Surgical Endoscopy - Springer

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

U l t r a s o u n d and I n t e r v e n t i o n a l Techniques

�9 Spnngcr-Verlag New 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 ALTERNATIVE TO ENDOSCOPIC REMOVAL OF CECAL POLYPS Gina L. Adrales, M.D., Sharon L. Goldstein, M.D., Brent D. Matthews, M.D., Richard L. Sigmon, Jr., M.D., Kent W. Kercher, M.D., B. Todd Heniford, M.D., Department of Surgery and Charlotte Clinic for Gastrointestinal and Liver Diseases, Carolinas Medical Center, Charlotte, North Carolina

The endoscopic approach to cecal polyp resection harbors several possible complications, including the risks of perforation and bleeding. In addition, failure to remove the polyp in its entirety frequently requires multiple endoscopies for resection and confirmation of resection. Laparoscopic "radical appendectomy" represents a safe alternative to endoscopic treatment with the potential to reduce the risk of recurrence and subsequent malignancy.

Four I~atients with edenomatous polyps of the cecum were treated with laparoscopic resection of the appendix and cecum to the level of the ileocecal valve ("radical appendectomy") and intraoperative colonoscopy. Three of the four patients had villous adenomas of the cecum (3 to 4.5 cm). One patient had a 3 cm tubulovillous adenoma. There were two male and two female patients, ages 46 to 61 years, (mean 54). Two patients presented with occult gastrointestinal bleeding. Three of the four patients had significant co-morbidities, including diabetes and coronary atheroscterotic disease. One patient, with a history of alcoholic cirrhosis, underwent intraoperative liver ultrasound and liver biopsy and had the longest operative time. Operative time ranged from 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 with adequate margins. There have been no postoperative complications observed during the 2 to 12 month follow-up.

Laparoscopic "radical appendectomy" can be a safe and effective alternative to endoscopic removal in the treatment of cecal adenomatous polyps. This procedure can attain definitive resection, allow complete and accurate pathologic evaluation, and negate the need for repeated endoscopies and piecemeal removal of polyps. Our brief operative times and absence of complications support this laparoscopic technique as a reasonable approach in the management of cecal polyps.

LAPAROSCOPIC RESECTION OF A BLEEDING ILEAL LYMPHANGIOMA Gina Adrales, M.D., Sharon Goldstein, M.D., Brent Matthews, M.D., Robert T. Yavorski, M.D., William C. Sugg, M.D., B. Todd Heniford, M.D., Department of Surgery and Charlotte Medical Clinic, Carolinas Medical Center, Charlotte, North Carolina.

Gastrointestinal lymphangioma is a rare entity. These benign tumors are composed of abnormally dilated lymphatic channels. Though often asymptomatic, small intestinal lymphangiomas may become clinically significant as the cause of intestinal obstruction, intussusception, or hemorrhage. We present an unusual case of laparoscopic resection of a bleeding ileal lymphangioma and a review of the literature.

A 33 year-old man presented with progressive fatigue and syn- cope. The finding of severe microcytic anemia prompted an upper and lower endoscopic evaluation, which were both negative. Subsequent enteroclysis revealed a 3.0 cm ileal tumor suggestive of a hemangioma. Exploratory laparoscopy, intraoperative liver ultrasound and resection of a mid-ileal nodular tumor were performed. The pathologic findings were consistent with benign lymphangioma of the ileum. The patient remains stable at two months follow-up.

Lymphangioma of the small intestine are highly unusual tumors. However, the frequency of diagnosis is increasing with the expanding role of endoscopy in patient care. There are reports of resection of these tumors endoscopically in the literature. Lymphangiomas are often sessile and widely-based neoplasms, which may limit endoscopic evaluation and resection. As illustrated in this case presentation, laparoscopy provides an effective method of diagnosis and curative resection of intestinal lymphangiomas.

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LAPAROSCOPIC SURGERY OF THE DISTAL PANCREAS: EXPERIENCE ON THE LEARNING CURVE William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin MD, Michael J McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and Academic Surgical Unit, Leeds General Infirmary, Leeds. UK

Laparoscopic surgery for distal pancreatic pathology presents new challenges. These have been evaluated in a review of our initial experience.

Seventeen patients underwent laparoscopic distal pancreatectomy and two had enucleations of benign tumours, age range 14-82 yrs (median 60). Indicat ions included cystadenomas, endocrine tumours, chronic or familial pancreatitis and a pseudocyst. Operative t imes ranged from 130-550 mins (median 300) and the median postoperative stay was 11 days (range 3-63). Patients have been fol lowed for 5-78 months (median 27).

There were five conversions, due to intra-operative bleeding (n=2), unsuspected mal ignancy (n=2) and uncertain anatomy (n=l) . Four collections required interventional radiology. There were also two pancreatic fistulae, two wound infections and two subsequent laparotomies; one for bleeding and one for a splenic infarct. One patient with chronic obstructive airway disease died from MRSA pneumonia.

Collections and fistulae ceased when oversewing of the pancreatic stump was abandoned. Serious wound infections were e l iminated by the in t roduct ion of a tota l ly wa te rp roo f bag. Troublesome bleeding due to fibrosis, obesity and access has become less of a problem with use of the Harmonic Scalpel and lately, the Ligasure.

With experience and appropriate equipment, laparoscopic distal pancreatic surgery is both feasible and safe.

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AN INITIAL EXPERIENCE OF LAPAROSCOPIC PSEUDOCYST DRAINAGE. William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin MD, Michael J McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and Academic Surgical Umt, Leeds General Infirmary, Leeds, UK

Fourteen consecutive patients (age 28-75 years, median 51.5) with symptomatic pseudocysts were treated laparoscopically.(Table) When present, necrosis was debrided. Cyst-gastrestomy was initially performed through a longitudinal gastrostomy but is now performed by an intreluminal approach to minimise trauma to the anterior stomach wall. The patients have been followed for a median of 9 months (range 1-63).

Excellent visualisation of the interior of the cavity was obtained, allowing removal of necrotic tissue and clipping of a large, potentially troublesome vessel under direct vision. There were two recurrences, both in the drainage group (p=O.005), which were managed successfully by interventional radiology. There was one minor chest infection and an episode of acute urinary retention among the cyst-gastrostomy group. One wound infection occurred in a patient who was converted to laparotomy.

Although endoscopic or percutaneous methods for pseudocyst drainage have been advocated, the surgical approach of effective drainage and debridement of necrotic tissue remains the gold standard with lower recurrence and infection rates. Intra-luminal, laparoscopic cyst-gastrestomy com- bines these principles with a safe, minimally invasive approach. It provides excellent visuahsation of the cavity and is superior to drain insertion.

lirne Converted Die t Dischazge. (min) (day) (day)

C y ~ ~ - G a s t ~ (n=3) 270 0 6 9

C y s t ~ -Intraluminal (n=7) 180 1 4 7

Drain (n=4) 180 1 5.5 25.5

Cyst-jejunostomy (n= 1) 250 I 5 10

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

Objective. To evaluate the outcome and problems of laparoscopic gastro-jejunostomy.

Method. Review of our experience Results. Twelve gastrojejunostomies were performed on eleven patients, age range 50-83 years (median 78), with gastric outlet obstruction due to malignancy (n=9) or chronic pancreatitis (n=2). Both antecolic (n---8) and retrocolic (n=4) anastomoses were performed. Two patients also had a concomitant cholecystojejunostomy. Eight anastomoses were stapled and the remainder, were sutured. The method of anastomosis did not significantly affect the operating time, which was a median 162.5 minutes (range 130-290). Impenetrable adhesions, a friable gallbladder and sheer tumour bulk prompted three conversions. Post-operatively there were two episodes of haematemesis; one settled spontaneously and the other required laparotomy and oversewing of the staple line. Diet was recommenced by 7.5 days (median) but three patients continued to vomit. Two died on days 6 and 8 from camino- matosis.

Two patients experienced late recurrences of gastric outlet obstruction. The first, due to an inflammatory pancreatic mass, settled with conservative treatment. The other, with tumour infiltration of the anastomosis, had a new gastrojejunostomy formed laparoscopicatly, 98 days after the initial procedure.

Follow-up of oncology patients for 6-390 days (median 73) found that palliation was obtained for a median of 68 days (range 0-390). "lime in hospital as a result of gastric outlet obstruction was a median of 16 days (range 6-31). Conclusion. Lapamscopic gastrojejunostomy can offer good palliation of gastric outlet obstruction without a laparotomy. However, it is still subject to gastric paresis and the nature of the underlying disease process.

L A P A R O S C O P I C C H O L E C Y S T O J E J U N O S T O M Y FOR MALIGNANT DISEASE. AN INITIAL EXPERIENCE William G Ainslie, MBChB, Basil Ammod MD, Michael Larvin MD, Michael J McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and Academic Surgical Unit, Leeds General Infirmary, Leeds, UK

Patients with obstructive jaundice due to pancreatic and hepatobil- iary malignancies have a poor prognosis. Palliation should be minimally invasive to optimise quality of life. The purpose of this review is to evaluate the outcome and problems encountered during our initial experience of laparoscopic cholecystojejunostomy.

Fourteen patients with obstructive jaundice secondary to cholangio- carcinoma (n=2), pancreatic cancer (n=11) or an islet cell tumoux (n=l) had a laparoscopic cholecystojejunostomy. Two patients had concomitant gastrojejunostomy for gastric outlet obstruction. Five patients had the procedure performed at a staging laparoscopy ant two progressed to pancreatico-duodenectomy once their jaundic~ had been relieved. Four procedures followed failed ERCP stent inset. tion.

There was one convers ion due to a f r iable ga l lb ladder Postoperatively, one patient had a bile leak and another, a suture line bleed - both settled spontaneously. In the latter patient, the jaundice failed to resolve, and pemutaneous insertion of a metal stent wa., necessary.

Excellent relief of jaundice was achieved in the other thirteer patients, with bilirubin level falling from a median of 358.5pmol/1 pre operatively to 102h'mol/I by discharge, and 31.5pmol/I at subsequen follow-up (p<0.001). Relief of jaundice was obtained for 115.5 day.' (median, range 0-895) with a follow-up of 153.5 days (median, rang~ 14-895). Only two patients had recurrent jaundice just prior to death.

Laparoscopic cholecystojejunostomy is an effective palliative proce dure for obstructive jaundice and is easily performed when stagin(. laparoscopy reveals the turnout to be inoperable. It can also reliev~ severe jaundice prior to a definitive procedure where endoscopic stenting is unavailable.

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LESS INVASIVE NEEDLE THORACOSCOPIC LASER ABLATON FOR BULLA OF PRIMARY SPONTANEOUS PNEUMOTHORAX. Akinori Akashi.

Nodhisa Shigemura, MD, Tomoyuki Nakagid, MD, Takeshi Oriyama, MD*, Toshihiro Okada, MD ~ Uko Chou, MD*, Shigeto Maeda, MD',Gakuhei Son, MD*, Satoshi Matsuzaka, MD', Yuuichi Kondo, MD*, and Hisashi Kosaka, MD'. Department of Thoracic Surgery, and General surgery*, Takarazuka Municipal Hospital, Hyogo, Japan

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) for the bullectomy of patient with primary spontaneous pneumothorax(PSPJ has become ~e popular procedure. Without bullectomy, we have performed laser ablarion for bdla by needle thoracoscopy(nsedle-VATS:2-3mm in diameter) as less invasive surge~. To clarify its usefulness, prospective study was performed about indication, anaJgesia, complication, and recurrence. METI.IODS: From 1997 to 2000, 95 cases which undanHent VATS procedure with stapler 10ullectomy(bulla size: >2 cm) or needle-VATS procedure with only laser ablation for bulla(<2 on) were analyzed. We have our protocol to determine a indication of VATS or needI-VATS procedure, according to the size of bulla iden~ed by high-reselubon chest CT. RESULT: 43 cases(45%) underewent VATS procedure, and 52 cases(55%) underwent needle-VATS procedure. In the needle-VATS group, operatarion time was shorter than thet of VATS groulX39.8• 17.5 minutes vs. 56.6 • minutes; p<0.0f). Usage of non- steroidal anti-inflammatory drugs for postperarive wound pain could he reduced in needle-VATS group (11.2% vs. 58.8"/0; p<0.001). There were no complication in the needle-VATS group, 10ut 3 complications (6.9%) in the VATS group, including prolonged air leakage(>5 days) in 2 and refractory intercostal pain in 1(p<0.01). The rate of recurrence after operation was similar in both groups(1.9% vs. 2.3%). CONCLUSION: Needle-VATS procedure was thought to be less invasive than VATS procedure and as useful as VATS primary spontaneous pneumothorax.

C O M P U T F U N SWINE. Robed J. Albrecht, MD; Victor B. Kim, MD; James A. Young, MD; L. Wiley Nifong, MD; W. Randolph Chitwood, Jr., MD; William H. Chapman, MD., Department of Surgery, East Carolina University School of Medicine, Greenville, NC

Recent developments in minimally invasive surgery include computer enhanced robotically assisted surgery. We investigated the feasibility of robotically assisted Nissen fundoplication in a swine model.

Nissen fundoplications were performed in ten anesthetized swine using the daVinci(tm) robotic surgical system (Intuitive Surgical, Mountain View, CA). Following the creation of a pneumoperitoneum, a three-dimensional thidy-degree endoscope was introduced through a 12mm port in the midline 6cm below the xiphoid process. Two robotic instrument arms were introduced through 10mm ports placed bilaterally at the level of the umbilicus in the anterior axillary line. An accessory 10mm port was placed in the left midclavicular line 3cm below the left instrument arm for the ultrasonic dissector and suture delivery. In addition, a fourth 10mm port was placed 3cm inferior and lateral to the right instrument arm for liver retraction. Times were recorded for the foUowing: robot preparation; port placement; dissection of the esophageal hiatus; stomach mobilization; and placement of sutures. Mean times are expressed in minutes+standard deviation.

Setup rime was 17+-3 min. "13me for port placement was 12+-4 min. Short gastric vessels were divided in 10+-5 min. Hiatal dissection and fundus mobilizarion was completed in 19+-12 rain. Sutures were secured in 18+-5 min. Total procedure time was 59+-25 min.

Superior three-dimensional videoscopic imaging and precision of motion are afforded by the robotic system. The procedures were performed efficaciously, with times comparable to conventional laparoscopic techniques. The seven degrees of freedom supplied by the robotic instrument arms provide identical motion to that of the human shoulder, elbow, wrist, and grasp. Computer enhancement facilitates suture placement, knot tying, dissection of the hiatus, and development of the postesophageal window. This technique may prove to be a beneficial adjunct to laparoscopic Nissen fundoplicerion.

LAPAROSCOPIC DONOR NEPHRECTOMY THROUGH A PFANNENSTIEL INCISION AS AN ALTERNATIVE TO CONVENTIONAL OPEN TECHNIQUE Shaghayegh Aliabadi-Wahle M.D., Ashutosh Tewari M.D., Viken Dzoudjian M.D., John Ferrara M.D., Departments of General and Transplant Surgery, Henry Ford Hospital, Detroit, Michigan

The explosion of endoscopic technique has had a groat impact =n many fields of surgery. Most recently, laparoscopic donor nephrectomy has been introduced as an alternative to the conventional open procedure. The less invasive nature of laparoscopy, reduced recovery time and improved cosmesis may augment the potential donor pool. The current review was undertaken to assess this institution's experience with laparoscopic donor nephrectomy using pneumosleeve through a pfannenstiel incision.

The records of all patients who had undergone donor nephrectomy over the past 16 months were reviewed. Data with regards to patient demographics, operative time, safety, hospitalization course as well as transplant recepient outcome was collected.

Forty-three patients successfully underwent donor nephrectomy during this time period. Twenty-six of these procedures were accomplished by the laparoscopic technique. The two groups were similar with regards to age, gender and the presence of previous abdominal surgery. The average operative time was longer for the laparoscopic group (264 minutes vs. 123 minutes, p<0.05); however, average hospital stay was shorter (3.9 days vs. 4.8 days, p<0.05) in the open group. Intraoperative complications occurod in 2 patients in the open group and none in the laparoscopic patients. Postoperative complications requiring re-admission occurred in 2 of the open group patients. The incidence of delayed graft function in the recepients was higher in the minimally invasive procedures, though overall long term graft function is similar in the two groups.

We offer laparoscopic donor nephroctomy using the pneumosleeve through a Pfannenstiel incision as a viable option to the conventional technique.

L A P A R O S C O P I C R I G H T H E M I C O L E C T O M Y : NINE Y E A R P R O S P E C T I V E R E S U L T S FROM A S I N G L E I N S T I T U T I O N J.ARTURO ALMEIDA MD, DARREN MITER DO, MORRIS E. FRANKLIN MD, DANIEL ABREGO MD, DAVID PAULSON BS, TEXAS E N D O S U R G E R Y INSTITUTE. SAN ANTONIO,TEXAS

While much has been published in the literature about laparoscopic colon surgery, there is minimal focus on roght- sided disease. Herein we describe our nine-year experience with laparoscopic right hemicolectomy (LRH) in an unselect- ed group of patients. Special emphasis is placed in our technique for intracorporeal anastomosis.

METHODS AND RESULTS: From April 1991 to April 2000,ninety patients underwent a LRH at our Institution. Information regarding indication for operation, surgical procedure, operative time, blood loss, pathology and postoperative course were recorded in a prospective, non-randomized fashion. Eighty-six percent were completed laparoscopically by either total intracorporeal anastomosis or by laparoscopically assisted extracorporeal anastomosis. To date there have been no port site metastases, and the rate of wound infection is 1%. The conversion rate diminished significantly with experience. Operative time, blood loss and postoperative morbidity and mortality are all comparable to published results.

CONCLUSION: Laparoscopic righ hemicolectomy is feasible, safe and effective therapy for the treatmet of benign and malignant proximal colonic pathology under both elective and emergent conditions. The combined use of totally intracorporeal anastomosis and strict adherence to principles of once- logic surgery can effectively prevent postoperative complications

LAPAROSCOPIC SPLENECTOMY: THE IMPACT OF EXPERIENCE AND TECHNOLOGICAL ADVANCES ON OPERATING TIME BJ Ammori, N Georgopoulos, D Davides, W Ainslie, DR Norfolk, M Stringer, MJ McMahon, The General Infirmary at Leeds, United Kingdom

Objective of the Study: The laparoscopic approach to splenectomy appears to offer advantages over open surgery in the management of refractory heematologic disorders, but was associated with a considerable increase in operating time. The objective of this study was to determine the impact of experience and technological advances on operating times of laparoscopic splenectomy. Methods and Procedures: Between 1993 and 2000, 36 consecutive patients with haematologic disorders underwent laparoscopic splenectomy at our institution. Electrocautery and metal clips were applied for the dissection and division of the short gastric and splenic vessels in the initial 13 patients. Division of the short gastric vessels was effected with the ultrasonic coagulator (Harmonic Scalpel) in the subsequent 23 patients, whilst the smart bipolar coagulator (Ugasure) replaced clips for the division of the splenic vessels in the most recent 7 patients. The groups were compared using the Mann- Whitney U test, and the results are expressed as medians and interquar- tile ranges (IQR). Results: The procedure was converted in two of three patients with gross splenomegaly and in none of the patients with normal-sized spleens (5.5%). In-hospital mortality and postoperative morbidity were 0% and 11% respectively. Median postoperative hospital stay was three days. The operating time was significantly shortened with the growth in exped- enca and the introduction of the ultrasonic coagulator [electrocautery and clips 240 (195-265) minutes vs. Harmonic Scalpel and clips 150 (120- 160) minutes; p=0.007] and subsequently of the bipolar coagulator [Harmonic Scalpel and clips 150 (120-160) minutes vs. Harmonic Scalpel and ligasurel00 (70-120) minutes; p=0.007]. Conclusion: With the growth in experience and the introduction of techno- logically-advanced instrumentation, laparoscopic splenectomy can be accomplished safely and within a significantly reduced operating time.

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SELECTION OF GASTROESOPHAGEAL REFLUX PATIENTS WITH PRIMARY RESPIRATORY SYMPTOMS FOR ANTI-REFLUX SURGERY M Anvari MB BS PhD, CJ Allen MB BCh, Departments of Surgery and Medicine, McMaster University, Hamilton Ontario Canada

Studies have dernenstrated that 60 to 80~ of patients with chronic respiratory disorders such as asthma and COPD suffer from gastmesophageal reflux disease (GERD). Respiratory symptoms such as cough, choking attacks, wheezing, shortness of breath and recurrent chest infections maybe the pfirnary prasenting symptoms in a patient with gastmesophageal reflux disease. Surgical selection of patients who have not responded to medical therapy with proton pump inhibitors may be difficult. Over the last eight years we have performed laparoscoplo fundoplications in 172 patients with confirmed GERD who presented pdrnarily with respiratory complaints: 56% with cough, 24% with asthma, 10% with recurrent aspiration. 78% of patients have undergone s~x month follow up assessment including 24 hr pH, manometry, symptom score and quality of life. While laparoscopic surgery was effective in control of heartburn in 93% of patients, it was only effective in improving the respiratory symptoms in 81% of patients at six months. Multiple regression analysis showed that preoperative cough score, association of respiratory symptoms and reflux events on 24 hr pH and randomized Bemstein test, and a score > 7 for lipid laden macrophages on sputum analysis was associated with greater improvement of respiratory symptoms after surgery.

Laparoso~ic anti-reflux surgery is effective in controlling the respiratory symptoms associated ~ chronic gastmesqEnageal reflux disease, if there is dear correlation between symptoms and reflux events prior to surgery. A randomized Bemstein test, sputum lipid index and objective assessment ot symptoms on and off PPI may be useful preoperative tools for selection cl patients with primary respiratory complaints from GERD for anti-reflux surgery.

LAPAROSCOPIC GASTRIC SURGERY FOR BENIGN AND MALIGNANT DISORDERS M Anvad MB BS PnD, D Hong MD, M Lewis BSc, Depertrnent of Surgery, McMaster Univem,.,h.'y, Hamilton Ontario Canada

Lapamscopic techniques are increasingly used for surgical tP_.atment of disorders. We reviewed our experience with 23 patients who had

undergone laparoscopic gasthc surgery for benign (14) and rnalignant (9) patients over the last 5 years. The mean age of patients with benign cKsor- dam was 70 (range 48-76), and 71 years (range 63-95) for malignant disorders. The most common indication for surgery of benign disorders was complicated peptic ulcer disease (10 patients) for which a variety of procedures including vagot~w and distal gasb'ectomy, vagotomy and pyloroplas- ty, posterior vagotomy and seromyotomy were performed. The procedures for the gastiic carcinoma included three distal gas'cectornies, three subtotal gastrectomies, one total gesb'ectomy, one esophagegastrectomy and one wedge resection. The mean operating time for benign and malignant surgeries were 163.4:L452 min (range 119-280 min) and 215d=84.5 min (range 104-370 rain) respectively. There was no difference in mean blood loss

the two groups which was 250 ml and 100 ml respectively. Patients in the benign group tolerated clear fluids earlier, median of 1 day versus 4 clays in the malignant group. The length of hospitalization was significan T different between the two groups wi~ a median of 4 days for the benign gr~Jp and 14 days for the malignant gr~Jp. There were no major complications in the benign group and two major complications in the malignant group. One patient developed a myocardial infarction following the surgery and died on day 42 alter surgery. A second patient suffered a tibia fracture requiring operative therapy. Follow up of cancer patients has revealed two patients with a recurrence after a median of 12 months and seven other patients are disease free with a follow up of 25.75=17.7 months (range 3-53 ~ ) .

Conclusion: Laparoscoplo gastric surgery is effective and cardes a significant improvement in length of I'x~d:~ization and recovery for patients with benign disorders. The application of these techniques for gastric cancer requires further assessment.

VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR PULMONAR~ METASTASIS OF COLORECTAL CARCINOMA Motoi Aoe, M.D., Hideki Itano, M.D., Itaru Nagahiro, M.D., Yoshihum Sana, M.D., Hiroshi Date, M.D., Akio Andou, M.D., Nobuyoshi Shimizu M.D., Department of Surgery II, Okayama University Medical School Okayama, JAPAN

We think Videe-assisted thoracoscopic surgery (VATS) is useful for pul monary metastatectomy. Resection of solitary pulmonary metastasi., from colorectal carcinoma provides additional survival and we think VAT~ should be chosen for this procedure. Objectives: To evaluate the usefulness of VATS for pulmonary metastate ctomy of colorectal carcinomas. Methods: Twenty-one cases of pulmonary metastatectomy of colorecte carcinoma were performed from January 1985 to December 1999. Nin, out of 21 cases were treated with VATS, 12 were treated with standan thoracotomy. We compare the patient_fs back ground, operative time volume of blood loss, use of analgesics, hospital stay, medical costs, an~ survival between VATS group and thoracotomy group. Additionally, medi astinal lymph nodes sampling were performed five out of nine VAT, c cases to determine whether mediastinal lymph node dissection is nece~ sary or not. Results: The mean of operative time, blood loss during operation, dur~ tion of epidural analgesia, and post-operative hospital stay is 105 rain., 3 ml, 3 days and 8 days in VATS group and 137 min., 72 ml, 6 days, an 16 days in thoracotomy group. There are no differences of medical cost between two groups because of expensive disposable devices. Thre out of nine VATS cases were dead and 6 were alive. Eight out of 12 the racotomy cases were dead and 4 were alive. The mean survival time an observation time after pulmonary procedure is 32.6 and 35.6 months i VATS group and 43.2 and 95.0 months in thoracotomy group. None ( 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 via standard thoracotomy for solitary pulmonary metastasis of colorec~ carcinoma, because of its shorter hospital stay, less invasivenese, at~ equal pest-operative survival. 2, Mediastinal lymph nodes dissection not necessary for solitary pulmonary metastasis of colorectal carcinoma

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IMPROVED RESULTS WITH A MODIFIED TECHNIQUE FOR LAPAROSCOPIC REPAIR OF VENTRAL HERNIAS Bart Appeitans MD, Hans Zengerink MD, Hank ten Cate Hcedemaker MD, Department of surgery, Academic Hospital Groningen, Groningen, The Netherlands

Introduction: Laparoscopic repair of indsional hemias larger than 4 cm2 (i.e. peritoneal onlay with an expanded polytetrafluoroethylene (ePTFE) patch) is an attractive alternative to conventional open repair. However, the use of the ePTFE patch is frequently (up to 16 to 43 % in some series) complicated by a seroma between the patch and the abdominal wall. In order to reduce the incidence of seroma formation, we have modified the standard technique by adding coagulation of the hemial sac with the Argon enhanced etectrosurgicel beamer. Methods: Our modified technique was applied in 30 consecutive patients (mean age 57 yrs, range 30-83 yrs). Hemia sizes varied between 4 and 20 cm diameter (mean 8,6 cm). All patients were seen for follow up at 10-14 days, 6 weeks, 3 months, and 6 months after surgery. Results: Conversion to conventional repair was necessary in 6 patients. In all remaining 24 patients repair with the ePTFE patch was performed with our modified technique. The coagulation procedure was technically easy to perform. Seroma was seen in 2 patients of whom one was an acute repair for strangulation of a recurrent umbilical hemia. Mean operating time was 93 min (range 40-150 min). Hospital stay was 6 days (range 2-8 days). One recurrence occurred which was repaired using the same technique. Conclusions: Our findings confirm that laparoscopic repair using the ePTFE patch is technically feasible and effective with short hospitalization and quick return to normal activ'~des after surgery. Our results suggest that coagulation of the hemial sac shohld be added to the standard procedure as it substantially reduces the formation of seroma. Definite proof requires further evaluation, preferably in a comparative study.

I N C I D E N T A L G A L L B L A D D E R E C A N C E R - A TERT IARY HOSPITAL EXPERIENCE Chandrakanth Are MD, Pierre Chanoine, Mark A Talamini MD, Charles J Yeo MD, Keith D LUlemoe MD., Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

OBJECTIVE: The frequency of incidental gal lbladder cancer (IGBC) detected by post-operative histo-pathology (HP) has been reported to be around 0.3-1.5%, While uncommon, the intra or post-op diagnosis of IGBC creates a unpleasant di lemma.We decided to determine the incidence in a tertiary referral centre and analyze our experience with the IGBC.

METHODS: Data was reviewed from patients that underwent routine LC for benign disease from January 1995 to June 2000. Patients with known gallbladder cancer or pre-operative suspicion for the same were eliminated. History, indication for surgery and HP were analyzed

RESULTS: A total of 1106 LC were performed during this period. Two patients (incidence of 0.18%) with unsuspected gallbladder cancer pre-operatively were found to have the same on HP post-operatively. These patients had similar findings intra-operatively, where the GB's were found to be hard, thick walled, unyield- ing to the graspers and surrounded by adhesions raising the suspicion of cancer. These findings along with inability to perform the procedure laparoscopically led to conversion to an open procedure in both patients. One patient had adenocarcinoma of GB and the second was diagnosed with small cell cancer of the GB. Both patients underwent gallbladder liver bed resection and portal lymph node dissection at a subsequent stage within one week from the original surgery.

CONCLUSIONS: We conclude that, the frequency of IGBC is very rare and in our experience is even rarer than other reported series. If the cancer is missed pre-operatively, characteristic findings at the time of surgery should raise a suspicion of cancer to prompt conversion to an open procedure.

ENDOSCOPIC ROBOTIC TELEMANIPULATOR VERSUS CONVEN- TIONAL LAPAROSCOPIC INSTRUMENTS: COMPARISON OF LAPAROSCOPIC TASK PERFORMANCE FOR SURGICALLY NAIVE SUBJECTS William Arnold MD, David Brock PhD, Raymond J. Connolly PhD, Ibrahim AbdelKaderSalama MD, Woojin Lee PhD, Gary Rogers MD, Steven D. Schwaitzberg MD, Center for Minimally Invasive Surgery, Department of Surgery, New England Medical Center, Boston, MA. Brock Rodgers Surgical, Norwood, MA

Background: Endoscopic robotic devices may overcome the limitations of conventional laparoscopic instruments. The distally articulated instruments utilize additional degrees of freedom useful when performing complex endoscopic maneuvers. Most robotic systems, however, lack haptic feedback. We assessed the performance of surgically naive participants using a robotic device versus conventional laparoscopic instruments. Methods: 10 medical students were given three endoscopic tasks to perform with the robot (BrockRogers, Norwr MA) and conventional laparoscopic instruments: peg transfer, pattern tracing, and needle driving in axial and non-axial orientations. For the robot, pattern tracing was performed on fiat and cushioned surfaces. Performance was assessed on the basis of timing and accuracy. Results: The average time to complete the peg transfer was 76+-25 sec for the conventional vs 120+-50 sec for the robot (10=0.0069) with similar error rates. Pattem tracing was performed faster with the conventional, 69+-30 sec vs. the robot (flat and cushioned surface), 122+-47 sec (p=0.004). When tracing on a hard surface, the robot group had a significantly greater number of errors than the conventional group. Tracing on a cushioned surface that provided visual clues to the amount of pressure applied reduced the robot error to the level of the conventional group and was significantly 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 errors with the exception of superior time and accuracy for the robot working in the 12 - 6 o'clock orientation versus off-axis conventional suturing. Conclusion: Articulated robotic instruments improve performance when driving a needle in a non-axial direction. Despite the tele-manipulator's ability to maneuver with greater degrees of freedom, the surgically naive operator is hindered by the lack of haptic feedback. The use of certain visual clues seems to partially ameliorate this loss.

A SIMPLE AND EFFECTIVE TECHNIQUE FOR FUNDUS DOWN LAPAROSCOPIC CHOLECYSTECTOMY [1mothy R Barnett, MD, Prasanta K Raj, MD FACS, Richard C. Treat, MD, George Castillo, MD, Falrview Hospital - DeparlTnent of Surgery Cleveland Clinic Health System

Introduction: For the past decade, the performance of laparoscopic cholecystectomy has mainly been limited to a single technique: commencing dissection of the gallbladder at the infundibulum, and proceeding upwards toward the fundus. Descriptions of fundus down cholecystectomy have been reported in recent surgical literature, but these techniques often involve additional pertWtrocar sites, special liver retractors, or use of the harmonic scalpel. While these methods have been successful, they often increase the cost and time associated with performing fundus down cholecystectomy.

Methods: For the past year, we have been performing fundus down cholecystectomy for both elective and acute cholecystectomies. In our series, this technique has proven to be equally and sometimes more useful than standard cholecystectomy. We use the same trocars and instruments that we routinely employ in laparoscopic cholecystectomy. As is usually done, we first bluntly dissect the cystic duct and cystic artery in the triangle of Calot. Then, we perform our fundue down dissection by using two 5 mm smooth graspers, with which to create a fold in the peritoneum at the apex of the gallbladder. Hook electrocautery is used to start the dissection. One forceps is then placed on the tag of peritoneum left on the apex of the liver bed, and the other is used to grasp the gallbladder, providing adequate countertrection to continue the fundus down dissection with electrecautery. As we near the infundibulum, any branches of the cystic artery are ligated with clips, and the gallbladder is removed from the liver bed.

Results: Our technique was successful in all patients in whom it was employed. Even for acute cholecysititis, no conversion to the standard approach or to open cholecystectomy was required, and often times proved more beneficial in correctly identifying anatomy. Further, no additional instruments were used, proving our technique cost effective. Finally, this technique prevented any significant increase in operative time that might occur in other methods described.

FORMAL INTERPRETATION BY RADIOLOGIST OF INTRAOPERATIVE CHOLANGIOGRAM IS NOT NECESSARY David Earle, MD, Bernard Benedetto, MD, Department of Surgery, Baystate Medical Center, Springfield, Massachusetts

Most intraoperative cholangiograms(IOC) are read by the surgeon and a radiologist. We examined the need for 2 official interpretations in a retrospective comparison. We developed an IOC interpretation score(IOCscore) with 1 point assigned for each of the following: cystic duct, intra-& extra- hepatic ducts,filling defects & flow into the duodenum. RESULTS: 52 IOC's were performed in 59 patients. 45 females & 14 males had a mean age of 49.4 years(20-80). Indication for operation was biliary colic(38),acute cholecystitis(8),gallstone pancreatitis(6),biliary dyskine- sia(4),other(3). Mean surgeon & radiologist IOC score was 4.3 & 3.0 respectively. The radiologist never read 2 cases, and dictated 9 as "see op note". The most commonly omitted details were the cystic duct(surg- 21,rad-18) and intrahepatic ducts(surg-11,rad-17). Other details were rarely omitted. Nearly all of the surgeon's interpretations were recorded the day of surgery. Radiologist reading was dictated an of average 4.4 days (1-8) after the study was completed. There was one case of discordant interpretation between readers that presented with acute cholangitis, had pre-op ERCP/sphincterotomy and extraction of 1 of 2 stones. At operation, clearance of the duct was successful laparoscopically. The final IOC interpretation by the radiologist was "filling defect in CBD", and surgeon as no filling defects. Cholangifls developed 4 months later with widely patent ampulla & no CBD stones on ERCP. 2 cases of retained CBD stones presented 3&4 days post.op, both managed with ERCP. One case revealed CBD stones cleared laparoscopically with the final IOC interpreted as normal by the surgeon. Radiologist interpretation was "see cp note". The other case was for acute cholecystitis. Filling defects noted on IOC were interpreted as air bubbles by the surgeon, and as "normal, but limited study" by the radiologist. CONCLUSION: Interpretation of IOC by surgeons who routinely perform IOC is comparable to a radiologist, and eliminating this step should lower the overall cost of IOC with no disadvantage.

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DOES KEYHOLE REALLY NECESSARY? RESULTS OF A PROSPECTIVE RANDOMIZED STUDY Metin BERBEROGLU, M.D.1, Feyzan ERCAN M.D.1, Ferruh BALABAN 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- Ankara, 2Korkuteli and 3PolaUi State Hospitals, 4SSK Ulus Hospital-Ankara, TURKEY

Objective: Some surgeons are preferred to cut the meshes half way in size and lay half of it under the cord structures. However, numbers of surgeons leaves the meshes over the spermatic structures without cutting. We compared these two different way of mesh placement technique and recorded the duration of dissecting, mesh placement and total operating pedods, with surgeon and patient satisfactions.

Method: In this clinical study, 20 male patients were operated under general anestheasla in two groups by totally extraperitoneoscopic technique which presenting unilateral hernias. In group I, keyholed meshes were used. In group II, meshes were placed over the spermatic vessels without making any keyhole. Meshes were secured with tacks in beth groups. Patients were operated with these two different technique consequently. Meshes were dimensioned 15x12 cm in size.

Results: There were 40 (ages 23-76, mean 58) patients with 15 right (7/8) and 25 left (13/12) hemias having 13 direct (6/7) and 27 indirect (14/13) sacs. There were significant differences between the groups for total operation time (Mean operating time were 35.05-M,.91 in group I and 24.1r in group II) and mesh placement times (mean times were 10.6e3.15 in group I and 3.9-~1.7 in group II). Dissection time's shows no significant differences and mean values were 23.9~-6.3 in group I and 20.2-~4.63 in group II. Cord edema was seen in 5 patients (25%) in group 1 and 2 (10%) in group II. According to the subjective pain scale method, scrota] pain average was 27.5+7.16 in group I and 43.5-z9.8 in group I1. The differences between the groups was significant (p>0.01).

Conclusion: Placing the meshes without splitting, reduces the operative time and specially the dissection and mesh placing time. Meanwhile, we encountered less edema in cord structures. Surgeon satisfactions were excellent due to easier laparoscopic dissections and mesh placement by mason of fewer movements to achieve the proper mesh placemenL We recommend that surgeons should not make keyholes on the meshes during laparoscopic hernia repair.

NEW TECHNIQUE FOR SUTURING TROCAR HOLES Metin BERBEROGLU M.D.1, Feyzan ERCAN M.D.1, Ferruh BALABAN M.D.1, Turhan SAYGIN M.D.2, Can ERTURK M.D.3, Atila AKOVA M.D.4 I I .T .E.M. Advanced Medica l Techno log ies Educat ion and Training Center-Ankara, 2Eregli-Konya, 3Antalya and 4Adana Numune State Hospitals

Objective: As very well known, suturing of the instrument port inc is ions is di f f icult , t ime was t ing and spec ia l ins t rument required part of the laparoscopic operations. Somet imes surgeons are unable to stitch specially in fatty patients with bleeding from the trocar site in absence of special instrumentations.

We describe an easy method for suturing trocar site incisions by using a conventional needle holder and laparoscopic grasper which can also be performed by beginner laparoscopists.

Description: Step 1: An atraumatic straight needle grasped which is headed at the same direction of a conventional needle holder and passed far edge of the incision of the target trocar and when emerged from peritoneum, it is grasped by an grasping instrument. The tail of the suture must be c lamped for anchoring. Step 2: Then the needle is retrieved from the trocar which is used for grasping instrument. Thread is cut in half way and clamped. Step 3: Same suture is passed from the near edge of the same incision of the target trocar and first two steps are applied identically. Step 4: Needle is cut and two free ends were tied to each other at the grasping forceps trocar. Step 5: Then, both tails is fully pulled and tied securely at the target port is being sutured. Removing the target trocar is making this procedure easier.

Conclusion: We are applying this method in port bleedings and stitching the 10 mm trocar sites. We are recommending this method in absence of special laparoscopic instruments such as puncture closure device, laparoscopic needle holder.

LAPAROSCOPIC TRANSPERITONEAL BILATERAL NATIVE NEPHRECTOMY FOLLOWING RENAL TRANSPLANTATION Daniel W Birch MD MSc, Anil Kapoor MD, Department of General Surgery and Urology, St Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada

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 complications and a lengthy recovery period. Minimal Access Surgery is an option to reduce morbidity and recovery time in this select group ol patients. However, these patients have often had peritoneal dialysis catheters, episodes of peritonitis and there is concem regarding the effecd of the pneumoperitoneum on renal graft function. At our institution, a team approach has been used to successfully complete bilateral laparoscopic nephrectomy in a renal transplant patient. The team comprises a General Surgeon and Urologist who have fellowship training in advanced laparoscopic procedures. The patient is a 51 year old female with a renal transplant and document. ed vesico-ureteric reflux. Despite combined antibiotic therapy she continued to have symptomatic bacteriuria and recurrent pyelonephritis Ultrasound demonstrated bilateral hydronephrotic kidneys with thin parenchyma. The patient underwent bilateral nephrectomy via a transperitoneal approach. She was positioned in right decubitus for left nephrectomy, all port sites were closed after the completion of the procedure and ths patient re-positioned in left decubitus for right nephrectomy. For this procedure, 4 trocars were used on each side: 1-10mm trocar and 3-5mm tro. cars. Specimens were morcellized through the 10mm trocar sites. Tota OR time, including repositioning and sterile preparation was 6.5 hrs, There were no intra-operative or post-operative complications. The patient was discharged home on the 2nd post-operative day. She was seen at 4 weeks following surgery, fully recovered and without limitation,r in activity. We have used a team approach in the performance of advanced lapa~ scopic procedures with good success. Given our initial success wiU- these and other procedures, we will continue to develop our laparoscopir experience in the transplant and urology population.

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FACTORS PREDICTIVE OF CONVERSION FROM LAPAROSCOPIC TO OPEN CHOLECYSTECTOMY IN GANGRENOUS CHOLECYSTITIS Karin Binmofe, MD; Sandeep Devata, BS; Sherri Yong, MD; Ellen Yetter, MD; Vafa Shayeni, MD Department of Surgery Loyola University Medical Center Maywood, IL

Background: Laparoscopic approach is the standard of cure for elective cholecystectomy. Although acute cholecystitis is no longer a contraindication for laparoscopic cholecystectomy, there is a high incidence of conversion to laparotomy when gangrenous cholecystitis is encountered. Identifying factors predictive of conversion from laparoscopic to open cholecystectomy may help reduce operative length and cost.

Methods: Between August 1996 and August 1999, 39 patients underwent cholecystectumy for gangrenous cholecystitis, defined histologically as acute cholecystitis with transmural necrosis. Eight patients underwent open cholecystectomy without attempted laparoscopy. The remaining 31 patients were retrospectively assessed for factors predictive ofcunversion to open. Patient demographics (age and ~cnder), clinical prc.wnt~tinn (len~,-~h of % -"---.7.!."~'; " ~ ho:,pi.*=lLT.:tion prior tc ~u."ge.'3', weight and maximum temperature), laboratory values O,VBC, liver and pancreatic enzymes), sonographic findings (wall thickness, presence of air in the wall, ductal dilatation, pericholecystic fluid, maximum gallbladder and gallstone size and sonographic Murphy's sign), and surgeon's experience were reviewed.

Results: Fourteen of the 31 procedures were converted to open. Patient demographics, clinical presentation, laboratory values and sonographic findings were not different between the two groups. Thirteen of the operations were performed by 1 surgeon, I I of which (85%) were completed laparoscopically. The remaining 18 operations were performed by 10 other surgeons, 6 of which (33%) were completed laparoscopicaliy (p<0.0l). The incidence of complications was the same in both groups.

Conclusions: Laparoscopic cholecystectomy for gangrenous cholacystitis may be performed safely and with a low incidence of conversion to open. Surgeon's experience is the only factor predictive of eonversion from laparoscopic to open cholecystectomy for gangrenous cholecystitis.

THE EFFECT OF INSUFFLATION GAS VOLUME ON INTRA- ABDOMINAL TUMOUR CELL MOVEMENT S Brundell BS, K Tucker BSci, P J Hewett BS, Division of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia

Earlier work has demonstratad that trocar site metastases may be due to the deposition of free intra-abdominal tumour cells on trocars and trocar sites. Such free intra-abdominal tumour cells move within the abdomen cavity during insufflation and we hypothesised that the volume of insufflated gas may influence the degree to which this occurs.

Radiolabeled LIM 1215 human colon cancer cells were injected into the peritoneal cavity of 22 female pigs. Three 12ram trocars were inserted at the umbilicus, left and right lilac fossa and the abdomen was insufflated with CO2. The movement of cells within the abdomen was traced on a gamma camera for a 2-hour study period. The b'ocars were removed and the trocars sites excised and the numbers of cells on each was calculated. The movement of cells out of 6 intra-abdominal regions was calculated and analysed against the volume of insufflated gas.

