Introduction: LESS, also known as single incision laparoscopic surgery, has emerged as one of the newest surgical modifications of laparoscopic surgery. LESS procedures can be performed using various combinations of articulating and straight instruments with various angled or flexible cameras while achieving similar results to standard laparoscopic surgery in terms of surgical outcomes. LESS procedures can be more costly but the increased costs may be off-set by the improved cosmetic outcome and possibly less postoperative pain.

Methods and Procedures: A retrospective study from North Shore Long Island Jewish Health System evaluating operative times, estimated blood loss and complications from LESS procedures in the general surgery, bariatric surgery, gynecology and urology departments was performed. LESS was performed in 207 cases throughout the respective departments at one institution over a period of 1.5 years by multiple surgeons.

Results: A total of 207 cases were performed successfully with no mortalities or major morbidities. Institutionally there were five (N=10) complications or 4.8% that included: 1 anastamotic leak in a radical prostatectomy (1 out of 1), 2 (2%) biliary leaks after cholecystectomy (2 out of 85), 1 (8%) port replacement in a laparoscopic gastric band (1 out of 12), and were five (N=5) or 2% wound infections. 3 were bacterial and 2 represented Candida overgrowth. Operative times were comparable to standard laparoscopy. There were six (N=6) or 3% cases that required the placement of additional ports. All of the laparoscopic gastric band patients had one 3mm subxiphoid port placed for liver retraction. No cases were converted to open for completion. To date no patients have developed an incisional hernia.

Conclusion: LESS has become a popular and integrated part of General Surgery, Gynecology, and Urology. LESS can be scarless and are the closest procedures to incisionless or Natural Orifice Transluminal Endoscopic surgery (NOTES). In our experience, LESS can be performed safely and effectively without major complication or mortality. We believe there is a patient population who will benefit from and appreciate this near scarless technology. LESS procedures should be more easily accomplished as we improve upon technology of access, instrumentation, organ retraction and cameras. We believe LESS will continue to be a part of General Surgery, Gynecology and Urology and surgeon adoption should increase as the technology with these procedures improves.

Session: Poster

Program Number: P552

Objective: To compare the post-surgical complications between patients operated on cholecystectomy and who not among obese persons meeting criteria for gastric bypass surgery in Medellín, Colombia.

Method: A case-control study was done. In this research participated a total of 134 patients over 18 years old who met criteria for gastric bypass surgery due morbid obesity; 88.1% were women. A group of 23 patients were operated on cholecystectomy plus gastric bypass surgery, and other group of 112 patients with-out cholecystectomy was taken as control. Confounding variables were controlled by logistic regression.

Results: The mean total observation time from the procedure was 67.1 minutes (SD=27.1), and for hospital stay was 50.2 hours (SD=18.8). A total of three people (2.2%) presented early minor post-surgical complications. The surgical time was higher for patients with cholecystectomy than patients without it {86.9 minutes (SD=52.0) vs. 63.0 (SD=15.8) p=0.001}. The hospital stay was similar in both groups {47.4 hours (SD=4.6) vs. 50.8 (SD=20.5) p=0.429}. The frequency of complications was also comparable in both case and control patients (Fisher’s Exact Test, p=1.00, two-tailed).

Conclusions: Cholecystectomy additional to gastric bypass surgery increases significantly time surgery. Nevertheless, it does not alter number of early complications among patients who receive gastric bypass surgery or hours of hospital stay.

Key words: Cholecystectomy, gastric bypass, laparoscopy, obesity, morbid (Palabras MeSH).

Session: Poster

Program Number: P082

Methods: We reviewed the pictorial documentation of 100 cases of LC. Our standard of practice is to keep eight pictures per frame during a LC. These pictures describe the critical points during the procedure. Occasionally, due to some interesting findings, additional pictures are taken. These pictures serve as an essential guide for proper management of patients when presenting with post-operative complaints. We believe the first picture must be the way the gallbladder was initially identified with/without adhesions to correlate the symptoms with the operative findings. Next, management of the cystic duct as well as the cholangiogram itself are photographed. Then, the occlusion and division of the cystic artery and liver bed evaluation are photographed. Finally, we document whether the gallbladder was removed entirely without perforation, as well as the process of extraction.

Results: There were no intraoperative complications that were noted in the last 100 patients that we have seen. Nine patients required an additional post-operative office visit did well without any further testing because of the pictorial documentation of the LC. This led us to believe that the documentation of the pictures helped with early post-operative period complaints, thus saving health care money and aiding patient care. One patient required an ERCP with stone extraction. The intervention was carried out promptly because of the advantage of pictorial documentation. Finally, when patients continue to have similar pain after LC, the documentation of the initial operative findings of the gallbladder with/without adhesions are of insurmountable value for future medical management.

