPERATIVE LOWER ENDOSCOPY IS A USEFUL TOOL I1~ FOLLOWING EXPOSURE TO PNEUMOPERITONEUM. P. Ziprin LAPAROSCOPIC COLECTOMY Oded Zmora, MD, Adam Dinnewitzer FRCS, D.Peck PhD, P.F. Ridgway AFRCSI, A. Darzi FRCS FACS, MD, Alon Pikarsky, MD, Jonathan Efron, MD, Eric G Weiss, MD, Juan 9 Academic Surgical Unit, Imperial College School of Medicine. St Nogueras, MD, Steven D Wexner, MD, Department of Colorecta Mary's Hospital London W2 1NY. United Kingdom Surgery, ClevelandClinic Rodda, Fort Lauderdale, Florida

Background: Exposure to a carbon dioxide pneumoperitoneumused in Objective: Assessment and localization of colonic pathology may bE laparoscopic surgery can increase the occurrence of peritoneal metas- more difficult in laparoscopicsurgery as palpation of the specimen is diffi tases; for this to occur cells must attach to the mesothelium.We therefore cult, and perception may be distorted. Therefore, the aim of this stud~ analysedthe effect of a carbon dioxide pneumopedtoneumon tumourcell / was to assess the use of intra--operativelower endoscopy for evaluatJor mesotheliuminteractions and mesothelia]cell surface expression. of the colon in laparoscopiccolorectai surgery. Methods: Pdmary cultures of human peritoneal mesothelialcells (HPMC) were derived from omental samples. Monolayers of HPMC ceils were Methods: A retrospectivechart review of the patients who underwen exposed to either an in vitro carbon dioxide (CO2) or helium (He) pneu- segmental colonic resectionwith primary anastomosis was perfon'nedt( moperitoneumfor 4 hours or left under normal growth conditions (control). determine the rate and charactedstiosof the use of intraoperativeIowe Colonic (SW1222) adenocarcinomacells abilityto adhereto the monolayer endoscopy. The results were compared to a group of open colectomie., was assessed. matched by surgeon and procedure. In parallel w~ these study alterations in mesothelialcell surface expres- Results: 233 patients had laparoscopic segmental colon resectionan( sion of avB3 and av integrinwere analysed. anastomosis between 1991 and 2000. Intaoperative lower endoscop,. Results: Figuresare expressedas mean % of control was used in 24% (n=57) of these patients, compared to 18% in the opel Adheranceto mesothelium matched group. In the laparoscopic group, intaoperative Iowe CO2 141 +/-10 endoscopy was performed in 42% (n=101) of the patients in whom tht He 136+/- 8 pathology was located in the sigmoid colon or rectum, compared to 119 of the patients with pathology proximal to the sigmoid colon, or encom Expressionof av133 passing the entire colon. The main indication for intaoperative Iowe CO2 200 +/- 20 endoscopy was to assess or localize the pathology in Co4~ rule out syn He 198 +/- 16 chromous pathologies in 8%, and asses an anastomosis in 27% However, 42% of the patients had more then one intaoperative Iowe Expressionof av endoscopy during their laparoscopiccase. The informationgathered fron CO2 122 +/- 7 intaoperativelower endoscopy was judged to directly influence the ope; He 111 +/-2 ative decisions and management in 71% of the patients and provide reassuring informationin the rest of the cases. (Adherence, avB3 & av expression - CO2 & He Vs Control, P < 0.05 ('T'ukey-Krarner)) Conclusions: Lower endoscopy is a useful tool for the intaoperatiw assessment of colonic pathotog;es and anastomoses in Japaroscopi, Conclusions: Exposureto either a carbon dioxide or helium pneumoperi- colon resections.These results suggest that surgeons performinglaparc toneum causes an increase in the ability of tumour cells to adhere to scopic colorectai surgery may benefit having the expertise of performin! mesothelium. This indicates a mechanism of how the operative environ- lower endoscopy. ment influencestumour growth. $176

THE ECONOMIC IMPACT OF FLEXIBLE ENDOSCOPY IN THE DURATION OF HEMODYNAMIC DEPRESSION DURING LAPARO- A LARGE, GROUP PRACTICE SETTINGKeith A. Zuccala, SCOPIC CHOLECYSYECTOMY Randall S. Zuckerman, M.D., Michael Gold, M.D., Matthew Jones, B.S., Tara Erb, M.A., Steven J. Heneghan, M.D., Jeffrey L. Ponsky, M.D., Department of Surgery, The M.D.,Departments of Surgery and Research Computing, Bassett Cleveland Clinic Foundation, Cleveland, Ohio Healthcare, Cocperstown, New York

Purpose:There has been confusion and debate regarding We previously prospectivelyevaluated the effects of pneumoperitoneum the value added by the incorporation of flexible gastroin- and patient position on hemodynamics during laparoscopic cholecystecto- my and found that patient position had no effect on Cardiac Index (CI), testinal endoscopy into a general surgery practice. The Stroke volume (SV) and Left Ventdcular End Diastolic Volume (LVEDV). purpose of this study was to assess the economic impact of Analysis of that data showed that the adverse hemodynamic changes flexible endoscopy performed by general surgeons in a associated with anethesthesia and pneumoperitoneum were short lived large group practice setting. with values tiending towards baseline during the operative peried. The pur- pose of this study was to examine the duration of negative hemodynamic Methods:Total practice size was 11 surgeons, 3 of which effects during laparoscopiccholecystectomy. performed flexible endoscopy on a regular basis as well as Thirty-eightpatients undergoing laparoscopic cholecystecomyby a sin- traditional surgical cases. Based on a retospective review gle surgeon were enrolled in the study. Hemodynamic data was collected of billing records for the calender year 1999, the total via a trans-thoracic bioimpedance monitor (IQ, Renaissance Technology). amount billed for all surgical procedures was compared to Baseline readings of were taken prior to establishing pneumoperitoneum. Data was the collected continuously over the course of each case. billing for flexible endoscopy. Two of the three endosur- Patients were compared to their baseline value. Data was analyzed every geons performed colonoscopies and EGD's in addition to 5 minutes with the paired t-test used to determine statistical significance. their open and laparoscopic surgeries, while the third per- Baseline was defined as the point prior to insufflation. With insufflation formed ERCP as well. to 15 mm Hg CO2, CI fell from a baseline value of 2.82 UmWrn2 to 2.66 Umin/m2 ( p = 0.04), SV from71.58 ml to 65.44 ml ( p = 0.002) and Results:There were a total of eleven surgeons in the prac- LVEDV from 111.46 ml to 102.68 ml ( p = 0.003) At 5 minutes, all values tice, three of whom performed endoscopy in addition to were further depressed. At 10 minutes all values were no longer signifi- other surgical procedures. The total percentage of billed centiy differentfrom baseline with CI 2.78 L/min/rn2 (p = 0.76), SV 67.42 ml income for the department attributable to endoscopy was (p = 0.14) and LVEDV 102.26 ml (p = 0.179). Values reached those at 12.2% The three endosurgeons contributed 29% to the baseline at 15 minutes and did not waiver for remainder of each case or the next 35 minutes. total gross billings of the department. Patients undergoing laparoscopic cholecysteotomy undergo significant Conclusion:Flexible endoscopy can contribute significantly hemodynamic depression with pneumoparitoneum. These hemodynamic to the income of a surgical practice. changes are short-livedand loose their statistical significanceat 10 minutes from the time a patient undergoes pneumoperitoneum.