Increased gas insufflation volumes resulted in increased intra-abdominal movement of tumour cells (Kendalrs tau, p=O.01), however no correlation existed between contamination of trocars or trocar sites and insufflated gas volume (Kendalrs tau, p=0.82).

This study demonstrated that the movement of free intra-abdominal tumour cells is increased when larger insufflated gas volumes are used. However, this does not result in additional cells being deposited on trocar sites and it is unlikely that this factor by itself may increase the rate of trocar site metastases.

THE EFFECT OF TR0CAR CHOICE ON TUMOUR CELL ADHERENCE, S BnJndell + BS K Tucker BSci, B Chatterton BM, P J Hewett BS, Division of Surgery, The Queen Elizabeth Hospital, W00dville South, South Australia

A model to examine of tumour cell adherence to laparoscopic trocars and to trocar sites was developed.

Thi~/-six plastic smooth and thi~-six metal trocars were introduced through the shaved abdominal wall of a cadaveric sheep and suspended in a water bath containing radiolabelled LIM 1215 human colonic cancer cells for 30 minutes. Radioactivity on both trocars and trocar sites was measured and the numbers of cells adherent to each structure calculated.

Increased numbers of cells were detected on metal b'ocars (p<0,0001) when compared with plastic trocers. Si#cantly greater numbers of cells were also detected on the trocar sites through which metal ~ocars had passed than on ~ocar sites through which plastic tr~rs had passed

In this model, the use of metal trocars as opposed to plastic tr0cars resulted in increased deposition of tumour cells both on the trocar and on the site through which the trocar had been passed.

HAEMATOGENOUS SPREAD AS A MECHANISM FOR THE GENERATION OF ABDOMINAL WOUND METASTASES FOLLOWING 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, Woedville South, South Australia.

It has been suggested that direct contamination of port sites with tumour ceils is the etiological mechanism responsible for the majority of port site metastases following laparoscopic surgery, but it is unlikely to explain the development of all. We sought to determine whether haematogenous spread might also play a role in the development of some port site metastases.

Two groups (30 rats) of male Dark Agouti rats were studied. Under general anaesthesia the first group (20 rats), underwent a period of 15 minutes of laparoscopic insufflation, followed by injection of 10 s adeno~rcinoma cells in a cell suspension into the internal jugular vein and a further 15 minutes period of insufflation. The laparoscopic ports were then removed and wounds dosed and marked.

In the second group (10 rats), an identical procedure was followed, except a 2.5cm midline laparotomy was performed 15 minutes after the commencement of anaesthesia, and insulflation was not used. The laparotomy was dosed in 2 layers. Rats were killed 15 days later and the injection site, laparoscopy wounds and laparotomy wound were examined 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. Whilst haematogenous spread is a possible mechanism in the development of port site metastases, the low number of port site metastases in this study suggests that this mechanism is unlikely to be a major contributor to the problem of wound metastasis following laparoscopy.

INCREASED INSUFFLATION PRESSURE DECREASES TUMOUR CELL CONTAMINATION OF TROCARS AND TROCAR SITES DURING OPERATIVE LAPAROSCOPY. S Brundell BS, K Tucker BSci, P J Hewett BS, Division of Surgery, The Queen Elizabeth Hospital, Woodville South, South Ausb'alia

This study was designed to evaluate the effect of insufflation pressure on tumour cell contamination of trocars and trocar sites during operative laparoscopy.

Radiolabeled LIM 1215 human colon cancer cells were injected into the peritoneal cavity of a total of 8 female pigs. The insuftiation pressure was varied in 4 groups between 0 and 12mmHg. Three 12mm trocars were inserted at the umbilicus, left and right lilac fossa and the abdomen was insufflated with C02. At the end of a 2-hour study period the pigs were euthanised. The lmcars were removed and the trecars sites excised. These were placed on a gamma camera and the numbers of cells present on each were calculated.

The use of increased insufflation pressure, possibly by a mechanical effect in I~ing the b'ocars away from intra-pedtoneal cells reduced trocar and trocar site contamination, (Kendalrs tau, p=0.01).

If as is likely, this study parallels clinical practice, increasing insufflation pressure may help to reduce the numbers of viable tumour cells displaced to trocar sites during laparoscopic surgery for an intra-abdominal malignancy. Furthermore if ~'ocar site metastases are related to the deposition of tumour cells within trocar sites, this may also have a role in helping to reduce the rate of trecar site metastases.

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LAPAROSCOPIC SURGERY FOR GASTROINTESTINAL STROMAL TUMORS: TECHNIQUE AND RESULTS L. Michael Brunt. MD. J. Chris Eagon, MD, Mary A. Quasebarth, RN, Nathaniel J. Soper, MD. Department of Surgery, Washington University School of Medicine, St. Louis, MO.

Aims: The purpose of this study was to review our surgical technique and results in patients with gastrointestinal stromal tumors (GIST) treated laparoscopically. Methods: From Feb. 1996 - March 2000, 12 patients with GIST underwent laparoscopic resection. Data were obtained reu'ospectively by review of medical records and by telephone interview with patients. Data are reported as mean + SD. Results: Mean patient age was 64 + 14. years (range 42-88 yrs). Presenting features were upper GI bleed (N=9), reflux (N--2), and incidental finding (N--l). Ten tumors were in the stomach, one in the distal esophagus, and one in the jejunum. Mobilization was carried out with an ulU'asonic coagulator and tumor excision with a linear stapler, either totally laparoscopically (8 cases) or in a laparoscopic-assisted fashion (4 cases). Concurrent intraoperative gastroscopy was used in 9 cases. Mean operative time was 142 _+ 61 rain and blood loss averaged 90 + 107 ml. Ten tumors were removed by wedge excision and 2 required resection and reanastomosis (antrectomy in 1, jejunal resection in I). Patients ate a regular diet at 2.7 + 2.2 days postoperatively and median postoperative hospitalization was 3 days. Complications were a hypertensive exacerbation in 1 patient and a peripancreatic fluid collection and prolonged ileus in one patient. Mean tumor size was 4.2 :l: 1.4 cm (range 1.8- 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 episodes of GI bleeding, or tumor recurrences at a mean follow-up interval of 20 months (range 4-54 mos) postoperatively. Conclusions: Lapasoscopic resection of GIST is safe and should be the preferred surgical approach unless the tumor is locally invasive.

A PROSPECTIVE COMPARISON OF PEG PLACEMENT IN PATIENTS WITH AND WITHOUT CUNICAL INFECTION Maureen G. Burdett, MD, Brian J. Dunkin, MD, Joel Turner, MD, William Chiu, MD, Eugene Cho, MD, John L. Flowers, MD, Department of Surgery, Division of Surgical Endoscopy, University of Maryland School of Medicine, Baltimore, Maryland

The timing of PEG placement has implications regarding discharge planning in hospitalized patients. Endoscopists have avoided placing PEGs in patients with clinical evidence of active infection for fear of a higher rate of complications. This study investigates the incidence of wound complications in patients with active infection undergoing PEG placement.

A prospective evaluation of 116 patients undergoing PEG placement between 2/99 and 4/00 formed the basis of this study. Patients with clinically active infection were defined as having a temperature > 101.5F, leukocytosis > 11,500/ul, culture positive or radiologic evidence of infection. These patients were compared to controls with no evidence of infection. PEG sites were monitored for an average of 7 days. PEG site infection was defined as the presence of purulent discharge and/or erythema. The two groups were age matched. The rates of PEG site infection were compared using beth the Chi Square and Fisher exact methods.

There were 81 patients in the active infection group and 35 patients with no clinical infection. The overall incidence of PEG site infechon was 9.5% (11/116). The incidence of PEG site infection in the active infection group was 7.4% (6/81) and 14.3% (5/35) in the no infection group. Patients with PEG site infection in the active infection group had erythema alone (3/6) drainage alone (2/6) or drainage and erythema (1/6) versus those in the no infection group with erythma (1/5), drainage (1/5), and drainage and erythema (3/5).

Active clinical infection does not effect the incidence of exit site infection in patients undergoing PEG placement. This data supports early placement of PEGs in patients with ongoing clinical infection with the potential for decreased complications from nasogastric tubes and earlier discharge.

LAPAROSCOPIC CHOLECYSTECTOMY IN THE MULTIPLE SCARRED ABDOMEN. Roger Buzatu MD, Presanta Raj MD, Department of Surgery, Falrview Hospital, Cleveland, OIL

Laparoscopic Cholecystectomy was first performed by Dubonis et al. in the late 1980's. Subsequently it gained rapid ___ao,~tance and application because of its promise of more rapid recovery. In the past, patients with previous extensive abdominal surgery were excluded from the benefits of the minimally invasive technique, Initial epigastric port placement technique was developed with this in mind The following report is a case series of the experience of one surgeon in applying the technique initial epigaslric port placement for laparoscopic cholecyst~omy in the multiple scarred alxlomen. This apprmoh was performed on p~ents with prior history of alxlominal surgery,

with dominant abdominal scars, in which dense alxluminal adhesions were anticipated. Informed consent was olXained, and the poss~ility of r to open was outlined prior to proceeding. The technique involves placement of an initial lOmm Hasson trocat under direct visualization in a subxiphoid location. The camera is then introduced, and using the location of adhesions as a guide, a second 5ram trocar is placed in the right aMominal wall. The 5mm port is then esed as a working port to lyse perinmbilical a~esions. Once successful a&esiolysis is performed, a 10ram umbilical port is established, the camera changed to this location, and dissection continued in standard fashion.

The technique was successfully performed in 9 of 11 patients. Conversion to opez occurred in cases where density ofa~esions made continued laparoscopic dissecgon unsafe.

in recent reviews of the reasons for conversion to open technique, adhesions fror previous abdominal surgery are consistently listed as one of the top two. At the same time, numerous studies have shown the multiple advantages of la~oscopic Vs. open cholecystectomy. This technique offers an approach that can allow for laparoscopy to be performed on abdomens previously considered prohibitive bcaa~ of duminant scarring and history of previous multiple surgmes

Sl l2

LAPAROSCOPIC ASSISTED RESECTION FOR CARClNOID TUMOR OF THE TERMINAL ILEUM Roser Buzatu. M.D., Prasanta Raj, M.D., Depadment of Surgery, Falrview Hospital, Cleveland, Ohio.

Cardnoid tumors, 1/3 of small bowel tumors, develop from intraepithelial serotonin pcocludng endocrine cells and are located typically in the terminal ileum. Patiente usuelly present in ~le eixth or seventh docade with complaints of vague abdominal pain, or in cases of advanced d i ~ with obstructive syml:~ms. DiagnosiJc delay is common resulting in advanced stsge at Ixesentation in mont __~-ses__.

The following is a case mpod of the pioneering use of Laparoscopy in performing a dght hemicolectomy and terminal illectorny with pdmary anastamods for a locally metastatic 1.5 cm cardnoid tumor of the terminal ileum. The surgery was performed in 1901, end the pa~e~ has remained ~ _ _~.~_ _ _ free at 9 yr. follow up.

The patient is a 58 year-old male who presented to his gastroenterologist the complaints of chronic diarrhea and right-sided vague abdominal

pain. Work up included a BE and ~ ~ich revealed 2.5cm ~ ! e pol~e of the Cecum and Hepatic flexure. En6~___- :(r l~pay ms nagative for malignancy, but given the dze and n ~ surgery was recommended.

The procedure was performed using a 10ram infraumbilical tronar for initial exploration, fol lold by the Introduction of four additional pods for d i ~ . ~ was L ~ in mobilization of the colon and terminal ileum. A limited RUQ transverm indsion allowed for limited exploration and dalivery of the specimen. On limited exidoredon a mass was palpaide in the temllnal ileum. Cam ws taken to obtain adequate margins proxlrnally, and to Indude the root of the mese~ery. Reenaetamods was performed using a GIA ~alder in side-to-dda fashion. Pathologic examination revealed a 1.5 cm cardnold tumor of the torminal ileum, with 1 of 10 LN positive for

This case demonstrates serty innovative use of iapm','~co~, and given ~e excellent outcome with icog te~n follow up, suggests a ~ _no~__bie role for I ~ assisted ~re~ ~ _on of surly stage distal small bowal tumor~

Efficiency in Thoracoscopic Procedures: A Model for all Minimally lnvasive Procodum. Roan Caccavale, M.D., J.P. Bocage, M.D., W. Peter Gels, M.D., Steven W. Petenon, D,O., department of Surgery and Minimally lnvasive Learning Center, St. Peter's University Hospital, New Brunswick, Hew Jersey. Introduction:Historically, thoracuscopic procedures have dramatically diminished insult to patients, but have been cumbersome to perform due to positioning of the patient, single lung ventilation, and imposition of the rib cage. We have addressed each of these issues and shortened procedures dramatically. Methods: In the past 36 months we have used a combination of team development, video assessment of team performance, minimizing instruments, Jod facility enhancement to safely shorten all segments of VATS proced~:~. To document the results, 45 consecutive procedures were evaluated as to (I) pat;-=t entrance to OK, (2) intubatinn, (3) bronchoscopy- single lung occlusion, (4) patient positioning, (5) set-up drape, (6) procedure time, (7) closure --dressing, (8) exit from room, (9) turnover times. Procedures included" 30 lung resections, (wedge, Iobectomy, pneumonectomy), two esophagectomies, and multiple biopsies and pleurodesis. Time intervals for each segment of each procedure and the mechanisms of efficiency were recorded. Results: Average time from room entry to surgical incision for all procedures was 21.7 minutes (separated into 4 segments). Technical procedure times averaged 37 minutes; the shortest being wedge resection (18 minutes) and the longest being pneumonectomy (162 minutes). Lobectomies averaged 49 minutes. Wound closure, exit from room, and turnover time cumulatively averaged 36.5 minum. Factors influencing these data included cooperative team approach, specific identification of tasks, surgeon participation in team effort, minimizing number of instruments, strategic use of sophisticated technology, and video assessment of procedure choreography. Conclusions: These data delinate that focusing on maximum efficiency during sophisticated VATS procedures allows a minimum of resource utilization, diminished anesthesia time, decreased the length of operative risk, and promotes improved outcomes per unit cost. Further, this experience provides a "best practices" model for minimally invasive surgery.

OPEN CECECTOMY IS ASSOCIATED WITH SlGNIRCANTLY MORE PULMONARY METASTASES THAN LAPAROSCOPIC CECECTOMY OR ANESTHESIA ALONE IN MICE Joseph Carter, MD; Irena Kirman, MD, PhD; Anthony Oh, MD; Peer Wildbrett, BS; George Stapleton, E~S; Zishan Asi, BA; Ryan Fowler, BS; Marc messier, MD; Richard L. Whelan, MD; Department of Surgery, Columbia College of Physicians and Surgeons, New York, NY

Objective: The surgical resection of malignancies may result in the hematogenous spread of tumor cells which, in turn, may lead to metastases(mets). Further, iaparotomy is associated with greater postoperative immunosuppression and increased tumor cell proliferation than either pneumoperitoneum (pneumo) or anesthesia alone. It has been demonstrated, in a munne model, that sham iaparotomy is associated with a higher incidence of lung mets than C02 pneumo. The purpose of this study was to determine the incidence of lung mets after open and laparoscepic-assisted bowel resection. Methods: A murine pulmonary metastasis model was used. Six week old female A/J mice(n=30) were randomized into 3 groups: 1) anesthesia control(AC), 2) laparoscopic cecectomy under C02 pneumo(LC), or 3) open cecectomy (OC). Immediately after the procedure, all animals were given tail vein injections of 7.5 x 10'~4 TA3Ha tumor cells. After 14 days, mice were sacrificed and the lungs/trachea exdsed en bloc after injection the trachea with India ink. The lungs were later immersed in Feket's solution to bleach the tumor nodules. 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 OC, 124.4. The OC group had significantly more mets than the AC group(p<0.05, Mann-Whitney Test). There were no significant differences noted when the LC group was compared to eider the AC or OC groups. Conclusion: Open cecectomy is associated with significantly more lung metastases than anesthesia alone, in this model. Although laperoscopic cecectomy resulted in less mets than the open group the difference was not significant. Although not proven in this study, these differences may be the result of laparotomy related immunosuppression and trophic stimulation of tumor cells. Further studies are needed to assess whether laparoscopic procedures are, in fact, associated with a lower rate of metastases.

LAPAROSCOPIC TREATMENT OF GROIN HERNIA: 1350 CASES TREATED Luc iano Casc io la , M.D., Graz iano Ceccarelli, M.D., Lelio Di Zitti, M.D., Walter Mazzoli, M.D., Michele d'Ajello, M.D.

We present a review of our experience of 1670 inguinal herniorrhaphy over the past 8 years, 1350 cases treated by laparoscopic approach (TAPP technique), and 320 by conventional tension-free open technique. We compare the results (patients compliance, post-operative pain, recurrences, morbidity) of the laparoscopy with open herniorrhaphy.

This is a retrospective review of 1670 inguino-femoral hernias treated between August 1992 and March 2000. The laparoscopic approach was exclusively the trans-abdominal pro-peritoneal (TAPP) technique, it was performed in 948 patients (1350 hernias), 276 (20,3%) were recurrent hernias, 855 males and 93 females (ratio: 9/1), median age of 45,6 years (range:19-82). The bilateral case were 42% (11% of them were discovered during laparoscopy), they were treated using two different prosthesis. In 87 patients were performed additional surgical treatment (cholecystectomy, treatment of varicocele, lysis of adhesions, etc.).

Our overall recurrence rate using TAPP technique was of 8 cases (0,6%), with a median follow-up of 4 years (minimum 5 months). In only one case it was necessary to convert in open technique because of an important abdominal adhesion syndrome. Only one important complication (bowel obstruction), 16 seromas, 2 t rocar si te hernias, 9 abdomina l wal l hematomas. The median operative time was of 35 minutes for unilateral and 55 minutes for bilateral hernias, after the first 100 cases (learning period).

In our experience laparoscopic hemiorrhaphy, using TAPP technique, is safe, well accepted by all patients (general anesthesia wasn't a problem), with very good results; of course it need an adequate training and experience in laparoscopy.

COMPLETELY LAPAROSCOPIC COLECTOMY FOR CANCER. Luciano Casciola, M.D., Lelio Di Zitti, M.D., Graziano Ceccerelli, M.D., Massimo Rambotti, M.D., Raffaele Valeri, M.D., Department of Vascular and Mininvasive Surgery, San Matteo Hospital, Spoleto, Italy

Laparoscopic colectomy is possible, safe and widely accepted by now; it offers patient-related benefits similar to those described for other laparoscopic procedures. Some indications for laparoscopic bowel resection (i.e. cancer) are still controversial. We present a retrospective analysis of a series of 106 colonic malignancies laparoscopically performed.

138 completely laparoscopic colonic resections were performed between May 1994 and July 2000. Surgical indications were: benign disorders (diverticulitis) 32 cases (23,2%), 106 colonic malignancy (76,8%). We prefer to perform the vascular control by clips "step by step"; the stapler is used for bowel resection, a mechanical completely intra-corporeal tension-free anastomosis is performed at last. To remove the bowel specimen from the abdominal cavity we use to put it in a large bag and to pull it out of a 3-4 cm enlargement of a trocar-site (in the left lower quadrant or in the umbilical ring). An important contribution is offered by ultracision dissector.

In 10 patients (8,6%) of 116 laparoscopic approach for colonic tumors, we decided, after a laparoscopic beginning, the convertion to open procedure. The right hemicolectomy were 18, the left colectomy (hemicelecto- my, sigmoid resection, low anterior resection of rectum) were 88. No intra-operative complications were observed; post-operative complication were: 2 wound infection, 1 abdominal haemorrhage, 2 trocar hernias. No anastomotic leak were observed. The median operation time is of 150 min for righ hemicolectomy and 165 for left colectomy. One case of port- site recurrence.

The laparoscopic colon-rectal surgery can reproduce the techniques performed in open surgery, respecting all oncologic principles. After a period of adequate training all can appreciate the advantages of laparoscopy: shorter hospital stay, less postoperative pain, short-term post-operative ileus, earlier retum to daily activity, etc..

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ANASTOMOTIC STAPLE-LINE REINFORCEMENT ENHANCES THE SAFETY OF LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR MOR- BID OBESITY Frank H. Chae, M.D., Robert C. Mclntyre, M.D., Greg V. Stiegmann, M.D., Department of Surgery, University of Colorado Health Sciences Center, Denver, Colorado, USA.

Anastomotic staple line failure (leakage or bleeding) is a major complication associated with Lapamscopic Roux-an-Y Gastric Bypass (LRYGB) for morbid obesity. Although staple line failure occurs infrequently, such complications are potentially devastating. We hypothesized that staple line failure could be diminished or eliminated by the use of a staple line reinforcement. The purpose of this study was to assess the feasibility and efficacy of bovine podcardiai strips as an anastomotic staple line reinforcement in LRYGB surgery.

METHODS: Patients with body mass index (BMI) of 39 kg/m2 or greater had totally Laparoscopic Roux-en-Y Gastric Bypass. Bovine pericardiai strips were incorporated into the Endo-GIA stapler cartridgas to reinforce the staple lines created.

RESULTS: Since May 1999, 17 of 17 morbidly obese patients (all female) had successful LRYGB with staple line reinforcement. The mean age was 39 (range 22-53) and the mean BMI was 44 (range 39-60). Co-morbiditiss included hypertension (12), heart disease (4), diabetes (8), chronic lung disease (3), sleep apnea (15), hypercholesterolemia (5), gastroesophageal reflux disease (11), and osteoarthritis (12). The mean operating time was 4.7 hrs (range 3.5- 6.5). Addition of the anastomotic reinforcement added an average 12 minutes operating time per case. Minor complications included 1 port site wound infection. No anastomotic failures or other major complications were observed. The mean time to retum to oral intake and hospital stay was 1.5 and 3 days respectively. All patients lost weight (mean 9.5 kg/month) with a mean follow-up of 6.5 months (range 1-15).

CONCLUSION: Anastomotic staple line reinforcement using a bovine pericardial stnp is feasible, safe, and may enhance the safety of Laparoscopic Roux- 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. Feliciotti, A.M. Paganini, M. Guerderi, A.Tamburini, S. Perretta and E.Lezoche Istituto di Scienze Chirurgiche Universit~ degli Studi di Ancona. ITALY

In pancreatic surgery laparoscopy has a role in diagnosis, staging and curative or palliative surgical procedures..

Since 1993 four spleen.preserving laparoscop=c distal pancreatectomies and three enucleations of pancreatic solid and cystic lesions were performed in our institution. Spleen preservation was considered in order to avoid the risk of sepsis and thrombosis as reported in the literature.

In the distal pancreatectomy group (A) there were three female and one male (mean age 51.3 years, range 20-70 years). In the enucleation group (B) two patients were female and one male ( mean age 52,3, range 42-63 years). All patient underwent preoperatively MRI. In all cases intraoperative ultrasonography (6,5 MHz laparoscopic probe) was performed. Mean operative time was 172.5 rain (range 120-240 rain). In group A hystology revealed two mutinous and one serous cystadenomas, and one insulinoma. In group B. two insulinomas and one serous cyst were observed.

In group A no postoperative complications were observed patients were discharged on avarage 6 postoperative (p.o.) day. In group B one 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. Return to daily activities was rapid as in the case of a young female (20 years old) of group A that returned to her agonistic sport activity in three weeks. At a mean follow up of 28 months (range 4-84 months) no late pancreatic fistula or recurrence are reported.

In conclusion our experience suggests that laparoscop=c surgery for benign lesions of the pancreas is feasible and safe in the hands of surgeons skilled with advanced laparoscopic expertise.

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

The juxtaglomerular cell tumor is an extremely rare tumor of the kidney. Hypertension is the most common clinical finding due to the renin production but the correct preoperative diagnosis is very difficult to reach. We report the case of a patient that was b'eated laparoscopically with kidney preservation.

A 45 old male was referred to our department because of a solid mass of undear origin located in the right mesorenal region, detected by ultrasonography, CT scan and cdoncscopy. This patient was previously investigate for persistent hypertension. The serum levels of renin, plasma renin acth~'7 (PRA) and aldosterone were normal.

Laparoscow was performed in order to obtain a correct diagnosis and to resect the lesion. Five 10/12mm ports were placed and a 45 ~ iaparoscope was used. Alter a wide dL~=ectJon of the right and

colon the mesorenal lesion was visualized. Laparoscopic ultrasonography ( 6.5MHz probe) was peffom,,ed confirming a well capsulated lesion of the kidney. Ultrasonic shears and cautery were used to r__~,ct__, the lesion with a five millimeters tumor free margin. Fibnn glue was fappiied on the resect~ margin to opt~ize the h ~ i s . Postoperat~ly a acute acalcoulous cholecys~s was observed, tn~ated with medical therapy. The patient was then discharged on p.o day g. Blood pressure returned to normal values.

Juxtaglomerular cell b.rnors of the kidney are rare CaL~_~.eS r hypertension that are frequer(dy t~'eated with nephrectomy. In this ia _parc~___~ allowed a curatve resection of tile tumor with ~dnr presen, ation..

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COMPUTER ENHANCED ROBOIICALLY ASSISTED TELEMANIPU- I.AllVE CHOLECYSTECTOMY William H.H. Chapman, M.D., Robert J. Albrecht, M.D., V'ctor B. Kim, M.D. James A. Young, M.D., L. Wiley Nifong, M.D., W. Randolph Chitwood Jr., M.D., Department of Surgery, East Carolina University School of Medicine, Greenville, N.C.

Considerable developments have occurred over the last 10 years in the field of computer enhanced robotically assisted surgery. With the recent approval of the da Vinci(tin) system (Intuitive Surgical, Mountain View, CA) by the FDA for general abdominal surgery, we initiated assisted elective cholecystectomies at our institution. We present data to date from our initial series of ten patients.

Ten cholecystectomies were performed using the robotic system. Following the creation of pneumoperitoneum, a three-dimensional viewing thirty-degree endoscope was placed through a midline 12 mm port located 2 cm above the umbilicus. The two robotic instrument arms were placed through 8 mm ports bilaterally in the midclavicular line at the level of the camera port. An accessory 10 mm port was placed in the midaxil- lary line 3 cm lateral and inferior to the robot's right instrument arm giving access for a grasper. Length of time was recorded for the following: robot preparation; port placement; robot positioning; cystic artery and duct dissection and ligation; gallbladder dissection; total robotic assistance time; and total procedure time. Mean times are presented in minutes + s.d.

Robot preparation and draping time was 13+-4 min. Pods were placed in 6+-1 min. Dissection and ligation of the cystic duct and artery were performed in 10+-4 min. The gallbladder dissection required 10+-7 min. Total robotically assisted time was 37+-10 min. Total procedure time was 60+-25 min. There are no complications to date.

All cholecystectomies were completed efficaciously, with times comparable to conventional laparoscopic methods. The robotic system is readily mastered by OR assistants, and technical expertise is easily gained by an experienced laparoscopic surgeon. Telemanipulative robotically assisted choleoysteotomy can be performed safely, and this technique may well be applicable to more complex laparoscopic procedures.

MULTIPLE FRAME INTEGRATION IMPROVES VISIBLE CON- TRAST USING MINIMALLY INVASlVE SURGICAL INSTRUMENTA- l iON W. Charash*, M. Shaw, A. Park, Depts. of Surgery, University of Kentucky and Boston University*

Objective: Visible contrast during minimally invasive surgery (MIS) is limited by available light. We devised and tested a novel method of improving perception of low contrast detail in 'real time'. Methods: Video images were obtained using a standard color video camera and a 10mm 0degree laparoscope. Images were digitized and analyzed in 'real time' utilizing a digital signal processor. Images were displayed using a NTSC standard video monitor. Custom software was designed to allow display of the actual camera output or the digital sum the most recent 2, 3, or 4 frames. This yields an effective frame rate of 30, 15, 10, and 7.5 fps, respectively. Target images of known contrast were created. Random sequences of 12 numbers of density 0.5000 (1.0000 = black, 0.0000 = white) were print- ed on backgrounds with densities that varied between 0.4875 and 0.5 in 7 steps of 0.00125. Contrast was defined as the difference between character and background density divided by character density. Thus, contrast was varied between 0.025 and 0. Normal volunteers (n=14) were used to determine the readability of the target images. The actual number of errors was recorded for each of the seven (12 digit) targets at each of 4 frame rates. An analysis of Variance (ANOVA) was used to determine differences between frame rates. Results: There was a significant improvement (p<0.0003) in readability as frame rate was reduced for all targets with contrast between 0.0250 and 0.0125. Improvement with each frame rate reduction was greatest for images with the poorest contrast. A 10-fold improvement in readability was seen at 7.5 fps with a target contrast of 0.0125. Conclusions: Multiple frame integration, with a consequent decrease in effective frame rate, results in a significant improvement in identification of low contrast detail. Future work to determine applicability of this method to various surgical procedures is warranted.

NEEDLESCOPIC HELLER MYOTOMY Patrick M. Chiasson M.D., David E. Pace M.D., Christopher M. Schlachta M.D., Joseph Mamazza M.D., Eric C. Poulin M.D., The University of Toronto Centre for Minimal ly Invasive Surgery, Toront.o, Ontario, Canada

Minimally invasive surgical techniques and procedures continue to evolve. This report examines our early experience applying needlescopic technology to the surgical management of achalasia.

A retrospective analysis of Heiler Myotomy procedures performed at our institution since January 1, 1997 was performed. The results of 14 Needlescopic Heller Myotomy procedures (utilizing instruments with an external diameter of 2-3 mm) were compared with that of 15 Laparoscopic Heller Myotomy procedures. Both demographic and short-term outcome data were compared for each group. Analysis was performed utilizing chi-square, Fisher exact test, and student t-test where appropriate.

Both groups were similar with respect to age (37.1 vs 43.3 yr., p=0.58) and gender (8/6 vs 8/7, p=0.84). However, the needlescopic group weighed less (72.2 vs 83.5 kg., p=0.049). Intra-operatively, the needlescopic procedures were shorter (98 vs 132 min., p=0.03). There were no conversions to open surgery or difference in the number of intra-operative complications (0/14 vs 1/15, p=l.0) for either group. Post-operatively, the groups were similar with respect to complications (0/14 vs 1/15, p=l.0), time to normal diet (1.5 vs 2.0 days, p=0.23), and analgesia requirements (17.1 vs 29.6 morphine equivalents, p=0.86). Nonetheless, the needlescopic group had a shorter length of stay in hospital (1.1 vs 2.0 days, p=O.04).

In selected patients, Needlescopic Heller Myotomy is a viable treatment option resulting in a shortened operative time, a decreased length of stay and improved wound cosmesis.

THORACOSCOPIC ESOPHAGECTOMY WITH PREOPERATWE CORTI- COSTEROID FOR THORACIC ESOPHAGEAL CANCER REDUCES SURGICAL INVASIVENESS AND MAINTAINS CURABILITY Masahiro Chin,M.D., Kiminebu Watanabe,M.D., Yasunori Morohoshi,M.D., Yoshiki Kuriya,M.D., Takashi Akalshi,M.D.,Ph.D., Depatment of Surgery, Sakata City Hospital, Sakata, Yamagata, Japan

We have induced thoracoscopic esophagectomy with preoperative corticosteroid administration for patients with thoracic esophageal cancer. However, the application of thoracoscopic procedure for advanced case remains controversial. We investigated low invasiveness and curability of this procedure. Up to today, 47 patients of thoracic esophageal cancer were treated with thoracoscopic procedure with lymph node dissection since 1995 March. And we also induced preoperative corticosteroid administration since 1994 January. So the serial 32 operative ~atients with thoracic esophageal cancer since 1993 January were divided into three groups, group A: n=11was treated with thoracotomy procedure without preoperative steroid, group B: n--8 was treated with thoracotomy with preoperative steroid, and group C: n=13 was treated with thoracoscopic procedure with preoperative steroid. These items were compared among the three groups, such as operating time for the thoracic part, the amount of intrathoracic blood loss, the amount of time the respirator was used and oxygenic inhalation was needed, serum value of bilirubin, and the pestoparative heart rate. Significance of any values was tested using Student_fs t-test or x2 test. Finally the survival rate of 47 patients treated with thoracoscopic procedure was evaluated. Although there was no difference in operating time for the thoracic part among the three groups, the amount of intrathoracic blood loss was significantly less in group C than in other two groups. The amount times of respirator and oxygen inhalation used were significantly shorter in group C. Occurrence of hyperbilirubinemia was also significantly reduced in group C. postoperative tachycardia was significantly reduced in both group B and C. The 5 year survival rate of 47 patients ( 19 without lymph node metastasis, 28 with lymph node metastasis ) treated with thoracoscopic technique was 55.6%. We concluded that thoracoscopic procedure with preoperative corticosteroid reduced surgical ~nvasiveness and its curability could stand comparison with thoracotomy.

L A P A R O S C O P I C G A S T R I C W E D G E R E S E C T I O N : LOCALIZATION AND PERCUTANEOUS LESION LIFTING TECHNIQUE G.S. Choi M.D.1, W. Yu M.D.1, H.Y. Chung M.D.1, W.Y. Tak M.D.2, S.K. Kim M.D.2, Y.O. Kweon M.D.2, Y.H. Choi M.D.2, J.M. Chung M.D.2, Department of Surgery1, Department of Gastroenterology, Kyungpook National University Hospital, School of Medicine, Jung-gu, Taegu

Background: laparoscopic surgery has been introduced into the treatment of benign or malignant gastric tumors. Methods: From April 1996 to April 2000, laparoscopic wedge resection of the stomach has been undergone in 25 patients with 20 benign, 5 malignant tumors. In beginning of the period localization of the lesion was tried by preoperative tattooing in 10 patients but in the later 15 patients, intra-operative endoscopy was used. Resections with lesion lifting by percutaneous suturing and anastomoses were performed by hand and staplers in 9 and 16 patients respectively. Results: Laparoscopic localization of the lesion failed in 3 patients who had preoperative tattooing. Mean operative time was 155.4(65-260) min. Mean hospital stay was 6.72(2- 14) days. In two patients open conversion was done. One suture line bleeding and trocar incision site hernia occurred in different three patients post-operatively. Conclusions: pre-operative tattooing was not a reliable method so that needed in t raoperat ive gastroscopy. Percutaneous lesion lifting was effective and could avoid extratrocars. Laparoscopic wedge resection of benign or malignant tumor was a feasible and useful procedure.

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LAPAROSCOPIC REDUCTION OF AN ACUTE JEJUNOGAS- TRIC INTUSSUSCEPTION G.S.Choi M.D., W.u Department of Surgery, Department of Gastroenterology*, Kyungpeok National University Hospital, School of Medicine, 50, Samduk 2 ga, Jung-gu, Taegu, Korea

Retrograde jejunogastric intussusception is a rare, also, laparoscopic treatment of this complication is hardly to be found in the medical literatures. We successfully performed laparoscopic reduction of acute incarcerated jejunogastnc intussusception,

A 52-year-old man was admitted to Kyungpook Nation University Hospital emergency room with aggravated hematemesis and abdominal pain for one day. He had undergone antrectomy and Billorth II gastrojejunostomy 20 years ago due to chronic complicated duodenal ulcer. Initial vital signs and laboratory findings were stable only except rapid pulse rate(119/min) and elvated serum amylase(209 IU/L.)leukocyte count(17900/mm3), we performed gastric endoscopy and abdominal CT scan which showed a typical bowel intussusception.

Under the general anesthesia and pneumoperitoneum, careful reduction of intussusception of the efferent limb of jejunum out of the stomach was commenced in a traction and counter traction manner which was guided by gastroscope to exclude presence of any lead. No attempt to anchor the reduced bowel loop to the other intra peritoneal viscera was done.

The patient resumed oral intake at the 2nd post-operative day and was uneventfully discharged at the 5th post-operative day. During 6 months- follow up showed no recurrence.

Laparoscopic reduction of an acute jejunogastric intussusception was effective and safe method to treat it.

NUMBER OF MINIMIALLY INVASIVE SURGERY (MIS) CASES REQUIRED FOR COMPETENCY Uyen Chu, MD, Adrian Park, MD, Donald Witzke, PhD, Michael Donnelly, PhD.,Michael Mastrangelo, MD, Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky

Objective: The purpose of this study was to obtain estimates from MIS surgeons regarding the number of cases a trainee must perform to be competent in 13 core laparoscopic procedures.

Methods: Structured questionnaires exploring competency issues were mailed nationally to leading experts in the field of MIS. The response rate to date approaches 50%. A smaller number of surveys were also administered to nonexperts. Data were analyzed using ANOVA and post hoc Student-Newman-Keuls test.

Results: Estimates of the number of procedures to be performed for competency were not significantly associated with several demographic measures such as % of practice involved in MIS procedures or years in surgical practice. Thus, the estimates of the experts and non-experts were pooled. The number of laparoscopic cholecystectomy and inguinal hemiorrhaphy cases to be performed by an average, non- expenenced resident for competency were 40+-31 and 40+-20, respectively. The number of cases a surgeon, competent in laparoscopic cholecystectomy and inguinal hemiorrhaphy, needs to perform for the 11 additional procedures divided into 4 statistically significantly different levels. For example, colon surgery has to be performed about the same number of times as a lap chole. Laparoscopic biliary surgery needs to be performed about 22 times; spleen about 15 times, and appendectomy about 10 times. These and other procedure numbers will be reported in detail. Experts and non-experts tended to agree (within 15%) on whether specific procedures should be core or not, with the exception of laparoscopic adrenalectomy where they differed by 33%.

Conclusion: These data indicate the varying number of times core laparoscopic procedures need to be performed by average surgical residents to achieve competency. Th~s information can be used to plan curriculum length and sequence for general surgery residents and fellows in MIS.

FLUID REQUIREMENTS AND MOBLL1ZATION IN LAPAROSCOPIC VS OPEN RIGHT

HEMICOLECTOMY PATIENTS

H. Chut, MD, T. M. Young-Fad~ MD, M& Divi~io~ of Coleecal Sure'y, Mayo Clinic, Rochmer, MN.

BACKGROUND:. Minimally inwmive ma'gery may ha physiolollically Im ~e~u l to F~mt~. Heeu~al ~ have Ix~n ludied, b~ fluid requinm~m and m'ine volumm u diuimUy rd~mt indi~ of strea nmi~me have u~ b~u repom~.

AIMS: To compare fluid rec~iremm~t~ and urine velema of equivalent IN~u'esooplc v~ opon pationts.

METHOd: Rmr~aive chxq review ofSO ~ undergoing Ir d~t hcmimkctomy (LAP) w~ im'fomed. Cues wee m.~ed to opm mnerols (OPEN) for petemia cenfouadee o f ~ . ~d~.. ~ ~ d d ~ ofop~fio~ l)iumi�9 ~1 pdor ~ mrg~ w~ m~. Opaive dauih included OR time md IV fluid. Fluid requiremena and urine volume* pe" 24 hems wee remrdat f~ Ihe flnt 4 day,, i~luding day of ma'gmy.

RESULTS: B~th greWs wee nztchai for L, onda" (M:F = 2'.3 for inch 8reup) md ap (58 yrs OPEN n 57 ~ LAP). Sb~ p~ca~ (OPEN) md ~% (LAI') h~ ~ ,Moadml ~ a y . Twdve (OP~)md 7 (LAP) p~mU us,d dinmicL Ibe most commoa ~q~amis wu cmc~ f~ b OPEN md Crohn's diseaeinflmLAF. MmnORfiazwu 176min(OFEN)vs 157 rain(LAP) [P=0.2331. MmnOR~uld vnm 3342ml (OPEN) ~ 2389ml (LAP) [1~0.002]. Mean fluid requinmem on day of stegmT were 54.~ lml (OPEN) vz 3685ml (LAP) iF- 0.002], while urine volumes wee 1096ml vz 1039ml (P- 0.594~ Fluid r e ~ on pea.,op day (POD) I wee 3385ml vs 3017ml (P- 0.726) tad mine 2071ml "a 3008ml r e . e l y . ( ~ . 0 1 ) Fluid r e ~ on POD 2 wee 2866ml va 2694ml (1~ 0.536) and

2664ml n 3414ml respectively. ~ 0.004). Fluid requitemonts on POD 3 wee 2644ml n 2174ml (P-0.409) tad ta~ne 2420ml n 1930ud respeaivdy (P= 0.322).

CONCLUSIONS: ~ k pto~date* compared with the open ceuuteq~t require lea fluid dating the prou~dure and have ~ fluid needs in the fu~ 34 hom~ while havlns equivdmt urine ont~. Fluid needa on POD l e e simibr, but LAP l~tieuts mebilize an additiemd lira" of urine. Thh ttond continues on POD 2. Thus LAP i~ieru mobilize fluids etrlier and uvertll require lea total fluid than OPEN. The LAP approach may have benefits in petieua intolmmt of fluid ~ md my reduce the incidmoe of po~..op CHF md tttbl flbrill~t/on, both p,xt-op mmplimtione mneb,t~l with fluid mobilization.

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SLEEP ARCHITECTURE IN PATIENTS WITH GASTROE- SOPHAGEAL REFLUX DISEASE JA Cohen MD, PA Harris PhD, DW Byrne MS, A Ara in MD, L Khai tan MD, MD Holzman MD, KW Sharp MD, WO Richards MD., Section of Surgical Sciences, Vanderbilt University, Nashville, TN

Subjective questionnaire data suggest that patients with gastroesophageal reflux disease (GERD) do not sleep as well as normal control subjects. The purpose of this study was to corre late ref lux events with t ime spent in deep sleep.

We studied five male subjects, three of whom complained of nocturna l s ymp toms cons is ten t with GERD, using overnight polysomn0graphy and simultaneous esophageal pH monitoring.

Subject # of reflux events % of night in stage 3 sleep 1 0 18.5 2 2 18.8 3 17 15.4 4 99 14.1 5 312 8.3

Correlation Coefficient: -0.96

We conclude that the number of pH events in this group of subjects closely correlates with the time spent in deep sleep.

LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH A NOVEL ELECTROSURGICAL SNARE IN A PORCINE MODEL William Collyer M.D., Jaime Landman M.D., Cassio Andreoni M.D., Ephrem Olweny B.S., Chandru Sundaram M.D., and Ralph V. Clayman M.D., Washington University Division of Urology, St. Louis, Missouri

We evaluated the safety and efficacy of laparoscopic partial nephrectomy with a novel arcing-gap electrosurgical snare in a porcine model.

A novel electrosurgical snare based on high current density arcing and parenchymal compression, was deployed with an ERBE generator set at 200W in the ENDOCUT mode for renal transection. Five domestic pigs weighing 50 to 70 kg underwent unilateral laparcscopic partial nephrscto- my; 6 weeks later each animal underwent contralaterai partial nephrectomy just prior to sacrifice. Three additional animals underwent hem- inephrectomy at the level of the renal hilum.

Mean transection time with the snare was 5.6 minutes. In 9 of 10 cases, the snare provided perfect hemostasis. In one case, the snare detached from the handle and required re-placement to complete the renal transection. In this case argon-beam coagulation controlled minimal bleeding.

In all ten cases the renal collecting system was transected. In 6 cases no urinary extravasation was noted. In 3 cases argon-beam coagulation was used to seal small sites of leakage from the collecting system. In 1 case, three laparoscopic sutures were placed to close a defect in the collecting system resistant to argon-beam closure. No urinomas developed in the 5 chronic animals. Pathologic evaluation at 6-week's follow-up revealed a maximum depth of injury/fibrosis of 5-mm. All 3 heminephrec- tomies were completed with perfect hemostasis; however, all 3 animals developed strictures of the renal pelvis; likely due to the proximity of the snare to the pelvis.

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 THE URINARY BLADDER. A CASE REPORT Daniel Cottam MD, Piotr J Gorecki MD, Marcio Curvelo, MD, David Weltman, MD, Nassau University Medical Center, East Meadow, New York

The role of laparoscopy as a diagnostic modality in trauma has been reported. However, therapeutic laparoscopy for trauma remains an obscure and controversial subject. We present a case of a laparoscopic exploration with suture repair of a traumatic bladder rupture.