Conclusions: Proper, important, pictorial documentation should be saved and used as a future reference in clinical settings like lab data and x-ray findings. We described eight essential steps of pictorial documentation in a LC that are of significant value for patients with post-operative follow-up. Proper management can be initiated in the early post-operative period in cases where a complication arises because of access to actual operative findings.

Session: Poster

Program Number: P551

Methods: We reviewed 750 consecutive cases of LC at our institution. No patients developed deep vein thrombosis (DVT) post-operatively requiring anticoagulation. Only one case of symptomatic PE requiring treatment occurred. There may have been additional cases of undiagnosed, minor PE that were not symptomatic. The patient was treated with anticoagulation therapy and did well.

Results: PE is a rare complication in LC. Although obesity and venous stasis due to pneumoperitoneum appear to increase the risk factors for development of PE, our impression is that it may not be clinically significant. We are pursuing a study to assess the effect of venous stasis in the early post operative period by utilizing Doppler evaluation. Length of surgery may be a factor, which only can be studied after accumulating a larger series of patients.

Conclusions: Although pneumoperitoneum decreases venous return leading to venous stasis, it does not probably increase the incidence of pulmonary embolism. We, therefore, do not recommend extra precautionary measures for prevention of PE in LC.

Session: Poster

Program Number: P187

Aim
We aimed to analyse our data on LARS performed as a definite treatment in the management of refractory upper and lower respiratory diseases.

Method
Data were analysed between January 1996 to October 2007. During this period 1107 LARS were performed. There was a total of 1006 cases of Laparoscopic Nissen fundoplication. 60 of these were performed for referrals other than reflux oesophagitis- from ear nose and throat (ENT) and respiratory departments- 26 from ENT and 34 from Respiratory specialties. The common causes for referral from ENT specialty was laryngitis, sinusitis, laryngospasm, hoarseness, sore throat and chronic cough. All the 60 patients reported improvement in symptoms. The significant finding of this study was that 41 (82%) of patients were off all medications indicating the effectiveness in curing the ENT and respiratory complications as a consequence of GORD. The median age for the patients was 44 years, range 16 to 88. There was no significant complication and all the procedures were completed laparoscopically.

Conclusions
LARS can be seen as a definitive treatment in failed medical management of upper and lower respiratory and ENT cases. The treatment is highly effective and allows patient to rid themselves of lifelong medication.

Take home message
LARS is highly effective and should be offered to cases of failed medical treatment of upper and lower respiratory tract illnesses arising from GORD.

Session: Poster

Program Number: P363

Methods: All patients who underwent screening upper endoscopy during the workup for bariatric surgery were included in this study. Patients whom had endoscopy elsewhere were not included in this study. Any suspicious areas of the esophagus were biopsied and sent for pathological examination.

Results: The time period of this study was December 2007 to September 2009. There were 101 upper endoscopies performed in 86 patients. Repeat endoscopies were performed for retained food particles or re-evaluation of a mass/ulcer. There were 11 (12.8%) patients that had pathological evidence of Barrett’s esophagitis. All patients had Barrett’s metaplasia and no patients had dysplasia.

Conclusions: Barrett’s esophagitis is seen a higher incidence in the bariatric surgery population than the normal population. The pathophysiology of this increased incidence should be explored. Additionally, these data suggest routine endoscopy in morbidly obese patients may be indicated. Lastly, further research should focus on the true clinical implications of the findings of Barrett’s metaplasia in this patient population.

Session: Poster

Program Number: P383

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Methods: Consecutive patients who had undergone laparoscopic adjustable gastric banding were given an IRB exempted survey. This survey ascertained the patients’ thoughts on difficulty getting adjustments, difficulty scheduling adjustments, pain of adjustments, and fear before first adjustment. The responses were on a Likert scale of 1 to 10. Higher scores were a more positive response (no fear, no pain, and no difficulty). All band adjustments were done by a bariatric surgeon with the use of local anesthesia under fluoroscopic guidance.

Results: There were 27 patients in this series. The patients had an average of 4 adjustment of the band. They relayed an average of 5.0 for fear before their first adjustment but less pain (7.5) from the adjustment. The patients did not report that it was difficult to either schedule or get an adjustment (8.0 and 7.9 respectively). However, 60% would rather have a band that could be adjusted without a needlestick.

Conclusions: While many patients would rather have a band that did not require a needlestick for the adjustments, the amount of pain or difficulty of the adjustment was not high. Patients do have some fear before their first adjustments. Bariatric surgeons who perform laparoscopic adjustable gastric banding to be aware of this fear and take steps to address this during the preoperative education process.