A 25-year-old man was brought to the Emergency Room after a head on collision. On arrival he was alert, awake, orientated, and all his vital signs were stable. Physical examination was unremarkable with the exception of gross hematuria upon insertion of the urinary catheter. CT scan of the abdomen demonstrated a small amount of free intra-peritoneal fluid. An antero-posterior cystogram was obtained which showed no intraperitoneai or extraperitoneal leak. Repeat examinations of the abdomen revealed a mild tenderness in the lower abdomen. Because of the presence of unexplained free intraperitoneai fluid and equivocal signs of peritoneal irritation exploratory laparoscopy was performed.

Three 5-mm ports and 5-mm camera were used. Laparoscopic examination of the abdomen revealed free fluid and a 4-cm rupture at the dome of the bladder. The rest of the abdominal exploration was unramarkable. The laceration was sutured in two layers using a intracorporeal technique. His recovery was prompt and uneventful and he was discharged on the second postoperative day with a indwelling urinary catheter. Eight clays after the operation, a repeated cystogram revealed no evidence of leak and the catheter was removed. We conclude that laparoscopic exploration for trauma in hemodynami-

caily stable patient can be safely performed. All principles of abdominal exploration for trauma can be adhered to while utilizing three 5-mm ports. The advantage of laparoscopic technique is not only to determine the need for laparotomy, but also to provide therapy for stable patients using minimally invasive techniques. A prospective study is needed to determine the role of advanced laparoscopy in managing the stable trauma patient suspected of having an intraabdominal injury.

AN INTERNET-BASED DATA COLLECTION AND REPORTING TOOL FOR CLINICAL RESEARCH John Cowan, B.S, Susan L. DeMeester, M.D., Kevin B. Johnson, M.D., Howard S. Kaufman, M.D., Departments of Surgery and Pediatrics, The Johns Hopkins Medical, Baltimore, MD

Introduction: The objective of this study was to develop and imple- ment an Intemet-based data entry and management system for use in clinical research. Currently, clinical data collection frequently relies upon information transfer from static paper forms to database programs. Database files often reside on one or more desktoptlaptop computers and are subject to inadvertent deletion, asynchronous merg- ing, and breaches of confidentiality. Methods: A template-driven Intemet data collection and reporting tool was developed using Cold Fusion, r. v 4.0. The application and database were housed on an iP- protected Windows NT, r. server using a secure socket layer. A main menu page provided options for entering and accessing patient data, updating relational tables, and viewing statistics. The templates were compiled by the system and contained information regarding the data to be collected, forms generation and validation, relational tables, and data reporting and analysis. The application was applied to a retrospective surgical series of patients who underwent treatment for rectal cancer. Results: Pre-, intra-, and postoperative clinical, laboratory, radiographic, and pathologic data on >200 patients were successfully entered from multiple locations by several investigators. The database could be downloaded only by users with the highest security access. Study statistics were obtained and will be demonstrated with the application. Conclusions: Intemet-based clinical research systems provide an efficient, secure, and versatile means for collecting and reporting data. The application supported revisions in forms generation, data collection, and data analysis. Monitodng features alerted the investigators as to which subjects needed more data. This approach centralized the database and provided numerous portals for data entry. Although an initial capital investment in software, hardware, and Intemet connec- tions were required, this technology can be applied to numerous clinical investigations and may result in overall costsavings

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LAPAROSCOPIC CHOLECYSTECTOMY: OUTPATIENT VS INPATIENT MANAGEMENT Myriam J. Curet, MD, Michael Contreras, Diana M. Weber, MD, Roxie Albrecht, MD University of New Mexico School of Medicine, 2211 Lomas, Blvd., Albuquerque, NM

Objective: This prospective randomized trial was undertaken to determine if patients undergoing an elective laparoscopic cholecystectomy may be discharged home 4 hours postoperatively with similar levels of pain and nausea, similar complication and readmission rates and equal satisfaction as patients kept overnight. Methods: All patients presenting for an elective laparoscopic cholecystectomy underwent randomization to an outpatient group (OPD) who were discharged alter a 4 hour postoperative stay, or an inpatient group (IP), admitted ovemighL Variables measured were degree of pain (scale of 1-10) and nausea/vomiting (scale of 1.4), amount of pain and nausea medication taken, number of phone calls, readmissions or complications, and degree of satisfaction with their procedure (scale of 1-4). Statistical analysis was performed with t-test or Fisher's exact test as appropriate. Results' Eighty patients were initially enrolled. Two were converted and 4 required admission after being randomized to outpatient, leaving 37 OPD and 37 IP. The OPD patients received more oral pain medication prior to discharge (2.1 doses vs 0.8 p<0.05). However, their degree of pain was similar to IP patients (4.2 vs 4.3). Phone calls, readmission rates and complication rates were similar in both groups. Patient satisfaction was 3.8 at one month for both groups. Conclusions: Patients undergoing elective laparoscopic cholecystectomy, who are discharged home at 4 hours postoperatively, will experience the same satisfaction with no increase in complications as patients kept ovemighL Selected patients should be offered outpatient management following laparoscopic cholecystectomy.

SPLENIC ARTERY ANEURYSM REPAIR: EVOLUTION OF A MINIMALLY INVASIVE APPROACH John de Csepel, MD, Michel Gagner, MD., Division of Lapamecopic Surgery, Mount Sinai School of Medicine, New York, NY

Therapy for splenic artery aneurysms (SAAs) has traditionally required a laparotomy. A small number of case reports since 1993 have described laparoscopic management, usually consisting of an anterior approach to aneurysm resection or splenectomy. The purpose of this study was to evaluate our experience with laparoscopic SAA repair.

A retrospective review of medical records over a four-year period at two institutions was conducted. Six consecutive patients treated for SAA by a single surgeon were identified. The follow up period ranged from 2 to 52 months.

There were five women and one man with an average age of 49 years (range, 37 - 63 years). Three patients were diagnosed with SAAs by incidental radiographic findings, while the rest were symptomatic. The first three patients had aneurysm resection or splenectomy, while the last three underwent aneurysm exclusion. An anterior approach was used for the first five patients. The most recent patient underwent a lateral approach to aneurysm exclusion. The average aneurysm size was 3.1 cm (range, 2.5 - 5 cm), estimated blood loss was 82 ml (range, 20 - 300 ml) and operative time was 143 minutes (range, 80 - 190 minutes). Aneursym resection and 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 exclusion patients. Complications consisted of an asymptomatic hyper- amylasemia (n=l) and low-grade fevers (n=2). Postoperative spleen scan revealed increased perfusion over time in patients who had undergone a spleen-preserving procedure. There were no splenic abscesses.

Our series of SAA patients demonstrates an evolution of laparascopic treatment from an anterior to a lateral approach and from aneurysm resection or splenectomy to aneurysm exclusion. A lateral approach permits a spleen-preserving procedure by providing excellent distal splenic artery exposure without disruption of splenic collateral blood supply. Aneurysm exclusion avoids the morbidity associated with aneurysm resection and splenectomy

EXPERIENCE FROM 27 CONSECUTIVE LAPAROSCOPIC REOP- ERATIVE BARIATRIC SURGERIES John de Csepel, MD, Michel Gagner, MD, Paolo Gentileschi, MD, Theresa Quinn, MD, Subhash Kini, MD, Daniel Hen'on, MD, Emma Patterson, MD, Alfons Pomp, MD, Division of Laparooopic Surgery, Mount Sinai School of Medicine, New York, NY

Ten to 25% of patients undergoing obesity surgery will require a revision. Reoperation is associated with increased morbidity and has traditionally been done in open fashion. The purpose of this study was to determine the feasibility and safety of performing reoperative badatdc surgery using a laparoscopic approach.

A retrospective review of medical records over a 22-month period was conducted. Twenty-seven consecutive obesity surgery patients, who had undergone a laparosoopic revision, were identified.

Twenty-six of the 27 patients were women. The average age was 40.3 years (range, 20 to 58 years) and original preoperative body mass index (BMI) was 51.6 kg/m2 (range, 42 to 66.5 kg/m2). Seventeen of the 27 primary badatdc surgeries were open procedures. They consisted of a vertical banded gastroplasty (n=12), a gastric band placement (n=9), and a gastric bypass (n=6). After the primary surgery, the lowest average BMI was 37.6 kg/m2 (range, 21 to 52 kg/m2), which increased to 42.7 kg/m2 (range, 29 to 56 kg/m2) before reoperation. Twenty-four of the 27 reoperations were for insufficient weight loss. On average, the revision was undertaken 52 months after the primary procedure. Twenty-four of the 27 reoperations were conversions to a gastric bypass. A second reoperation was required for insufficient weight loss on four occasions. The average operative time was 232 minutes (range, 120 to 480 minutes) and length of hospital stay was 3.7 days (range, 1 to 9 days). Twenty-six percent of patients (n=7) experienced complications including pneumothorax, gastric remnant dilation, gastrojejunostomy stenosis, port site hemia and protein malnutrition. One operation was converted to an open procedure. The average BMI was 35.9 kg/m2 (range, 27 to 45.5 kg/m2, p<O.001 v. BMI before reoperation) 8 months after surgery.

Our results compare favorably with those reported in the open reoperative badatdc surgery literature. A laparoscopic approach may be considered a feasible and safe alternative to an open operation.

LAPAROSCOPIC RESECTION OF SMALL BOWEL LESIONS CAUSING LOWER GASTROINTESTINAL BLEEDING: THE IMPORTANCE OF METHILENE-BLUE STAINING BY INTRAOPERATIVE ANGIOGRAPHY Salva Delgado MD, Miguel Pera MD, Juan C. Garoia-Valdecasas MD, Manuel Pera MD, Oscar Estrada MD, Emilio Riera MD, Xavier GonzaJez MD, M.I. Real MD, Antonio M. Lacy., Service of Gastrointestinal Surgery. Institut de Malalties Digestives. Section of Interventional Radiology. Hospital Clinic. University of Barcelona. Spain

Selective angiography has been demonstrated to be extremely useful in the diagnosis of patients with gastrointestinal (GI) bleeding of obscure origin.One of the advantages of angiography is the ability to control the bleeding either by mesenteric vasopressin infusion or supraselective tran- scatheter embolization.However, the risk of complications,especially bowel isquemia,is not dismissable.Laparoscopic-assisted small bowel resection is easy and allows a fast recovery.However, most of the lesions causing bleeding may be difficult to lecalize.The aim here was to investigate the utility of angiography-guided methilene-blue staining in the laparoscopic treatment of small bowel lesions causing GI bleeding.Between October 1999 and August 2000,we treated 4 patients with diagnosis of lower GI bleeding originated in the small bowel.Mean age was 61.5 years(2 males/2 females).Bleeding was chronic in 3 patients and massive in 1 .Previous diagnostic workup, inciuding endoscopy and scintigraphy was normal.Angiography of the superior mesenteric artery identified small hypervascularized lesions in the ileum in all 4 patients.There was extravasation of contrast in 2 cases.Before the operation, a microcatheter was placed in the most distal branch supplying the lesion. Pneumoperitoneum was established by the Veress technique.The laparoscope was inserted by a 12-ram trocar placed infraum- bilically and the small bowel loops were explored.Four ml of methilane-blue were infused and staining of a short segment of the ileum was observed.Laparoscopic-assisted resection was performed and a side to side extracorporeal stapled anastomosis was done by a 4-cm incision in the righl lower quadrant.Postoperative course was uncomplicated and the mear postoperative hospital stay was 3.2 days.Histopathological evaluatior showed acute ulcers in 2 cases,angiodysplasia in 1 patient and lymphoma in 1 case.There was no recurrence of bleeding.Angiography-guided methilane blue staining is an easy and safe technique that facilitates ident]ficatior of small bowel bleeding lesions prior to laparoscopic resection.

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LAPAROSCOPIC VERTICAL BANDED GASTROPLASTY WITH ROUX- EN-Y GASTRIC BYPASS FOR MORBID OBESITY. Aureo L DePaula, MD, Ostemo Q. Silva, Osvaldo G. Ramos Jr. and Klyoshi Hashiba, MD. Deparbnent of Surgery, Instituto ING, Goi~nia, Brazil.

The three most frequently used badatnc surgeries are the Roux--en-Y gastric bypass (RYGBP), the vertical banded gaskopiasty (VBG) and the adjustable gastnc banding (AGB). The RYGBP has achieved better weight loss in long-term follow-up. The aim of this study is to demonstrate the results of the association of VBG to RYGBP performed iaparoscopically (LVBG-RYGB).

From November 1997 to July 2000, 156 patients undenvent LVBG-RYGB according to the criteria of the "NIH Consensus Development Panel" of badatdc surgery. Patients with previous esophageal and gastric surgew, BMI greater than 85, age under 16 and over 65 and severe coaguiabon disorder were excluded. Ninety-six patients were female and 60 ware male. Mean age was 37.8 (16 - 65). Mean BMI was 49.1 (33.5 - 83). FiRy-seven (36.5%) paints were considered superobese. Associated diseases included: diabetes(8.3%), hypertension (38.4%), sleep apnea(7%), disUpidemia (27%), cholelithiasis (11.5%), o bes#y-hypoventilation syndrome- OHS (4.5%), arthritis (31%), GERD(14%), asthma(3.2%).

Mean operative time was 19groin (150min - 7h). Early postoperative complications included wound infection(1.4%), leaks(I.4%), pneumonia (1.4%), diges~ve bleeding (2.8%) and perforated jejunal ulcer(O.7%). Median hospital stay was 3.1 days (2 - 25 days). Postoperative follow-up ranged from 1 to 33 months. Late postoperative complications included 16 marginal ulcerations, 1 anastomotic stricture treated endoscopically and 1 band erosion. Mean excess weight loss was 51% in 6 months, 73.4% in 12 months, 78.2% in 18 months, 76.9% in 24 months and 76.6% in 33 months. All GERD, sleep apnea, cholelithiasis and OHS patients had resolution of their medical problems. Hypertension, diabetes and asthma had papal improvement. Quality of life was improved in all patients.

Laparoscopic vertical banded gastropiasty with Roux-en-Y gastric bypass proved to be technically feasible, with low complication rate, significant weight reduction and improvement of associated diseases.

LAPAROSCOPIC SPLENECTOMY IN THE TREATMENT OF SPLENOMEGALY Stanley DeTurris M.D., Robert Cacohione M.D., Alfonse Pecoraro M.D., Anil Mungara M.D. and George Ferzli M.D, Department of Surgery, Staten Island University Hospital, Staten Island, New York

Anecdotal evidence has suggested that spleens greater then 3000 grams may prove technically too demanding for laparoscopic removal.

We reviewed our experience with laparoscopic splenectomy from 1992 to 1999. Of 86 laparoscopic splenectomies performed during this interval, six patients had postoperative splenic weights greater than 3000 grams. In these six patients we examined age, operative indications, conversions to open procedure, spleen weights, accessory incisions, operative times, blood loss, transfusions, drain placement, deaths, complications and hospital stay.

Spleens were successfully removed in all six patients without conversion. Mean age was 65 years (range 58-75.) Operative indications were non-Hodgkin's lymphoma in four patients, sideroblastic anemia in one end hypersplenism in one. The average spleen weight was 3525 grams (range 3050.4800.) All six required accessory incisions for spleen removal, two using a hand-assisted transabdominal port. Mean operative time was 172 minutes (range 127-250 minutes.) Estimated blood loss was 590 co (range 400-700 cc) and 2 patients required transfusion (including one patient with a preoperative hemoglobin of 7.9 mg/dl.) No drains were placed. There were no deaths and no major complications. There were three minor complications including an abdominal wall hematoma, postoperative diarrhea end atelectasis. There were no pancreatic leaks. Average hospital stay was 2.5 clays (range 2-4 days.) There were no port site metastases on follow-up.

Laparoscopic splenectomy for massively enlarged spleens greater then 3000 grams is both technically feasible and does not appear to pose undue risk to patients. Our conversion rate was much lower than anecdo. tal evidence suggests for spleens of this size. Operative times, blood loss, morbidity and hospital stays are consistent with published series. We conclude that iaparoscopic splenectomy is appropriate for spleens greater than 3000 grams.

LAPAROSCOPIC-ASSlSTED ILEOCOLIC RESECTION FOR PEDIATRIC CROHN DISEASE Ivan Diamond and Jacob C. Langer, MD, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario

Background: Laparoscopic-assisted ileocolic resection for Crohn disease has been reported as an acceptable alternative to the open procedure in adults. We evaluated our initial experience with this procedure in the pediatric population. Methods: Fifteen adolescents underwent ileocolic resection for documented Crohn disease. Retrospective analysis of intraoperative and early post-operat ive results was done, compar ing those undergoing the laparoscopic-assisted approach with those having open resection. Data were compared using Student t- test. Results: Eight adolescents (mean age 15.6yrs) underwent open resection and 7 (mean age 16.2 yrs) underwent laparoscopic- assisted resection. No patient had undergone previous resection. The two groups did not differ with respect to t ime from diagnosis to surgery, indications for surgery, preoperative medical therapy, or length of intestine resected. Operative time for the laparoscopic-assisted group was slightly longer than for the open group (160 vs.130 rain), but this was not statistically significant. There were no intraoperative complications in either group. While no statistically significant differences were noted for number of days of narcot ic, total dose of narcotic, and t ime to resumption of regular diet, the patients undergoing laparoscopic- assisted resect ion were d ischarged 2 days ear l ier (5 vs. 7, p<0.05) than the open group. Complications included 1 wound infection and 1 intraabdominal abscess in the open resection group, and 1 patient with a prolonged ileus in the laparoscopic- assisted group. Conclusions: Laparoscopic-assisted ileocolic resection is a safe alternative to open surgery in adolescent patients with Crohn disease.

TOTALLY LAPAROSCOPIC AORTOBIFEMORAL BYPASS FOR AOR- TOILIAC OCCLUSIVE DISEASE : EXPERIENCE WITH 39 PATIENTS Yves M. Dion, M.D., M.Sc.*, Geoffroy Wamier de Wailly, M.D.*, Carlos 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

The aim of this case series was to assess the feasibility of a totally laparoscopic aortobifemoral bypass (LABF) for aortoiliac occlusive disease.

Thirty-nine patients (27 men, 12 women) were submitted to a LABF according to the "apron technique" we previously described. Three had rest pain and the others incapacitating claudication. The mean preoperative right ABI was 0.66 (0.16-1.00) end the left was 0.61 (0.26-1.02).

Operative, aortic cross-clamp, end enastomotic times were respectively 302 (185-510), 95(42-189), end 48 (18-155) minutes. Blood loss was 646 (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 clamp. Patient 6 had the graft damaged during insertion, which, when recognized, needed repiaosmenL Patient 7 had an unsatisfactory anastomosis made in a calcified aoRtiC stump. Anastomotic bleeding followed endarterec- tomy of the aoRtic stump and a second laparosoopic enastomosis, which was ultimately judged adequate after conversion. Four minor intraoperative complications were recorded and one patient needed a concomitant femoro-popiiteal bypass for iatrogenic femoral artery dissection.

Mean intensive care unit (ICU) and postoperative hospital stays were respectively 2.29 (1-6) end 6.35 (3-23) days. One patient suddenly died on the sixth postoperative clay after a normal recovery, likely from arrythmia or pulmonary embolism.

Mean follow up averages 17.5 months (1-49). Patient 5 needed a reoperation for acute aoRtiC false eneurysm. One patient suffered a stroke three months postoperatively, another one needed a left profundoplasty one year postoperatively and one patient had revision of a femoral anastomosis 10 months after the original surgery.

Totally laparoscopic aortobifemoral bypass for occlusive aortoiliac disease is safe and feasible. Surgery time is now almost comparable to open surgery. Benefits (ICU end post-op, stays) similar to those demonstrated in general surgery are becoming apparent.

T H E EDUCATIONAL IMPLICATIONS OF THE IMPOR- TANCE OF C L I N I C A L J U D G M E N T IN PERFORMING LARPAROSCOPIC SKILLS. Michael B. Donnelly, PhD., Donald Witzke, PhD., Michael Mastrangelo, MD, Adrian Park, MD., Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky

Objective: The purposes of this study were: 1) to determine the importance of clinical judgment in performing basic laparoscopic skills and 2) to discuss the implicat ions of those findings for training residents in MIS.

Methods: 23 of 48 MIS experts and 14 non-experts from convenience samples returned a questionnaire concerning the influence of clinical judgment (CJ-a cognitively complex skill)on the performance of 18 basic laparoscopic skills (LS). In addition, the LS were evaluated on 5 other dimensions related to technical skills (e.g. hand-eye-coordination). A technical skills complexity index (TSCI) was also developed for each LS.

Results: The LS could be divided into 3 CJ levels (high, middle, and low) based on their mean ratings. Similarly, TSCI divided the LS into 3 levels of skill complexity. The correlation between the CJ and TSCI indices was .16 (p > .05) indicating that a laparoscopic skill's cognitive complexity is independent of its technical complexity. E.g., Trocar positioning requires significant CJ but little TSCI; while, "using non-dominant hand" requires little CJ but significant TSCI.

Conclusion: The results of this study have important impli- ca t ions for t ra in ing res iden ts in l apa roscop i c ski l ls. Competent performance of laparoscopic skills is not developed in a straight linear fashion; time must be allocated for the maturation of the judgmental aspects of these skills.

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HAND ASSISTED LAPAROSCOPIC COLON SURGERY (HALS) Jan Dostalik, M.D., Ph.D., Surgery Department of Municipal Hospital Ostrava, Czech Republic

AIM: Laparoscopic colon surgery belongs to the category of the more difficult ones to perform. Specially, low anterior resections or abdominoperineal resection are operations that take a long time. An insertion of a hand of an operating surgeon into the abdominal cavity makes the operation simpler and faster. METHODS: We use a special device, Japanese hand-port LAPDISC, which allows a surgeon to insert a hand into abdomen cavity while preserving pneumoper- intoneum. For low anterior resections or abdominoperineal resections we perform an incision of 7.5 cm (3 in) in the left lower abdomen. In this short incision we input a hand-pert LAPDISC. This multi-functional device allows a small opening for a laparoscopic instrument, or a wide opening for an insertion of a hand into the abdomen cavity, or a complete closure of the hand-port while preserving the pneumoperitoneum. RESULTS: Between 1993 and end of August, 2000 we performed 230 laparoscopic colon operations, including 34 low anterior resections and 30 abdominoperineal resections. We used a HALS method for 13 of them. The operating time of the low anterior resection and abdominoperineal resections with laparoscopic assistance was on average 187 minutes. The operating time of procedures using HALS method was on average 156 minutes. The HALS method allowed to shorten the operations by 31 minutes. CONCLUSION: The HALS method should be used when a pert of the procedure is performed in front of the abdominal wall, or if the operation results in colostomy. A surgeon with an inserted hand in the abdominal cavity can utilize a palpation examination that is usually used at open surgery. Soft palpation of organs and digital preparation together with the use of harmonic scalpel cuts on the operating time. Also, the HALS method keeps all the advantages of the mini invasive surgery.

E S O P H A G E A L CLEARANCE AND GASTROESOPHAGEAL REFLUX AFTER LAPAROSCOPIC HELLER MYOTOMY Karen Draper M.D., Jonathan Cohen M.D., Leena Khaitan, M.D. Ronaid Clements M.D., Peter Wang M.D., Kenneth Sharp M.D., Michael Holzman M.D., William Richards M.D., Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

The addition of an antireflux procedure during Heller myotomy for achalasia is controversial. We report the incidence of reflux and the rate of esophageal clearance for solid food following laparoscopic Heller myotomy with and without Dor fundoplication in 25 patients.

Twenty two patients who had undergone laparoscopic Heller myotomy and 3 patients who had undergone laparoscopic Heller myotomy § Dor fundoplication were studied postoperatively. All patients underwent postop esophageal manometry and 24 hr pH testing. Symptoms of dysphagia and reflux were evaluated using a Likert scale ranging from 0 to 100. Ten patients also had evaluation of esophageal clearance using a bolus of scrambled egg labeled with technetium-99. Images of the esophagus were taken every ten seconds for 15 minutes.

Seventeen men and 8 women (mean age=48 +/- 11 yrs) were studied. Esophageal clearance for solids was poor in all 10 patients. 8 of 10 pts. cleared less than 10% of the bolus after 15 minutes. Clearance rate was not related to postop LES pressure or to the dysphagia symptom score. All patients had aperistaltic esophageal contractions on manometry testing. Pathological reflux (>4.2% total time) was noted in 3/22 Heller patients and in 1/3 Heller-Dor patients postoperatively. The reflux incidence was not related to postop LES pressure, dysphagia symptom score, or reflux symptom score.

Postoperative clearance for solids is poor following laparoscopic Heller myotomy. This is likely due to continued esophageal aperi- stalsis. Postop pathologic reflux can be found in a small number of 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.

LOW PRESSURE LAPAROSCOPY FOR OBESITY SURGERY Moshe Dudai MD, Sasha Levin MD, Misgav Ladach Hospital, Jerusalem Israel

Morbid obese paUants are in high risk for surgery because of respirator~ complications, thromboembolic complications and cardiac complications, la general Laparoscopy reduces the operative dsk but because of th~ pneumcperitoneum those tPd'ee groups of complications are paffially retained To further reduce the operative risk of the obese patients, we developed technique to eliminate the CO2 pneumoperitoneum complica6ofls. Knowing the "Gassless" Laparoscopy in obese patients is a great chalenge, we devalopeq the "Low Pressure Laparoscopy" technique, it is a Laparoscopy in combinatioe with mechanical, abdonminal wan elevation by Endolift (Storzt), with Icy pressure, 5-9Cm, Co2 pneumopedtoneum. Adding low pressure of Co2 to thq abdominal waU lift by the Endolift, allowed to pull away the excess fat and tc achieve good exposure with clinical insignificant Co2 pneumoperitoneun pressure. After having experience with 312 (of total 386) patients in prospective study wq realized that the 'Low Pressure Laparoscopy" technique has sever= advantages: A) Anesthesia -"soft and stable': the expired Co2 didn't excee~ 37ram Hg, the 02% was above 95%, blood pressure and pulse didn't rise a~ ma W times as often seen in Laparoscopy. The use of relaxants, anesthetics an~ gesses was reduced up to 50%. B) Recovery - "Fast': recovery lime was shor 1-3 (2) hr, short time for 02 supply 1-5 (3)hr, only 0-3(1) doses of simple 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/normal activity in 3-7 days. C Complications 'Law': 1 leak 1 LLL pneumonia with effusion, 5 linear( athelectasis, 1 nonsurgical mortality. D) Surgery - this technique offers bette exposure and partial liver retraction and reduced operative time (60 rain in the last 200 patients) by using variable pressure. "Low Pressure Laparcscopy ~ for obesity surgery fadrdates the Anesthesia Recovew and Surgery and enables to accept High Risk Patient otherwis~ refused. This method can be applied to all upper and lower abdomen operatior~ - the way we operate on a daily basis.

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COMB~EO PROSPECTIVE CUNICAL AND EXPERIMENTAL STUDIES OF LAPAROSCOPIC REPAIR OF INCISION AND VENTRAL HERNIA. Moshe I~udai MD - Misgav Ladach Hospital, M. Herbert MD - Assaf Harofeh Medical Center, Israel We have conducted ongoing experiments to reduce adhesion formation and improve results in a two layer laparoscopio intrapedtoneal onlay mesh (IPOM) repair of incisional and ventral hernia and have applied the results clinically. Laparoscopic repair offers advantages over open technique in operating and recovery time, visualization of the defect and low recurrence rate, but concerns remain about adhesion formation and intestinal obstruction. In prior experience we found onlay Gortex patch was unsatisfactor 7 because of slippage and adhesion formation in one out of 16 patients. We have developed a two layer technique using Butterfly Mesh in the defects and on top a wide propylene (Prolen). Animal experiments showed a way to protect the surface of the prolene to reduce adhesions. In four sets of animal experiments we compared incorportation and adhesion formation of Prolene alone, Prolena embedded in PDS and Prolene covered on its visceral surface with Surg~cel. Because of fewest adhesion, we subsequently selected the Composite of Prolene and Surgical for a second set of expenments in attempting to reduce the adhesions that formed predominantly at the edge of the mesh. We achieved this by overlapping the Surgical around the edge and by orienting the staples perpendioulady to and around the edges. In a final set of experiments, we found that wetting the Surgical with saline once the composite was in position, transformed it to a gelatinous film that further reduced adhesion. We applied the later experience in the repair of the incisional ventral hernias in 127 patients. The patients ages were 32-86 years, individual defects ranged from 3-22 cm, and with multiple defects, up to 35cm. Operating time was 0.75-2h with an average of 1.2h, Liquid diet was started at 8-10h. Only non-narcotics analgesic was needed with 1-3 doses per patlenL Patients were discharged on the 1 = to 3 ~ day and returned to normal activity between 3 to 7 days (average 5d). Five patients had significant abdominal pain which resoved at 3-5 weeks. One patient each developed a superficial umbilical infection (not on port site), small bowel fistula (from a repaired enterotomy), and three developed recurrence. Two patients were converted to open because of massive bowel adhesion. There have bean no intestinal obstructions after a ma)dmum of 61/= years follow-up. We experimentally perfected a technique of incisional/ventral hernia repair and designed a composite mesh of surgical and Prolene that produced the smallest amount of adhesions. We have successfully applied this IPOM two layers composite mesh repair in 127 patients with good results and low morbidity.

LAPAROSCOPIC MANAGEMENT OF SEVERE ENDOMETRIOSIS WITH COLORECTAL INVOLVEMENT, Hags-Joachim Dueorae. M.D.. Anthony J. Senagora, M.D,, T, Falcone, M.D., Peter Marcello, MD, Depaflment of Colorectal Surgery, Minimal Invaslve Surgery Canter and Department of Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio.

Symptom resolution and fertility alter surgical management of Stage IV endometdosis requires exdsion of all endometnal deposits, including those involving the intestine. Data from open surgical sedes indicates that removal of intestinal disease requires bowel resection. The purpose of this report Is to describe our expadence with simultaneous laparoscopic exdston of pelvic and Intestinal endometdosis. The surgical goal was complete ablation of all endometdal deposits, mobilizaton of pelvic organs, and limited use of bowel resection, oophoractomy or hysterectomy.

All patients with Stage IV endometdosis and bowel involvement from 2/1998- 712000 were included. All visible disease was excised from the pelvic sidewalls and intestinal semsal surfaces, with bowel.resection reserved for cases with deep invasion or extensive involvement. Surgical procedure (exdsion versus resection), length of stay (LOS), complications, and symptom relief were al;aiysud.

The sedes consisted of 33 patients with mean age of 34.7t-0,9 years. Local excision of intestinal and pelvic disease was accomplished in 23 cases with a mean LOS of 1.4r days (excluding 7 outpatient procedures). Bowel resection was only required in 10 cases: proctectomy (n=6);small bowel resection (n=2); ileocoecectomy (n=l); and rectal disc-excision (n=l). The mean LOS in resection cases was 6.2:1:1.5 days. Only 3/33 patients (9.1%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Preoperatively, all patients had pelvic pain which resolved in 85 %. One colorectal anastomotic leak required a temporary laparoscopic loop ileostomy. Conversion was necessary in n = 3 patients. Even though technically demanding, radical laparoscopic excision with

preservation of reproductive organs and limited use of bowel resection can be accomplished in the majodty of patients. Impo[tantiy, the need to resect bowel can be minimized, allowing limited hospitalization in most patients.

LAPAROSCOPIC GASTRIC BYPASS HAS SHORTER LENGTH OF STAY AND LESS COMPLICATIONS BUT IS MORE COSTLY COM- PARED WITH OPEN GASTRIC BYPASS J. Chris Eagon, M.D. and Donna Matin, R.N., Department of Surgery, Washington University School of Medicine, St. Louis, MO

The laparoscopic approach to Roux-Y gastric bypass is safe and effective, but the relative cost is unclear. Our aim was to compare hospital costs of patients undergoing open (OGB) or laparoscopic (LGB) gastric bypass. From 7/97 through 8/00, 129 patients with BMI of 37-64 underwent GB by a single surgeon at a teaching hospital, 65 OGB and 64 LGB. Outcome variables were length of stay (LOS), presence of postop complications, and inpatient costs (total, OR, room, pharmacy, supplies). Statistical compadsons were made with chi-square and t- test analysis after removing cost and LOS outliers (20GB, 1 LGB). The OGB cohort had a higher BMI (54 vs 48, OGB vs LGB), and lower fraction of women (73% vs 91%). Subgroup analysis by BMI decile and among women did not affect results. Cohorts did not differ in age (44y vs 43y) or comorbidity frequency: DM 28% vs 22%, HTN 48% vs 58%, Sleep apnea 52% vs 48%. LOS was shorter with LGB (5d vs 3d). There was one mortality at home on POD 8 from a PE (OGB). Morbidity was more frequent with OGB (53% vs 17%). Minor wound infection (25% vs 8%), incisional hernia (18% vs 3%), and stomal stenosis (15% vs 2%) were more common after OGB. Gastrograftin swallow in all patients between POD 4 and 9 showed one contained leak (LGB) in a patient after endoscopic treatment of an anastomotic bleed. One LGB patient developed a subphrenic abscess requiring percutaneous drainage on POD 15. Transfusion was more frequent in LGB (4% vs 10%). Conversion of LGP to OGP occurred in 2 cases (3%) due to splenic bleeding and a proximal jejunal injury. Percent loss of excess weight at 1 year was similar within BMI deciles (78% vs 88%). Total costs were greater with LGB ($10755 vs $11588). OR costs were higher in LGB (4089 vs 7878) due primarily to disposables and OR time. This more than offset lower costs in areas such as room (2189 vs 1168) and pharmacy (1481 vs 970). LGB achieves similar weight loss with shorter LOS, but OR and total costs are higher. Complications are less frequent but many occur in the outpatient setting and are not reflected in hospital costs.

TECHNICAL REVIEW OF TROCAR SITE CLOSURE David B. Earle, MD Dept of Surgery, Baystate Medical Center, Springfield, MA

Incisional hemias after laparoscopic procedures are not uncommon. The incidence is estimated to be 0.021-3.1%, but the true incidence is unknown. It is generally agreed to dose all pod sites >gmm. Necessity has spawned a vadaty of methods to accomplish this task. I have categorized them in a way that is logical, and suggests uses other than that o~ginally suggested: 1) needle-sized graspers, 2) snares, 3) eyelet/spring-loaded needles, 4)

hook-type needles, and 5) standard open instruments.

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USE OF MINIMALLY INVASIVE SURGICAL TECHNIQUES IN TRAUMA David Earle, MD, Marwan Jaber, MD, Dept of Surgery, Baystate Medical Center, Springfield, Massachusetts

We examine our early experience with minimally invasive surgery(MIS) applied for trauma patients at an urban trauma center. 16 hemodynamically stable patients evaluated by a single surgeon between 3/97 & 11/98 were 80% male with a mean age of 27.5. Mechanism of injury was blunt trauma (2), stab wound (8), and gunshot wound (6). MIS techniques employed were laparoscopy(11), thoracoscopy(3), or both(2). The mean injury severity score (ISS) was 9.4 (2-22) and overall length of stay (LOS) was 6.8 days (9 hours-19 days). There were no deaths, and no missed injuries. The conversion rate to open operation was 19% - two laparotomies and one thoracotomy. Patients with thoracic injuries requiring tube thoracostomy had a mean LOS of 8 days (3-19) and a mean ISS of 12.4 (4-22). Those without thoracic injury had mean LOS of 4 days (9 hours-11days) and a mean ISS of 6.8(2-17). There was one laparotomy requiring only minor debridement of a grade IV liver injury, and grade I right renal injury. Therapeutic maneuvers performed were repair of serosal intestinal injury(2), diaphragm repair(2), and evacuation of retained hemothorax(2).

In conclusion, MIS techniques can be employed safely for a variety of traumatic conditions. Both diagnostic and therapeutic maneuvers can be performed with these techniques. The application of MIS techniques should minimize morbidity from non-therapeutic operations, but not at the expense of an elevated missed injury rate. Like other areas of MIS, results depend on the skill level of the surgeon and the equipment availability at the institution.

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PROSTHESIS AUGMENTATION OF THE LOWER ESOPHAGEAL SPHINCTER IN SWINE David Easter, MD, R Summers, MD, I< Binmoeller, MD, M Yurek, BS, G Johnson, MS, S Harris, MS, P Miles. PhD., Department of Surgery, University of California at San Diego; and, Endonetics Inc., San Diego, CA.

OBJECTIVE: We postulate that multiple, preformed, expandable pros. theses can be easily and accurately placed within the submucosal plan~ of the esophagus in pigs using a simple endoscopic delivery system METHODS: An endoscopic overtube system was developed for th~ delivery of multiple expandable prostheses. Adolescent pigs (n = 25) hac 2-15 prostheses placed into the distal esophageal wall using these steps 1) surveillance endoscopy, 2) passage of the overtube-endoscope sys tern, 3) stabilization of the delivery site, 4) saline expansion of the submu cosa, 5) prosthesis delivery, and 6) repeat steps 3-5 as necessary Sessions were video recorded. Animals had post-procedure endoscop~ at I week, 2 weeks, and at sacrifice. Successful delivery was ultimatel~ assessed by explant histopathology. RESULTS: Prosthesis insertior was successful in 92/94 delivery attempts, and required between 3-1. = minutes of effort per s~te. Five successfully-placed prostheses wer~ unavailable for followup because of immediate animal sacrifice. Using prototype system (n = 54): 44 prostheses remained safely within a sub mucosal location, 9 were lost at one week- presumably because o superficial sloughing- and, 1 was found deep to the muscular layer of the esophagus. A simple modification to the delivery system resulted in 100% retention at one week (n=33), and no instance of esophageal perforation No prosthesis was lost in any animal if endoscopically visible at 1 week Tissue explants revealed encapsulated and intact prostheses that were surrounded by chronic histiocytic fibrosis within the submucosa. Then was no sign of active inflammation or abscess formation. CONCLU SIONS: We have demonstrated that expandable prostheses can be eas ily and accurately delivered into the submucosal esophagus of pigs Multiple prostheses are well tolerated and retained without significant tis sue reaction. Future studies will attempt to assess 1) removability, and 2 prosthesis-induced changes in esophageal sphincter function.

PREVENTING CYSTIC DUCT LEAKS-- BACK TO THE BASICS David S. Edelman, MD, Department of Surgery, Baptist Health Systems, Miami, Florida

Cystic duct leaks have increased since the introduction of laparoscopic cholecystectomy (LC). An alternative technique for cystic duct and artery ligation was developed. The technique returned to the basic surgical tenet of ligation using suture ties with an occasional clip used when further security was deemed necessary by the operating surgeon. The purpose of this prospective review was to analyze cystic duct leaks, complications and costs compared to a standard LC using clips and disposible canulas.

Four hundred-sixty (460) consecut ive LC's were performed from March 1997 to July 2000. A 5mm angled dissector would mobilize the structures in the triangle of Calot and place 2-0 silk ties around them. A knot pusher would triple ligate the cystic duct and artery prior to division or cholangiography and bile duct exploration. Three 5mm canulas were used in the upper abdomen and an 11 mm Hasson canula in the umbilicus.

OR time averaged 42 minutes compared to 40 minutes for all other surgeons using clips and kits. There were no cystic duct leaks, but a single duct of Lushka leak occured in the silk tie group. There were no bile duct injuries in the silk tie group. There were 15 bile leaks in 2501 patients in the control group. Costs were $254 less using silk ties and reusable canulas, a $100,000 cost savings.

This study showed that an alternative method of securing the cystic duct and artery exists that lowers the incidence of cystic duct leaks while being extremely cost effect.

INFLUENCE OF HANDLE DESIGN ON THE SURGEON'S UPPEF LIMB MOVEMENTS, MUSCLE RECRUITMENT AND FATIGUi DURING ENDOSCOPIC SUTURING Tarek A Emam MCh; Tim ( Frank PhD; George B Hanna PhD; Alfred Cuschieri MD Department of Surgery Molecular Oncology& Surgical Skills Unil Ninewells Hospital & Medical School, University of Dundee Dundee, Scotland

Background: Little work has been done to investigate the kinemal ice (motion analysis) and kinetics (muscle work, muscle fatigue comfort) of surgeons during laparoscopic surgery. These wer~ investigated in the present study in the dominant upper limb of suv geons during endoscopic suturing.

Methods: Three different handles (conventional finger-loop, rocke and ball handle prototype) were compared in a study involving Ii surgeons suturing porcine enterotomies with each of the 3 instrL ments. The endpoints were performance parameters, motion anal~ sis and muscle work and fatigue of the surgeon's dominant upps limb with subjective scores for comfort level and manoeuvrability.

Results: Task quality and efficiency were significantly better wit use of the ball and rocker handle needle drivers compared to fingel loop instrument during endoscopic suturing with lower angula velocity at the elbow and shoulder joints, more pronation and les supination. The integrated muscle work was much lower for bot rocker and ball handles. Significant muscle fatigue especially of th arm flexors and deltoid was observed only with finger-loop instrL ments. Comfort and manoeuvrability rating scores were higher wit both handles compared to the conventional finger-loop. The ba handle was more manoeuvrable but somewhat less comfortabl than the rocker system.

Conclusion: Different pattern of joint movements, reduced muscl power exerted during endoscopic suturing and hence absence c muscle fatigue were documented with ergonomic needle driver (rocker and ball) compared to the conventional finger-loop instrL ments. These differences translate to a better and more efficier task performance w~th enhanced comfort.

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LAPAROSCOPIC APPENDECTOMY IN COMPUCATED APPENDICITIS Thomas Fabian, M.D., Anita Gambhir, M.D., Patricia Camuto, M.D., Madanne Ulcickas Yood, D.Sc., M.P.H., Steven M. Yood, M.D., M.P.H., Department of Surgery, Hospital of Saint Raphael, New Haven, CT

Appendicitis is the most common surgical emergency and laparoscopic appendectomy has become a more popular procedure for treating this condition. Its use, however, has been questioned in cases of perforated and gangrenous appendicitis because of concems regarding the risk of intraabdominal infection. On the other hand, infection of the operative incision is the most common cause of morbidity after open appendectomy for complicated appendicitis.

To quantify and compare the outcomes of laparoscopic to open appendectomy in patients with perforated or gangrenous appendicitis, we retrospectively reviewed all laparoscopic appendectomies performed at a large community teaching hospital over a 3-year pedod (1997-2000). We evaluated postoperative length of stay, wound infection (defined as a wound that required drainage and a positive culture) and intraabdominal complications (including abscess and bowel obstruction).

During the study period, 57 laparoscopic and 116 open appendectomies were performed for complicated appendicitis (microperforation, perforation, or gangrenous). The mean length of stay for the laparoscopic group was 2.1 days, while the open group was 3.9 days (p = 0.0001). There were no wound infections in the laparescopic group and 11 in the open group (p = 0.02). There was 1 intraabdominal complication requiring intervention in the laparoscopic group and 4 in the open group (p = 0.53).

Postoperative intraabdominal abscess and wound infection are known complications of open appendectomy. In this study the risk of both of these complications was lower in the laparoscopic group. Although the sample size in this series is small, the results indicate that laparoscopy for perforated or gangrenous appendicitis is feasible and results in fewer complications and a shorter length of stay compared to open appendectomy.

LAPAROSCOPIC ENDOBILIARY STENTING: A SIMPLIFIED APPROACH TO THE MANAGEMENT OF OCCULT COMMON BILE DUCT STONES. Robert D. Fanelli, MD; Matthew J. Tiemey, DO; Keith S. Gersin, MD Surgical Specialists of Westem New England, PC; Berkshire Medical Center, Department of Surgery; University of Massachusetts Medical School.

Three years ago we described laparoscopic placement of biliary stents as an adjunct to lapamscopic common bile duct exploration (LCBDE) for treatment of occult common bile duct stones (CBDS). LCBDE was performed to clear all CBDS prior to stent placement in 16 patients by either choledochotomy or transcystic methods. We now present a modification of our technique and our experience with 48 additional patients.

All patients presenting for elective cholecystectomy were treated using a standard 4-port laparoscopic approach. Routine intraoperative fluoro- cholangiography revealed occult CBDS in 48 patients during 36 months. In our initial series, stents were placed for biliary decompression, to protect the ductal closure, and guard against the complications associated with retained CBDS. Closed suction drains were used routinely and all patients 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 were placed transcystically, and extemal drains were not employed.

Stant placement added 9 to 26 minutes to operative time over laparoscopic cholecystectomy alone. Forty-four patients (92%) were discharged the day of surgery, and 4 patients (8%) were observed overnight. Outpatient ERCP 1 to 4 weeks after surgery was successful in clearing CBDS in all patients. Stents were retrieved without difficulty in all cases, and 3 to 36-month follow up demonstrates no surgical, endoscopic, or stent related complications to date.

Laparoscopic biliary stent placement for the treatment of CBDS is a safe, rapid, technically less challenging alternative to existing methods of LCBDE. It preserves the benefits of minimally invasive surgery for patients, and provides all surgeons with a less difficult, highly successful method for treating occult CBDS. Stent placement virtually assures success of postoperative ERCP with complete stone clearance.

Quality of life before and after laparoscopic Nissen fundoplication. Marcus Feith, M.D., Hubert J. Stein, M.D., Christian MOebius, M.D., Hubertus Feussner, M.D., J.ROdiger Siewert, M.D., Department of Surgery, Technische UniversitSt MOnchen, Klinikum r.d.lsar, Munich, Germany

Introduction: Gastro-intestinal reflux disease (GERD)is a very common disorder in the western world. The acute disease can be sufficiently treated by medical therapy. To prevent relapse many patients require life- Ion~g medication. In these patients lapar0scopic antireflux surgery offers a good altemative. The aim of this study was to evaluate the postoperative results and compare pre- and postoperative quality of life alter laparoscopic Nissan fundoplication. Methods: Clinical investigations including esophageal manometry, pH monitoring and endoscopy and previously validated Quality of life Index were applied before and a median of 41 month after surgery in 75 patients. Results: The percent total time with pH <4 decreased from 10.4% to 3.2% on 24 hour pH monitoring. The mean pressure of the lower esophageal sphincter improved from 8.1 to 12.3 mmHg. Esophagitis healed in 93% of the patients, but intestinal metapiasia in the distal esophagus persisted in all patients when it was present before surgery. The overall Quality of life Index signiflcanUy improved from 86+_16 to 116+16. Conclusion: The data show that the iaparoscopic fundoplicaUon provides effective and durable relief in patients with GERD. The Quality of life Index significantly improved after surgery.

MALPRACTICE LITIGATION INVOLVING LAPAROSCOPIC CHOLECYSTECTOMY Alberto R. Ferreres, MD and Vicente P.Gutidrrez, MD, Department of Surgery. University of Buenos Aires. Forensic Advisory Council to the Supreme Court of Justice.

Background: Malpractice litigation has become widespread in our country in the last decade, both in the criminal as in the civil courts. Since the introduction of laparoscopic cholecyst-ectomy (LC) in 1990 and the subsequent rise in biliary tract injuries, it has represented one of the most common surgical procedures involving malpractice claims. Material and methods: A total of 30 malpractice claims related to patients who underwent LC were retrospectively analyzed and their clinical charts reviewed.

Results:The 30 claims originated after LC performed in public hospitals (17) and private ones (13)of the city of Buenos Aires. The average age was 42.8 years and 12 were female. The injudes were the following: 1) Direct injuries to the bile duct: 14 cases (7 grade I, 3 grade II, 2 grade II1 and 2 grade IV) 2) Vascular and bleeding mishaps: 5 3) Biliary leaks: 4 4) Injuries to the digestive tract: 3 5) Others: 4 Mortality was 36%.The age of the surgeons sued was: 25-35 y: 9, 35- 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 expertise was: less than 50 cases: 4, 50-100 cases: 5, 100-500 cases: 12 and more than 500 cases: 4. 20 claims were filed in the criminal courts and 10 in the civil courts. Mean time for filing the claim was 6.7 months after the first operation.

Conclusion: laparoscopic injuries after LC must be accepted as a risk of the performance of the procedure. Gross evidence of negli- gence, imprudence or unskillfulness must be achieved for proof of guilt.

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THE USE OF OCTYLCYANOCRYLATE TISSUE ADHESIVE IN THE CLOSURE OF LAPAROSCOPIC INCISIONS Alberto R.Ferreres MD, Edmundo Cataldi MD, Juan J. Acoglani MD, Mercedes Patifio MD and Michael Cornwell MD, Department of Surgery Hospital

Objective: to compare the use of octylcyanoacry-late tissue adhesive (OTA) with subcuticular suture (SCS) for the closure of skin incisions of laparoscopic port sites.

Study design: between november 1998 and january 1999, 200 patients undergoing different laparoscopic procedures were randomized (using a computer-generated random numbers table) to one of two port-site skin closure techniques. Mean age was 48.5 years (range: 16-81) and 125 (62.5%) were females. The laparoscopic procedures included: 122 cholecystectomies (56%), 41 appendectomies (20.5%), 37 inguinal hernia repairs (18.5%) and 10 Nissen fundoplications (5%). The techniques were: use of OTA (Dermabond, Ethicon Inc.)or subcuticular closure with monofilament 4/0 sutures. If port site incisions were enlarged for withdrawal of specimens a fascial closure with vycril 0 was used. "13me, difficulty, complications and cosmetic results were evaluated.

Results: a total of 732 port sites were included: a) 200 10 mm umbilical skin port sites, 115 (57.5 %) closed with OTA and 85 (42.5%) with SCS, b) 210 10 mm sites: 123 (58.5%) with OTA and 87 (41.42%) with SCS, c) 322 5 mm sites: 169 (52.48%) with OTA and 153 (47.51%) with SCS. The preparation of incisions for closure and bleeding control took 2 minutes for the OTA group and 0.5 minutes for SCS. Average delay 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 postoperative 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 laparoscopic port sites and its advantages are reviewed.

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The standard TEP inguinal hernia repair w a s modified to detemine whether the degree of early post-opentive and late persimat pains associated with even laparoscopic surgery could be improved upon without jepordifing the integrity of the repair itself.

Nine (9) male patients, ages ranging from 17-72, underwent ten (10) inginal hernia repairs via the totally extra-peritoneal (TEP) approach with balloon dissection and $cneral anesthe~L Supplemental local anesthetic agents were not used. A 10xl5 r polypropylene mesh was fixed in pos~ion flora the contralstecal aspect of the pubis tO the ipsilateral meac crest u " t~z~ l~J~ tiglUr sealant {Tissed/Baxt=) rather than the 5nun. hdical titaaium screws. All the procedures were uneventful without early or delayed complications.

Patients reported significa~ less pare =xl required fewer doses of oral narcotic arudg~cs in the week following the procedure than that typical of our practicc or in the literature. There have been no early recunenr

All major series' comparing laparoscopic and open hemiordmphy report less pain aad an earlier return to normal function with the minimally invasive approach. Yet even lap~oscopic procedures can be associated with significant early post-opmU~e pdn and a dgnificant percentage of patients will exlxmence transient episodic pair= as late as one year, similar to open surgery patients. The= symptoms are larg~ a fimction of the meat= of E,r ofthe proshe~ mesh to tissue, one which may be able to be successfldly modified by the use of a biologic ageat. Early resu~ are promid~ as far as these ~ =d Ioss-torm follow-up will be pursued to dctcm~.e ~ the rate of recurrence is the equal of mcdu=ic~ fixation.

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RHABDOMYOLYSIS AS A COMPLICATION OF LAPAROSCOPIC DONOR NEPHRECTOMY: A REPORT OF 2 CASES Frederick C. Finelli,MD,JD; Truman Sasaki, MD; Yolanda Becker, MD., The Program for Advanced Lapareacopic Surgery, Washington Hospital Center, Washington, D.C. and The DMsion of Transplantation, University of Wisconsin, Madison, Wl

Introduction: Rhabdomyolysis is a rare and potentially devastating complication. Although it has been descnbed in urologic, vascular and orthopedic surgery, it has not been repoded following laparoscopic surgery.

Case 1: A 35 y.o. man underwent hand-assisted left donor nephrectomy in right lateral decubitus position. The oparatJve time was about 6 hrs; blood loss was 150 ml. He complained of dght mid-back pain upon awakening and 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 rhabdomyolysis was begun. The serum CPK was 2,651,256 IU/L. Serum creaUnine reached 2.5 mg/dl. He was discharged on POD 8 and at 2 months had completely recovered.

Case 2: A 27 y.o. man underwent uneventful laparoscopic donor nephrectomy in the right lateral decubitus position. The operative time was about 6 hours; blood loss was 100 ml. Upon awakening, the patient complained of severe right buttock pain and leg weakness. Myoglobinuria was found and the serum CPK was 54,260 IU/l_ Compartment pressure was elevated (31- mm hg). Treatment was begun. The creatinine reached 1.9 mg/ml. He was discharged home on POD 4. At 6 months he still had numbness of the dght thigh and scrotum and had developed reflex sympathetic dystrophy.

Discussion: Rhabdomyolysis following surgery can result from vascular compromise due to prolonged pressure on immobilized muscle. Long operative times and decubitus positioning predispose to this condition. The rarity of this complication can lead to difficulty in diagnosis. Immediate postoperative pain in an area remote from the surgical site should trigger a strong suspicion of this diagnosis. Prompt diagnosis and aggressive hydration and alkalization will usually prevent permanent kidney damage. Fasciotomy is needed in some cases.

Conclusions: Rhabdomyolysis can occur after prolonged laparoscopic surgery, especially in decubitus position. Careful positioning, shortened operative times and heightened awareness can limit the occurrence and severity of this complication.

LONG TERM EFFECTS OF ELECTROLYSIS AS A MODALITY FOR THE PALLIATIVE TREATMENT OF PANCREATIC CANCER Beverley G Fosh MBChB, J Guy Finch MBChB, Addan Anthony MBBS, Karen K Riches MBBS, Guy J Maddem PhD MS, Departments of Surgery and Pathology, The Queen Elizabeth Hospftal, Adelaide, South Australia

Objective Of Study In pancreatic cancer the majority of patients are offered palliative treatment, usually in the form of a surgical bypass to alleviate symptoms. No ablative techniques are currently employed to either treat or palliate pancreatic cancer, although there are recent reports of radiofrequency ablation in the porcine pancreas. Electrolysis is the delivery of a direct current between an anode and cathode to induce Iocaiised necrosis, The aim of this study was to assess the long-term effects of electrolytic pancreatic ablation in the porcine model

Description of Methods Eiectrelysts was delivered to the head of pancreas in nine healthy pigs. Each pig received 150 Coulombs (amps x seconds). The pancreas and other organs were hawested at 2 weeks (n--3), 4 weeks (n--3), and 8 weeks (n--3) to assess long-term responses. A histological score for pancreatic injury was derived by analysis of sections with Haematoxylin and Eosin stains, and immuno-fluorescence.

Results Eight pigs survived the procedure and gained weight. One pig died of a perforated bowel 2 days post procedure. Pancreatic duct dilation was noted in all surviving pigs and was due to fibrotic obstruction at the site of the electrelytic lesion. There were no fistulas or pseudocysts. The histology of the area ablat- ed showed fibrosis and some chronic inflammatory changes. The pancreatic histological score was not related to the length of time following electrolysis. There was no histological evidence of any other end-organ injury related to the procedure.

Conclusions Other than iccaiised pancreatic duct obstruction, there were no other long-term complications of pancreatic electrolysis. In humans, malignant pancreatic obstrucl~n would be a pre-existing cond~on. There was no evidence of systemic effects of the procedure. Excluding methodological problems, electrolysis appears to be an effective ablative technique for the palliative treatment of pancrea~ carcinoma. The application of electrolysis as a minimally invask'e technique is now being explored.

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INVESTIGATION OF THE SHORT-TERM EFFECTS OF ELECTROLYSIS AS A NOVEL TREATMENT FOR PANCREATIC CANCER Beverley G Fosh MBChB, J Guy Finch MBChB, Adrien Anthony MBBS, Karen Riches MBBS, Guy J Maddern PhD MS, Departments of Surgery and Pathology, The Queen Elizabeth Hospital, Adelaide, South Australia

Objective Of Study This study aims to investigate the short-term local and systemic effects of producing an electrolytic lesion in the head of the pancreas gland in a porcine model. Pencreatic cancer is a biologically aggressive disease with only 15-20% of patients suitable for a "curative" surgical resection. This, combined with the poor 5 year survival figures indicates that aitemative palliative methods for symptom relief should be explored. Electrolysis is a novel ablative technique. A direct current (DC) delivered via electrodes inserted into tissue generates chemicals that are locally cytotoxic. It is effective end reproducible, with negligible thermal effect end has the potential to be delivered endoscopically.

Description of Methods 22 pigs underwent a laparotomy and electrolysis to the head of the pancreas of between 50 to 200 Coulombs (amps x seconds). Blood samples were obtained pre end post-electrolysis. All animals were killed at 72 hours. "tissue samples were histologically analysed.

Results Two pigs died of complications. Electrolysis produced volumes of necrosis in the pancreas in a linear dose-related manner. Histology showed inflammation was Iocalised to the electrolytic lesion. Serology revealed a transient rise in amylase, leukocytes and CRP, which was not dose-related.

Conclusions Electrolysis produced necrosis in the pancreas in a reproducible dose-dependent manner. Systemic effects were only observed at the highest doses of electrolysis. This technique shows promise as a palliative treatment for patients with non-resectable pancreatic tumours and has the potential to be applied as a minimally invasive technique.

A LAPAROSCOPIC CURRICULUM WITH SKILLS TRAINING IMPROVES RESIDENT PERFORMANCE ON SKILLS ASSESSMENT. Dennis L. Fowler. M.D. and Nancy J. Hogle, B.S.N. Dept. of Surgery, Allegheny General Hospital, Pittsburgh, PA.

Teaching laparoscopio skills in the operating room significantly lengthens OR time and has the potential to cause complications that cannot easily be corrected laparoscopically. Despite this, there is no proven method to teach laparoscopic skills outside the operating room, and there is no established method to assess laparoscopic skills other than the somewhat subjective evaluation of a mentor.

Eight residents (4 beginning as PGY-1 and 4 beginning as PGY-2) participated in a laparoscopic curriculum consisting of 16 sessions during a 2-year period. Each session included a didactic portion and a lab portion. Some didactic sessions were dedicated to technique, but most were about procedures. Some lab sessions were dedicated to techniques such as tying, but most were about specific surgical procedures. Skills were assessed at the beginning of the curriculum and at the end of each year for two years. The previously reported skills tests measured both speed and accuracy in each of 7 different laparoscopic techniques, including cutting, clipping, suturing, and tying (Fded, et al., McGill Univ., Monb'eal).

All residents improved their skills assessment scores each year. The mean scores at each interval were analyzed with paired t-tests. The average score for each level of resident improved significantly. Level Scores Fall '98 Scores Spring'99 Scores Spring '00 p

PGY-1 310 988 1159 .005 PGY-2 904 1357 1458 .006

Residents who participated in a laparoscopic curriculum with skills training significantly improved their skills assessment scores. This type of training has the potential to improve performance in the operating room.

LAPAROSCOPIC ASSISTED COLONOSCOPIC POLYPECTOMY: THE TEXAS ENDOSURGERY EXPERIENCE MORRIS E. FRANKLIN MD, J.ARTURO ALMEIDA MD, EDUARDO PARRA-DAVILA MD, DANIEL ABREGO MD, JOSE A.DIAZ, JORGE BALLI MD, TEXPS ENDOSURGERY INSTITUTION. San Antonio, Texas

INTRODUCTION:We present a technique combining colonoscopy and laparoscopy to remove troublesome polyps without the need for segmental resections.

METHODS: From May 1990 to September 1999 laparoscopic monitored colonic polypectomies were performed in 47 patients with a total of 60 polyps being removed. All polyps undergo immediate frozen section analysis. If the pathological evaluation indicates malignancy then a segmental resection may be performed, otherwise the patients are decompressed and fed within a short period of time prior to discharge.

RESULTS: The polyps were located most commonly in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps). The most common histopathologic diagnosis was tubulo-vil- Ious adenoma in 28 polyps followed by villous adenoma in 11 polyps. In three cases histopathologic diagnosis revealed malignancy necessitating segmental resection (1 low anterior resection, 2 right hemicolec- tomies), which were performed laparoscopically. Patients received a liquid diet within 6 hrs, were discharged in an average of 21 hours and retumed to full activity most commonly within days. The only complication presented in this group of patients was an umbilical port seroma. Virtually all patients (97%) behaved as if only a colonoscopy was performed. Pain at the trocar sites was managed with Acetaminophen 600mg P.O. as needed,

CONCLUSION: Laparoscopic monitored colonoscopic polypectomy allows patients to undergo removal of colonic polyps without a segmental resection. This less invasive procedure yields recovery times similar to that of colonosoopy alone and, the potential complications of a segmental resection are avoided. All polyps are examined by frozen section and if a malignancy is encountered a laparoscopic resection can be performed.

LEFT UPPER QUADRANT VERESS NEEDLE PUNCTURE FOR CREATION OF PNEUMOPERITONEUM: INmAL EXPERIENCE WITH 776 PATIENTS Joseph A. Franklin, MD; James A. Young, MD; Cadyle Dunshee, MD, MBA; Melvin S. Swanson, Ph.D.; William H.H. Chapman, III, MD, FACS; Kenneth G. MacDonald, Jr., MD, FACS., Section of GI Surgery, Dept. of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC

Obesity and prior abdominal surgery once excluded patients from laparoscopy because of complications related to pneumoperitoneum creation. Veress needle puncture at Palmer's point, located in the mid-axillary line 3crn inferior to the subcostal arch, is advocated to decrease insuffiation complications in these patients. This series characterizes both safety end efficacy of left upper quadrant (LUQ) Veress needle puncture end provides the largest study of this technique in general surgery patients.

Retrospective chart analysis was performed from January 1997 to January 2000. Patient demographics, operative diagnoses, technique of pneumoperitoneum, and complications related to creation of pneumopedtoneum were evaluated using frequency distribution end means.

776 laparoscopic procedures were performed on 764 patients during the study period. Ages ranged from 7-92 years; 62.1% of patients were female, 37.9% were male. 62 patients (7.9%) were excluded due to prior LUQ instrumentation, patient disease, or surgeon preference; Paimer's point was theoretically useable in 714 patients (92.1%). Obesity was observed in 172 patients (24.1%); prior abdominal surgery was appreciated in 136 additional patients (19.1%). Technical failure occurred in 3 of 714 (0.42%). Major complications (i.e., requiring operative intervention) occurred in 2 of 711 patients (0.28%)-serosal bowel injury (n=l) end carbon dioxide embolus (n=l). Minor complications were identified in 5 of 711 patients (0.70%) but required no operative intervention-needle perforation of liver, stomach, or omentum. No patient died or required conversion to laparotomy because of the technique of pneumoperitoneum.

LUQ puncture for establishment of pneumoperitoneum is safe end well tolerated in a diverse general surgery population. Because of the favorable complication rate, the general surgery division at this institution uses Palmer's point almost exclusively.

LAPAROSCOPIC NON ANATOMICAL HEPATECTOMY IN A CANINE MODEL Eldo E. Frezza MD, ~na Raldt MS, Sayeed Ikramuddin MD, William Gourash CRNP, James Luketich MD, Philip Schauer MD., Minimally Invasive Surgery Center, University of Pittsburgh

The purpose of this study was to establish an animal model for laparoscopic hepatectomy and determine feasibility and safety. Methods.Two groups of ten female dogs (mean weight 20kg) underwent laparoscopic non-anatomic resection of approximately 500 of the total liver mass.Group I was evaluated for 48 hours postoperatively to assess for immediate postoperative complications.Group II was evaluated for 14 days postoperatively to assess for longer-term complications.At the end of the observation period, animals were euthanized.Low-pressure pneumoperitoneum (6mHg) was used.A variety of dissection and hemostatic techniques were employed including endoscopic stapling and bipolar electrocautery. Laparoscopic ultrasound was employed for major vessel identification.The liver specimen was extracted through an approximately 7-cm mcision and weighed. For Group II animals, a drain was placed to assess for postopera- the bile leak. Results.In group I, 3 animals developed a pneumothorax requiring premature euthanasia while the other 7 survived the 48 hours observation period.No significant pedoperattve bleeding occurred.The mean EBL was 66 ml.The 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% (POD10).Mean glucose (mg%) remained stable between 118 and 130 at 1 and 5 days.One biliary leak at a resection site was confirmed (10%).Total Bilirubin remained in normal range in all animals except two (one associated with a bile leak the other unknown cause).Mean GOT (UI/L) and GPT (UI/L) peaked at 1675 and 1279 respectively but retumed to near normal levels by POD 10.There was no evidence of pulmonary embolism in either group. Conclusion.Laparoscopic non-anatomic hepatectomy in a canine model is feasible with minimal perioperatlve bleeding and a relatively low rate of bile leak using currently available dissectnon and hemostasis techniques.The canine model appears to be helpful in evaluating resection methods prior to use in humans despite anatomic differences with human liver anatomy.

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BOWEL OBSTRUCTION AFTER LAPAROSCOPIC GASTRIC BYPASS FOR MORBID OBESITY EIdo E Frezza MD, Sayeed I k ramudd in MD, Michael Feder le * MD, Wi l l i am Gourash CRNT, MSN, Phil ip Schauer MD, Min imaly Invasive Surgery Center and Radiology* Department, University of Pittsburgh

Bowel obstruction resulting from internal hernias are a recognized but rare complication of open Roux-en-Y gastric bypass. This study describes our experience with bowel obstruction following the laparoscopic approach to Gastric bypass. Methods. We reviewed our experience with postoperative bowel obstruction in 405 patients who underwent LRYGBP between July 1997 and August 2000. Results. Eight patients in the series (2%) developed a postoperative bowel obstruction requiring operative management. Their mean BMI was 46 (range: 38-65) and the average age was 45 (range: 29-56). Five occurred in the early postoperative period and 3 occurred late (> 3 months). Internal hernias through mesenteric defects (4) were the most common cause followed by obstruction at the entero-enterostomy (3), and adhesions (1). In 6 patients the obstruction was managed laparoscopically (1 conversion) and two patients underwent exploratory laparotomy. In all cases the obstructions were successfully managed without requiring bowel resect ion. In two cases the en tero-en teros tomy required revision. All patients recovered uneventfully, except for one patient who eventually succumbed to a pulmonary embolus. Conclusion. Internal hernias appear to be a significant cause of bowel obstructions after laparoscopic gastric bypass. They develop because bowel herniates through mesenteric defects resulting from creation of the Roux-limb. Secure, suture closure of these defects should be performed before completing the operation in order to prevent intemal hernias and subsequent bowel obstruction.

MEDIAL RETROPERITONEAL APPROACH FOR LAPARO- SCOPIC- ASSISTED COLECTOMY FOR COLON CANCER Masaki Fukunaga,M.D., Akio Kidokoro,M.D., Toshiaki Iba,M.D., Kazuyoshi Sugiyama,M.D., Tetsu Fukunaga,M.D., Shoichi Fuse,M.D., Kunihiko Nagakar i ,M.D. , Masaru Suda M.D., Sei ichi rou Yos ikawa,M.D. , Nobuyoshi A ihara,M.D. , Depar tment of Surgery, Juntendo Urayasu Hospital, Juntendo University ,Urayasu, Japan

Laparoscopic- assisted colectomy has been common in the treatment for colon cancer. However, it can be difficult -especially for advanced colon cancer to perform lymph node dissection including regional blood vessels (D3 dissection)via laparoscopy. There are three main approaches to D3 dissection: lateral, medial, and retroperitoneal. The purpose of this study is to evaluate the appropriate approach to perform D3 dissection. We chose the medial approach with early retroperitoneal mobilization from medial to lateral ( medial retroperitoneal approach ; MRA). The advantages of MRA are the ease and safety of mobilizing the mesecolon from the retroperitoneum, the ease of utilizing the rotation technique for D3 lymph node dissection and its consonance with the no touch isolation technique.

Of the 217 patients reviwed, the ilnitial 50 cases were excluded for this study, six of the initial group were converted to open surgery, for 81 lateral approach was used. (There were no conversions in this group.), and for 86 MRA was indicated. Only one case was converted to open surgery, and that for reason of massive adhesion. There were no intra-operative complications related to this procedure. Operating time for MRA is shorter than that of lateral approach. There was no significant difference in blood loss between the two groups. Incidences of post-operative complications for MRA were less than for those of the lateral approach.

We conclude that the medial approach with early retroperitoneal mobilization( MRA ) is a safe a~d feasible technique for performing lymph node dissection, including regional blood vessels, for advanced colon cancer.

CHANGES IN COAGULATIVE FIBRINOLYTIC SYSTEM AFTER THO- RACOSCOPIC ESOPHAGECTOMY AND TRANSTHORAClC ESOPHAGECTOMY Tetsu Fukunaga M.D., Akio Kidokoro M.D., Masaki Fukunaga M.D., Kumhiko Nagakari M.D., Seiichiro Yoshikawa M.D., Department of Surgery, Urayasu Hospital of Juntendo University, School ot Medicine CHIBA, JAPAN

Changes in the coagulative flbdnolytic system after major operation arG 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. ine whether the postoperative coagulative fibrinolytic system differs ir cases of thracoscopic esophagectomy and the conventional transthorack esophagectomy with radical lymph nodes resection. [Methods] Subjects for the study were 15 patients who underwent radical thoraco scopic esophagectomy (thoracoscopy group) and 15 patients who under went radical transthoracic esophagectomy (thoracotomy group) for thoraci( esophageal cancer. In each subject, platelet count, prothrombin time acthi ty (PT), activated partial thromboplastin time (APTr), TAT, PIC, D-dimer, t PA and PAl-1 were measured before and immediately after the operation and on the 1st, 3rd and 7th P.O.D. [Results] 1 .Platelet count decreased postoperatively in beth groups, with a more sig nificant decline seen in the thoracotomy group (3POD 12.6 vs 16.8103/pl). 2.Coagulation function was enhanced postoperatively in both groups; in terms of observed changes in TAT, aggregation was enhanced for a Ionge peded in the thoracotomy group (3POD 33.2 vs 47.8 ng/ml). 3.Fibdnolytic function was enhanced postoperatively in both groups; no dit ferencas in the extent of fibrinolytic function were seen between the tw, groups. [Conclusions] Postoperative enhancement of coagulative function was less marked iJ patients who underwent thoracosoopic esophagectomy than in those wh, underwent transthoracic esophagectomy. Changes in the postoperath, coagulation system suggested that thoracosoopic esophagectomy cause less trauma to subjects than transthoracic esophagectomy.

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ACQUIRING LAPAROSCOPIC INTRACORPOREAL KNOTTING TECHNIQUES-EVALUATION IN A CENTRAL EUROPEAN COUNTRY Istvan Gal, M.D.. Ph,~), 1 Gergely Csaky, M.D., Ph.D. z, Gy6rgy Weber, M.D., Ph.D. 3, Zoitan Szabo, Ph.D. ~.lDepartment of Surgery, Bugat Pal University Hospital, Gy6ngy6s, 2Department of Surgery, County Hospital, Miskotc, 3Department of Surgery, University Medical School of P6cs, Hungary, 4M.O.E.T. Institute, San Francisco, CA, USA

Acquiring the sldils for laparnscopic suturing and knotting techniques can be a considered a prerequisite to learning advanced laparoscopic procedures. Although disposable mechanical devices are available to simplify the tissue approximation task for surgeons, their use is associated with higher operating costs, and they are not universally applicable. The purpose of our study was to evaluate and compare in the acquisition of intracorporeal knot tying techniques using reusable instruments in two groups of surgeons. The skills of 17 specialists and 12 residents, ranging in age from 26-57 years of age, were compared. Hands-on training workshops on advanced laparoscopic procedures were conducting, ranging from 1.5 to 2 days (15-20 hours) in length. After each surgeon had practiced the knordng techniques three times, their performance limes were measured for tying a simple fiat knot; the number of erroneous movements were also noted and evaluated. The average time for creating a fiat knot d~fered significantly in the group of specialists who had an average performance time of 58.8 seconds (range of 7-100 seconds), whereas the residents group averaged 15 seconds (range of 6-29 seconds). The mean number of erroneous movements corresponded to the average performance lime: 3.4 (0-9) in the group of specialists and 1.08 (0-3) in the resident's group. Following the first round of evaluations, the participants continued to practice their slu'lis. On the second day, creating a complete knot (simple square knot, with a third opposing fiat knot) was the next task. The average performance time for the specialists was 178.8 seconds (range of 65-230 seconds) and in the resident's group: 143.5 seconds (range of 97-205 seconds). The mean number of erroneous movements were similar in both groups: 5 (0-9) and 4.9 (2-12) respectively. The authors conclude that the acquisition of laparoscopic instracorporeol knot tying techniques is dependent on practice rather than whether the surgeon is in training or not.

LAPAROSCOPIC MANAGEMENT OF OBSTRUCTIVE JAUN- DICE IN AN ARGENTINEAN RURAL HOSPITAL Alex Gandsas, MD1; Fernando Telleria, MD2 and Jorge E. Lenzi, MD2, 1- Department of Surgery, University of Kentucky, Lexington., 2- Department of Surgery, iMEC, Junin, Argentina.

Percutaneous transhepatic intervention with or without endoscopic management is not universally available in developing countries to treat patients suffering from obstructive jaundice. We report the experience at a rural hospital in Argentina, using a minimally-invasive approach to provide adequate long term biliary drainage using several types of biliary-enteric bypass procedures.

From October 1993 to July 2000 Forty-three patients (24 females and 19 males, aged 60-96 years) underwent one of the following procedures: choledocoduodenostomy 34 (79%); hepaticojejunostomy 7 (16%); chotecystojejunostomy 1 (2%) and hepati- coduodenostomy 1 (2%). All surgical procedures were indicated for: choledocholithiasis 20(47%), pancreatic cancer 14 (33%), bile duct cancer 3 (7%), gallbladder cancer 3 (7%), revision of previous choledocoduodenostomy 1 (2%); lymphoma 1 (2%) or chronic pancreatitis 1 (2%).

Thirty seven procedures were successfully completed laparoscopically. Six conversions were required for: cancer of gallbladder and pancreas, bleeding and technical difficulties. Operative time averaged 156 +/- 10 minutes. The mean postoperative hospital stay was 7 +/- 2 days. Post operative complications included bile leak (3), wound dehiscence (1), intestinal perforation (1), ente- rocutaneous fistula (1) and infection (2). There were 5 deaths during the immediate post op period due to bleeding and sepsis.

Laparoscopic biliary-enteric bypass is an alternative and feasible approach to provide an adequate drainage of the biliary system when percutaneous and/or endoscopic techniques are not available. When applied to debilitated patients carrying a malignant disease, the psychological burden of carrying an external drainage with its side effects can be spared.

GASTRIC REMNANT CARCINOMA: RE-EVALUATION OF SCREENING ENDOSCOPY Christopher J. Gannon, M.D., Brett Engbrecht, M.D., Lena M. Napolitano, M.D., Barbara L. Bass, M.D., Department of Surgery, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, Maryland

Objective: Gastric remnant oarcinoma (GRC) after resection for peptic ulcer disease is an uncommon entity that is potentially cured by surgical intervention. A recent case of advanced GRC prompted a review of the role of screening endoscopy in this population. Case: A 67-year-old male presented with complaints of chronic postprandial pain in the epigastric region. The patient had undergone a vagotomy, antrectomy, and loop gastrojejunostomy for peptic ulcer disease 25 years prior. Abdominal CT revealed markedly thickened walls of the gastric remnant with infiltration of the adjacent fat planes. An esophagogastroscopy demonstrated erythematous, friable remnant mucosa. Gastric biopsies revealed invasive adenocarcinoma. At laparotomy a large tumor mass involving the gastric remnant and the antecolic loop gastrojejunostomy was identified. Further exploration revealed a firm nodule in the left lobe of the liver and several small nodules on the diaphragm and the lesser omentum. Biopsies confirmed metastatic adenocarcinoma at all sites. Curative resection was abandoned. Discussion: GRC typically presents more than 20 years after the initial gastric procedure and has a history of poor survival rates. With increased use of diagnostic endoscopy, GRC has been detected at earlier stages. Recent cohort studies demonstrate that GRC has similar survival rates after stage stratification when compared with primary proximal gastric carcinoma. The incidence ratio of GRC in patients with resection for benign disease increases from 1.4 for the 5-20 year postoperative interval to 3.9 from 21-40 years and finally to 7.3 from 40-45 years after surgery. Conclusion: The increased incidence of GRC in later decades (>20 years) after operation in conjunction with decreasing numbers of patients suggests that screening endoscopy should be considered on a 2-5 year basis in this population. Furthermore, any endoscopy undertaken in post- gastrectomy patients should include biopsy of the gastric remnant because early GRC can often have a normal mucosal surface appear

MINIMALLY INVASlVE DIRECT TRANSDUODENAL BIUARY STENT- ING FOR PANCREATIC CANCER Sashidhar V Ganta M.D., Seth Gendler M.D., Geredo Magana M.D., Madhu Rangraj M.D., Department of Surgery, Department of Gastroenterology, Sound Shore Medical Center, New Rochelle, New York

Recently biliary endoprostheses assumed significant role in palliation of obstructive jaundice in pancreatic cancer patients. ERCP and PTC being the usual mutes, we present a novel and effective approach for this unfortunate group in the event of failure with using these traditional methods. To date this method is not reported in litereture.

Two weeks after ERCP and stent exchange, an 80-year-old female presented with abdominal pain, vomiting, fever and jaundice for four days. She was diagnosed with pancreatic cancer six months ago and underwent ERCP with stent placement. Endoscopic stenting on this admission was unsuccessful secondary to proximal duodenal obstruction. Patient underwent laparoscopic Gastro Jejunostomy and direct Trans duodenal biliary wall-stent placement successfully. Open duodenotomy was performed and a metal stent was deployed directly through the previous papillotomy into the CBD, without endoscopy. Her biliary and gastric outlet obstructions were palliated effectively as evidenced by symptom relief and objective data. She was tolerating diet by post-operetive day two. However, 17 days later she finally succumbed to the disease.

Randomized studies suggested that endoprostheses are as effective as surgical bypass in relieving jaundice, but late complications secondary to stent occlusion are common and a significant source of morbidity. The advent of expendable metal stents allow placement of conduits with much larger lumen, thereby significantly increasing median stent patency. (273 vs. 126. days, David's et al.) ERCP and PTC are the traditional approaches used to place the biliary stents. However, in some patients either approach may not be feasible and these patients have miserable death. The approach we described may be of help to some properly selected patients.

The authors suggest this innovative approach as an aitemative in selected patients. The technique could be further refined to avoid duodenotomy, and attendant morbidity.

THE USE OF NEEDLESCOPIC INSTRUMENTATION IN LAPARO- SCOPIC PROCEDURES DOES NOT INCREASE SURGICAL TIME GARCIA-RUIZ ANTONIO M.D., CHAVEZ-RODRIGUEZ JUAN JOSE M.D., HAGERMAN GONZALO M.D., LOPEZ LETICIA M.D., SUBSEC- CION DE CIRUGIA DE MINIMA INVASION , HOSPITAL CENTRAL MILl- TAR

INTRODUCTION: Preliminary reports on the use of needlescopic techniques had advocated increased surgical time in comparison with conventional laparoscopic operations. After formal laparoscopic training we have used needlescopic instrumentation (diameter <3.3 ram) for a variety of laparoscopic procedures. AIM: To determine if the use of needlescopic instrumentation increases operative time compared to standard laparoscopic techniques. STUDY DESIGN: Prospective, longitudinal, comparative, non-randomized. EXCLUSION CRITERIA: BMI > 26, perforated inflammatory process. METHODS: From Aug 1999 to Aug 2000, we have performed a total of 127 laparoscopic procedures (38 using needlescopic instrumentation). According to selection criteria we have the following results:

Needlescopic Cholecistectomy n=14 Mean Time(MT)= 64.74 Laparoscopic Cholecistectomy n=23 MT=49.38 p=0.0001 Needlescopic Nissen n=11 MT=96.36 Laparoscopic Nissen n=38 MT=87.76 p=0.1156 Needlescopic Appendectomy n--6 MT=55.83 Laparoscopic Appendectomy n---6 MT--40.83 p----0.0488 Needlescopic Heller n=2 MT 147.5 Laparoscopic Heller n= 6 MT=135.83 p=O.4058 and one Needlescopic Splenectomy was performed in 80 mins.

we have not converted any needlescopic procedure to laparoscopic nor conventional open surgery and we have had no postoperative complications in the needlescopic group after a 10-month follow up. CONCLUSION: The use of needlescopic instruments has many applications in laparoscopic general practice. In selected cases and for experienced surgical teams, their use does not result in longer operative time(clinically significant) as compared to standard laparoscopic techniques.

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LAPAROSCOPIC NISSEN FUNDOPLICATION LEADS TO OVERCORREC- TION OF VECTORVOLUME IN A PiG MODEL OF GASTROESOPHAGEAL REFLUX. Kanm A. Gawad, M,D,, Christian Rempf, Robin Wachowiak, Chri- stian Bloechle, M.D.,PhD., Jakob R. Izbicki, M.D., PhD., Department of Sur- gery, University Hospital Eppendorf, Hamburg, Germany.

Laparoscopic treatment of gastroesophageal reflux disease (GERD) has become very popular over the past years. Several techniqes of total or partial fundoplication are applied not knowing what the mechanisms of function really are. The purpose of this study was to elucidate these mechanisms in an experimental model.

Twentyfour pigs of the german landrace were included. Vectonrolume was assessed by repetetive (x4) 6-channel water pedused rapid-pullthreugh manometry performed in apnoea and without the use of muscle relaxation. Gastreesophageal reflux was induced by open cardiomyotomy. Sufficiency was confirmed and perforation excluded by esophagogastroscopy. Animals were randomly allocated to receive 360 ~ (Nissen type), 270 ~ posterior (Tou. pet type) or 180" anterior (Dor type) fundoplications performed laparoscopically 2-3 days alter myotomy. Manornetry was performed at baseline, 2 days post myotomy, 10 days and 60 days post fundoplication. Statistical evaluation of differences was tested by using the paired t-test, All values are provided as mean.

Pigs had a median weight of 56.8 (48.4-65.2) kg at entry, 57.35 (48- 67.1) kg after myotomy and 70.1 (62-81.4) kg at the end of the study. Maxi- mal (15.8 vs. 10.8 mmHg) and mean (9.5 vs. 6.8 mmHg) sphincter pressure as well as vectorvolume (1977 vs. 823 mmHg2*cm) were significantly (p<0.05) reduced by myotomy. All three different procedures led to a significant increase of all these parameters with Nissen fundoplication showing the most excessive increase in maximal pressure (34.9 vs. 78.9 mmHg) and vectorvolume compared to postmyotomy values (915 vs 5014 mmHg2*cm) as well as normal values (1977 vs 5014 mmHg2*cm).

The overcon'ection of vectorvolume as well as maximal sphincter pressure by 360 ~ (Nissen type) fundoplication assessed by rapid pullthrough manometry in this experimental model may be an explanation for the increased percentage of dysphagia following this procedure in the clinical setting.

ENTEROSCOPIC TREATMENT OF EARLY POSTOPERATIVE BOWEL OBSTRUCTION Keith S. Gersin MD, Jeffrey L. Ponsky MD, Robert D. Fanelli MD Department of Surgery, University of Cincinnati, Department of Surgery, Cleveland Clinic Foundation, Department of Surgery, Berkshire Medical Center

Early postoperative small bowel obstruction (EPSBO) occurs in nearly 1% of patients undergoing laparotomy and has a mortality rate exceeding 17%. Nasogastric (NG) decompression is successful in 78% of patients. Repeat laparotomy has been recommended when obstruction does not resolve after 14 days of NG decompression. We report 4 patients with EPSBO treated successfully with push enteroscopy after failed NG decompression. Methods: Four patients who failed NG decompression underwent push enteroscopy instead of repeat laparotomy. EPSBO was diagnosed if obstruction lasting more than 14 days developed after initial resolution of postoperative ileus or high NG output persisted for 21 days in the absence of prolonged ileus or sepsis. Small bowel series or CT was utilized when radiographic assessment was necessary. The Olympus SIF 100 push enteroscope was introduced with an overtube using topical anesthesia and intravenous sedation. After maximal insertion, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy and the patients followed clinically. Flatus, defecation, and tolerance of diet defined resolution of EPSBO. Results: EPSBO resolved 24-36 hours following enteroscopy and all patients were discharged on general diets 48 hours after return of bowel funct ion. Readmission has not been necessary during 12-24 month follow-up. Conclusions: Our experience suggests that push enteroscopy is successful in treating EPSBO and should be considered prior to re-operation. Repeat laparotomy may not be necessary and push enteroscopy may reduce patient morbidity, cost, and hospital lengths of stay associated with this uncommon surgical complication.

A MODEL FOR EVALUATION OF LAPAROSCOPIC SKILLS: IS THERE CORRELATION TO LEVEL OF TRAINING? Gabriela A. Ghitulescu, M.D., Anna M. Derossis, M.D., Uane S. Feldman, M.D., Donna Stanbridge, R.N., Gerald M. Fried, M.D. Centre for Minimally Invasive Surgery, McGil University, Montreal, Canada

Performance of basic laparoscopic skills has been measured objectivel~ and scored in a trainer box with a video-endoscopic optical system. ,~ series of structured tasks has been previously developed and described along with an objective scoring system. The performance scores of al subjects evaluated to date were related to level of training.

One hundred and forty nine subjects were tested performing ; laparoscopic tasks (peg transfers, pattern cutting, clip and divide, use of ligating loop, mesh fixation, suturing with intraoorporeal and extracorporea knots). Performance was measured using a scoring system that rewards( both speed and precision. Student's t test was used to evaluate difference,, between junior (PGY 1,2,3) and senior (PGY 4,5, fellows, attendin( surgeons) participants. Data were analyzed by linear regression to asses,, the relationship of performance to level of training for each task.

There was a significant difference between the performance of junior vs senior participants, and good correlation between level of training an( P.errfaOs~nancle * for ea~h tesk3,(Data 4r,e mea~SD).l (*~.0001,7:'p<=-.OoO~t~;,

Junior 1175.-67131r 74.+21 59-J:38 275-J:781189~152 142:t:80 988333 Senior 173+46170-~53 78+20 955:30 332i-67 358.t:117 2005:80 1409+-29;

r .5 .39 .25 .51 .48 .56 .39 .62 Analysis of all participants who have been evaluated with the laparoscopiq

skills model has shown that there is correlation between level of training anq performance on all seven tasks, thus showing construct validity. Basi~ laparoscopic skills models such as this one can become useful in th~ evaluation and improvement of technical skill in trainees and practicin! surgeons.

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A MODEL FOR EVALUATION OF LAPAROSCOPIC SKILLS: IS THERE EXTERNAL VAUDITY? Gabdela A. Ghitulescu, M.D., Anna M. Derossis, M.D., Liane S. Feldman, M.D., Donna Stanbridge, R.N., Gerald M. Fried, M.D. Centre for Minimally Invasive Surgery, McGill University, Montreal, Canada

A video-endoscopic optical system and trainer box have been used to devise a serias of skill testing tasks, along with an objective scoring system. Seventy surgeons and residents at our institution were compared to seventy nine subjects from other institutions.

One hundred and forty nine individuals were tested performing 7 laparoscopic tasks (peg transfers, pettem cutting, clip and divide, use of a ligating loop, mesh fixation, suturing with intracorporeal and extracorporeal knots). Performance was measured using a scoring system that accounted for both speed and precision. Student's t test was used to evaluate differences between subjects at the host(H) institution and at outside institutions(NH), controlling for level of training.

At the junior(Jr) level (PGY 1,2, 3), there was a difference between the two groups for tasks 1 and 5, where non-host subjects performed better. There was no difference in performance at the senior(Sr) level (PGY 4,5, fellows, attending surgeons).