Session: Poster

Program Number: P081

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Methods and procedures: An IRB approved retrospective chart review of a prospectively maintained database was conducted to identify obese patients (BMI>30) who underwent either LA or HAL surgery for elective left colectomy, sigmoid colectomy, low anterior resection and total proctocolectomy between January 2004 and June 2009.

Results: 136 patients were identified 84 in the LA and 52 in the HAL groups of a mean age of 58 and 51 years (p<0.0136) respectively. Both groups were comparable regarding BMI, gender, and ASA scores. The most common indication for surgery was diverticulitis (LA 49 vs. HAL 30) and the most common surgical procedures were sigmoidectomy (LA 53 vs. HAL 32), total colectomy (LA 11 vs. HAL 12), and anterior resection (LA 15 vs. HAL 6). While the HAL group had a statistically significantly shorter operative time (LA 220 vs. HAL 180 min, p=0.0085), reduced blood loss (LA 200 vs. HAL 100 ml, p=0.0012), lower conversion rate (LA 35 vs. HAL 6, p<0.0001), and shorter post operative hospital stay (LA 6 vs. HAL 5 days, p=0.0425), the overall length of incision, intraoperative complications, post operative complications and number of ports were not statistically significant between the two groups. Excluding the operation which were converted the length of incision was significantly shorter in LA group (LA 6 vs. HAL 7.5 cm, p=0.0043) and postoperative hospital stay was similar in both groups (LA 5 vs. HAL 5 days, p=0.6712).

Conclusion: LA and HAL surgical approaches are comparable related to safety and feasibility in obese patients. The length of operation, estimated blood loss, the conversion rate and post operative hospital stay were decreased in HAL group while the length of incision was decreased and postoperative hospital stay was similar with LA group in successfully completed cases. Although HAL may be justifiable in this group of obese patients, the majority of patients who undergo LA surgery can still benefit from a significantly smaller incision.

Session: Poster

Program Number: P169

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Methods: Between July 2000 and June 2009, eight consecutive patients (8 female; mean age 71.0, range 65-77 years) with full-thickness rectal prolapse underwent laparoscopic rectopexy. In the same period, 143 patients underwent perineal rectosigmoidectomy. Thirty-five age-matched patients were selected (35 female; mean age 73.8, range 66-79 years).

Results: Three patients (37.5%) in the laparoscopic rectopexy group and 13 patients (37.1%) in perineal rectosigmoidectomy group had previous operation history for rectal prolapse. Mean follow-up period were 7.2 months (range 1.0 ~ 15 months) and 15.9 months (range 0.1 ~ 85.9 months), respectively. In the laparoscopic rectopexy, operation time was longer (116.5 vs 77.4 hours, p < 0.05). But, hospital stay was same in both groups (4.4 vs 4.5 days, p > 0.05). Postoperative complications were one included an incisional hernia in laparoscopic rectopexy group (12.5%) and three (8.6%) included acute renal failure (1), urinary retention (1) and one anastomotic leak in perineal rectosigmoidectomy group.. Recurrences were 2 (25%) in laparoscopic rectopexy group and 4 (11.4%) in perineal rectosigmoidectomy group.

Conclusion: Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with full-thickness rectal prolapse but results in increased operative time, increased postoperative complications, and higher recurrence rate as compared to perineal rectosigmoidectomy. However large randomized trials, with comparative methodology are needed.

Session: Poster

Program Number: P168

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Methods: Surgeons were randomly selected from a diverse participant pool and divided into experimental (n=5) and control groups (n=4) and included attending surgeons. The experimental group performed approximately ten minutes on a virtual ring placement task with a virtual laparoscopic simulator (see Figure 1) within thirty minutes prior to surgery while the control group directly performed the laparoscopic surgery. Fifteen laparoscopic cholecystectomies were video-recorded and perspectives captured from both the endoscopic view and a view of the surgeons’ hands in the surgical field. Five surgeons from the experimental group conducted ten surgeries and four surgeons from the control conducted five. The video was rated by three expert physicians for smoothness, efficiency and accuracy. The results were then analyzed using unbalanced two way ANOVA.

Results: Experimental group that warmed-up demonstrated significantly better performance in all three measures (p<0.03). Figure 2 shows the bar-graphs

Figure 1. VR Simulator used in the experiment Figure 2. Results of the experiment.

Conclusions: The investigation into pre-operative warmup prior to actual laparoscopic surgeries resulted in evidence that such activity provides advantageous benefits to performance. This result builds on the existing body of literature that has proven the advantage of simulation on learning and transfer of skills in the long term and suggests that simulation exercises performed prior to surgery can significantly improve a surgeons focus, smoothness, efficiency and accuracy. This is further evidence of the robustness of transfer of skills from VR to OR even as warmup

Session: Poster

Program Number: P234

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