Data are mean values + standard deviation Task 1 2 3 4 5 6 7 Total H Jr 83i~o4 128_+58 75+1E 57+40 258+8~ = 183+163 132:1:77 917:1:360

NH Jr 159-J:44 13EL-50 74:1:2E;62:t:36 297i63! 196:1:141 154:t:84 1076.+.279 p 0 .53 .81 .63 .02 .71 .25 .03

H Sr 160-J:4~ 180+-36 30+-2;!102:1:23 332:1:73 364+123 202:t:69 1419-~.266 NH Sr 181+4:164i-62 78+_1, r 91~:33 334i-64 356+115 200-J:88 1404+318

p .07 .16 .70 .13 .92 .79 .93 .83 This data provides evidence for external validity in inanimate testing of

laparoscopic skills.

DIAGNOSTIC AND THERAPEUTIC LAPAROSCOPY FOR TRAUMA. A TECHNIQUE OF SAFE AND SYSTEMATIC EXPLORATION Piotr J. Gorecki M.D., Daniel Cottam M.D., George Angus M.D., Gerald Shaftan M.D. Department of Surgery, Nassau University Hospital, East Meadow, New York

Laparoscopy has a limited role in the evaluation of stable trauma patients. The main concems addressed in the literature are the potential for missed visceral injury and its limited role for therapeutic applications. We present a simple technique for the systematic exploration of the abdomen for suspected intraabdominal injury using a series of three consecutive trauma patients (two penetrating, one blunt), over a six month period at a level one trauma center.

All patients underwent complete exploration of the abdominal cavity through three 5-mm ports. The first port was placed in the umbilicus for the camera and the second and third ports were located in the dght upper and left lower paramedian area for instrumentation. A 30-degree laparoscope was utilized for all diagnostic and therapeutic explorations. The procedures started with the inspection of the pelvic organs, followed by running 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 performed. Each of the presented patients was found to have a significant injury traditionally requiring therapeutic laparotomy. Additional ports for retraction were used as needed once injuries were identified. Therapeutic procedures consisted of sutudng an intrapedtoneal bladder rupture, draining of a lacerated tail of the pancreas, and obtaining hemostasis of an actively bleeding penetrating wound to the left lobe and caudate 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.

We conclude that the presented laparoscopic technique enables systematic exploration of the abdomen, which follows the principles of open exploration. The role of laparoscopy in the management of stable trauma patients is likely to increase as more surgeons acquire advanced laparoscopic skills. A modem prospective study is needed to determine the role of therapeutic laparoscopy in stable trauma patients.

V I D E O - E N D O S C O P I C T R E A T M E N T OF HEPATIC AND LUNG HYDATID DISEASE Vlad imi r Grubnik M.D, Ph.D., Sergey Chetverikov M.D., Ph.D., Pushpendra Sharma M.D., Sabri A. Nidary, Department of Surgery, Odessa State Medical University, Odessa,Ukraine

Introduction: For the aim to reduce the occurrence we proposed some improvements in laparoscop ic t rea tment of hydatid cysts of liver.

Methods and procedures: For the last 7 years, 59 patients with one or more hydatid cysts of the liver were treated laparoscopicaly. In 9 patients co-existing cysts were observed in the lungs. The laparoscopic procedure was performed with the help of 3 or 4 trocars. The abdominal cavity was filled with CO2 at 10-12 mm Hg pressure. Special needle was used to aspirate the hydatid fluid and germicide solution was injected into the cyst cavity. Endocyst and the daughter cysts were aspirated and removed with the use of endoscopic bags. The endoscope was advanced into the cyst cavity to check. In 32 patients (I group) we used Nd YAG laser at the power 20-30 W to coagulate the cyst cavity. In 27 patients (11 group) the cavity was irrigated with scolocidal fluid and saline solution. 7 patients with co-existing hydatid cysts in the lungs were operated thoracoscopicaly and 2 by thoracotomy.

Results: Minor compl icat ions were observed in 2 (6.3%) patients from the I group and in 7 (27%) from the II group. Temporary bi le l eakage was observed only in 5 (15.8%) patients from the II group. There were no deaths, major com- p l icat ions and convers ion to open surgery in any of the groups. Follow-up t ime ranged from 6 months to 6 years. In 2 (7.4%) patients from the II group recurrence was observed.

Conclusions: The use of laser coagulation of the cyst cavity improves the results of laparoscopic t reatment of hepat ic hydatid disease.

LAPAROSCOPIC TREATMENT OF COMPLICATED DUODENAL ULCERS YURI GRUBNIK M.D. Ph.D, VLADIMIR GRUBNIK M.D. Ph.D., PUSHPEN- DRA SHARMA M.D., VLADIMIR KARLUGA M.D., VLADIMIR FOMENKO M.D. Dept. of surgery, Odessa State Medical University, Odessa, Ukraine

Introduction: Conservative treatment of the ulCer disease is not so effective in Ukraine like in Western Europe due to social and economical situations. Operative treatment of duodenal ulcer disease is still economically feasible in Eastem Europe. Methods and procedures: Laparoscopic operation were performed in 149 patients for management of complicated peptic duodenal ulcer disease. Indications for operation were: bleeding in 97 patients, perforation in 36 patients, stenosis in 8 patients. In patients with bleeding, vagotomy was performed after successful endoscopic hemostasis. Taylors procedure - posterior trunk vagotomy and anterior seromyotomy was performed in 82 patients. In 69 patients anterior seromyotomy was performed by contact Nd- YAG laser, which was more effective than seromyotomy by scissors. In 15 patients Gomez-Ferrer procedure - postedor trunk vagotomy and resec~on of the lesser curve by stapler was performed. In 36 cases with perforation, 19 patients were operated by intracorporal suturing of the perforated ulcer, 9 patients by omental patch to the perforation defect. Taylor's vagotomy and sutudng of the ulcer defect was performed in 8 cases. In category of patients with stenosis, 4 patients were operated by bilateral posterior truncal vagotomy with gestroenterostomy. In 3 cases we performed Taylor's vagotomy and pyloroduodenoplasty. In one case Taylor's operation and balloon dilatation of the duodenum were performed.

Results: Postoperative mortality was zero. Complications were observed in 12 cases. Conversion was performed in 6 cases. Analysing the results of 4 years of post-operative observations, 90 % of patients were graded as Visick I or II, 3.8 % were Visick III and 6.2% was considered as Visick IV.

Conclusions: Our experience shows that laparoscopic vagotomy by Taylor and Gomez-Ferrer procedures are adequate operations in conditions of successful eradication of Helicobacter pylori. Lapamscopic procedures can be performed successfully in patients with complicated duodenal peptic ulcers.

LIQUID PHASE GASTRIC EMPTYING IN COLONIC ANASTO- MOSES AT DIFFERENT SITES Omer Gunal, M.D., Berrak (~.Yegen M.D., PhD.*., Department of Surgery, D0zce School of Medicine, Abant Izzet Baysal University, DUZCE.TURKEY. Department of Physiology, Marmara University Medical Faculty. IstanbuLTURKEY

Gastric emptying (GE)plays a crucial role when determining the oral feeding time after surgery. Current study was done to evaluate the effect of colonic anastomosis which has been done at different parts of the colon on gastric emptying.

42 Adult 200-250 g weighed Wistar-Aibino rats were divided in to six groups. Control (Group-I; n=7) group did not undergo operation. Sham groups underwent midline laparatomy and GE measurement was done on postoperative 1st (Group-2; n=7 )and 10th (Group-3; n=7)days. Group-4 and 5 underwent rectum and ascending colon anastomosis respectively, and subjected to the gastric emptying test on first potoperative day. Group-6 and 7 underwent same operations respectively, and subjected to the gastric emptying test on postoperative 10th day. Liquid gastric emptying test has been performed by using the methyl cellulose phenol red method. On postoperative 1st day, gasrtic emptying rate were 34,9+-1.5 % and 50.9+-5.2 % in rectum and ascending colon anastomosis groups respectively. GE in rectum anastomosis was significantly less (49.9+-7.8 %) than the ascending colon anastomosis (72.5+-2.1%) on postoperative 10th day. GE rate in Sham group was similar to the control group on postoperative 10th day.

Rectum or ascending colon anastomosis causes a significant decrease in liquid gastric emptying on early postoperative period. This delay persists even on the postoperative 10th day in rectum anastomosis but not in the ascending colon anastomosis. Anastomosis at diferent sites on the colon causes different gastric emptying rates.

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DOES ENDOTHELIN-1 PLAY ROLE IN P O S T O I P E R A T I V E INTRAPERITONEAL ADHESION FORMATION BY REGULATING THE INTESTINAL BLOOD FLOW? (3met G0naI,M.D.,Y0ksel Arykan,M.D.,Mustafa Deniz*, Berrak (~.Yegen*,M.D.PhD., Department of General Surgery, D0zce School of Medicine, Abant Yzzet Baysal University, DOZCE,TURKEY.Department of Physiology*,Marmara university, school of Medicine. YSTANBUL, TURKEY.

Pathogenesis of postoperative intraperitoneal adhesion formation is still being a subject of investigation. Local peritoneal ischemia is one of the factors that is responsible for the postoperative intraperitoneal adhesion formation. The current study was planned to investigate the role of ET-1 as a potent vasoconstrictor agent in the local peritoneal ischemia and subsequent peritoneal adhesion formation. 28 Adult Wistar Albino rats weighed 200-230 g were divided to four groups. Control group (Group-I; n=7) did not undergo an operation. In adhesion group (Group-2; n=7),1x1 cm peritoneal patch excision from the right abdominal wall and caecal abrasion were done as the"adhesion model operation". Sham group (Group-3; n=7) had only laparatomy. After "adhesion model operation" treatment group (Group-A; n=7) received a non-selective ET-1 receptor blocker Bosenthan (30 mg/kg) intraperitoneally, once a day for five days. Intestinal blood flow through the superior mesenteric artery was measured by doppler ultrasound, at postoperative tenth day. Adhesion scores of the groups were calculated. Mean intestinal blood flow was significantly increased in adhesion group (81.9+-5.6 ml/100g) when compared to Group-1 (65.5+-1.2 ml/100g). Bosenthan caused a significant decrease (44.3+-6.9 ml/100g) in intestinal blood flow when compared to group-1 and 2. Sham group (62.2+-1ml/100g) had similar blood flow level with the control group (65.5+-1.2 ml/100g). Adhesion scores were similar in adhesion and besenthan groups. Sham group had nearly no adhesion. Non-selective blockade of ET-1 has no effect on intraperitoneal adhesion formation. Adhesion formation increases the intestinal blood flow. Chronic intraperitoneal ETA and ETB receptor blockade causes a decrease in the blood flow of adhesion formed intestinal tissue.

D E L A Y E D L IQUID P H A S E G A S T R I C E M P T Y I N G RATE BY COLORECTAL DISTENSION CAN BE REVERSED BY ESTROGEN C)mer G0nal*,M.D.,Ayhan Bozkurt, Ph.D, Berrak (~.Yegen,M.D.,Ph.D. Department of General Surgery, Duzce School of Medicine, Abant Yzzet Baysa University, Duzce, Turkey, Department of Physiology, School of Medicine, Marmara University, Istanbul, Turkey

Colorectal distension that can be occurred in many surgical clim- cal situations may affect the gastric motility. Gastric emptying rate is an important measure in the evaluation of gastric motility. The purpose of this study was to investigate the effect of different modes of rectal distension and estrogen on gastric emptying rate. 32 Male 200-250 g weighed Wistar-AIbino rats were divided to three groups. Group-1 (n=8) subjected to gastric emptying test without undergoing any operation. Group-2 (n=8) has been applied to painless colorectal distension for one hour. Group-3 (n=8) subjected to painfull colorectal distension for one hour. 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 distension. Colorectal distension has been created by indwellig a number six foley catheter through the rectum 2 cm above the anal verge. Pain stimuli was determined according to electromyograph- ic measurement from the abdominal muscles. Gastric emptying test has been performed by the methyl cellulose phenol red method. Gastric emptying rate was found 72.1+-3.5 % in Group-1. Colorectal distension decreased the gastric emptying rate to 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). Group-4 gastric emptying rate increased even above control levels (80.5+-4.9 %). Painful rectal distension causes significant inhibition of gastric emptying rate. This inhibition can be reversed by estrogen therapy.

LAPARDSCOPIC NISSEN FUNDOPUCATION WITHOUT AN INDWELLING DILATOR. Gupta M, Yuh J, Chen P. Departments of Surgery, Huron and Robinson Memorial

Hospitals, Cleveland and Ravena, Ohio.

Although passing a large esophageal dilator is a safe technique in open

fundoplication, the same may not be assumed for the laparoscopic operation,

since the lower esophagus is unsupported during per oral insertion of the dilator.

latrogenic perforation occurs in as high as 3%. We tested the hypothesis that

good fundoptication can be performed without a dilator in a consecutive series of

35 patients (Group I), using simple precautionary measures, such as routinely

visualizing a 0.5-1 an space between the fundic wrap and ~'e esophagus upoil

lifting the wrap. The results, compared with a consecutive series of

bougie-assisted wrap (group II), were similar, the follow-up being 100% in both:

Group I (n=35) Group II (n=71)

Esophageal tear 0 1

Pneumothorax 1 1

Conversion to open 0 2

Dilation required 2 4

Revision for reflux 1 1

Ventral hernia 0 1

Total complications 4 g

We conclude that a floppy fundoplication can be performed without an

indwelling dilator ~ results similar to the conventional technique.

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VALIDATION OF INANIMATE LAPAROSCOPIC SKILLS TESTING USING RESIDENCY IN-TRAINING EVALUATIONS SE Haqarty, MD, AM Derossis, MD, LS Feldman, MD, GA Ghitulescu, MD, D Stanbddge, RN, GM Fried, MD. Centre for Minimally Invasive Surgery, McGill University, Montreal, Canada.

Objective: Technical skills of residents have traditionally been evaluated using subjective In-Training Evaluation Reports (ITERs). An objective model for assessment of fundamental laparoscopic skills has been developed (FLS). This model measures skill at performing 7 tasks: 1) peg transfer 2) cutting 3) clipping 4) endoloop 5) mesh fixation 6) intra-corporeal and 7) extra-corporeal knot tying. The goal of the current study was to assess if residents with high ITERs would also have high FLS scores. Method: Technical skill as graded in the ITER was compared in a blinded fashion to FLS scores for 50 residents. The proportion of superior ITERs during the year in which the resident was assessed by the FLS was calculated. The median proportion of superior evaluations for the whole group was 33%. Residents were divided into two groups: high ITER (>33% superior) or low ITER (<33% superior). Students' t test was used to compare FLS scores between the two groups. Results: Residents with high ITERs performed significantly better than those with low ITERs in tasks of peg transfer, cutting, intra- and extracorporeal knot tying (see below). Conclusion: Residents with higher skills in vivo, as assessed by the in-training evaluations, also perform better in the FLS skills model. (HIGH=high ITER group, LOW=low ITER group, data is presented as mean • standard deviation)

Task n 1" 2* 3 4 5 6* 7* HIGH 21 84-1-74 124• 74::1:20 70• 267::1:89 216::1:148 138:1:80 LOW 28 145!-50 177:t:34 86• 92:1:36 284:t:100 365+127 184+73 p .0018 .0009 .0710 .0513 .5391 .0005 .0396

L A P A R O S C O P I C H E R N I O R R H A P H Y OF EXTERNAL SUPRAVESICAL HERNIA; A CASE REPORT Masanobu Hagiike M.D., Kinihiko Izuishi M.D., Hisashi Usuki M.D., Takashi Maeba M.D., Hajime Maeta M.D., Department of Surgery, Kagawa Medical University, Kagawa, Japan

External supravesical hernia is very rare, and its diagnosis is difficult. We report a case of external supravesical hernia which was diagnosed and repaired by laparoscopic technique.

A 76-year-old male with history of right inguinal herniorrhaphy and proximal gastrectomy admitted our hospital with complaint of mass and pain in the right groin. Physical examination showed a thumb-tip-size mass in right inguinal lesion. The mass was easily released into peritoneal cavity by hand. In addition, we find a hernia defect in the left groin. We diagnosed bilateral inguinal hernia. Laparoscopic herniorraphy (transabdominal preperitoneal repair) was scheduled. Under laparoscopic examination, a hernia defect was observed in the right supravesical fossa. The size of hernia defect was 1.0 cm in diameter. We covered widely hernia defect with polypropylene mesh and fixed to preperitoneal layer. Left inguinal hernia defect was also covered by mesh to strengthen the fragile part. Postoperative course was uneventful.

Laparoscopy is a useful diagnostic tool in the evaluation of groin mass. It enables the surgeon to visualize and define accurately a variety of hernia defects. In addition, it is a significant repairing tool of hernia defect. It has been reported that supravesical hernia was caused by extensive fragility of abdominal wall structures provoked by the previous operation or increasing age. Therefore, to repair the hernia defect, it might be important that the de fec t is covered widely. Laparoscopic techn ique should be appl ied to external supravesical hernia.

ESOPHAGEAL MYOTOMY IN AN OPOSSUM MODEL Valerie J. Halpin, MD, Chandra Prakash, MD*, Laura Harolan, BSN*, Donna R. Luttmann, RN, Thomas A Meininger, Ray E. Clouse, MD*, Nathaniel J. Soper, MO Department of Surgery and Institute for Minimally Invasive Surgery, *Division of Gest~oentemlogy, Washington University, SL Louis, Mlssoud.

Didelphis virginianls, the North American opossum, has esophageal musculature and motility similar to humans and potential to be a useful model to evaluate surgical treatment of gastroesophageal reflux. The purpose of this study was to assess the effect of esophageal myotomy on lower esophageal sphincter (LES) function.

Successful laparoscopic esophageal myotomy was performed in 6 animals. Manemetry data were obtained preoperatively and post-myotomy in awake animals using a 21-lumen perfusad transoral catheter. These data were analyzed using a computedzed acquisition and display system capable of generating 3-dimansional topographic plots.

There was a significant redu~on in LES post-deglutitive contraction pressure and a trend for reduction in LES basal pressure. There were no significant chan! as in the residual LES pressure or peristaltic parameters. Pressures are ex }ressed as mean + standard deviation. LES Pressures Basal Contraction Residual

(mmHg) (mmHg) (mmHg) Preoperative t8.8 + 8.4 69.8 + 9.4 4.66 +_ 4.75 Postoperative 10.5 + 5.4 45.6 ~ 19.0 5.03 + 1.61

P = .067 P< 0.03 P = .861 In the opossum, esophageal myotomy diminishes LES pressures

but does not abolish its function completely, perhaps due to crural influences. Further manipulation of the LES complex may be necessary to develop a satisfactory reflux model.

LAPAROSCOPIC DOR VS. TOUPET FUNDOPUCATION FOLLOWING ESOPHAGEAL MYOTOMY IN AN OPOSSUM MODEL Valerie J. HalDin. MD. Chandra Prakash, MD," Laura Haroian, BSN,* Donna R. Luttmann, RN, Thomas A. Melninger, Ray E. Clouse, MD,* Nathaniel J. Soper, MD Department of Surgery and Institute for Minimally Invasive Surgery, *Division of Gastroenterology, Washington University, SL Louis, Missouri.

The role of fundopllcation following esophageal myotomy for achalasia remains controversial. There are proponents for both anterior (Dor) and posterior (Toupet) partial fundoplication. The purpose of this study was to compare anterior to posterior fundoplicaUons following esophageal myotomy in an opossum model.

Laparoscopic esophageal myotomy was performed in 8 animals. Laparoscopic fundoplication was performed 3 weeks post-myotomy (4 Dor, 4 Toupet). Manometry data were obtained preoperatively, post-myotomy, and post-fundoplication in awake animals using a 21-lumen perfused transoral catheter. These data were analyzed using a computerized acquisition and display system capable of generating 3-dimensional topographic plots. Immediately following sacrifice LES competence :v3: assessed by measuring in situ gastric pressure at the point of esophageal reflux during gastric infusion with saline.

There was no significant difference between Dor and Toupet in restoration of LES basal or post-deglutitive contraction pressure. The Toupet significantly increased the residual pressure compared to the Dor (15.45 vs. 6.35 mmHg, p<0.02). At sacrifice the Toupet group refluxed at a significantly lower gastric pressure compared to the Dor group (5.5 vs. 35 mmHg, p<0.005),

In vivo manometric pressures following Dor and Toupet fundoplicaUon did not predict in situ anatomic reflux in this animal model. Further studies are warranted to determine the antireflux mechanisms of partial fundoplication, espedally following myotomy,

PNEUMOPERITONEUM DOES NOT INFLUENCE TROCAR SITE IMPLANTATION DURING TUMOR MANIPULATION IN A SOUD TUMOR MODEL Valerie J. HalDin, MD. Robert K UndenNeed, MD, Dan Ye, MD,PhD, Daniel H. Cooper, BA, Mark Wright, Suzanne M. Hickerson, BS, William C. Connett,' PhD, Judith M. ConneR, PhD, James W. Fleshman, MD. Department of Surgery, Washington University, SL Louis, Missouri.

The purpose of this study was to assess tumor implantation at abdominal wall wounds following surgical manipulation of a solid intraabdominal tumor in the presence of pneumoparitoneum.

GW-39 human colon cancer cell suspension (0.1 ml of 50% v/v; 3.35 x 107 cells) was injected into the omentum of golden Syrian hamsters through a midline incision. At 2 weeks the omental tumor was harvested and the animals were randomized to one of eight groups: bivalve(At, crush(B), epithelial stripping(C), or complete excision without manipulation(D); each with and without pneumoperitoneum. Four 5-ram trocars were inserted through the anterior abdominal wall, the manipulated tumor was reinserted through the midline, swept through all four quadrants, and removed. The midline incision was closed and pneumoperitoneum at 7 mmHg was maintained for 10 minutes. Tumor implantation at trocar sites and midline wound Incisions were documented grossly and histologically 7 weeks later.

Tumor manipulation increased implantation at trocar sites (p<0.001) and midline incisions (p<0.001). Pneumoperitoneum did not increase tumor implantation at trocar sites (p=0.gg3) or midline incisions (p=0.886).

Group A + B + C D Wound location Mldline Trocar Mldtine Trocar

Pneumo- 77% 53% 45% 9% peritoneum (103/133) (2811530) (20 /44) (151176) No pneumo- 77% 49% 51% 10% peritoneum - (101/132) (2611528) (21141) (161164)

Tumor Implanlolion at ttocar sites Is due to spillage of tumor dudng manipulation and not to pneumopedtoneum itself.

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COMPARISON OF ROBOT VERSUS HUMAN LAPAROSCOPIC CAMERA CONTROL: IMPACT ON SURGEON EFFICIENCY E(~ Hamilton, M,0., GV Kondraske, Ph.D., CA Fischer, B.S., ST Tesfay, R.N., DJ Scott, M.D., R Teneja, RJ Brown, B.S., DB Jones, M.D. Southwestern Center for Minimally Invasive Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas

Surgical robot assistance is being used to perform a wide range of laparoscopic procedures. Previous reports suggest robot-assisted camera control (RACC) may be superior to a human camera driver in terms of overall quality of the view, directional precision, as well as long-term cost savings. We hypothesize that use of RACC results in increased surgeon efficiency because of increased economy of motion and decreased operative time.

Twenty pigs (n= 20) were randomized to undergo laparoscopic Nissen fundoplication with either a human or voice-controlled, AESOP 2000 robot- assisted camera system (Computer Motion, Goleta, CA). The operative procedure was standardized for all animals. Operative time was recorded separately for dissection and suture phases.

Data were recorded as Mean + standard deviation. Analysis was performed by T-test.

Camera Driver

Human (n: 10~ AESOP(n: 10) Dissection Phase (minutes) 23,4 (t. 7.4) 22.2 ~. 7.1) p= NS Suture Phase (minutes) 24.7 ~ 4.2) 25.7 (+ 8.1) p= NS

We conclude that robot-assisted camera control is comparable to a human camera driver in terms of time to perform key parts of a laparoscopic Nissen fundoplication. Robot-assisted camera control demonstrated no objective benefit using this measure. Economy of motion, as a component of performance, requires further data analysis.

DA VINCI-ASSISTED TOTALLY ENDOSCOPIC PROCEDURES IN THE ABDOMINAL SURGERY Makoto Hashizume, MD, PhD, Keizo Sugimachi, MD, PhD, Mitsuo Shimada, MD, Modmasa Tomikawa, MD, Youichi Ikeda, MD, Ikuo Takahashi, MD, Ryou Abe, MD, Fusashi Koga, MD, Shinichiro Maehara, MD and Shouzou Konishi, MD, Department of Disaster and Emergency Medicine and Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Objective of the study: For complex minimally invasive procedures to become more widely adopted by surgeons, significant improvements must be made in the operating evironment. Robotic and computer.assisted systems are making exceptional progress in the field of minimally invasive cardiac surgery. However, the efficacy of these procedures has not been demonstrated as dramatically in general surgery as in cardiac surgery. We report the techniques of our first experiences performing complete total endoscopic procedures in patients with colon cancer, gastric cancer, splenic tumor, esophageal hiatal hernia assisted by the da Vinci system.

Methods: From July to September 2000 the computer enhanced surgical system, da Vinci was successfully used in ten patients who underwent totally endoscopic surgery. The operative procedures were ileocaecal resection in one patient with early colon cancer, distal gastrectomy in two patients with early gestfic cancer, splenectomy in two patients with malignant tumor and idiopathic thromcytopenic purpura, cholecystectomy in two patients, inguinal hemiorrhaphy in two patients, and repair of the esophageal hiatal hemia in one patient. The anastomoses were performed in the functional anastomosis for the colon and in a manual fashion for the stomach assisted by the da Vinci system. Hemostasis was done with an electrocautery and ligatures of the vessels.

Preliminary results: All procedures were successfully performed. There were no major intraoperative complications. There was no transfer to open surgery. The operative time of the robotic surgery was still longer in all patients than that of the conventional endoscopic procedures. The anastomoses were more precise and easier w=th the Endo-Wdst of the da Vinci than those in the conventional surgery.

Conclusion: This technological innovabon should help surgeons overcome various difficulties in order to perform more precise, safer and less minimally invasive abdominal surgery in the coming era.

IMPACT OF CO2 AND HEUUM INSUFFLATION ON CARDIORESPIRA- TORY PARAMETERS DURING PROLONGED PNEUMOPERITONEUM Eric J. Hazebroek MD1, Jack J. Haltsma MD2, Ewout W. Steyerberg PhD3, Ron W.F. de Bruin PhD1, Richard L. Marquet PhD1, Nicole D. Bouvy MD PhD1, Burckhard Lachmann PhD2, H. Jaap Bonier MD PhD1, 1Dept. of Surgery, University Hospital Rotterdam-Dijkzigt, 2Dept. of Anesthesiology and 3Dept. of Public Health, Erasmus University Rotterdam, The Netherlands

Rodents are often used to investigate local and systemic effects of laparm scopic surgery. Since the purpose of experimental studies is to extrapolate experimental findings to daily practice, knowledge of cardiorespiratory changes in animals exposed to pneumoperitoneum is essential. The objective of this study is to determine the impact of CO2 and helium insufflation on arterial pH, pCO2, 1:)O2, blood pressure and respiratory rate during prolonged pneumoperitoneum in the spontaneously breathing raL

5 groups of 6 rats were exposed to intraperitoneal CO2 insufflaton (6 and 12 mmHg), helium insufflation (6 and 12 mmHg) or abdominal wall lift (gesless control) during 120 minutes. A cannula was placed in a carotid artery for blood pressure monitoring and drawing blood samples. Before insufflation, baseline measurements of mean artedal pressure (MAP), respiratory rate and arterial pH, pCO2 and pO2 were determined. Blood gases were obtained at 5, 15, 30, 60, 90 and 120 minutes during pneumoperitoneum. MAP and respiratory rate were recorded every 15 minutes. Statistical analysis was performed with a repeated measures ANOVA test (p < 0.05 is significant).

CO2 insufflation (6 and 12 mmHg) directly caused a decrease in pH (p< 0.001) and an increase in pCO2 (p= 0.01) compared to both helium groups and the gesless control group. Acidosis and hypercapnia were not influenced by intra-abdominal pressure. Abdominal gas insuffialJon caused a significant increase in respiratory rate (p= 0.036), independent of type of gas. CO2 insuffiation at 12 mmHg increased MAP (13= 0.006) during 30 minutes, but after this, no influence of gas type or insufflation pressure on bleod pressure could be detected.

Abdominal CO2 insuffiation resulted in acidosis and hypercapnia, independent of the intra-abdominal pressure. Helium insufflation can prevent the Occurrence of respiratory acidosis during prolonged pneumoperitoneum in the spontaneously breathing rat.

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LAPAROSCOPIC RESECTION OF DUODENAL TUMORS B. Todd Heniford, MD, Sharon L. Goldstein, MD, Brent D. Matthews, MD, Kent W. Kercher, MD, Frederick L. Greene, MD., Department of Surgery, Carolinas Medical Center, Charlotte, NC

The duodenum's size, retroperitoneal location, close proximity to vital structures, and limited disease states has resulted in few reported laparoscopic operations on this organ. The purpose of this study was to review our experience with laparoecopic resection of duodenal masses. All cases were prospectively followed from 7/96 to 9/00. Seven patients presented with duodenal masses. Four were found secondary to leeding; 3 were incidentally discovered. All patients underwent laparoscopic surgery. There were 3 females and 4 males with an average age of 55 years (36-66 years). Pathology included 2 lipomas, 2 stromal tumors, and 3 adenomatous polyps. Two were in the first portion of the duodenum and 5 were in the second. All lesions were removed with the aid of an endoscope to localize the tumor. Three lesions were resected full thickness and 2 were enucleated. Two required 5-7 cm incisions after laparoscopic mobilizatiGn to remove them due to their proximity to the ampulla; the others required 4 trocars. Laparoscopic closure of the duodenum was performed with interrupted, intracorporeal sutures. In addition to the duodenal resections, 2 cholecystectomies with cholangiogram (to assess the ampulla following resection) and a Nissen fundoplication were performed. Average hospital stay was 4.4 days (3-7 days). There were no complications and no deaths. With an average of 6 months of follow-up, there has been no documented recurrence or complication. Laparoscopic resection of duodenal tumors is safe and feasible. Endoscopic-assistance is extremely helpful to localize the tumor and determine its relationship to the ampulla. Even when open resection is required, laparoscopic assistance can limit the laparotomy incision.

THORACOSCOPIC AND LAPAROSCOPC SURGERY FOR THO- RACIC ESOPHAGEAL CANCER Masayuki Higashino M.D., Shinya Tanimura M.D., Yosuke Fukunaga M.D., Harushi Osugi M.D., Osaka City General Hospital, Department of Gastroenterological Surgery, Osaka, Japan

One hundred and fourteen esophageal cancer cases have undergone thoracoscopic and/or laparoscopic surgery for these 5 years in our insti- tutional hospitals. Noting cases since 1997 when a laparoscopic technique for the abdominal procedure was introduced, we have performed 34 open surgery, 26 thoracoscopic and laparoscopic (TL Group), 28 thoracoscopic and laparotomy (T Group), and 24 laparoscopic and thoracotomy (L Group) surgery for this disease, meaning recent increase of the laparoscopic cases. Above 3 thoracoscopic and/or laparoscopic groups were compared with 80 conventional open surgery cases (C Group) which were performed before introduction of the thoracoecopic technique. Results: The 3 major complications after surgery, pulmonary troubles, anastomotic insufficiency, and recurrent laryngeal nerve palsy, were 7%, 4%, and 24% respectively in TL group, 23%, 5%, and 23% respectively in T group, 8%, 0%, and 12% respectively in L group, and 16%, 3%, and 16% respectively in C group. This summarized that the recurrent laryngeal nerve palsy is higher in the thoracoscopic surgery than in thoracotomy procedure and that the pulmonary troubles are lower in the laparoscopic surgery than in laparotomy procedure. Mean number of nodes dissected, mean duration of the operation, and mean blood loss were not differ among those 4 groups. As far as postoperative respiratory function was concerned, the reduction of percentage of the vital capacity was lower in the T group than in thoracotomy cases, resulting a better tolerance of the exercise. Conclusion: Although the laparoscopic and thoracotomy surgery' was the best procedure among these groups in terms of the postoperative complications, distant respiratory function was the most maintained in the T group. This implied that if the ratio of recurrent laryngeal nerve palsy had been reduced the thoracoscopic and laparoscopic surgery would be the best procedure for the esophageal cancer.

LAPAROSCOPIC CHOLEDOCHOTOMY AND REPAIR USING ZEUS ROBOTIC TECHNOLOGY. Celes~Q M. Hollend~, MD, Michael J. Torma, MD, Laramie N. Dixey, RN, Department of Surgery, Louisiana State Universit 7 Health Sciences Center.Shreveport and Biomedical Research Foundation, Shreveport, Louisiana

The purpose of this study was to determine the feasibility of performing longitudinal choledochotomy and repair with ZEUS robotic technology.

Methods: 20-30 kg pigs were operated on by 2 surgeons =n this non- survivor protocol. The control group underwent laparoscopic longitudinal choledochotomy with repair (n=10, 5 per surgeon). The experimental group unde~vent the same procedure using ZEUS robotic assistance (n=10, 5 per surgeon). Times for anesthesia, robotic set-up, and anastomosis were measured along with technical complications.

Results: Anesthesia Anastomosis Set-up Complications (minutes) (minutes) (minutes)

t-test p=0.007 p = 0 . 0 4 p=0.0004 p=0.008 Control n=10 128~2 79+41 3=+3.3 9 (n=7) ZEUS n=10 235+91 140+73 12+5 4 (n--4)

o Complications: Control group: leak-3, 50 Y, narrowing-2, common duct injury- 1, liver/stomach injury-I, conversion to open-l, back wall sutured-l. ZEUS group:leak-2, back wall injury-2.

Condusion: ZEUS robotic assisted longitudinal choledochotomy and repair is technically feas~le. Significant differences in anesthesia and anastomosis times likely represent the learning curve, since current anastomotic times are 70-90 minutes for a robotic end-to-end anastomosis. Set-up times are inherently longer for ZEUS. Additionally, back wall injuries in the ZEUS group were eliminated once scissors were used instead of a scalpel. The highly signiticant difference in complication rates markedly favors robotic assistance. Survivor studies are needed to further validate these results. Nonetheless, ZEUS robotic technology offers the promise of expanding applications in advanced iaparoscopic surgery.

ROBOTIC-ASSISTED SURGERY IMPROVES TIME AND ACCURACY OF ADVANCED LAPAROSCOPIC TASKS PERFORMED BY SURGICAL RES- IDENTS Santiago Horgan M.D., Marcia I. Edison Ph.D., Daniel Vanuno M.D., Jose Cintron M.D., W. Scott Helton M.D., Minimally Invasive Surgery Center, Division of General Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois

Robotic assisted surgery is projected to accelerate the learning curve for advanced laparoscopic surgery, but little data exists to support this contention. This study tested the hypothesis that novice surgeons would learn advanced laparoscopic skills more quickly using a robotic assisted surgical system than using conventional two-handed laparoscopic surgical techniques. Twelve surgical residents (PGY1 - PGY5) participated in the initial study. Each resident was given a brief orientation to the DaVinci(tm) Surgical System and was given standardized instructions to perform 2 simple two-handed laparoscopic tasks. Task 1 was transferring 10 lifesavers out of a box onto a nail using the non-dominant hand while holding a 30-degree camera with the dominant hand. Task 2 was passing a needle through 9 keyhole pins placed in an S pattern. Each resident was given 5 minutes to practice these tasks with both standard laparoscopic needle drivers and with the DaVinci (tm) Surgical System. After the practice session, each subject performed these tasks using the robot and using conventional two-handed laparoscopic technique. Subjects were scored using a standardized assessment tool based on accuracy and time. We sought to determine whether there were significant differences in resident performance of the tasks using paired T-tests and chi-square analysis. Results for Task I showed no significant difference in time or accuracy (13< 0.05). The number of residents completing Task 2 was significantly higher using the robot (9/12) versus using conventional two-handed lapamscopic technique (2/12)(p <0.001). Accuracy was also significan~ improved on Task 2 when the robot was used. We conclude that for learning speed and accuracy of simple surgical tasks, robotic surgical assistance is at least as good as conventional laparoscopic techniques. However, for complex tasks, both speed and accuracy are enhanced by the DaVinci(tm) Surgical System. These findings suggest that robotic surgery will accelerate the learning and performance curve for advanced laparoscopic skills.

LIVER METASTASES ARE LESS ESTABLISHED AFTER GASLESS LAPAROSCOPY THAN AFTER CO2 PNEU- MOPERITONEUM AND LAPAROSCOPY IN A MOUSE MODEL Takanobu Hoshino, M.D., Hideyuki Ishida, M.D., Ikuya Takeuchi, M.D., Masaru Yokoyama, M.D., Hiroshi Okita, N.D., Daijo Hashimoto, M.D., Department of Surgery, Saitama Medical Center, Saitama Medical School

Background: Although the liver is the most frequent site of recurrence after conventional open surgery for colorectal cancer, the effect of laparoscopic procedures with or without gas insufflation on the development of liver metastases is largely unknown. Methods: Male BALB/C mice inoculated intraportally with colon 26 cells were randomized to undergo CO2 pneumoperitoneum (n=14), abdominal wall lifting (n=14), full laparotomy (n=12), or to serve as controls without any procedures other than tumor inoculation (n=13). Results: The growth of liver metastases 14 days after surgery was enhanced following full laparotomy (P<0.01) and pneumoperitoneum (P<0.01) as compared with that in the control, while there was no difference in the growth of liver metastases between abdominal wall lifting and the control (P=0.99). Conclusions: These results suggest that the defense against liver metastasis is better preserved following the gasless procedure than following laparotomy and CO2 pneumoperitoneum in this animal model.

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LIVER METASTASES ARE LESS ESTABLISHED AFTER GASLESS LAPAROSCOPY THAN AFTER CARBON DIOXIDE PNEUMOPERITONEUM AND LAPAROSCOPY IN A MOUSE MODEL Takanobu Hoshino, M.D., Hideyuki Ishida, M.D., Ikuya Takeuchi, M.D., Masaru Yokoyama, M.D., Hiroshi Okita, N.D., Daijo Hashimoto, M.D. 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 cancer, the effect of laparoscopic procedures with or without gas insufflation on the development of liver metastases is largely unknown. Methods: Male BALB/C mice inoculated intraportally with Colon 26 cells were randomized to undergo carbon dioxide pneumoperitoneum (n=14), abdominal wall lifting (n=14), full laparotomy (n=12), or to serve as controls without any procedures other than tumor inoculation (n=13). Results: The growth of liver metastases 14 days after surgery was enhanced following full laparotomy (P<0.01) and pneumoperitoneum (P<0.01) as compared with that in the control, while there was no difference in the growth of liver metastases between abdominal wall lifting and the control (P=0.99). Conclusions: These results suggest that the defense against liver metastasis is better preserved following the gasless procedure than following laparotomy and carbon dioxide pneumoperitoneum in this animal model.

LAPAROSCOPIC PARTIAL ADRENALECTOMY Ibrahim M. Ibrahim M.D., Fred Silvestri M.D., Department of Surgery, Section of Laparoscopy, Englewood Hospital and Medical Center, Englewood, N.J.

Total adrenalectomy performed laparoscopically may become the standard for the treatment of benign adrenal tumors. On the other hand, partial adrenalectomy is infrequently performed, reserved for the patient cohort at risk for iatrogenic Addison's disease were total adrenalectomy to be carried out.This includes patients with a single adrenal gland, bilateral disease and the multiple endocrine neoplastic syndromes. We recently treated a patient by partial adrenalectomy in order to preserve paired organs, an indication we believe to be appropriate in a young person. This type of operation can be performed effectively, safely and indeed was easier than total resection. Laparoscopy affords superior visualization of anatomy. Mobilization and dissection of the adrenal is facilitated by the delicate laparoscopic instruments that reach deep into the recesses of the retroperitoneum. Clearly long term followup studies are necessary, but we believe that adrenal preserving procedures deserve serious consideration in selected cases. (A two minute video accompanies the presentation).

LAPAROSCOPIC HARVESTING OF OMENTUM FOR USE AS A PEDICLE OR MICROVASCULAR FLAP Ibrahim M. Ibrahim, M.D., Fred Silvestri, M.D., William Boss, M.D., Department of Surgery, Section of Laparoscopy, and Department of Plastic Surgery, Englewood Hospital and Medical Center, Englewood, N.J.

Omental Transposition is a recognized but infrequently employed procedure for providing vascularized tissue to heal infected sites, improve the milieu for poorly vascularized tissue or to provide coverage for an exposed prosthesis. The challange of chronically non healing wounds in two elderly patients form the basis of this report. In both cases, the omentum was harvested laparoscopically and used in one instance as an omental pedicle flap to cover an infected stemal wound. In another patient, the omentum was used as a free flap to cover a large pretibial, post radiation wound. This procedure required microvascular technique. The wounds in both patients healed within few weeks with full skin coverage. The omentum can be harvested laparoscopically by dividing its attachment to the greater curvature of the stomach with an harmonic scalpel, care being taken to avoid injury to the gastroepiploic arcade. Detachmment from the spleen is performed with relative ease including separation from the abdominal wall and colon. The free flap method requires dissection of the gastroepiploic vessels 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 laparotomy and espeQally the need for complicated muscle flaps that are associated with significant morbidities,

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ENDOSCOPIC THYROIDECTOMY: PATIENT SELECTION, TECH- NIQUE, AND PRELIMINARY RESULTS William B Inabnet, Ill, MD and Michel Gagner, MD, Mount Sinai Medical Center, New York NY

Objectives: Conventional thyroidectomy is performed through a cervical incision, necessitating myocutaneous flaps to gain access to the thyroid gland. The aim of this study was to report our initial experience with endoscopic thyroidectomy, a new minimally invasive technique for thyroid excision.

Methods: Between Sept 1998 and July 2000, 22 patients underwent endoscopic thyroidectomy. Exclusion criteria included patients with nodules greater than 3cm, muitinodular goiter, Graves disease, or malignancy. There were 20 females and 2 males with a mean age of 42 years (17-66 years). Indications for surgery included follicular neoplasm (n=9), indeterminate cytology (n=7), recurrent thyroid cyst (n=2), HQrthle cell neoplasm (n=l), and toxic thyroid nodule (n--3). Endoscopic thyroidectomy was performed with CO2 insuffiation utilizing 4 trocars (1 X 10mm, 1 X 5ram, and 2 X 3mm trocars). A combination of titanium clips and ultrasonic energy were used for hemostasis. The specimen was placed in a small bag for extraction.

Results: Nineteen of 22 cases were completed endoscopically with a mean operating time of 200 minutes (100-330 min). Operative procedures included left thyroid iobectomy (n=10), left subtotal thyroidectomy (n=2), right thyroid Iobectomy (n--4), right subtotal thyroidectomy (n=2), and isthmusectomy (n--4). There were no major complications, but 3 patients developed mild hypercarbia. Final pathology yielded a diagnosis of follicular adenoma (n=13), HQrthle cell adenoma (n=l), oncocytic adenoma (n=l), thyroid cyst (n=l), multinodular goiter (n--4), and papillary thyroid carcinoma (n=2). One of the patients with papillary carcinoma underwent open completion thyroidectomy without evidence of residual disease. All patients were highly satisfied with their cosmetic result.

Conclusions: Endoscopic thyroidectomy is a technically feasible and safe procedure that leads to an excellent cosmetic result. Prior experience with endoscopic parathyroidectomy is recommended.

A MODEL FOR EVALUATION OF LAPAROSCOPIC SKILLS: DOES IT REFLECT IMPROVEMENT OVER RESIDENCY TRAINING ? Kashif Irshed MD, Gab~la Ghitulascu MD, Liane S. Faldman MD, Anna Derossis MD, Donna Stanbridge RN, Gerald M. Fried MD Centre for Minimally Invasive Surgery, MOGill University, Montreal, Canada

Laperoscopic skill can be measured objectively in a simulator using the FLS program (Fundamentals of Laperosc~ic Surgery). Skills ere assessed in a trainer box with a video-endoscopic optical system. The purpose of this study was to evaluate whether the FLS scores reflect improvement in laperoscepic skills expected to occur during residency training.

Eighteen general sa-gical residents were asked to complete seven tasks at

lrensfering (1"1), patten outing (12), dipl~ng and d'rviding ('1"3), plating a ligaling loop(T4), mesh placement and Exation(T5), inlracorpareal knot tying (T6), and extracorl:x~eat knot tying 0"7). Each task was assigned a score based on precision and timing. Residents were first evaluated at a mean time of Z1 yasrs into their rasidency lralning and again at 3.S ye=s, giving a mean interval of 1.8 years. The paired t-test was used to compare performance of each subject at the two different limes in their training. Results:

PG IT T21T31T4 Tsl 8 17 2.1199 144 I 78 I 74 2491248 161 10s3

p I o.o131o.o191o. I o. 1 Performance overall and for each task (except 1"5) improved significantly

over the follow-up period. The simulator is a valid tool for assessing laperoscopic skill and for evaluating residents' progress over their training.

LAPAROSCOPIC FUNDOPLICATION IS THE APPROPRIATE SURGICAL MANAGEMENT FOR PATIENTS WITH BARRETT'S ESOPHAGUS OR A LARGE HIATAL HERNIA K Irsh~d MD,LS.Faldman MD,S.Mayrand MD,D.Stanbridgo RN, G.M.Fried MD, McGill University Health Center, Division of General Surgery, Montreal, Canada.

Objective: Barrett's esophagus (BE) and hiatai hamias (HH) have been associated with advanced gastro-esophageel reflux disease (GERD) and short esophagus. The aim of this study was to examine the objective and subjective results of patients with BE and large HH who undergo laparoscopic fundoplication (LF) without any esophageal elongation. Methods: From January 1995 to May 2000, 65 consecutive patients underwent LF. BE was present in 25 end a large HH (>5 cm on barium swallow) was present in 17 patients. All patients underwent preoperative manometry and endoscopy with biopsy, 95% underwent 24-hr pH testing and 75% underwent badurn swallow. A GERD specific quality of life (QOL) questionnaire (Velanovitch et al.) was completed by 88% of patients. Post-opsrative evaluation included manometry and 24-hr pH studies at 3 months and QOL assessment at 3,6,12,24 months. Results:

+BE -BE LHH SHH

Pre-op Post~p Pre.op Post-op Pre-op QOL at LESP LESP % % QOL ~ 2 years 1

mmHg I mmHg I pH<&01 pH<4.0 t o to 45 (severe)

7.54 17.2 18.4 1.4 23.3 0.8 7.50 17.1 11.4 1.3 23.4 0.2 5.4 14.5 17.7 1.,4 27.7 1.0 8.2 18.7 12.4 1.2 22.2 0.3

(p<O.01, paired t-t~t). SHH-small HH, LHH- largo hiatai hernia. No patients in these two groups required reoperation end none had a return of symptoms over 2 yeats. There was no difference in postoperative complications in all groups. Conclusion .t.F without an elongation gastroplasty in patients with BE and large HH effe~vely controls reflux disease and provides prolonged symptomatic relief.

LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR A YOUNG MAN WITH SUPERIOR MESENTERIC ARTERY SYNDROME JR Isaacson MD, GS Smith MD, GL Falk MD, Department of Endosurgery/Upper GI Surgery, Concord Hospital, University of Sydney, NSW, Australia

INTRODUCTION: Superior mesentedc artery syndrome is a rare disorder most commonly affecting young adults. The clinical picture of chronic vascular compression of the third portion of the duodenum usually presents with intermittent fullness and bloating after meals, vomiting, and weight loss. Conservative treatment includes nasogastric tube decompression, prokinetic agents, and postprandial positioning. If these fall, the operation of choice is duodenojejunostomy. Laparosoopic duodenojejunostomy for SMA syndrome was first described by Gersin and Heniford in 1998. We report a case of SMA syndrome treated definitively by laparosoopic duodenojejunostomy and provide medium-term (one year) fellow-up. PROCEDURE: The patient, a thin 31-year-old male diagnosed with SMA syndrome, had failed medical management. He was prepared for surgery. A stapled side-to-side duedenojejunostomy was created to the third portion of the duodenum through the transverse meseoolon using three five millimeter and one twelve millimeter ports. RESULTS: The patient was discharged home four days postoperatively eating and drinking without pain. He subsequently had a weight gain from 50kg to 62kg over the next several months; however, he continued to have intermittent periumbilical pain, which he desoribes as "50%" of the preoperative level. A gastrcecopy performed at about nine months postoperatively showed a new diagnosis (not seen on preoperative gastroscopy)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 inhibitor and a prokinetic agent. CONCLUSION: Laparoscopic duodenojejunostomy provides a minimally invasive surgical altemative to the patient, while not sacrificing the technique of the original open procedure. The procedure can provide symptomatic relief, but long-term follow-up is crucial for this difficult set of patients.

SPREAD OF INTRAPERITONEAL TUMOR CELLS FOL- L O W I N G C A R B O N D I O X I D E P N E U M O P E R I T O N E U M Hideyuk i Ishida, M.D., Masaru Yokoyama M.D., Nobuo Murata, M.D., Ikuya Takeuch i , M.D., Dai jo Hash imoto , M.D.,Yasuo Idezuki, M.D, Department of Surgery, Sai tama Medical Center, Saitama Medical SchooI,Kawagoe, Saitama, Japan

Background: The influence of pneumoperitoneum with carbon dioxide on intraperitoneal tumor cells remains controversial. This experimental study was performed to invest igate the spread of intraperitoneal tumor cells following carbon dioxide pneumoperitoneum in rats. The effects of different insufflation pressures were also examined. Methods:Male Donryu rats we igh ing 180-220g were i n t rape r i t onea l l y in jected with 5X1000000 ascites hepatoma AH 130 cells and randomized to 4 groups: Group A (n=14) and Group B (n=15) received CO2 pneumoperitoneum at 5 mmHg and 10 mmHg for 30 min, respectively; Group C(n=15) underwent a xipho-pubic laparotomy for 30 min; and Group D (n=15) underwent trocar placement alone for 30 min. Survival t imes and frequency of trocar site implantation (for Groups of A, B, and D)at autopsy were evaluated. Results: The median survival (days) was 17.0 in Group A, 15.5 in Group B, 15.5 in Group C, and 32.5 in Group D (P<0.05). The frequency of trocar site implantation was 57% in Group A, 53% in Group B, and 46% in Group D (NS). Conclusions: These results suggests that, compared with the sham-treatment, pneumoper i toneum with carbon dioxide may not fascilitate port site metastasis, regardless of the pressure of insufflation. However, similar to full laparotomy, pneumoperitoneum with carbon dioxide may promote the spread of tumor cells.

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METHOD OF VIDEOTHORACOSCOPIC PARASTERNAL LYMPHADIS- SECTION IN BREAST CANCER DIAGNOSE AND TREATMENT Artur H. Ismagilov M.D., Eugine I. Sigal, PhD., Rinat G. Hamidullin M.D., Albert M. Guimranov M.D., Hasan M. Gubaidullin M.D., Department of Breast Surgery, Kazan Republic Oncology Center, Kazan, Russia

In our clinic we developed a technique of performing videothoracoscopic 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 and axillary collector 3 thoracoports are introdeuced into the pleural cavit~ in the following way: along the medioolavicular and medioaxial lines in th~ 5th intercostal space and along the anterior axillary line in 4th intercosta space. Pulmonary ventilation is dis-connected from the operation side thoracoscope and manipulators are introduced into the pleural cavity. Th~ parietal pleura is dissected in parallel with intemai vessels using electr~ surgical retractor (from the level of the 1st inter-costal space down to th~ 4th intercostal space). After mobilization the internal breast vessels ar~ clipped and resected, the fat with lymph nodes are sepa-rated and th( preparation is removed. The pleural cavity is drained up to 2 days.

20 cadavers were used to study the adequacy of VTS PLAE volume Simultaneously VTS PLAE from one side and a traditional (open) lyn phade-nectomy from the other side were performed followed by the exam ination of lymph nodes number. In the course of the experiment with car davers histologi-cal assay of the preparation removed the average num ber of parastemal lymph nodes was 2.5+-0,56 and 2,3+-0,3) by VT, r PLAE and traditional (open) method, respectively (P>0,1). It reveals th, full value of VTS PLAE.

Parastemal lymph nodes metastases were observed in 53 (19.9%) c 266 patients (control group) with the isolated affection of the parastem.~ col-lector in 2 (2,17~ of them (the axillary collector being not alfected 1 Frequecy of metastatic lesion in parastemal lymph nodes depending o= localization of a tumor in breast has the following indecies: maximun number of lymfatic nodes metastatic lesion took place in cases of tumc localization on the border of lower quadrants (3 Dun of 8 37.5%).

DOES SMOKE FROM LAPAROSCOPY CONTAIN INFECTIVE VIRUS? Patric k G. Jackson. M.D.*. Alberto R. Iglesias, MD, Donald R. Czemlach, MDI Stephen R.T. Evans, MD, Patricia S. Latham, MD' Department of Surgery and' Pathology, George Washington University, Washington, D.C., and *Department of Surgery, Massachusetts General Hospital, Boston, MA

During laparoscopic surgery, a smoke plume is commonly expelled into the operating room in order to improve clarityo(field. Elactrosurgical smoke has been shown to contain at least viral particles, but not necessarily infective virus. The goal of this study was to determine the presence of infective virus in the smoke generated during laparoscopic dissection.

Twelve Sprague-Dawiey rats were injected intraperitoneally with 10(5) plaque-forming-units of MAV-1 or the same volume of complete media. One week after inoculation, half of both the viral and media-only rats were subjected to pneumoperitoneum without eiectrocautery. The remaining half of each group underwent laparoscopy with electrocautery, of the spleen. Pneumoperitoneum was expelled into chambers containing confluent plates of mouse kidney(RAG) cells. All plates were then cultured for 1 week, and plaques counted. Viramia was confirmed by culture of plasma samples from infected rats at the time of surgery. A reference curve for plaque formation was created by aerosolization of dilutions of a known viral concentration.

Aerosolized standard concentrations of virus created dose-dependent plaque formation in confluent RAG cells. Aerosolization of virus free media over confluent RAG cells did not induce plaque formation. Viremia was present only in rats injected with virus only. All injected rats were viremic. Laparoscopy with or without electrocautery did not induce plaque formation

As shown by this study, aerosolized MAV-t virus is indeed infective to RAG kidney cells. However, no viable virus was isolated from either the smoke plume or pneumoperitoneum alone. Even in viremic rats, smoke generated during electrocautery does not contain viable adenovirus. While this finding suggests that electrosurgical smoke does not pose an occupational threat, it is unclear if the study can be extrapolated to other viridae.

THE IMPACT OF CARBON DIOXIDE ON MONOCYTE-MACROPHAGE CYTOTOXICITY Petdck G. Jackson, M.(~.*, Donald R. Czemiach, MD, Alberto R. Iglesias, MD, Stephen R.T, Evans, MD, Patricia S. Lath~, MD' Depa~ment of Surger/and' Pathology, George Washington University, Washington, D.C., and *Depa~r~mt of Su~r/, Massachusetts General Hospital, Boston, MA

Pentoneal macrephoges derive from monocytes, and thek functions include pbegocytosis, cytoldne secrelJon, and cytotolddty. When exposed to C02, macroldtages demonstrate impaired adJvity. The goals of this study were to detemline the impact of human macrephar on peritoneal tumor growth, and the significance of C02-induced human macrophage suppression on tumor impaantadon.

A human monocyte-macrophage cell line, THP-1, and a human colon cancer cell line, LS174T, were cultured for 2 hours in ei~r 100% or 5% C02. Sixty ~yntc rats were divki~ into 6 groups of 10 arimais each, injected intraperitoneally with media or cells as below, and housed lor 2 weeks. AI necropsy, all tumor nodules were counted by a blinded obse~,er and confirmed b~ a blinded pathdi

Complete' THP.1 cells THP-1 cells Media exposed to exposed to

5% 002 100% C~ Group 1 X X Group 2 X X Group 3 X Group 4 X Group 5 X Group 6 X

LS174T cells LS174T cells exposed to exposed to 5*/, C02 5% C02

X X

X X

Group 1 and 2 rats showed no nodule fotmalJon. Group 3 rats developed 3.9 (• tumo nodules. Group 4 rats developed 4.1 (• nodules. Group 5 rats had 6.3 (4- 0.6) nodules; group 6 rats had 6.6 (4- 0.7) tumor nodules. Rats injected with THP-1 cells and LS174T cell had lewer nodules t ~ rats injected with LS174T ceils alone (,o<0.01 for all comparisons).

Ca~oon dioxide exposure did not impair the monocyte.macrophage cyto0dc activity. As th Fesa~e of THP.1 significantly reduced tumor nodule formation, the monocyte-macrophag may play an important role in suweillance against neoplastic ceils.

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GIANT HERNIAS WITH LOSS OF DOMAIN: A CASE SERIES. ANTONI JURKIEWlCZ, M.D., CORRADO P. MARINI, M.D., JOHN MCNELIS, M.D., DEPARTMENT OF SURGERY, LONG ISLAND JEWISH MEDICAL CENTER, NEW HYDE PARK, N. Y.

Giant hernias with a loss of intra-abdominai domain are infrequently encountered. However, the incidence may be increasing because of immigration from areas of the world with fewer medical resources. Successful management of these difficult hernias require awareness of potential 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 obstruction. Pneumoperitoneum was established with a single lumen catheter to a pressure of 15 to 20 mm Hg for two weeks in order to re-establish intraabdominal domain prior to hernia repair. Repair was then accomplished through a groin incision after omentectomy. His preoperative course was complicated by pulmonary emboli requiring anticoagulation and vena cava filter. Case 2 was a 70 year old Russian female who presented with a complete bowel obstruction seoonoary to a giant incisional hernia. Loss of domain was managed with a midline incision and a large madex mesh placed without tension to span the gap between fascial edges. Despite this, the patient developed abdominal compartment syndrome requiring ventilator support for two weeks. Case 3 was a 60 year old Indian female with a long- standing giant incisionai hernia and intermittent bowel obstruction. Loss of domain was managed at surgery with a long midline incision and construction of a temporary silo using the patients redundant skin. The patients postoperative course was uncomplicated and hernia repair was successfully completed several weeks later when intra-abdominal domain was re- established by the pressure created by the silo.

Patients with giant hernias with loss of domain can be difficult to manage. The potential complications and some management strategies and surgical options are illustrated in this series of three cases presenting to our hospital between 1997 and 2000.

LAPAROSCOPIC EXPLORATION FOR PANCREATIC INJURY. Robert Kalimi, M.D., Piotr J. Gorecki, M.D., L.D. George Angus, M.D., and Gerald W. Shaftan, M.D. Department of Surgery, Nassau County Medical Center, East Meadow, New York.

The use of laparoscopy as either a diagnostic or therapeutic tool in the trauma patient has been debated in the literature. In this report we describe a patient with penetrating injury to the pancreas who was treated laparoscopically.

A 34-year-old female was admitted with a stab wound to the lower back. CT scan of the abdomen revealed minimal haziness of the tissue planes in the region of the tail of the pancreas and the splenic hilum. During laparoscopic exploration a 5 mm ultrasonic dissector was used to transect the gastrocolic and gastrosplenic ligaments allowing exposure of the pancreas. On exploration a 5-mm laceration in the tail of the pancreas was noted which was surrounded by an area of fibrinous exudates. Pancreatic duct injury was not suspected based on the location and degree of the injury. Posterior wall of the stomach and the gastroesophageal junction were examined and did not reveal evidence of perforation. A closed suction drain was placed in the retropancreatic space and another at the splenic hilum. Postoperatively the patient recovered uneventfully, and was discharged on the eighth postoperative day tolerating a regular diet.

In this report we present a case of a stable patient with an injury to the pancreas, who underwent laparoscopic exploration. The area of pancreatic injury was assessed and drainage was achieved laparoscepically. We suggest that with increasing experience, selected pancreatic injuries may safely be treated laparoscopically in the stable trauma patient.

MICROWAVE COAGULATION THERAPY FOR HEPATOCELLULAR CARCINOMA m A PREUMINARY REPORT OF THE FIRST US TRIAL T Kato, MD, S Tamura, MD, N Yamashiki, MD, J Casillas,MD, D Levi, MD, M Berho,MD, T Seki,MD, E Schiff,MD, A Tzakis,MD, Divisions of Transplantation, Immunopathology and Hepatology, University of Miami, School of Medicine, Miami, Florida, Department of Surgery II, Osaka University Medical School, Osaka, Japan, and Third Department of Medicine, Kansai Medcal College, Osaka, Japan

Objective: To assess the safety and efficacy of microwave coagulation therapy (MCT) for hepatocellular carcinoma (HCC) in patients awaiting liver transplant (OL'r). Background: Control of tumor growth while waiting for OLT is ~ l y important for patients with HCC. MCT is an ablabve therapy developed in Japan. For more than a decade it has been used routinely in the management of HCC. We applied this technology to OLT candidates with localized HCC. This is a preliminary report of the first US trial of MCT. Patients and Methods: A microwave generator (Microtaze| AZWELL.Inc, Osaka, Japan) with specialized probes (16G-22G needle) was used in the study. Seventeen OLT candidates have been enrolled in the study (mean age 56.2 years). All patients were cirrhotic secondary to hepatitis C (n=12), hepatitis B (n---3), and cryptogenic (n=2). Their Child's scores were:Child A (n=7), B (n=9), and C (n=l). 15 patients had a single lesion and two had more than one lesion. The size of the largest tumor ranged from 1.5cm to 5.0crn (median 4.0cm). All were deemed unresectable due to tumor location and/or the severity of the hepatic dysfunction. Results: Nineteen MCT abla- tions were performed either laparoscopically (n=12) or percutaneously with ultrasound guidance (n=5) or CT guidance (n=2). Simultaneous laparoscopic choleoysteotomy was performed in two patients with tumors adjacent to the gall bladder. Hand-assisted laparoscopy was used in two cases for exposure. Tumor ablation was assessed by helical CT with IV contrast. All twelve patients with elevated AFP pdor to the MCT expadenced a decrease (mean value decreased from 1048 to 205ng/ml). Nine patients have received OLT. Complete tumor ablation was confirmed in the explanted livers. Two have died post-transplant of causes unrelated to HCC. Neither had evidence of tumor recurrence. The other 7 patients are alive and tumor free at 1-18 months after the OLT. Eight patients are waiting for OLT 1-19 months after MCT. Conclusions: This preliminary experience suggests that MCT may control HCC progression in patients awaiting OLT.

LAPAROSCOPIC DONOR NEPHRECTOMY AND RECIPIENT OUTCOMES AT A COMMUNITY HOSPITAL Leon V. Kalz. M.D.. Ashutosh KauI, M.D., KetuI Chauhan, B.S., Mark Dreeel)sch, B.S., Sluart R. Geffner, M.D., Department of Surgery, Sabt Barnabas Meckal Center, LJv~geton, New Jersey.

Laparoecopic donor nephrectomy has been ut~zed in Univel~y Hospitals with excellent results. The purpose of ~ study was to critically analyze our results

Ioparcecopic donor nephreotomy done at a community hospital with a busy transplant center.

We did a r ~ o ~ e study of our rrst 35 laperco~pic donor nophrecton~es and compared ~em with 52 open donor nephrectomies done during ~ same period. Si~cence of any changes was tested using Student's t-teat independent va~bles.

Comparison of laparcecol~O versus open technique revealed a dgr~cant difference in e~matad blood ]osa (59 co vs. 132 c=), Iongth of stay (3.11 days vs. 5.12 clap) and'dme to resump~on of solid (aet (123 days vs. 2.4 days) (P<0.01). There was no signiicant difference in total operating room time (245 vs. 189 mino), intraopera~e inUavenous fluid used (3040 co vs. 3431 co) and inlraopereUve udne output (425 ccvs. 512 cc). Thare was no ddference in the donor preoperative and postopera'~ BUN a ~ crea~nine (P>O.05). There was a difference in redpient creatbino level at the 2" postoperative day, 3-month and 6 month (ai P<O.OS)w~ Iowar leveb in the open harveat Iddneys. The recipient one-mor~ and one-year c r ~ levels, however, did not show dgniFcant difference. There were no morta~es in either donor group. Even lbeugh we were s~l in the eady leambg period of doing leparcecopic

donor nephrectomles our pa~ents had e better cosrne~c result, lost lees blood, resumed regular diet earlier and were discharged home sooner. Further prospec~ve studies v~l be helpful to evaluate the difference in the recipient renal func~on deponding on the harveat technme. Though advenced l a p a r ( ~ c skins are required our data suggests that with adequate U'aining, supervision and support, community hospitals with busy ~ansplant centers may be able to offer ~ procedure. Loparcececc donor nephrectomy represents a safe anerno~e to the ~ed, Jonal open donor nephrectomy even in a community

set~ng.

COMPARISON OF LAPAROSCOPIC AND OPEN LYMPHOCELE DRAINAGE Ashutosh Kaul, M.D, Leon V. Katz, M.D., Elaine Dressbach, B.S, Erin L Vermeulen, PAC, Mark Drassbach, B.S, Stuart R. Geffner, M.D., Department of Surgery, Saint Barnabas Medical Center, livingston, New Jersey.

Laparoscopic drainage of lymphocele after renal transplants has bean done at University Hospitals with excellent results. The purpose of this study was to critically analyze our results with laparoscopic lymphocele drainage at a community hospital with a busy transplant center. Significance of any changes was tested using Student's t-test with independent variables

Between March 1993 and August 1999 we did 852renal transplants and 113 of these developed symptoma~c lymphoceles requiring operative drainage (13.7%). Laparoscopic drainage was attempted in 39 and was suocessful in 29 cases. Comparison was made with 60 open cases done at the same time. Our average operating time was 59 rains for laparoscopic cases, 66 mins. for converted cases and 72 min. for open cases. Our average blood loss was 26 cc in laparoscopic and 65 cc in open. The average postoperative stay was 2.3 days in laparoscopic cases and 5 days in open cases. Comparison was also done between laparoscopic and open cases during the same period for complications, reoccurranca and change in creatinine in postoperative period. Our average follow up was 22 months.

Even though we were still in the early learning period of doing laparoscopic lymphoceh drainage our patients had a better cosmetic result, lost less blood and were discharged home sooner. Though laparoscopic skills are required our data suggests that with adequate training community hospitals with busy transplant centers may be able to offer this procedure. Laparoscopic drainage of lymphoceh results in minimal disability and acceptable complication rates. Therefore laparnscopic drainage should be considered as primary treatment for all patients with symptomatic post-transplant lymphoceles even in community centers.

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L A P A R O S C O P I C S U R G E R Y FOR T H E P A T I E N T WITH HIGH-RISK Michihiro Kawada M.D.,Hiedo Yamada M.D. and Yasunaga Okazak i M.D. Depa r tmen t of Surgery , Saku ra Na t iona l Hospital, Chiba, Japan

OBJECTIVE: Laparoscopic surgeries for cholecystolithiasi- sis,early gastric cancer and colorectal cancer have come to be so popular in Japan. Thus controversy cont inues to surround the use of laparoscopic resection in cases of the patients with high risk. To determine the amount of the invasion for the laparoscopic surgery, we assess if laparoscopic surgery may given to the high risk patients.

METHOD: Between 1984 and August 2000, 928 Patients underwent iaparoscopic surgery, of whom 25 pat ients with renal dysfunction or renal fai lure in Sakura National Hospital.

RESULT: Laparoscopic surgery was performed in 1 case of laparoscopic assisted distal gastrectomy, 8 cases of cholecystectomy, 1 case of surgery for the transverse colon cancer , 1 case of left hemicolectomy, 5 cases of low anterior resection, 5 case of colostomy. The surgical mean time was required 176 minutes(60-402). The average of serum Cre was 4.01mg/dl, BUN was 28mg/dl and K was 4.01mEq/l. None of the critical complication was found in the surgical period.

CONCLUSION: Within this prospective study, laparoscopic techniques were as safe as conventional surgical techniques if we operate them safer and quicker with laparoscopic instruments. It may be safer way for the patients who need opera- t ions suffering from other disease like renal dysfunct ion as 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 OF A TEACHING INSTITUTION George B. Kazantsev M.D., James P. Dorman M.D., Department of Surgery, University of Texas Health Science Center, and Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas

Introduction. Although safety and technical feasibility of laparoscopic ventral incisional hernia (VIH) repair with a PTFE mesh have been documented, difficulty handling and high cost are among the drawbacks of PTFE grafts. Polypropylene (PP) mesh is less costly and easier to handle laparoscopicaly, but the fear of adhesions restricts its use. Here we present early results of laparoscopic VIH repair with PP mesh, performed at a teaching institution.

Methods. Between July of 1998 and August of 2000, a total of 35 patients underwent laparoscopic VIH repair with PP mesh. Patients 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 (range 23.4-55.1). All procedures were done by PGY III-V level residents with direct supervision of a faculty member. Mesh was secured in place with a hernia stapler and transcutaneous sutures. Omentum was always positioned to cover underlying loops of bowel. Patients were followed in clinic at frequent intervals.

Results. No conversions were necessary. Average time of surgery 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- 760 cm2). Two small serosal lacerations occurred (repaired intracor- 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 patients (26.4%), but only one required aspiration. One hernia recurred (2.9%); there were no wound or mesh infections. Mean follow up was 6.3 months (range 1-17 months).

Conclusion. Preliminary results indicate that laparoscopic VIH repair with PP mesh is a safe and effective procedure as documented by low rate of recurrence and no infections. The technique is easily learned by residents with appropriate supervision. Further accrual of patients with careful follow up is antictpated.

LAPAROSCOPIC CHOI T.13OCHOLITHOTOMY K a z ~ , Tsuyosld Takahashi, Kouski Sato, Muneki Yoskida, Ken Shimada, Kouji Itabashi, Akira Kakita.

Department of Surgery Kitasato University School of Medicine, Japan

There are any treatment to remove chohdocholithiasis. In the first choice, we remove chohdocholithiasis by endoscopic duodenal papilla vater sphincterotomy(EST). If we could remove stones comphtely by EST, after some days laparoscopic cholecystectomy was performed. And if we could not remove by EST, laparoscopic cholecystectomy and choledochotomy were performed to remove stones. Before in these choledochotomy cases, we detained T-tube in the common bile duct(CBD) in laparoscopicaUy and T-tube drain were induced to extracorporation.

Recently we choose the method of p~mary closure of CBD without T-tube drain after chohdocholithotomy. This procedure is explained, dissec~on of CBD, cutting 10ram in length of CBD, and CBD closure is interrupted sutured using 5-0 absorbable thred after choledocholithotomy.

Complication cases were one stricture of CBD and one bile abscess. Two cases were recoverd.

The advantage of the primary closure will be able to reduce the hospital days after operation and cost benefit. However the disadvantage of this procedure have techical difficulty and some complications.

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HAND-ASSISTED L A P A R O S C O P I C A O R T O B I F E M O R A L BYPASS VERSUS TRADITIONAL AORTOBIFEMORAL BYPASS FOR OCCLUSIVE DISEASE Kent Kercher MD, Elias Arous MD, John Kelly MD, Karen Gal lagher RN, Demetr ius Litwin MD, Department of Surgery, Universi ty of Massachusetts Medical School, Worcester, MA

Aortobifemoral bypass grafting is the treatment of choice for patients with symptomatic aortoiliac occlusive disease. Yet, traditional operative exposure through a midline laparotomy incision carries significant morbidity. The authors compare operative and patient outcomes following hand-assisted laparoscopic aortobifemoral bypass (LABF) and open aortobifemoral bypass (OABF).

An initial series of patients who underwent hand-assisted laparoscopic aortobifemoral bypass grafting (n=8) were compared to a simultaneous cohort of patients treated w~th standard open bypass (n=10). The two groups were similar with respect to age, weight, and gender. Operative parameters, clinical outcomes, and complications were compared.

Hand-assisted LABF was successfully performed in all eight cases attempted. There was no difference in operative time between the laparoscopic and open groups (234 vs 206 min, p=0.99). Mean blood loss was comparable (562 mL [LABF] vs 756 mL [OABF], p=0.56). There were no conversions. Time to resumption of oral intake (1.8 vs 4.7 days, p=.001), and length of stay (3.8 vs 6.3 days, p=.0004) were significantly shorter in the laparoscopic versus the open group. There was one late death in the laparoscopic group related to pre-existing cardiac disease.

Hand-assisted laparoscopic aortobifemoral bypass is a safe and technically feasible procedure. When compared with the traditional open operation, this technique may result in shorter hospitalization, more rapid return of bowel function, and an earlier return to activity.

MINIMALLY-INVASIVE MANAGEMENT OF PARAESOPHAGEAL HER- NIATION IN THE HIGH-RISK SURGICAL PATIENT Kent W. Kercher MD, Brant D. Matthews MD, Sharon L. Goldstein MD, Robed T. Yavorski MD, Jeffrey L. Ponsky, Ronald F. Sing DO, B. Todd Heniford MD Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, and The Cleveland Clinic, Cleveland Ohio

Traditional management of symptomatic gastric volvulus involves hernia reduction, hiatai closure, and an antireflux procedure or gastropexy. However, patients with paraesophageal hemiation and multiple comorbidities may not tolerate formal operative repair. Endoscopic or laparoscopic- assisted endoscopic reduction and fixation of the stomach may provide a minimally-invasive treatment altemative in this setting.

A sedes of six high-surgical-risk patients presenting with symptomatic intrathoracic herniation of the stomach were managed with flexible endoscopy with or without laparoscopy.

All patients presented with symptoms of chronic gastric volvulus, including inability to eat, weight loss, regurgitation, and chest pain. Diagnoses were confirmed by barium swallow and upper endoscopy. Average patient 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 medical comorbidities (atrial fibrillation, congestive heart failure, diabetes mellitus, and/or hypertension). Paraesophageal hernia reduction and intraabdominal fixation of the stomach was achieved in all cases using flexible upper endoscopy and double percutaneous endoscopic gsstrostomy tube insertion. Laparcecopic assistance for reduction and gastropexy was utilized in 4 cases. Mean operative time was 33 minutes (28-40). Average LOS was 1.4 days (0-2). One patient developed a superficial PEG infection. Three have reflux symptoms managed medically. All resumed normal oral intake and achieved weight gain at mean follow-up of 4.8 months (1-7).

Our patients with symptomatic paraesophageai hemiation necessitated intervention to alleviate weight loss and chest pain and to avoid the complications of gastric ischemia and strangulation. In the high-risk elderly patient, endoscopic reduction and percutaneous gastrostomy with selective laparm scopic assistance may provide effective palliation with minimal morbidity.

ACHALASIA FOLLOWING FUNDOPLICATION Leana Khaitan, MD, Jonathan A. Cohen, MD, William O. Richards, MD Department of Surgery, Vanderbilt University Medical Center, Nashville, "IN Backqround: Achalasia is a motility disorder of the esophagus characterized by esophageal apadstaisis and non-relaxation of the lower esophageal sphincter. It is unclear whether achalasia may develop secondary to a funddonal distal obstruction such as a tight fundoplicetion (FP), or whether the FP may unmask undiagnosed achalasia. Materials and Methods: Four patients who had previously undergone Niesen fundoplication were referred to our institution for evaluation of severe dysphagia and a diagnosis of secondary achalasia. Only one patient had undergone preoperative manometry, which revealed normal peristalsis. The remaining three patients had undergone fundoplication based upon symptoms and esophagram alone. Three of the patients had had multiple previous lower esophageal procedures. After developing dysphagia, all undenvent esophagram and upper endoscopy. Three patients then underwent reversal of the Nissen FP and reconstruction with a Toupet FP. Results: All four patients had low amplitude (~=33.5 mmHg), apedstaltic contractions with a nnn-relaxing, norm=l amplitude LES (~= 21 5 mmHg). Barium esophagram and endoscopy were consistent with achalasia. Intraoparetive findings in the three patients who unden~ent takedown of the FP and revision to a Toupet FP were noted to have a wrap �9 2 cm in length or one that was too tight. While these 3 patients experienced relief immediately after surgery, all of the 3 patients have developed recurrent dysphagia months later. One of these patients continues to undergo dilations and another has since had the Toupat FP taken down. Conclusions: Achalasia discovered following FP is a clinical conundrum. Such cases confirm the recommendation for routine preoperative esophageal manomaW. These cases also highlight the technical considerations of FP, including division of all the short gastric vessels, performing the wrap over a large bougie, and creating a short, loose wrap. Our exparience indicates that repeat dilations and FP revision may be inadequate therapy. Complete takedown of the FP and anti-acid medication may be a durable option in treating these patients with findings of achalesia after fundoplica~n.

LAPAROSCOPIC ADHESIOLYSIS AND PLACEMENT OF SEPRAFILM: A NOVEL APPROACH TO PATIENTS WITH INTRACTABLE ABDOMINAL PAIN Leena Khaitan, MD, Jonathan A. Cohen, MD, William O. Richards, MD Department of Surgery, VanderbUt University Medical Center, Nashville, TN Backqround: It is controversial whether or not abdominal adhesions cause pain. Repeated operative treatment of these patients exacerbates adhesion formation following each procedure. Seprafilm (Germ/me, Tucker, GA), a bioresorbable membrane, has been shown to significantly decrease postoperative adhesion formation. We reviewed our experience with laparoscopic adhesiolysis and Seprafilm placement in this difficult population. Materials and Methods: Nine consecutive patients underwent laparoscopic adhesiolysis and placement of Seprafilm for chronic abdominal pain secondary to adhesions between July 1, 1998 and July 30, 2000. There were 8 females and 1 male. Patients had previously undergone an average of 5.2 abdominal procedures, of which 2 were for lysis of adhesions. All patients suffered from intractable abdominal pain for at least 4 months prior to procedure. Five patients had radiographic evidence of, or previous admission for bowel obstruction. Results: Two patients were converted to an open procedure due to very dense adhesions. Eight of the nine patients report excellent results (off all narcotic pain medications) from their procedure at an average of 9.4 month follow-up. The one complication occurred in a patient who was converted to an open procedure. This patient's postoperative course was complicated by an abdominal abscess and an enterocutanaous ~tule. She remains on narcotics for abdominal pain. All other patients report complete resolution of their preoperative abdominal pain. Most patients report that their pain resolved almost immediately post-operatively allowing early resumption of activities of daily living. Average hospital stay was 2 days for all patients. Those who had a completely laparoscopic procedure were hospitalized for less than one day. Conclusion: Patients who suffer from chronic, intractable abdominal pain as a result of adhesions from previous abdominal procedures benefit from a combination of meticulous laparoscopic adhesiolysis and placement of Seprafilm. This approach provides excellent relief of pain and interrupts the cycle of repeated operative procedures to lyse adhesions.

A VAUDATED ANIMAL MODEL FOR ACHALASlA, Ye~hodhan S. Khaianchee. M.D., Blair A. Jobe, M.D., David R. Urbach, M.D., Roger Van Andel, Ph.D., Luke Kinzie, R.N., Paul D. Hansen, M.D., Lee L. Swanstrom, M.D. Minimally Invasive Surgery Departx~nt, Legacy Health System, Portland, Oregon.

Achalasia, though a rare disease, represents significant patient morbidity. A validated reproducible animal model is necessary to investigate the etiology and potential treatments of the disease for humans. Previous animal models of achaiasia have not been completely validated using all of the manometric, radiographic and histopathologic cdteda established for achalasia. We present definitive validation of an animal achalssia model with manometric, radiographic and histopathologic criteria.

In 12 opossums (Diedelphis virginia) partial obstrudJon was created at the level of gastro-esophageal junction using a one-centimeter wide Gore-Tex band. Water perused manomeW and contrast esophagogram were performed before and at four weeks after banding. After final assessment animals were euthanised and histologic evaluation of esophagus was done under light microscope, Manometric values are expressed as medians (range). Statistical differences are assessed using the Wilcoxon Rank Sum test.

A non-relaxing lower esophageal sphincter (LES) was demonstrated in seven animals (median percent relaxation of LES decreased from 106.2 (92.9-129.7) to 36.2 (0-55). Five animals developed amotile achalasia demonstrated by a decrease in the mean body amplitude from 112.5 (88.8-145.5) mmHg to 28.7 (8- 35.7) mmHg0 (p< 0.01). Contrast esophagogram showed a classic bird's beak deformity and histologic evaluation demonstrated degeneration of the ganglion cells in the Auerbach's plexus. Two animals developed a vigorous vadety of achalasia charactedzed by simultaneous and repetitive contractions of high amplitude. Achalasia could not be demonstrated in one animal, and four animals died.

This represents validation of an accurate model of human achelasia based on physiology, radiographic characteristics, manometnc findings and histopathology. This model will be useful for investigating the etiology and potential treatments of achelasia in human beings.

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THE INFLUENCE OF DIFFERENT VASODILATATORIC AGENTS ON PORTAL VENOUS BLOOD FLOW DURING LAPAROSCOPIC CO2- INSUFFLATION Zun-Gon Kim, M.D., Elif Sanli, M.D., Thomas Schmandra, M.D., *Lukas Kr~henb0hl, Carsten N. Gutt, Department of General and Vascular Surgery, Johann Wolfgang Goethe-University, Frankfurt/Main, Gemlany * Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland

Recent experimental and clinical studies suggest that laparoscopic CO2- insufflation reduces macro- and microperfusion in splanchnic organs and portal venous blood flow (PBF). Doparnine was found to increase PBF by preportal vasodilatation and endothelin-1 (ET-1) receptor blockade might diminishing PBF by ET-1 dependant portal venous vasoconstriction. The current study investigates changes on portal venous blood flow during CO2-1aparoscopy using different intraabdominal pressures and application of different vasodilatatoric agents. 15 male WAG/Rij rats were randomized into 3 groups to obtain CO2- laparoscopy and low-dose doparnine infusion (n---5), selective ET-l-antagonist (JKC 302) infusion (n--5) or sodium chlodd infusion as control (n--5). A PE-50 cannula was inserted into the intemal jugular veine for drug apply and a Doppler ultrasound probe was placed around the portal vein. Following an equilibration time of 30min PBF was measured during lAP of 2mmHg, 4mmHg, 6rnmHg, 8mmHg, 10mmHg and 12mmHg. Data were analyzed by Kruskal-Wallis, Dunn and Holm test. Increased lAP lead to a linear decrease of portal venous blood flow (PBF) in the sodium chlorid control group. The application of ET-l-antagonist (JKC 302) and low-dose dopamine infusion significantly improved PBF when compared to sodium chlorid controls (p<0.05). No significant differences were found comparing PBF during ET-1 and dopemine application (p>0.05). Pharmacological vasodilatation of the splanchnic organs restores portal venous blood flow (PBF) reduction during laparoscopic CO2-insufflation whereas sodium infusion shows no effect. Whether improved hepatic perfusion may have beneficial effects on the liver function needs further investigation.

IMPACT OF CO2-EXPOSURE ON THE EXPRESSION OF TUMOR-ASSOCIATED MOLECULES IN DIFFERENT CUL- TURED TUMOR CELL LINES Zun-Gon Kim, M.D., Christoph Mehl, M.D., Matthias Lorenz, M.D., Carsten N. Gutt, M.D., Department of General and Vascular Surgery, Johann Wolfgang Goethe-University, Frankfurt/Main, Germany

Recent cl inical and exper imental data propose laparoscopic CO2-insufflation to enhance proliferation and metastatic potential of different gastrointestinal tumor cell lines. But the pathophysio- logical mechanisms for these f indings are still unknown. E- Cadherin, I-CAM1, I-CAM2 and CD44 are cell surface molecules, which are involved in the metastatic process, invasivness and behaviour of different tumor cell lines. Therefore the aim of the current study was to analyze the influence of CO2-exposure on the expression of tumor-associated cell adhesion molecules of different cultured tumor cells. Two colon cancer cell l ines, CX-2 (human colon carcinoma, n=80) and CC-531 (rat colon carcinoma, n=30) were exposed for 60 rain to a CO2-environment at 6 mmHg. Control groups were exposed 60 min to room air. The expression of E-Cadherin, I- CAM1, I-CAM2 and CD44 was measured directly, 12 h, 24 h, 48 h and 72 h after CO2-exposure by flow-cytometry. Data were analyzed by Wilcoxon-Mann-Whitney u-test. Expression of E-Cadhefin significantly decreased, while expression of I-CAM1, I-CAM2 and CD44 significantly increased after exposure to CO2-insuffiation, when compared to room air controls (p<0.05). The current study demonstrates CO2-exposure to alter the expression of tumor-associated molecules in cultured colorectal cancer cells. Whether decreased E-Cadherin expression and increased I-CAM1, I-CAM2 and CD44 expression due to CO2- insufflation might promote the metastatic potential of colorectal malignancies in-vivo needs further investigations.

LAPAROSCOPIC ASSISTED COLECTOMY FOR COLON CANCER. Mich~ Kobayashi. M.D.. Ken Okamoto, M.D., Tom A,ndo M.D., Naoshige Tohch~a M.D Kimio Matsuura, M.D., Keijiro Araki, M.D., Satoru Tamura, M.D.,* Department o Surgery and Internal Medcine*, Kochi Medical School, Nankoku, Kochi.

Laparoscop~c as.~ed cdiectomy (LAG) is now one of the surgical modal~des fo colon neoplasm. However, there is a discussion t t~ LAC should not be al~e~ for advanced cases because of the port site recurrence. From Janua~ 1997 tr December 1999, our indicat~ of the LAC was adenoma and cancer with mucesa or submucoeal invasion (F'rst period). After the inves~on of these cases, have changed it to the Dukes A cases (Second pedod). In this study, we review~ our LAC cases of both pedods.

Twenty-~ve cases (cancer; 21, aderloma; 4) underwent LAC for adenoma anq early colon cancer from January 1997 to December 1999 in our departmenl Twelve cases undenvent endoscopic rese(~on following LAC. Seventeen case underwent magnified colonoscopy (MC) to observe the surface slructure of th tumor (pit pattern) to diagnose the depth of cancer invasion. There were t~ cases with muscular invasion and 2 cases with subeeresal invasion, without U metastasis histologically. However, no cases showed recurrence so far.

Alter we have become to be able to perform D2 dissection ,se~ely, we ha~ changed its indication as Dukes A from January 2000. We performed CT scan f( the diagnesis of the T and N factors. Our policis are as foliows: 1) Try to perforr MC for eerty cases to grope for the possibility of the endoscopic mucesal resediJor 2) If the Laparoscop~c obsavat~ reveals the tumor shows seroeal exposure, w convert to the conventional laparotomy. 3) Even If we accomplish the D dissecl~ laparoscopically, we convert to the taparotomy for further LN diss~o for the cases, which the frozen section of N1 and/or N2 LN shows canc( metastasis. In the second period, wepedormedLACin9ceses. Threecase were subrnucosal invasion without LN metastasis. The cases, which ShONe muscular and subseroeal invasion, were I and 5 cases, respectively. One cas showed N1 posith~ by histological examination alter o ~ .

Some insMutes have presented that the same grade of the LN dissec~on a convent~nel laparotomy can be done. However, we performed only D dissection taparoscopically. For this reason, our indication of the LAC is Dukes, at present. The diagnoses by CT scan for T and N factors preoperat~ely an intraoperalNe frozen section for N factor are very importanL

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NORMAL SUPRAPANCREATIC AND PERIPORTAL LYMPH NODES ARE LARGER THAN ONE CENTIMETER BY LAPAROSCOPIC ULTRA- SOUND EVALUATION Amy J. Koler, MD, Michael C. lilly, MD, Maudce E. Arregui, MD, Department of Surgery, St. Vincent Hospital, Indianapolis, IN

OBJECTIVES: Laparoscopic ultrasound is being used to assess resectability of gi malignancies. Lymph node size greater than 1 cm is a cri- tarion for abnormal. This is not the case with penportal and suprapancreatic lymph nodes. To date, the echo characteristics and size of these nodes have not been described. We will define the laparoscopic ultrasound appearance of normal penportal and suprapancreatic lymph nodes.

METHODS: This is a prospective study of 21 patients with chronic acal- culous cholecystitis or cholellthiasis. Each underwent elective laparoscopic cholecystectomy with intraoperative ultrasound. Length and width measurements 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 PERIPORTAL long length 1.78 0.85-2.68 + - 0.52 long width 0.50 0.27-1.04 + - 0.17 trans length 1.68 0.87-2.53 + - 0.45 trens width 0.52 0.22-0.95 + - 0.20

Four lymph nodes had a L/W ratio < 2, and thus were considered to be round (9.5%). All others were described as being oblong. All of the lymph nodes were noted to have a hyperechoic center, surrounded by a thin, hypoechoic rim.

CONCLUSION: The average size of periportal and suprapancreatic lymph nodes is greater than 1 cm. For these nodes, size of greater than 1 cm should not be used as a criterion for malignancy.

Suprapubic approach: A novel access for laparoscop/c appendectomy 0 Kollmar M.D., K Z'graggen M.D., BM Buchholz, MK Schilling M.D. Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, Switzedand

The cosmetic result is one argument in favor of laparoscopic over open appendectomy. To further improve that cosmetic result we developed a laparoscopic access to the abdominal cavity through two suprapubic incisions placed in the line of the pubic hair. Patients: We compared operative characteristic, outcome and patient preference of three different accesses to the abdominal cavity for laparoscopic appendectomy in a retrospective study. Furthermore 24 healthy female persons were asked about their preferred procedure in regaKI to the cosmetic result. Results: Between 111997 and 08/2000, 149 patients underwent laparoscepic appendectomy and were assigned to either one technique (see fig. 1).

Fi,qure 1

technique 3 27" 24" 98

=emale / male 19/8 17/7 73125 ~9e 30,0• 31,2• 28~3:1:11~6 :)peration time (rain) 64,7 + 26,0 52T3 + 17f0 62r4 + 23~8 ~ospital stay (days) 3,5 + 1,2 3,8 + 1,6 3,7 + 1,4 I method (%) 10% 24/24 (100%) healthy interviewees preferred technique 2. Discussion: Operation time and hospital stay were similar between all techniques. The cosmetic result of technique 1 and 2 were supedor to technique 3. Patients and healthy interviewees preferred technique 2 over technique 1 and 3.

TRAINING OF LAPAROSCOPIC SUTURING SKILLS USING A NEW COMPUTER-BASED VIRTUAL REALITY SIMULATOR (MIST) PRO- VIDES COMPARABLE RESULTS TO AN ESTABLISHED PELVIC TRAINER SYSTEM Shanu N. Kothari, M.D. Brian J. Kaplan, M.D.,Edc J. DeMada, M.D, "timothy J. Broderick, M.D. Sue Clary, R.N. and Ronald C. Merrell, M.D. , Department of Surgery and Center for Minimally Invasive Surgery, Medical College of Virginia Campus of Virginia Commonwealth University, Richmond, VA

Objectives: The Yale Lapamscopic Skills Course utilizes pelvic trainer skills to improve performance in lapamscopic suturing (Amh Surg 1997;132:200- 204). The Minimally Invasive Surgery Trainer (MIST, VP Medical R, London) 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 Course. We hypothesized that the MIST would be equally effective to the Yale Skills in training for laparoscopic suturing.

Methods: 24 of 29 enrolled 3rd year medical students completed the study. They received detailed instruction in laparoscopic knot tying. Each student 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 Yale Skills for 5 sessions (3 skills/session) over a 5 day penod. Upon completion of training, all students were evaluated by a test consisting of 6 additional attempts to tie a laparoscopic knot. Improvement within groups 'was assessed by paired t-test, while percentage improvement from baseline between groups was assessed using ANOVA.

Results: 11 students completed training on the pelvic trainer and 13 on the MIST, Total knot tying time (mean +- SD) decreased significantly in the pelvic trainer group from 443 +- 135 to 311 +- 137 seconds (p<O.05). A significant decrease in knot tying time was also observed in students training on the MIST from 409 +- 109 to 256 +- 140 seconds (p<0.05). The percentage improvement in knot tying time did not differ significantly between pelvic trainer (30 +-21%) and MIST (39 +- 21%) groups.

Conclusions: The MIST is equivalent to the Yale Skills Course for training the advanced laparoscopic skill of intracorporeal knot tying. The MIST has the added advantages of being portable, does not require additional laparoscoplc equipment, provides detailed analysis of performance (e.g. time, accuracy, wasted movement, etc), and allows solo training sessions without the need for additional manpower

A PITFALL OF ENDOTIP. Fnm~ Ku~ni+hi M_D. Yoshincd Kwoda, M.D., Takmbi Urush/hara~.D., Kouhei Ishiytms, M.D., Nodaki Tokumom, M.D., Masayuki Shisbida,M.D., Depaunent of Surgery, Onomichi General Hospi~, Onomichi c~y, J apart

[INTRODUCTION] We have experienced a case of panpeitonids due to damqe of the smal/ imest/we by Eado TIP. We report aboutk. [CASE] The p~e~ was 46yea-s old female. Jamm'y llth 19991apaosmpic hysterectomy was peffomed. The patient compldned asthma on the secound day post operatively. But she could e~ Tl~rd day Uesu was co~'smed by abdominal x-p. Fourth day abdominal umdemess was seen.Free airwas seeaby sb~x-p.CT showed us freedrmd asdtes. We disgnosed it panpedto.m!ds. So m ~ o l d ' o n wu done. [OPI~TIVE FINDINGS] Inthesbdom/nal cav/tytherewasa plenty ofydlow

dight ascitestlntwas thou~tfow o~of the i~estimd fluid. We recked two

perfontions in the mesentedc borderof small int~e. Pandeto~s was dueto refute of the msll iwn~ Therefore we pedomed dr~e, ~ected ruptured sma//imetim~ and made a store,, of me small intestine. Soon alter opermon we

reviewed the video of the previous lapm'oscopic hysterectomy, confirmed that it could be/mposslble to make a dam~e 'to smal/ intestine by dm mmipulzion of hysterectomy. Fimd/y we could confinnthe raptureand leakof~ fluidby EndoTIP/nsertion ass ~ttroc~. Pint emergency apron/on two dsyslater, the Imi~t have fallen to endotoY;m~. We have done blcod dialysis to remove endotoxin and saved bet ~e . Two months l a ~ we repaired the s~na.And she is h~d~.hy now.

[CONCLUSION] As far as rdereace we could lock for ,there is no i=esdmd rutzu~ by Fade TIP. Our czse is the first c=e in the world. Endo TIP is a useful ~ , b u t abuse of it bt~gs disaster. The n~take [~nt of our case is inse~on of

Endo T/P without pneumopedtoneum. The lesson of our case is that we must

insert the Eado TIP according to Dr. Temamian's method.

OUTCOMES OF REPAIR PROCEDURES FOR PATIENTS WITH BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY 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., Ph.D.* First Department of Surgery, Faculty of Medicine, University of the Ryukyus. Department of Surgery, Nagasaki Chuo National Hospital*.

Laparoscopic cholecystectomy is associated with a higher incidence of bile duct injury than open cholecystectomy. This study evaluated the outcomes of repair procedures for bile duct injury dudng laparoscopic cholecystectomy.

A retrospective study of 14 patients with a median age of 49 years who suffered bile duct injury during elective laparoscopic cholecystectomy over 8 years were reviewed. The main outcome of the repair procedure was assessed using the records abstracted for demographic information, postoperative clinical data.

A diagnosis of bile duct injury was made during surgery in 9 patients, and after surgery in 5 patients. Thirteen patients suffered an injury to the common bile duct, while the remaining one patient to the right hepatic duct. As for the degree of injury, 9 patients had their bile ducts transected, 4 patients had a partial bile duct injury, 1 patient had a clipping. Four out of 7 patients undergoing duct-to-duct anastomosis and one with an end-to-side choledocoduodenostomy developed biliary stricture from 6 to 15 month after repair surgery. These patients consequently underwent hepaticojejunostomies as a second procedure. Primary closure in 3 patients for a partial injury, hepaticojejunostomy in 2 patients and 1 patient with removal of the clip all showed smooth postoperative course.

In conclusion, hepaticojejunostomy offers satisfactory results for bile duct injury during laparoscopic cholecystectomy, even after previous interventions have failed. In cases of duct-to-duct anastomosis for bile duct transection, the use of a long-term indwelling stents might be necessary,

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IS THERE A NEED FOR A FORMAL LAPAROSCOPIC TRAINING PROGRAM DURING A GENERAL SURGERY RESIDENCY? Karen Kwong, M,D., Terrence Liu, M.D., David Mercer, M.D., University of Texas-H0ust0n Medical School, Houston, Texas.

The acquisilJ0n of lapar0sc0pic skills and knowledge is an important component of all surgical kaining programs. M0~t programs do not have a formal laparosc0pic Iraining program and acquisition of knowledge is based on that reeiden~s operative expenence. II was our hypothesis that our residents had not acquired sufficient knowledge in lapar0scop I despite 'adequate' case numbers.

Methods: A proctored 45-multiple choice queelJ0n tapareso0pic exam, using the SAGE~ Manual as a source, was given to all residents (n=39) at the beginning of the year. None 0 the residents studied for the exam. Thus, it represented their current level of kn0~edge Exams were graded, c0~ect scores grouped by PG year, and scores compared by ~0-taile( student's T-Test (Table).

n Mean SD Range PG1 15 22.4 4.5 (13-29) PG2 7 23.9 2,5 (21-27) PG3 6 26.5 3,5 (22-31) PCA 6 30.2 2.6 (27-33) PG5 5 30.0 2.4 (27-33)

Results: None of the PG years scored higher than 73%. There was no differeno between PG1 and PG2 years (p=0.43). There was a trend toward signilicance between PG and PG3 years (p=0.06). Signilicant differences were noted when PG2 residents wet compared to PG4 or PG5's (p=0.0009 and p=0.001) respectively. PGI's versus PG4 an PG5's were als0 significantly different (p=0.00083 and p=0.002).

Conclusions: Our data indicate that our residents have a knowledge deficit in laparoscop when that knowledge is acquired through an operative experience. Although our residenl increased their knov~L-~je over time in the program, our data suggest that implementaSon a formal laparescopic kaining program would be beneficial in our General Surgery Resident and suspect that other programs would benefit as well. (Sponsored by Ethicon).

LAPAROSCOPIC TOTAL EXTRAPERITONEAL (TEP) INGUINAL HERNIA REPAIR - BEATING THE LEARNING CURVE PAWANINDRA LAL MS, FRCS(Ed), FRCS(Glasg), R K KAJLA,JAGDISH CHANDER MS, V K RAMTEKE MS., THE DEPARTMENT OF SURGERY, MAULANA AZAD MEDICAL COLLEGE & ASOCIATED LOK NAYAK HOSPITAL, NEW DELHI, INDIA

While Lichenstein tension free repair is now regarded as the gold standard in open hernia repair, Laparoscopic TEP repair has gained ground in the last few years as it is less invasive and preserves the "peritoneal sanctlty".lt however, has a longer and steeper learning curve due to the "inside out anatomical view", to which the surgeon =s not accustomed. Also, the standard teaching is that any laparoscopic procedure should be a copy of the basic open operation. While it has been true for cholecystectomy and other intraabdominal procedures, ut is not so for inguinal hernia where the above repair is not done in the routine surgical practice. No wonder, the steep learning curves and initial complications! We suggest a simplified model and protocol for resolving this unpleasant situation.

METHOD: In our center, we perform the open prepedtoneal operation popularized by Stoppa initially, on one side only to familiarize the surgeon with the anatomy of the pre-peritoneal space. All the anatomical land- marks are to be noted carefully. A minimum of 10 such operations would be required to enable the surgeon with better insight into this anatomy.The same procedure is then to be repeated in the laparoscopic operation. We have found the learning curve far less steep as the anatomy is now very familiar. In case of bleeding or excessive pneumopedtoneum, the procedure should be converted to open Stoppa operation, which the laparoscopic surgeon performs in open surgery, rather than TAPP. This enables the complication to be identified and noted for future. We feel that this practice would make the learning curve for laparescopic TEP less steep and also decrease the incidence of initial complications. It would also give added confidence in dealing with structures in this space 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.

RENAL ABLATION: AN IN VITRO COMPARISON OF CURRENTL~ AVAILABLE ELECTRICAL TISSUE MORCELLATORS Jaim~ Landman M.D., William C. Collyer M.D., Ephrem Olweny B.S., Cassic Andrecni M.D., Elspeth McDougall M.D., and Ralph V. Clayman M.D. Wahington University, Division of Urology, St. Louis, MO

Morcellation with the high speed electrical laparoscopic (HSEL) mor cellator (Cook Urological Inc., Spencer, IN) in an impermeable nylon/plastic sack (LapSac, Cook Urological Inc., Spencer, IN) ha.' remained unchanged since its inception nearly a decade ago. Sacl deployment and specimen entrapment remain relatively difficult an{ morcellatlon with this device is expensive and relatively slow. As such in an effort to facilitate specimen entrapment and moroellation, w~ adapted two currently available electrical morcellators (Steiner gyneco logical morcellator from Karl Storz Inc., Culver City, CA and the electri cal prostate morcallator (EPM) from Coherent, Inc., Sturbridge, MA) fo renal morcellation, and compared them to the HSEL morcellator.

All morcellation was performed through a simulated abdominal wa under direct laparoscopic vision. Ten porcine kidneys were ablate with each of the following techniques: 1.) HSEL morceUation in LapSac, 2.) HSEL morcellation in a fluid filled LapSac, 3.) Steiner tool cellation in an insufflated Endocatch sack (U.S. Surgical Inc., Norwal~ CT), and 4.) EPM morcellation in a fluid filled Endocatch sack. A medi fled laparoscopic trocar was constructed and applied for Steiner an, EPM morcellation. Time to complete moroellation, morcellation produ( size, and entrapment sack integrity were evaluated for each techniqu{ Cost data for each morcellator is also presented.

Morcellatlon times for Steiner, HSEL dry, HSEL wet, and EPM roD1 cellatlon were 6.0, 15.9, 14.7, and 26.0 minutes respectively. Fragmer sizes for these morcellators were 2.97, 0.65, 0.62, and 0.013 gram., respectively. A single entrapment sack perforation at the neck of th sack, was documented in a LapSac during routine HSEL morcellation.

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COMPARISON OF THE LIGASURE SYSTEM, TITANIUM CLIPS, ENDO-GIA STAPLER AND SUTURES FOR LAPAROSCOPIC VASCULAR CONTROL IN A PORCINE MODEL Jaime Landman M.D., Kurt Kerbl M.D., Cassio Andreoni M.D., William Collyer M.D., Ephrem Olweny B.S., Chandru Sundaram M.D., and Ralph V. Clayman M.D., Washington University Division of Urology, St. Louis, Missouri

Our goal was to assess the utility and define appropriate usage parameters of the 5-mm laparossopic UgaSure system for vascular control of small and medium sized vessels during laparoscopic surgery.

Twenty-five domestic pigs were divided into four groups. In groups 1 and 2 in situ bursting pressures were used to compare the LigaSure system to titanium clips and Endo-GIA staples for control of arterial and venous structures of varying sizes. In group 3 the LigaSure system was compared to standard bipolar energy for vascular control. In group 4 in vivo laparoscopic application of the LigaSure system was evaluated.

The LigaSure system with the 5-mm laparoscopic device was able to reliably seal arteries up to 6-mm and veins up to 12-mm in diameter with supraphysiologic bursting pressures. The Ligasure device was deployed twice at two overlapping sites on each vessel. Thirteen arteries with diameters of 6-mm or less were evaluated with a mean burst- pressure of 662 mmHg (range 363 to 1985 mmHg). Eleven veins with diameters s 12-mm were evaluated with a mean burst pressure of 233 mmHg (range 63 to 440 mmHg). Standard bipolar energy was less reliable, and vessel sealing could not be accurately assessed prior to vessel division due to local thermal tissue damage.

The UgaSure system is a viable option for laparoscopic management of vascular structures within well-defined parameters. Arteries up to 6-ram and veins up to 12-mm are reliably sealed with supraphysiologic bursting pressures. However, safe application of the system 1requires meticulous technique.

LAPAROSCOPIC MANAGEMENT OF GIANT PARAESOPHAGEAL HERNIATION Rodney J. Landreneau, M.D., Richard H. Maley, Jr., M.D., Robert J. Keenan, M.D., Paul McKesey, M.D., "13betha S. Santucci, R.N., Robin S. Macherey, R.N, Department of General Thoracic Surgery, Allegheny General Hospital, Pittsburgh, PA

Introduction: The anatomic distortion and technical difficulty inherent with repair of giant paraeeophageal hemiation have limited the use of laparoscopic approaches for the correction of these disorders. Materials and Methods: Since 5/1994, we have performed laparoscopic repair of paraesophageal hiatal hemias in 94 patients. Mean age was 62+-14 and 62%(58/94) were women. Pre and post operative manometric and prolonged pH testing were obtained on 31/94 (33%) patients. Ufestyle improvement and severity of heartbum/regurgitation and dysphagia were assessed on a 1-10 scale preoperatively and at 6- 12 months postoperatively. Principles of repair included: reduction of the hemia, excision of the sac, crural approximation, and fundoplication over a 54Fr bougie (Nissen-72, Toupet-22). Results: Operative time was 157+- 53 minutes. Length of stay was 2.7+-1.9 days. There were no mortalities. Conversion to Aopen@ repair was required in one patient (due to adhesions). Paired t tests comparisons of mean preoperative to mean 6-12 month scores showed significant improvement: lifestyle 6.9 to 8.1(p=0.001), heartbum/regurgitation 8.2 to 0.1(p=0.001), dysphagia 4.1 to 0.3(p=0.001). Differences in pre and post operative manometric findings were not significant; however, significant improvement in pH scores (15.0 to 2.1% of time pH less than 4) was seen in those patients tested (p=0.001). Conclusions: Our experience suggests that laparoscopic repair of giant paraesophageal hiatal hernias is a viable alternative to Aopen@ surgical approaches. Thoracic surgeons interested in the management of this complex process should become familiar with these minimally invasive techniques.

A PROSPECTIVE TRIAL OF ANALGESIA FOLLOWING ENDOSCOPIC EXTRAPERRONEAL INGUINAL HERNIOPLASTY: LOCAL WOUND INFILTRATION VERSUS EXTRAPERITONEAL INSTILLATION OF BUPWACAINE. Hun 9 Lau, M.D., Nivdtti G. Patil, M.D., Francis Lee, M.D., Wai K Yuen, M.D., Department of Surgery, University of Hong Kong Medical Center, Hong Kong SAR, China

Exlmperitoneel instillation of bupivacaine has been shown to be superior to placebo for postoperative analgesia following endoscopic extraperitoneel inguinal hemioplasly. The objective of the present study is to compare the efficacy of postopara~e analgesia by local wound infiltration and instillation of the extraperitoneel space with bupivacaine.

From 1 September 1999 to 2 June 2000, a total of 100 consecutive patients, who underwent unilateral endoscopic extraperitoneel inguinal hemioplasties, were randomized to receive eider local wound infiltration with 10ml of 0.25% bupivacaine (Group I, n=50) or instillation of the extmperitoneal space with 40ml of 0.25% bupivacaine after placement of mesh (Group II, n=50). Daily postoperative pain was assessed by visual analogue pain score, on a scale from 0 to 10, at rest and upon coughing. Total amount of oral analgesic consumed and clinical outcomes of the two groups ware compared.

The demographic features and types of hernia were comparable. Table 1 shows the mean pain scores at rest and upon coughing of the 2 groups (P=ns). The mean number of oral analgesic tablets consumed were 3 in both groups (P=ns). During follow-up, asympatomatic groin collection was more common in group II (n=4) than group I (n=2) (P=ns).

The authors conclude that extmperitoneel instillation of bupivacaine did not bestow any eddibonal pain relief compared to local wound infiltration with bupivacaine.

Table 1. Postoperative pain scores at rest and upon coughing. Pain score at rest Pain score upon coughing

Postop Days Group I Group II Group I Group II Day 0 2.3 2.6 4.5 4.7 Day I 1.4 1.8 4.5 4.3 Day 2 1.8 2.5 3.9 4.8

LAPAROSCOPIC ANTI-REFLUX SURGERY IN THE LUNG TRANSPLASPLANT POPULATION Christine L Lau, MD; Scott M Palmer, MD; Theodore N Pappes, MD; R Duane Davis, MD; Ross L McMahon, MD; and Steve Eubanks, MD, Departments of Surgery & Medicine, Duke University Medical Center, Durham, NC.

Background: Lung transplantation has emerged as a viable therapeutic option for patients with a vadety of endstage pulmonary diseases. As immediate posttransplant surgical outcomes have improved, the greatest limitation of lung transplantation remains chronic allograft dysfunction. Gastroesophageal reflux disease (GERD) with resultant aspiration has been implicated as a potential contributing factor in allograft dysfunction. GERD is prevalent in end-stage lung disease patients, and even higher in patients after transplantation. This review reports the safety of lapraoscop- ic fundoplication surgery for the treatment of GERD in lung transplant patients. Methods: Eighteen of the 292 lung transplants performed at Duke University Medical Center underwent anti-reflux surgery for documented severe GERD. The safety and benefits of laparoscopic fundoplications in this population was evaluated. Results: The anti-reflux surgeries included 13 laparoscopic nissen fundoplications and 4 laparoscopic toupets. Two of the 18 patients have reported recurrence of GERD symptoms (11%), however, 24-hour pH testing was normal in all patients. Two other patients reported minor GI complaints postoperatively (nausea, bloating). There were no deaths or intraoperative complications from the anti-reflux surgery. After fundoplication surgery 12 of the 18 patients showed measured improvement in pulmonary function (67%). Conversion was necessary in one patient (5.6%), due to extensive adhesions. Conclusions: GERD occurs commonly in the posttransplant lung population. Laparoscopic fundoplication surgery canbe performed safely with minimal morbidity and mortality. In addition to resolution of reflux symptoms, improvement in pulmonary function may be seen in this population after fundoplication. Lung transplant patients with severe GERD should be strongly considered for anti-rallux surgery.

TECHNICAL ASPECTS OF LAPAROSCOPIC TOTAL ABDOMINAL COLECYOMY David M. Lauter MD, Eric J Froines MD, Michael Theobold MD, and Lex Mottl MD, Group Health Cooperative of Puget Sound, Seattle, WA

Controversy exists around the role and appropriate indications for laparoscopic assisted colon resection. We present in detail our technique for laparoscopic assisted total colectomy, developed during 185 consecutive laparoscopic colon surgeries, including 14 total colectomies. The procedure is performed with the patient in a modified lithotomy position using two 12 mm ports and three 5mm ports. Instrumentation includes a 10 mm 30 degree scope, harmonic scalpel, 5 mm bowel graspers, and 5 mm flexible retractors for exposure of the distal rectum. Operative strategy is sequential mobilization of the entire large intestine from distal to proximal colon is followed by intracorporeal mesenteric division going from distal to proximal. Specifics of patient positioning, surgeon and assistant positioning, and technical pitfalls are presented for each sequence of mobilization and mesenteric division of the different segments of the large intestine. Technical pitfalls with specific solutions include splenic flexure mobilzation and distal rectal dissection. Specimen removal is performed through either a 5 cm suprapubic incision, a mini-Pfannensteil incision, or an ileostomy site, depending on the exact procedure performed. Standard anastomotic techniques are used as indicated. Retrospective review of our 14 cases demonstrated a 7% (1/14) conversion rate and a mean operative time of 185 minutes. We conclude that laparoscopic assisted total colectomy can be performed with acceptable operative times by GI tract surgeons with advanced laparoscopic skills and appropriate OR and OR team resources.

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EXTRACORPORAL SHOCK-WAVE LITHOTRIPSY (ESWL) FOR SYMPTOMATIC CHOLEDOCHOLITHIASIS IN THE ELDERLY Avraham Lebenthal M.D., Dov Wengrower M.D., Eran Goldin M.D., Dov Pode M.D., Petachia Reissman M.D., Sergey Lyass M.D., Departments of Surgery, Gastroenterology and Urology. Hadassah Hebrew University Medical Center, Ein-Karem, Jerusalem, Israel

Introduction: The majority of common bile duct (CBD) stones can be cleared successfully by ERCP. Large stones, un-retrievable from CBD by usual endoscopic methods, are usually approached surgically. Open CBD exploration carries a relatively high morbidity and mortality rate in elderly patients. Recent reports showed that a combination of ERCP and ESWL might be an alternative approach to this problem. Objective: The aim of this study was to asses the feasibility of ESWL in combination with ERCP in clearing large stones from CBD in elderly patients. Methods: Patients with symptomatic choledocholithiasis in whom ERCP failed to retrieve stones from CBD were referred for ESWL. All patients had severe co-morbid conditions, which precluded safe surgical procedure. After ESWL the patients undenNent repeated ERCP until complete removal of stones. Results: Five patients with mean age of 70 y. ( range 65-72) were included in the study. A total of 17 ERCP and 6 ESWL were performed. There was no morbidity and mortality after the procedures. In all patients the CBD was completely cleared of stones. The patients were followed for 86-24 months (mean 46) and remained asymptomatic. Conclusion: Elderly patients with CBD stones that are not extractable by ERCP may be successfully treated with ESWL followed by endoscopic removal of fragments. This approach appears to be a safe alternative to surgical common bile duct exploration.

COMPARING 5 V. 10 MM PORTS IN LAPAROSCOPIC NISSEN FUNDOPLICATION. Philip L Leggett, M.D., Charles O. Bissell. M.D.. The University of Texas- Houston Health Science Center (HNMC), Houston, TX.

Advantages of laparoscopic surgery include shortened hospital stay, decreased post-operetive pain and earlier retum to activity. Studies have indicated that these benefits are realized in laparoscopic Nissen flJndopiication. A Medline review of the literature revealed no studies investigating whether minimizing port size in laparoscopic Nissen [undoplicatton would augment these benefits.

A prospective, randomized study was conducted from December, 1999 to May, 2000. Fody patients ware randomized to undergo laparoscopic Nissen sith either 5 mm ports or 10 mm ports. Data was collected for operetive Lime, length of hospitalization, analgesic use while hospitalized, number of analgesic tablets used as an outpatient, time required to leave the home and return to baseline activities as well as post-operative pain. Fisher's exact or chi-square methods and Student's t-test ware used for statistical analysis.

Twenty patients under, vent laparoscopic Nissen with 5 mm ports and 20 ~ h 10 mm ports. The operative time (47.3 v. 48.7 rain,/7= 0.826) and length of hospitalization (1.2 v. 1.2 days, p=0.728) was similar for the two :lroups. Although not statistically different, the 5 mm group required fewer :loses of intramuscular analgesics (2.8 v. 3.4, p= 0.423) but more doses of 9ral analgesics (1.5 v. 1.1,/7= 0.346) while hospitalized. Once discharged from the hospital, the 5 mm group showed trends toward benefiting from the smaller ports in terms of the number of analgesic tablets consumed (11.6 v. 16.0, p= 0.352), duration of analgesic use (4.4 v. 5.5 days, p= 0.391), time to leave the 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-operetive pain (4.9 v. 5.8, p= 0.403).

Although statistical difference was not seen, the 5 mm group did show '.rends indicating that they benefited from the smaller port size. Trends ncluded decreased post-operative pain, reduced outpatient analgesic use, and earlier return to baseline activity.

CAN SURGERY IMPROVE THE QUALITY OF LIFE FOR ASTHMA PATIENTS WITH GASTROESOPHAGEAL REFLUX? Philip L Leggett, M.D, Hesham Atwa, M.D, The University of Texas-Houston Health Sdence Center (HNMC), I-husto~, TX.

FiReen million Americans suffer fi'om asthma, one proposed etiology of asthma is GERD. This study demonslrates the effect of laparoscupir N'men funduplic=ion on the symptoms, frequency of m~cation and ovcnll quality of life in asthma pstimts, Lap~oscopic Nissen ~doplicalion was performed on 231 patientsl~ueen

Januay 1997 and August 2000. Twmty five patimts were diagnosed with asthma. Telephone iatervicw ~ performed with all asthma patient~

Asthma was idmtified in 25/231 palients(10%). Six patients w~e excluded. had asthma as children which resolved sponmeously and three were lost to follow up. Follow up was performed on 22/25 patients (8~A). Follow up time was 1-44 months(mean 23.4). Five patients were on bronchodllators as needed and 12 used bronchodilators on a regu1~ basis. F ~ two percent of patients were oil steroids preq~nfively and 58% were tither s~n in the omergmcy room or admitted to the hospital for their asthma symptoms. No change in asthma symptoms was noticed in 36.8% and 63% showed either improvement or marked ~aprovement in their symptoms. Forty two percent had either disemtinued or decreased their bronchedilator therapy. Sixty four ~ctat have decreased or discontinued their steroid therapy. Sixty eight percent of patients showed an improvement in the qualit of life in relation to their asthma symptoms.

Ore'results indicate an improvement in the quality of life in relation to the aaluna symptoms with decrease in the f~qumcy and dosage of medications in asthma patients with GERD following I~eroscopic Nissen ~duplicatim.

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ULTRASOUND OF THE INGUINAL FLOOR TO EVALUATE HERNIAS Michael C. Lilly, M.D., Maurice E. Arregui, M.D., Departments of Surgery, St. Vincent Hospital and Health Care Center, Indianapolis, IN, Keesler Medical Center, KeeslerAFB, MS

Purpose: To evaluate the utility of ultrasound in the diagnosis of inguinal hernias and obscure groin pain.

Methods: A prospective evaluation of 65 consecutive groin explorations performed subsequent to percutaneous ultrasound examination. Patients were examined in an office setting, including a history and physical, and then an ultrasound of the inguinal region was performed. Ultrasound was performed by the staff surgeon and fellows. Patients were then taken to surgery for either a laparoscopic or open hernia repair. A comparison was made between the pre-operative and operative findings to determine the utility of groin ultrasound.

Results: 41 patients presenting with symptoms of groin pain or palpable groin bulge were evaluated with ultrasound of the groin. 24 of the patients went on to have bilateral repairs, thus making the study group consist of 65 groins. 50 laparoscopic and 15 open hernia repairs were performed. This included 19 groins without hernia by physical exam, and 46 with a palpable hernia. Overall, ultrasound was utilized to correctly identify the type of hernia (direct vs indirect) in 87.7%. In the 19 that there was not a palpable bulge, ultrasound identified a protrusion (hernia or lipoma) in 17. Two of these were false positives, and the 2 negative ultrasound exams were false negatives. Thus the accuracy of ultrasound to identify pathology in the evaluation of a groin without a palpable bulge was 79%. The overall accuracy of ultrasound in identifying a herniation was 94%.

Conclusions: Ultrasound is a useful adjunct in the evaluation of the groin for hernia, and can be performed by surgeons.

A NEW APPROACH TO TRANSANAL ENDOSCOPIC MICRO- SURGERY: ULTRASONIC DISSECTION AND THE STORZ OPERATION RECTOSCOPE Marco Maria Lirici-, MD, Massimiliano Di Paola, MD, Cnstiano GS Huscher,

MD Department of Surgery, San Giovanni Hospital, Rome, italy

Transenal endoscopic microsurgery is an effective procedure for treatment of large sessile adenomas and early cancers of the rectum that allows a precise full thickness resection of lesions under optical magnification. Unfortunately, TEM needs dedicated and rather expansive instruments and equipment. Other limits of the original procedure described by Buess are: high skill demanding closure of the defect with running sutures secured by silver clips, and control of bleeding especially in lesions located in the mild rectum. -Objective of the study-. The technical characteristics of the Storz operation rectoscope required the development of a slightly different procedure. Definition of indications and contraindications and cost-effectivenese evaiua- fion of the procedure were the main objectives. -Methods/technique-. Ultrasonically activated 5 millimetres, curved blade scissors are emploied for dissection and coagulation. Full thickness resection with adequate margin of clearance or simple mucosectomy or partial thickness resection may be performed. Closure of the tissue defect is accomplished by interrupted 3-0 PDS sutures secured by extracorpereal slipknots. -Preliminary results-. Ten TEM have been performed according to the above mentioned technique with the following indications: 4 adenomas, 4 ca in situ/T1 tumours, 2 "1"2 rectal cancers. Patients with T2 cancers underwent preoperative chemoradiation or postoperative radiation therapy. Follow-up ranged 24-1 months. No recurrences were observed. One complication occurred in a patient with adenoma: a bleending on postoperative day 6 that required new rectal suturing. -Conclusion/Expectation-. Compared to the original technique, TEM with the 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 complication described, coagulation is optimal and US scissors allow working in a pretty bloodless field. Overall costs are lower.

PEDIATRIC LAPARO~OPIC NEPI~OUP.ETEP~CTOMY FACILITATES RECONSTRUCTIVE SURGERY FOR COMPLII~ GENITOURINARY ANOMALIIr.q. Dould ~ Uu. M.D. Pb.D. D ~ Mm-~ M.D~ and Je=ep& Ortenbery~ M=D. CldMre|'s H ~ of New Odemm ud La~um Sl=e Usiverttly Sdlod of Medleh~ New Orlem~ Lo~a.t

Baekgrmmd: Renal dysplasia may be associated with lower urinary tract malformations or =3ntndatenl urcteral anomalies Traditional managemmt of throe complex urinary 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 marginally functional renal ~mits, wr have adopted the technique oflaparosc~ic nephroummamny (LN) in associmim with reconsm~w surgery for complex r m~my tract =omli~ M=tlNds: Eight children (7 boys and I girl) with an avenge age of 4 years (range: 6 mos.-12 yrs.) underwent LN with cmcomitant cmtralatml or lower urinary tract surgery, predominantly for recu~et =riB= 7 tract infecti0m or bladder dysfunction. LN was indicated due to dysplasia associated with postorior urethral valves, umeral ectopia, urctero~e or multicy=ic kidney. LN was perf=~=/through three 5-ram trochar sirra, with the majority of tissue and ~ dissection using a 5-mm harmonic scalpel. Specimm rmricvtl and low~ ='inm7 tract rs~nslructm (ure~ocystoplas~y. 2, saninal vesicle cyst excisim. 2, or uret='ocel=tomy- 1) were ac=mplished through a small suprapub~ m in five children. Nephrectomy specimens were removed through l ~ t sitm in thr~ elher chikkm. Childrm wae studiai for safety of surgay, pastq~erative recover, rmolutiml ofsymlXoms, and r results.

LN was perfumed =~=mfidly and safdy in spit= of more extrusive perinephric h'br=is in some easm. Opmt/ve times averaged 64 minutes (range 45 - 92 min.) fur the LN ~ P.~overy wm uniformly imevenfful and parenteral analgesics were unne~sm'y~pmt-opm~ve day2 in allcasm. T~etodisdmrge averaged I.$ days (hinge, I-3 d.) and no dd,ty~l cmnplimtions wzre identifi=d. Functional and emmet results ~ mmkkr~l ~cellmt in all cases, with the e~ceptioa of one patient who had pmistmt voiding ~ u n a i o a following acisl'on of a massive uraaoccele. Coar 121 mhancm the aq iml mmganag of complex urinmytract anoma/ies requiring B ~ 0 m m ~ o = y ~1 hams r=covw/. Debilitm/ng wick and/or separate incisions requinM to a d d ~ tl~s= widdy sepm~d anmnalim at the same setting can thus I~ avoided.

DETERMINING AN APPROPRIATE THRESHOLD FOR REFERRAL TO SURGERY FOR GASTROESOPHAGEAL REFLUX DISEASE Jean Y. Uu, MD, Samuel RG Finlayson, MD MPH, William S. Laycock, MD MS, Richard I. Rothstein, MD, Ted I_ Trus, MD, Heiko Pohl, MD, John D. Birkmeyer, MD, VA Outcomes Group, VA Hospital, White River Junction, ~ Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Background: Referral to surgery is usually reserved for gastroesophageal reflux disease (GERD) patients with poor quality of life despite medical therapy. However, an appropriate quality of life threshold for referral is not well- established. Objective: To determine what quality of life threshold for medically-managed patients would justify laparoscopic fundoplication to optimize long-term outcomes. Methods and procedures: Decision analysis using a Markov model to simulate long-term health outcomes after laparoscopic fundoplication or continua- tion of dally prescription medication over 10 years. Peer reviewed publications were located with a MEDLINE search for English-language articles for adult patients since 1994 to obtain probability estimates for the model. Health-related quality of life was represented in the model by utilities between 0 and 1.0, where 0 represents death and 1.0 represents freedom from disease. The base case analysis assumed a cohort of otherwise healthy patients with typical GERD symptoms who require daily medication. Results: Surgery is associated with better long term quality of life if the utility with medical treatment is below 0.99. For medically treated patients with a utility of 0.90 (equivalent to the health state of mild angina), surgery confers a benefit of 0.64 quai~ adjusted life years (QALY) over continuing medical treatment. For scores of 0.82 (equivalent to the health state of chronic colitis), the benefit of surgery is 1.18 QAI_Y. Sensitivity analysis shows these results to be relatively insensitive to reasonable variations in baseline risks of surgical mortality, surgical failure, and re-operation. Conclusions: Based on cument estimates of morbidity and mortality for laparoscopic fundoplication, this model suggests that surgery would benefit patients with even modest decrements in quality of life on medical therapy. Explicit quantification of utility scores for GERD patients should be considered to aid clinical decision making.

WHICH LAPAROSCOPIC OPERATIONS ARE THE FASTEST GROWING IN RESIDENCY PROGRAMS? Lo, P; Ahmed N; Chung R S. Department of Surgery, Hutou Hospital, Cleveland Clinic Health System, Cleveland, Ohio 44112.

Laparoscopic operations continue to increase in popularity but the extent has not been studied quantitatively. The growth can be expressed as the rate of change of the proportion of laparoscopic vs the corresponding open operation, ifa complete set of statistics have been kept. From the National Residont Operation Statistic, collected by ACGME, we tracked the proportion oflaparescopic vs open operations done by residents over the past four years, including the total operations performed. Results: (N = total number of procedures repotted; fraction=laparoscopic / total)

1995 1999 growth (A ~ Cholccystect N 82493 89057 +1.99%*

Fraction 0.637 0.827 +7.45%* Nisson N 6188 9060 +11.6%*

Fraction 0.223 0.392 +18.9%** Appendectomy N 35077 35262 +0.13%

Fraction 0.130 0.187 +10.75%* Hernia Repair N 56182 54610 -7.0%

Fraction 0.065 0.118 +20.38%** Colectomy N 36395 44145 +5.32%*

Fraction 0.024 0.032 +8.25%* * p<0.005; ** p<0.0001, t-tests performed on slop= of plot: number vs year.

The total number of operations increased in three of the five listed operations, but the laparoscopic proportion increased in all, though at diffcront rates. The largest growth rates are in laparoscopic groin hernia repair (+20.3$'/dyr) and Nisson fundoplication (+lS.tP/dyr), with appendectomy, colectomy, and cholecystcctomy also showing substantial growth..lust as laparo~opic cholecystectomy grew rapidly in the first half of the past decade, laparoscopic Nissan fundoplicatiou and hernia repair are enjoying the fastest growth currently in residency programs.

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A RANDOMIZED TRIAL OF HERMES-ASSISTED VERSUS NON- H E R M E S - A S S I S T E D FOR L A P A R O S C O P I C ANTI -REFLUX SURGERY James D. Luketich, M.D., Percival O. Buenaventura, M.D., 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 Thoracic Surgery and The Minimally Invasive Surgery Center, University of Pittsburgh Medical Center Health System, Pittsburgh, PA

Advances in robotic technology, including voice-activation of operating room equipment, are being introduced into the clinical practice of surgery but few reports have objectively evaluated their impact. This study was designed to assess the impact of the HERMES Voice-Activated system on operating room efficiency and user satisfaction.

This was a prospective randomized tdal of patients undergoing laparoscopic anti-reflux surgery performed by expedenced minimally invasive general and thoracic surgeons. Patients were randomized to HERMES- assisted or standard operating room procedure. Variables of interest were circulating nurse's time spent adjusting devices that are currently voice-controlled by HERMES, potential operating room cost savings, number of interruptions to adjust devices, and surgeon and nurse satisfaction (on scale of 1-10).

A total of 30 cases were randomized and performed by one of 2 sup geons. In the non-HERMES cases, nurses were interrupted for laparosoopic device adjustments on average 15.3 times per case which led to a statistically significant time advantage for HERMES-assisted cases (p=0.03). Average satisfaction scores for HERMES vs. non-HERMES cases for nurses were 9.2 and 5.3 (p<0.001), and for surgeons 9.0 and 5.1 (p<0.001).

The HERMES voice-activated system eliminated 15 physician directed nursing interruptions to adjust surgically related devices per case and reduced operating time by approximately 5 minutes per case. There was a marked user preference for HERMES voice-activation for both surgeons and nurses due smoother interruption-free environment.

BILATERAL L A P A R O S C O P I C A D R E N A L E C T O M Y - INITIAL EXPERIENCE Sergey Lyass M.D., David J. Gross M.D., David Hazzan M.D., Ben Glazer M.D., Petachia Reissman M.D., Dept. of Surgery & Endocrinology. Hadassah Hebrew University Medical Center, Jerusalem, Israel

Introduction: Laparoscopic adrenalectomy (I.A) is rapidly becoming the preferred approach to adrenal neoplasms, both benign and malignant. While the indications for unilateral LA are quite evident, in case of bilateral adrenal disease there is not enough data in the literature to support or condemn synchronous laparosoopic removal of both adrenals.

Objective: To assess the outcome of bilateral LA and compare it with the outcome of unilateral procedure.

Patients & Methods: All patients who underwent LA between 1996 and 2000 were evaluated. Data analysis included patients' age and gender, histological diagnosis, comorbid condition, length of procedure, morbidity, blood loss, conversion to open surgery, and length of postoperative stay.

Results: Between 1996 and 2000 years 54 patients underwent LA, 7 of them - bilateral in one session (4 male, 3 female, with the age range from 20 to 77 years). The indications for bilateral adrenalectomy were bilateral pheochromocytoma in 4 patients, Cushing syndrome in 1 patients, Cushing disease in 1 patient and 1 patient had Cushing disease with bilateral adrenal hyperplasia secondary to ectopic ACTH production. The procedure was usually done first from the right side, and, after repositioning of the patients, was followed by left adrenalectomy. The mean operative time was 6 hours, but in the last 3 cases it was less than 4 hours. The conversion rate was 14% (n=l), compared to 6.4% in unilateral procedures. This one case of conversion was due to technical problems after one side was already removed laparoscopically. There was no peostoperative morbidity, one patient received blood (1 unit) pedoperative- ly. The mean length of postoperative hospital stay was 6.8 days, while after unilateral adrenalectomy the patients stayed at the hospital less than 4 days.

Conclusion: According to this initial expedence bilateral synchronous laparoscopic adrenalectomy is technically feasible, safe, and associated with relatively short hospital stay.

UNIQUE FEATURES OF LAPAROSCOPIC CHOLECYSTECTOMY IN THALASSEMIA PATIENTS RAN KA'I'Z M.D., LYASS SERGEY M.D., ADA GOLDFARB M.D., MICHAEL MUGGIA-SULLAM M.D., ZVI GIMMON M.D., DEPT. OF SURGERY & HEMATOLOGY. HADASSAH UNIVERSITY MED- ICAL CENTER, JERUSALEM, iSRAEL

Objective: Hemolysis and multiple blood transfusions are the well-known reasons for a high incidence of symptomatic gallstones in thalassemic patients. This prospective study was designed to assess the feasibility and safety of laparoscopic cholecystectomy (LC) in this group of patients.

Methods and Patients: Thalassemic patients who underwent LC in our institution from 1996 to 2000 were evaluated. Data analysis included patients' age and gender, indication for chotecystectomy, comorbid condition, intraoperative findings, morbidity, blood loss, conversion to open surgery, and length of postoperative stay.

Results: There were 8 patients with thalassemia (2 patients with major and 6 with intermedia) who underwent elective LC. Indications for cholecystecto. my were biliary colic in 6 patients, previous gallstone pancreatitis and acute cholecysbtis each in 1 patient. Previous open splenectomy was performed in 6 patients. The following features were common and unique for all the patients: * Stgnificant hepatomegaly decreases the potential intra-abdominal space that requires lower than usual trocar placement. * Cirrhotic, hemosiderotic and firm liver does not allow safe and sufficient cephalad retraction of gallbladder. * Lack of adhesions in spite of previous open splenectomy. * Cystic lymph node is significantly enlarged. * The thalassemic patients usually have hemoslderin cardiomyopathy, which increases the risk of anesthesia and post.operative care. * The inherent jaundice of thalassemic patients does not necessarily require intra-operative cholangiography unless it is not associated with bile duct dilatation. No procedure was converted to open and there was no morbidity.

Conclusion: To allow safe LC in patients with thalassemia the surgeon should be familiar ~ some unique features in this specific group of patients. In spite of high prevalence of cholelithiasis in thalassemic patients we recommend to perform LC only in symptomatic patients, unless it is not associated with laparoscopic splenectomy.

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LAPAROSOCPIC ENUCLEATION OF PANCREATIC INSULINOMA - THE

IMPORTANCE OF INTRA-OPERATIVE ULTRASOUND Sergey Lyase M.D., David J. Gross M.D., Ben Glazer M.D., Richard Lederman M.D., Petachia Reissman M.D., Dept. of Surgery, Radiology & Endocrinology. Hadassah Hebrew University Medical Center, Ein-Karem, Jerusalem, israel

Introduction: Despite modem imaging preoperative localization of pancreatic insulinorna may be difficult making surgical management in such patients challenging. Intraoperative ultrasound (IOU) was shown to be effective for tumor localization and excluding synchronous pancreatic tumors during open surgery. The recent development and growing experience with laparoscopic ultrasound (LUS) made this medality useful in the laparoscopic management of pancreatic insulinoma. We present two cases of pancreatic insulinoma demonstrating the importance of LUS.

Case 1. A 28 year old female with a one year history of hypoglycemia, the endocrine evaluation confirmed the diagnosis of insulinoma. The preoperative imaging including spiral CT scan and endoscopic ultrasound (EU) failed to localize a tumor. The patient was explored laparoscopically, at that time, however, LUS was not available to us. In spite of thorough laparoscopic exploration of the entire pancreas, including the uncinate process, the tumor was not found. The operation was converted, and conventional IOU revealed a 15 mm tumor in the head of the pancreas under the surface, which was successfully enucleated.

Case 2. A 44 year old male was evaluated for recurrent episodes of dizziness and fainting. Biochemical tests revealed h=gh endogenous levels of insulin. Preoperative CT scan and EU failed to localize a tumor in the pancreas. Laparoscopic exploration of the pancreas 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 enucleation of the tumor was concluded laparoscopically. The pathological diagnosis confirmed insulinoma and the hypoglycem;a resolved completely in both patients after surgery. Conclusion. The development of the LUS has made pancreatic insulir.oma amenable for laparoscopic management. LUS is crucial for both tumor localization as well as exclusion of potentfal synchronous lesions. Although technically challenging laparosoopic enucleabon of pancreatic insulinoma is feasible.

LAPAROSCOPIC DISTAL PANCREATECTOMY FOR I N S U U N O M A .

Mahon D, Allen E, Heyburn P, Rhodes M., Norfolk & Norwich Health Care NHS Trust, UK.

Aims:A review of our experience of laparoscopic distal pancreatectomy. Patients & Methods:

Three cases of pancreat ic insul inoma were referred to us between July 1996 and March 2000. Patients had pre-operative radiological invest igat ions and we then proceeded to perform laparoscopic distal pancreatectomy. Intra-operative ultrasound was used for final Iocalisation and dissection was performed with a harmonic scalpel. The tail of the pancreas was excised by a linear cutter/stapler and removed in an endoscopic bag retrieval system.

Results: All three patients made a swift recovery, became normoglycaemic and suffered no major complicat ions. One patient underwent a planned laparoscopic splenectomy at the same time as the distal pancreatectomy.

Op ]3me Blood loss Hospital stay (minutes) (ml) (nights)

148 300 5 85 100 6 80 1800 3

Conclusions: Definitive treatment of pancreatic insuiinoma is by excision of the turnout. Traditionally this has required a major laparotomy not at all in keeping with the size of the turnout itself, however, a laparoscopic approach would appear to be perfectly feasible and offers obvious advantages to the patient.

HAND-ASSISTED LAPAROSCOPIC TOTAL GASTRECTOMY (HALTG) FOR EARLY GASTRIC CANCER Minoru Matsuda, MD. PhD*., K. Onodera*, Y. Kino*, T. Asama*, T. Munakata*, S. Kasai*, K. Kato** , Second Department of Surtery, Asahikawa Medical Co l l ege , A s a h i k a w a , H o k k a i d o , J a p a n * D e p a r t e r t m e n t of Endoscopic Surgery, Pippu Clinic, Pippu, Hokkaido, Japan**

Introduction: We present the operative technique and the advantage of hand-assisted laparoscopic total gastrectomy for early gastric cancer.Patients: We performed this operation to two patients (a 57-year-old man and a 70-year-old man). The indication of HALTD is limited to the early gastric cancers with submucosal invasion (TI: UICC) at U region of the stomach. Operative procedure: One 10mm and Three 5 mm trocars were inserted to the abdominal cavity. Then a 3 inches upper midline abdominal incision was made to set up the HandPo~_ (Smith & Nephew Inc. USA). The left gastroepiploic and short gastric vessels were dissected using laparoscopic coagulating shears (LCS_, Ethicon Inc.). The left gastric artery was clipped and dissected. The anterior and posterior vagus nerves were dissected preserving hepatic and antropyloric branch. The esophagus was divided, then stomach was pulled out from the HandPort site. After a 25mm anvil head (ILS_, Ethicon Inc.) was inserted into esophagus, the regional lymph nodes located along the right gastroepiploic artery, the right gastric artery, the common hepatic artery and the celiac artery were dissected under the direct vision through the abdominal incision. Total gastrectomy was followed by the reconstruction of the Roux-en-Y method using ILS_. Results: The mean operating time was 363.5 min. These patients were able to walk on the 1st postoperative day and take a meal on 5th postoperative day. The mean postoperative hospital stay was 16 days. Conclusion: This novel technique is available for minimally invasive surgery for the early gastric cancer.

LAPAROSCOPY-ASSISTED SURGERY FOR COLORECTAL NEO- P L A S M IS JUSTIFIABLE REGARDLESS OF THE A D V A N C E D AGE Hiroyoshi Matsuoka,MD., Tadahiko Masaki,MD.,PhD., Toshiyuki Mori,MD.,PhD., Masanobu Nakashima,MD.,PhD., Masanori Sugiyama, MD.,PhD., Yataka Atomi,MD.,PhD, The First Department of Surgery, Kyorin University, Tokyo, Japan

PURPOSE : The aim of this retrospective study was to confirm the feasibility of laparoscopy-assisted surgery (I_AS) for colorectal neoplasm in geriatric patients. PATIENTS AND METHODS : During May 1995 to April 2000, 74 patients with colorectal neoplasm underwent I.AS in our hospital. Fourteen patients were older than or equal to 75 years old (the aged group), and the remaining 60 patients were younger than 75 years old (the non-aged group). During the same study periods, 46 patients with colorectal neoplasm older than or equal to 75 years old underwent open surgery(OS group). Patients demographic features were compared between LAS-aged group and LAS- non-aged group (STUDY 1), and between LAS-aged group and OS-aged group (STUDY 2). A p-value less than 0.05 was accepted as statistical significance. RESULTS : In STUDY 1, neither patients gender, histroy of previous abdominal surgery, operative time, amount of hemorrhage, conversion rate to laparotomy nor preoperative and postoperative complications such as hypertension, diabetic, ischemic heart disease, or respiratory disease were statistically significant between beth groups. Futhermore, amount of postoperative analgesics, postoberative oral resumption, duration of hospital stay, recurrence rates were not significantly different. In STUDY 2, the mean operative time of the LAS group was significentiy longer than that of the OS group ( 273 min vs. 188 min : p = 0.015 ). Mean blood loss of the I.AS group was significantly less than that of the OS group ( 110 ml vs. 192 ml : p = 0.005 ). None of the remaining factors related to the preoperative and postoperative complications and recurrence were significantly different between the two groups. However postoperative oral resumption( p = 0.05 ) and duration of the hospital stay ( p = 0.057 ) tended to be earlier in the I_AS group than in the OS group. CONCLUSIONS : Laparoscopy-assisted surgery is an adequate treatment for colorectai neoplasm even in geriatric patients.

OPTIMAL TEACHING ENVIRONMENT FOR LAPAROSCOPIC VEN- TRAL HERNIORRHAPHY B. Todd Heniford, MD, Brent D. Matthews, MD, Charles L. Backus, DO, Kent W. Kercher, MD, Bill Teel, PhD, Frederick L. Greene, MD, Ronald F. Sing, DO, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina

The introduction of labaroscopic techniques after residency training has created a new teaching paradigm focusing on laparoscopic workshops with animate course training and limited preceptor instruction. The purpose of this study was to test the benefit of an animate course and evaluate the role of proctoring in learning to perform laparoscopic ventral hernia repair (LVHR).

Attending surgeons who had taken a 1-day course to learn LVHR (n = 59) were polled to determine their previous experience with laparoscopy and with LVHR since the course. The course included lectures, operative videos, and an animal lab.

Forty-eight (81.4%) attending surgeons taking the course responded. A p value < 0.05 was considered significant. Thirty-two (66.7%) surgeons had performed 179 LVHR (mean 5.6) since the course at a mean follow-up of 130.5 days. There were no statistically significant differences between the groups performing and not performing LVHR regarding academic]private practice (1::}=O.8) or opportunities to perform VHR (p=0.6). Fifteen (31.3%) surgeons were proctored (in their own hospital OR) by the lead author. Thirteen (86.7%) of the proctored surgeons have performed a LVHR compared to 19 (57.6%) of the 33 surgeons taking the course without a proctored intervention (p=0.05). Surgeons who had performed laparoscopic inguinal hernia repair, Nissen fundoplication, and common bile duct exploration were much more likely to perform LVHR (80%) after the course (p<0.0001). Surgeons performing laparoscopic cholecystectomy only were less likely to perform LVHR (42%), nearing statistical significance (p=O.08).

Surgeons with prior advanced laparoscopic surgery experience are more likely to perform LVHR after participating in a l--day course with an animate lab. Surgeons precepted in their own OR were also more likely to perform LVHR. Participation in an animate lab and a precepted experience may determine the future performance of advanced laparoscopic surgery.

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A MODEL FOR ASSESSMENT OF ADHESIONS UTILIZING MINI- LAPAROSCOPY Brent D. Matthews, MD, Broc L. Pratt, MD, Charles L. Backus, DO, Ronald F. Sing, DO, Kent W. Kercher. MD, Sharon L. Goldstein, MD, B. Todd Heniford, MD Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina

The purpose of this study was to assess the safety and cost savings of using repetitive mini-laparoscopy (2 mm) to evaluate the evolution of adhesion formation after the intraperitoneal placement of various prosthetic biomaterials in the New Zealand white rabbit model.

Polypropylene and polytetrafluoroethylene mesh were randomly placed mtraperitoneal in 44 New Zealand white rabbits. The peritoneum was left intact to simulate laparoscopic ventral hernia repair, Mini-laparoscopic evaluations were performed at 1, 3, 9, and 16 weeks. Evaluations were videotaped for blinded analysis. Adhesion formation was scored using a modified Diamond scale.

Four rabbits had anesthestic complications and died prior to mesh placement. Forty rabbits tolerated the mini-laparoscopic evaluations without complications. After the 16 weeks and 4 complete mini-laparoscopic evaluations, the rabbits were sacrificed and tissue in-growth was evaluated histologically. Cost savings using 40 rabbits with repeated mini-laparoscopic evaluation instead of 160 rabbits undergoing necropsy at 1, 3, 9, or 16 week intervals is summarized in Table 1. Total cost savings was $14,720.00. In addition, the study was completed in 16 weeks instead of 36 weeks because of housing restraints in our vivarium.

Table 1 Categor y Purchasing Housing OR Charges Postoperative Charges Savings $ 7200.00 $ 560.00 $ 2640.00 $ 2400.00

Necropsy Total $1920.00 $14720.00

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 TREATMENT FOR ACUTE GANGRENOUS CHOLECYSTITIS. Alexander Matz, M.D., Arkadi Ischakov, M.D., Ilan Charuzi, M.D., Ofer Landau, M.D., Shlomo Kyzer, M.D., Department of Surgery 'B', E. Wolfson Medical Center, Holon, Israel.

The role of laparoscopic cholecystect0my (LC) as the treatment of acute cholecystitis is well established. However, controversy persists about whether LC is the treatment of choice for gangrenous cholecystitis. We undertook the present retrospective study in order to determine the results of LC on patients operated for gangrenous cholecystiUs as compared to the results on those undergoing LC for acute cholecystitis without gangrene.

The study included 231 patients who had undergone LC for acute cholecystitis. The diagnosis of gangrenous cholecystitis was made only according to the histopathological report. Various variables, such as duration of preoperative symptoms conversion rate, intraoperative and postoperative complications, duration of the procedure and length of hospital stay, were analyzed.

The group of 231 patients consisted of 147 cases with various forms of acute cholecystitis without gangrene (Group A) and 84 cases with gangrene (Group B). The two groups were similar in demographic attributes and clinical characteristics except for the presence of more men among the patients in Group B. The conversion rates in Group A and B were 3.4% and 2.3%, respectively (P=0.9017). There were no significant differences between the groups regarding the length of surgery, incidence of intra- and postoperative complications and duration of hospital stay.

The intraoperative findings of gangrenous cholecystitis do not increase the chance of conversion or occurrence of intra- or postoperative complications.

EFFECTS OF FLUOROSCEIN DYE DOSAGE AND PNEUMOPERITONEUM PRESSURE IN THE LAPAROSCOPIC EVALUATION OF INTESTINAL 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., Department of Surgery, Allegheny General Hospital, Pittsburgh, PA.

Sodium fluoroscein administered IV and observed with an ultraviolet (UV) light is a preferred technique to determine intestinal viabdity intraoperatively via laparetomy. However, the use of fluorescein and UV light with laparoscopic visualization has not been well defined. This study compares the visualization of the fluorescence laparoscopically using different intraperitoneal pressures and different doses of fluorescein.

Sixteen 25 kg pigs were divided into eight groups of two pigs each. Four groups had a pneumoperitoneum of 7 mmHg, and four groups had a pneumoperitoneum of 14 mmHg. Alter devascularizing a 10-15 cm segment of small bowel, two filters (Kad Storz Endoscopy, Culver City, CA) were placed, one between the light source and the light cable to filter all but UV light, and one between the laparoscope and the camera to filter all but fluorescent frequency. One group receiving each pressure was given either 5 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,, or fiuoroscein dosages affected visualization of viable and ischemic bowel.

In all cases, viable tissue and intestine were visualized as fluorescent, whik the ischemic segment was a darkened silhouette against the fluorescent tissue. There were no differences noted between the groups with different pneumoperitoneum pressures when using the same fluoroscein dose. However, visualization was better with the intermediate doses (10 rng/kg and 15 mg/kg) than with the lowest or highest dose.

The pressure of the pneumopefitoneum (up to 14 mmHg) does not interfen with laparoscopic visualization of ischemic intestine using fluoroscein and U~, light in the porcine model. Optimal doses of fluoroscein are 10 mg/kg or 15 mg/kg. This technique using these doses and pressures has potential to assi in the evaluation of patients suspected of having mesenteric ischemia.

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COMPUTER ENHANCED "ROBOTIC" TELESURGERY: INITIAL EXPERIENCE IN FOREGUT SURGERY W. Scott Melvin, MD, Bradley J. Needlaman, MD, Kevin R. Krause MD, Carol Scheider, BA, RN, Randall K. Wolf, MD, Robed E. Michler, MD, E. Christopher Ellison, MD. Department of Surgery, The Ohio State University, Columbus, Ohio

New technologic advances have changed the way surgeons interact with their patients in the operating room. Computer enhanced telesurgery allows remote control manipulation of multi-articulated intracorporeal instruments. The daVinci tm Surgical System (Intuitive Surgical, Inc., Mountain View, CA, USA) was approved for general surgical use this year and we have employed it for the treatment of disorders of the upper gastrointestinal tract. We prospectively collected patient data to evaluate the safety and efficacy of the device.

Seventeen cases were done that included 10 anti-reflux operations, 4 Heller myotomies, 1 distal pancreateotomy/splenectomy, 1 diagnostic laparoscopy, and 1 esophagectomy with transthoracic esophagogas- trostomy. There were 8 females and 9 males with an average age of 45.7 years and weight of 182 Ibs. The average operative time was 178.6 minutes with a range of 88 - 458 minutes and the average robot time was 90.4 minutes with a range of 16 - 185 minutes. We generally used 2 operative ports, 1 camera port and 1 or 2 assistant ports. There were no conversions due to device failure. There were no major complications.

Computer enhanced robotic telesurgery is a safe and effective method of treatment for a vadety of disorders of the proximal gastrointestinal system. The advantages of three-dimensional imaging, scaled hand motions and intracorporeal articulation allow complex tasks to be performed. Devices and procedures that are currently available remain under development. Further advances and studies will define the true role of "robots" in the operating room.

LATE OUTCOMES OF DIAGNOSTIC LAPAROSCOPY FOR CHRONIC ABDOMINAL PAIN Elizabeth A. Mittendorf, M.D. and Raymond P. Onders, M.D., Department of Surgery, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio

Introduction: In order to determine the utility of performing diagnostic laparosoopy in patients with chronic abdominal pain, this study was performed to evaluate long-term outcomes in patients undergoing this procedure.

Methods: A retrospective review was performed of patients undergoing laparosoopic procedures between July, 1997 and July, 2000. Those undergoing diagnostic laparoscopy for chronic pain were identified and length of time with pain, number of diagnostic studies performed, intraoperative findings, interventions, pathology, and long-term follow-up were determined.

Results: Of 1308 laparoscopic procedures performed, 70 (5%) were for the evaluation of chronic abdominal pain. There were 61 women and 9 men with an average age of 42 years. The average length of time with pain was 74 weeks (range 8-260) and the average number of studies performed prior to surgical referral was 3.3. 53 (76%) patients had their procedures performed as outpatients with the remainder admitted for observation status. The average length of operative time was 70 minutes, no cases required conversion to an open procedure and no complications occurred. Findings included adhesions in 39, a hernia in 13, adhesions from the appendix to adjacent structures in 6, appendiceal pathology in 5, endometdosis in 3 and gallbladder pathology in 2. 10 patients had no obvious pathology. At the time of their initial postoperative visit, 75.7% reported their pain to be gone or improved. After an average follow-up of 74 weeks, 28.8% noted recurrence of their symptoms therefore 66.7% had long-term pain relief. No patient experienced any long-term complications and all reported satisfaction with their procedure.

Conclusions: Diagnostic laparosoopy can be performed safely, frequently on an outpatient basis, with good long-term results in patients with chronic abdominal pain.

CHRONIC RIGHT LOWER QUADRANT PAIN: LONG-TERM RESULTS AFTER LAPAROSCOPIC APPENDECTOMY Elizabeth A. Mittendorf, M.D. and Raymond R Onders, M.D., Department of Surgery, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio

Introduction: The purpose of this study was to evaluate the utility of laparoscopic appendectomy in patients with chronic right lower quadrant (RLQ) pain in whom preoperative imaging failed to identify an etiology.

Methods: A retrospective review was performed of patients undergoing diagnostic laparosoopy for chronic pain between July, 1997 and June, 2000. Length of time with pain, number of diagnostic studies performed, preoperath, e exam, intraoperative findings, pathology, postoperative pain status and long-term follow-up were determined.

Results: Of 70 patients undergoing diagnostic laparoscopy for chronic pain, 21 subjectively localized their pain to the RLQ. 15 (71%) had reproducible pain on exam. The average lengt~ of time with pain was 64 weeks (range 8-200) and the average number of diagnostic studies performed was 4. Intraoperative findings included adhesions in 5, adhesions from the appendix to adjacent structures in 5, a thickened appendix in 4 and an appendiceal mass, inflamed gallbladder and endometriosis in one each. 4 had no obvious pathology. All 21 patients had an appendectomy performed, 13 also had extensive adhesiolysis. Pathology revealed findings consistent with chronic appendicitis in 9, a feoal~ in 2, 1 appendix with inflammatory exudate and 1 with endometriosis. 7 were normal. Intraoperative appearance of the appendix did not correlate with pathologic diagnosis. At an average follow-up of 51 weeks, 17 have had resolution of their pain including all those with abnormal pathology except for the patient with fibrinous exudate who reports no change in his symptoms. 2 patients, both with pathologically normal appendices had early improvement but have subsequently experienced recurrence.

Conclusions: Diagnostic laparosoopy has a role in the treatment of patients with chronic RLQ pain. The intraoperative appearance of the appendix is unreliable in determining disease therefore all patients should undergo appendectomy. Pathologic findings are predictive of long-term success in symptom relief.

ADVANCED LAPAROSCOPIC SURGERY TRAINING COURSE: IMPACT ON SURGICAL SKILL AND THE CUNICAL PRACTICE PAT- TERNS Toshiyuki Mori M.D., Hiroshi Shimoi, M.D., Tadahiko Masaki, M.D., Masanod Sugiyama, M.D., Yutaka Atomi, M.D., Department of Surgery I, School of Medicine, Kyorin University, Tokyo, Japan

Background: Advance laparescopic courses, highlighting suturing skill, are needed for surgeons who routinely perform laparosoopic cholecystectomy before they start new demanding procedures. This study is conducted to assess the impact of the advanced laparescopic course on laparoscopic surgical skill and the clinical practice pattern of the participants. Method: A survey was mailed to all eighty one participants of our advanced laparosoopic courses, regarding suture techniques employed at the time of questionnaire, procedures performed in the clinical practice. The course consists of three half days, covedng sutudng practice, suture-closure of duodenal perforation, Nissen fundoplication, and nephrectomy. Results Twenty-eight out of eighty-one participants responded the survey (Response rate 34.6%). Acquisition or improvement of suturing skill was noted in 15 (53.6%). As a result, twenty-two surgeons are able to tie knots laparosoopicelly (78.6%), seventeen surgeons intracorporeally (60.7%) and five surgeons extracorporeally (17.9%). Nine surgeons started laparoscopic closure of perforated ulcer after the courses (32.1%). Skill acquis~ion or improvement in suturing was noticed in all. Seven surgeons started CBD exploration after the courses (25~176 Suturing skill of these surgeons at the course was none in all, and intracorporeal knot tying in all at the survey. F'Ne surgeons started laparosoopic splanectomy after the course (17.9"/.). Sutudng skiU of these surgeons at the course was none in all, and intracorporeal knot tying in all at the survey. No relation was found between skill acquisition and the profile of respondents, including age, experience in general or laparoscopic surgery. Conclusion Advance laparoscopic course has a tremendous impact not only on surgical skill, but on the clinical practice patterns. Surgeons who have learned suturing skill in the course tend to start more demanding procedures after thaL

MUSCLE ABILITY AFTER LAPAROSCOPIC HERNIOPLASTY VERSUS CONVENTIONAL REPAIR Nobuo Murata. M,D., Y. Makita, M.D., A. Odaka, M.D., H. tshida, M.D., K.$himomura, M.D., K. Takahashi, M.D., D. Hashimoto, M.D., Y. Idezuki, M .D. Department of Surgery and Rehbilifation, Saitama Medical Center, Saltama, JAPAN

It has been reported that laparoscopic hemioplasty (LH) yields reduced postopertive disability of exercise. However, no comparative data on muscle strength after LH and conventional repair (CR) have been collected. The aim of this study was to compare the strength of muscles related to the operation by muscle testing after LH and after CR.

Twenty-sevan patients with primary inguinal hernias were randomly divided into 2 groups according to surgical procedure: 14 patients were treated with LH (a preperifoneal technique) and 13 w{th CR (an itiopubio tract repair technique). Two types of muscle testing around the inguinal region by manual examination and using a musculator were performed pdor to and 1 week after ilia operat;or,.

There were no significant differences in muscle strength in the muscles around the inguinal region, except the iliopsoas muscle, between the 2 procedures. The muscle strength of the iliopsoas muscle was reduced in 6 patients in the CR group but in none of the patients in the LJ-I group by manual examination. The muscle strength of the iliopscas muscle by the musculator was 48.5 + 27.4 kg (mean + SD) in the LH group and 41.8 + 22.1 kg in the CR group before the operation. It was 50.5+27.0 kg in the LH group and 32.5 :1:21.0 kg in the CR group I week after the operation. There was a significant difference in the decrease in muscle strength in the iliopsoas muscle after the operation between the 2 groups.

In conclusion, since the muscle strength of the iliopscas muscle did not reduce after LH, we suggest that this procedure is more useful than CR, in terms of muscle strength.

EFFECT OF HEATED AND HUMIDIFIED GAS ON POSTOPERATIVE PAIN AFTER LAPARO$COPIC NI$SEN FUNDOPMCATION: A RANDOMIZED STUDY. Ninh T. Nauven. MD, GabrieUa Furdui, MD, Franco Canet, Steven Lee, BS, Bruce M. Wolfe, MD, UC Davis Medical Center, Sacramento, CA.

Heated and humidified gas has been shown to reduce intraoperative hypothermia, The aim of this study was to compare the effect of heated and humidified COz insufflation versus room temperature CO2 insuffiation on intraoperative urine output and postoperative pain.

Twenty patients undergoing leparoscopio Nissen fundoplication were randomized to receive either room temperature CO2 insufflation (group 1, n=10) or heated and humidified CO2 insuffiation (group 2, n=10). An external warming device was used intraoperatively in both groups. Core temperature, abdominal temperature, volume of gas delivered, in~'aoperative urine output, and number of lens fogging episodes were recorded. Postoperative pain was evaluated on day 1 by a visual analog scale (VAS) and narcotic requirements were recorded.

There was no difference between groups for age, operative time, and volume of gas delivered. No postoperative complications occurred in either group. Temperature Group Baseline 0.5 hour 1 hour 1.5 hour Core 1 35.7 • 0.5 35.9 • 0.6 36.1 • 0.5 36.0 ~ 0.6 (~ 2 35.9 ~ 0.4 36.0 • 0.5 36.2 • 0.4 36.3 • 0.3 Abdominal 1 35.6 • 0.7 35.7 • 0.7 35.4 + 0.7 35.1 • 0.5 (=C) 2 35.7 _+ 0.5 35.9 • 0.6 35.7 • 0.5 35.9 • 0.6* Data are given as mean :1: SD. *p < 0.05 versus group 1 (repeated-maesures ANOVA).

Compared to baseline value, core temperature remained stable in both groups. Abdominal temperature decreased by 0.5 ~ in group 1 but increased by 0.2 ~ in group 2. There was no significant difference for VAS, urine output, narcotic requirements, and number of lens fogging episodes between groups.

Laparoscopic tundoplication with room temperature C02 insufflation did not result in significant core temperature changes. Heated and humidified CO2 insuffiation during laperoscopic fundoplication minimized the reduction of intreabdominal temperature but did not enhance intraoperative urine output or reduce postoperative pain compared to room temperature CO2 insuffiation.

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CLOSURE OF CUTANEOUS LAPAROSCOPIC WOUNDS USING BUTIL-2-ClANOACRYLATE. C.,.lyI.M. Muto. M.D., S. UIIo, M.D., F. Pettar, Jti, M.D., L. Esposlto, M.D., G. Verrengia, M.D., V. Schiavone, M.D. - Video Surgical Operative Unit - Clinice Pinata Grande - Castel Voitumo (CE) - ITALY

In our s~cture we courrentiy use butil-2-cianoacrylata for repadng cutaneous laparoscopic access. We obtain very good results. In the time of minHnvasive surgery is very important good results about dcatTizzation of surgical wounds. Is't necessary a good "rostitutJo ed integrum �9 for littJe cutaneous laparoscopic access. Wounds cicatfizzabon is very difficult result of many reec'dor~ of connective and epifelial tessue that make function twice. In the connective tessue, after an ini~l inflammatory essudative rases, we obtain moltiplication of fibrobleste and endotatial ceils. Dudng first 24 hours we have collageno whose production is high dudng first week of dcatdzzation. Dudng fifth/sixt~ days we see formation of neevascoladzatJon of new tessue. Epitetlal tessue makes function that give reparation of wounds in third days. Maturation of new tessue gives functional e rnorphologic property of epidermids. At eights day we obtain a r that has less resistance, but after few months it takes good rasistence. Cutaneous cicab'izzation depends from general and local factors: costitution, age of patient;, coagulopathologies, nutriztonal factors; inflammation, venous or artarial deficit; temperature, kind, large, idratation of wounds. Wounds suture gives best dcetrizzation for first intention and it'lo important for a good aesthetic and fundJonal results. For suture we can use suture, adhesive substance and methaliic agraphes. All suture gives extra body resction. This reaction makes a not good dcelzizzation for ischemic reaction of tessue. In our private s~ctura, accreditate with italian S.S., we use b~'l.2. cianoacrylata for reparing cutaneous laparoscopic access, a fluid tessutal adhesive substance that in 10 seconds give pollmedzzation with good tollerability, no oncogeneeis, and spontaneous elimination with cutaneous rechange. We use this adhesive substance in 37 cases of patients operated usin laparoscopic access. For every patients we make 4 cutaneous access and we use butil-2-danoacJytate for reparing 100 cutaneous wounds. We ~'eaRed a~omeo wounds, above Langer tines, of 5 to 20 ram. After suturing understanding planes, we put adhesive substance on the wounds, with ster]l streeps above tha wounds. We remove the stedl sfzeeps alter 10 postoperative days. We obtain good dcetdzzation with good functional and aesthetic results. In only 4 cases we obtained not good linear wounds, one deiscence, and one granulomas. We don't obtain ipertrophic evolution of wounds repair. We can say that we obtained very good aestethlo and functional results using butii-2-cianoacrylate dosing cutaneous laparoscopic access and, very important, patients don't go to remove suture.

EFFECTIVENESS OF LAPAROSCOPIC ADHESIOLYSIS ASSESSED BY S E C O N D - L O O K LAPAROSCOPY D. Nio, W.A.Bemelman, A. Peters, F.W. Janssen, M.S. Dunker, J. Ringers, D.J. Gouma, Departments of Surgery and Gynaecology, Academic Medical Center, Amsterdam and Leiden University Medical Center, The Netherlands

Postoperative adhesions may cause infertility, bowel obstruction and chronic abdominal pain. Adhesions can be classified as �9 de novo " adhesions developed at the area of dissection (type a) or outside the area of dissection (type Ib), and reformed adhesions (type II). It is unknown how effective laparoscopic adhesiolysis is with respect to" de novo ' and reformed adhesions. The objective of this study is to asses~ the effectiveness of laparoscopic adhesiolysis assessed by seconC look laparoscopy. From January to November 1998 16 patients (14 women, 2 men) witl" chronic abdominal pain were included. Mean age was 42.8 year., (range 32-66). Mean number of laparotomies was 4.4 (range 1-7). Priol to laparoscopic lysis, adhesions were assessed using a modification o' the American Fertility Society (AFS) model. In addition the area of th~ organs covered with adhesions was measured using a calibratec laparoscopic probe. Next all adhesions were lysed taparoscopicatly Four to ten weeks after laparoscopic adhesiolysis patients had a sec ond look laparoscopy to evaluate de novo and reformed adhesions Efficacy parameters were number of adhesions, number of involve( organs, and total area. Statistical analysis was done using the statisti cal package of SPSS 9-0 for Windows. In one patient a" de novo" type l a adhesion was found during secon( look laparoscopy. A significant reduction of adhesions was found affe laparoscopic adhesiolysis in number of adhesions (50%, 5.9 to 2.9) number of involved organs (50%, 8.7 to 4.4), and total area (25%, 9; cm2 to 69 cm2). In conclusion, despite a certain effectiveness of laparoscopic adhesioly sis, more than half of the lysed adhesions reform. The laparoscopi~ approach is associated with a low incidence of de novo adhesions.

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EFFICIENCY OF MANUAL VERSUS ROBOTIC (ZEUS) ASSISTED LAPAROSCOPIC SURGERY IN THE PERFORMANCE OF STAN- DARDIZED TASK: A RANDOMIZED STUDY D. Nio, W.A.Bemelman, R. Kuenzler, K. den Boer, D.J. Gouma, T.M. van Gulik, Departments of Surgery and Surgical research, Academic Medical Center, Amsterdam, The Netherlands

Several robotic arms have been developed to assist in laparoscopic surgery. It is not known how efficient robotically assisted laparoscopic surgery is as compared to manual laparoscopic surgery. The objective of this study is to compare the surgical performance of manual and roboti- (:ally assisted laparoscopic surgery. Twenty medical students without any surgical experience were randomized to perform a set of laparosoopic tasks either manually or robotically assisted (ZEUS) to evaluate the efficiency of a set of basic endoscopic movements: dropping beads in receptacles, running a 25 cm rope, cap- ping a hypodermic needle, suture and laparoscopic cholecystectomy on a cadaver liver. All exercises were recorded on videotape for later time motion analysis. A quantitative time-motion analysis was carried out to evaluate the speed of skill performance and the number of actions. Primary efficacy parameters were total time and total amount of actions required to finish the several tasks. Statistical analysis was done using the statistical package of SPSS 9-0 for Windows. The time required to complete the dropping beads exercise and the laparoscopic cholecystectomy was significant longer when done robotically assisted (p---0.001 and p=0.05). Picking up the beads, grasping the rope and picking up either the needle or cap were tasks that required less actions to complete when performed robotically assisted (p=0.011, p=0.030 and p=0.015). Both beads and rope were more frequently dropped unintentionally in the manual performed exercises (p=0.031 and p=O.O24). In conclusion, robetically assisted laparoscopic surgery requires more time, but actions can be performed more precise as compared to manual laparoscopic surgery.

CLINICAL APPLICATION OF 3D CT ANGIOGRAPHY FOR LAPARO- SCOPIC COLORECTAL SURGERY: OUR PREUMINARY EXPERIENCE Kanji Nishiguchi M.D., Junji Okuda M.D., Masao Toyoda M.D., Shinsyo Morita M.D., Tetsuhisa Yamamoto M.D., Keitaro Tanaka M.D., Hiroshi Kawasaki M.D., Soyu Lee M.D., Nobuhiko Tanigawa M.D., Department of General and Gastreenterological surgery, Osaka Medical College, Osaka, Japan

Introduction: The purpose of the study was to examine the role of three dimensional (3D) helical CT angiography as an adjunct to laparoscopic surgery for colonic carcinomas. For the resection of sigmoid and upper rectal carcinomas using laparoscopic techniques, we routinely perform lymph node dissection around root of IMA with preserving the left colic artery. In add~on, for right sided colon carcinomas, we perform lymph node dissection exposing what we call the surgical trunk (superior mesenteric vein). For either of these procedures to be performed safely, vascular anatomy becomes an important issue. It is our opinion that accurate preoperative assessment of this vascular anatomy aids the surgeon in performing a safer operation.

Methods: The 3D helical CT angiograms of 5 patients were examined (3 left sided carcinomas, 2 right sided). The radiographic images were compared with intraoperative findings.

Results: For left sided cancers, we were able to accurately visualize the left colic artery as well as ascertain its relationship to sigmoidal branches using the 3D helical CT for all three patients. For both patients with right sided carcinomas, we were able to assess branches of the superior mesenteric artery as well as determine the presence (or absence) of a right colic artery. These findings were not only confirmed intraoperatively, but knowledge of this anatomy actually facilitated the operative dissection of these difficult regions.

Conclusion: Our preliminary experience with the 3D helical CT angiography is that it can accurately determine the surgical vascular anatomy important in the treatment for both left sided and right sided carcinomas. With further improvements in imaging quality of the 3D helical CT, it is likely that this will replace standard contrast angiography in the preoperative setting, and may play an important part in the preopera~e planning of cancer operations.

LAPAROSCOPIC NISSEN FUNDOPLICATION WITHOUT A BOUGIE: OUTCOMES ANALYSIS Yuri W. Novitsky, M.D., Kent W. Kercher, M.D., John J. Kelly, M.D., Karen A. Gallagher, R.N., Vinetta M. Hussey, A.N.P., and Demetrius E.M. Utwin, M.D., Department of Surgery, University of M~_ss Medical School, Worcester, MA

Background: Esophageal intubation with a beugie during LaDaroscopic Nissen Fundoplication (LNF) is used to gauge cah'ber of hiatal closure and prevent an excessively tight wrap. Intraoperative gastric and esophageal perforations by the bougie have been well documented. We report the results of LNF performed without a beugie at our institution.

Design: Retrospective review of 52 consecutive patients who underwent LNF without a bougie at a tertiary care hospital with a mean follow-up of 10.9+-7.8 (1-28) months.

Materials and Methods: Presenting symptoms included heartbum (86~ regurgitation (50%), epigastricJchest pain (48%), respiratory symptoms (15%) and dysphagia (12%). Sliding hiatal hernia was present in 28 (54%) 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 resting LES pressure was 13.9+-8.9 (5-40) mmHg. Mean distal esophageal amplitude was 72.6+-38.2 (21-200) mmHg. At operation, all short gastric vessels were divided, the crura were reapproximated, and a loose 360 degree fundoplication was performed without a beugie.

Results: In the immediate postopera~e period, 29 patients (56%) complained of mild, 5 (9.6%) of moderate and 2 (3.8%) of severe dysphagia. Average duration of early dysphagia was 4.5+-2.1 (2-8) weeks. Dysphagia resolved in 50/52 patients w~in 8 weeks. Persistent dysphagia was found in 2 patients (3.8%). One of them had severe preoperative dysphagia that was improved after LNF. One patient was successfully treated with esophageal dilatation at 8 weeks postoperatively. 15 patients (29%) had transient gas bloat with average duration of 6.5+-5.6 (2-24) weeks. Mild persistent reflux was noted in 7 patients (13.5%) with 6 requiring daily medications.

Conclusion: LNF performed without beugie offers a safe and effective therapy for GERD. While avoiding the potential risks of gastric and esophageal injury, in the experienced hands it provides low rates of postoperative dysphagia and reflux recurrence.

SYMPTOMATIC AND P H Y S I O L O G I C O U T C O M E S AFTER OPERATIVE TREATMENT FOR EXTRAESOPHAGEAL REFLUX Brant K. Oelschtager M.D., Thomas R. Eubanks D.O., Dmitry Oleynikov M.D., and Carlos A. Pel legrini M.D., University of Washington, Department of Surgery, Seattle, Washington

Pharyngeal pH monitoring has recently been used to identify patients with extraesophageal symptoms induced by gastroesophageal reflux. We employed this method of acid detection to evaluate patients with respiratory symptoms prior to and after laparoscopic Nissen fundoplication. METHODS: Twelve pat ients underwent symptom evaluat ion, esophageal manometry and 24 hour pH monitoring with a pharyngeal probe before and after laparoscopic Nissen fundoplication. Episodes of pharyngeal acid exposure were considered abnormal if the pH dropped below 4, occurred simultaneously with esophageal acidification, and occurred outside meal times and a one hour postprandial period. Continuous data was analyzed using student t-tast and ordi- nal data using a one-tailed Wilcoxon Ranks Sum test. RESULTS: Symptoms of aspiration, laryngeal irritation, and heartburn were improved by operative treatment (p<0.05).The LES pressure before and after operative intervention was 13mmHg and 18mmHg, respectively (p=0.09). There was a significant change in both upright (7.0% to 1.0%) and total (4.9% to 0.6%) percent time acid exposure in the distal esophagus after operative treatment. Pharyngeal acid reflux episodes were decreased from 4.7 to 0.7 episodes/24hr, (p=0.t5). CONCLUSIONS: Operative treatment of GERD is effective at controlling subjective and objective measurements of extraesophageal reflux. The use of pharyngeal pH monitoring may help in selecting which patients with respiratory symptoms will benefit from antireflux procedures.

REDUCTION OF LAPAROTOMY ASSOCIATED LUNG METASTASES AFTER PERIOPERATIVE FLT3 UGAND ADMINISTRATION IN A MURINE MODEL Anthony On, MD; Joseph Carter, MD; Peer Wildbrett, BS; George Stapleton, 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 Physicians & Surgeons, New York, N.Y.

Object~e: It has been established that laparotomy is associated w~h postoperative immuncsuppreesion, increased tumor cell proliferation, and an increased incidence of pulmonary metastases(mets) when compared to anestheeia(anesth.) alone. This study's goal was to determine the impact of periop administration of Fit3 ligand, a precursor that acts synergist=cally with GMCSF, on the incidence of lung mete after laparotomy or anesth, alone. ~ : A murine pulmonary metastasis model was utilized. Six week old NJ mice(n=70) were randomized to 4 groups: 1) anesth, control(AC), 2) anesth. control plus FIt3(ACFIB), 3) sham l a p a ~ ( O P ) , or 4) sham laparotomy plus FIt3(OPRt3). Groups 2 & 4 received daily intmparitoneal(IP) injections of 10mcg Fit3 in saline with 1% ~ serum albumin(MSA) for 5 days prior and 7 days alter surgery. Groups I & 3 received similar IP injections of saline with 1% MSA. On r day of surgery, tail vein injeclkx~ of 1.5 x 10"5 Ta3Ha meuse mammary carcinoma cells were given to all mice. Alter 14 days, the mice were sacrificed and the lung.Mmd~ea excised en bloc after injecting the trachea with Incr=a ink. The lungs were later immersed in Feket's solution to bleach lhe tumor nodules. Surface mets were counted by a blinded observer. Results: The OPRt3 subgroup had significantly fewer lung meta(38) then the non-treated Open subgroup(166,p=0.021 vs OPFIt3). The same was true for the AC subgroups( ACFIt3, 10 vs. AC, 50, p=0.001 ). As noted earlier, more lung mets were noted in the OP (166) than in the AC group(50) (1:)==0.048). Histolegic analysis of Fit3 treated mice revealed increased numbers of antigen presenting cells surrounding the tumors compared to controls. Conclusions: Laparotomy(vs AC) was again associated with an increased number of lung roots. Periop Fit3 treatment, presumably via up-regulation of ceU-medzated immunity, significantly r e d ~ ~he number of lung rnets after either anesth, alone or laparotomy. Further studies examining the role of periop i m r n u ~ l a t i o n in the setting of cancer seem to be indicated.

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TECHNIQUE AND RESULTS OF LAPAROSCOPY ASSISTED DISTAL AND TOTAL GASTRECTOMY FOR TREATMENT OF GASTRIC CANCER Yasunaga-Okazaki, M.D., Hideo-Yamada, M.D., Michihiro-Kawada, M.D. Department of Surgery, Sakura National Hospital, Sakura, Japan

Background: The use of laparoscopic curative resection for gastric cancer is growing,and Laparoscopy- assisted distal gastrectomy (LADG) has been gradually accepted for the treatment of early and advanced gastric cancer located in the body and antrum of the stomach. The patient with gastric cancer located in upper part of the stomach was treated by open total gastrectomy. So, we applied the double stapling technique of gastric bypass for morbid obesity to these patients.(Hand assisted laparoscopic total gastrectomy : HALTG)

Patients:From Jan. 1999 to Sep. 2000, LADG for gastric cancer limited to the submucosa ('1"1) and located in the body or antrum of the stomach were performed to 19 patients. From Sep. 2000. HALTG was performed to one patient with early gastric cancer located in cardia of stomach

Operative of LADG:Dissection and divide of the left gastric and right gastric arteries and veins, the left and right gastrcepiploic arteries and veins and D1 lymphadenectomy were performed under the pneumoperitoneum. Dissection of lymph node 7, 8a, 9, and 11th and resection of stomach with stapled end-t(> end anastomoses were performed via a minilaparotomy through an incision 5-7 cm long in the epigastric area.

Operation of HALTG:Operative methods are almost same as LADG, ant resection of stomach and reconstruction are different. After the stomach is complete mobilized the gastroesophageal junction is cut off by way of the lin, ear stapler. We have employed the esophagus as a conduit to introduce th( anvil of the stapling device into the stomach. The reconstruction is created a~ a Roux en Y esophago- jejunostomy performed by a circular stapler. These methods are performed by hand assisted. Result:The mean operative time of LADG were 142(97-219)min The mear blood loss were 150 ml. There were no severe early postoperative complica tions.

Conclusion:We conclude that these laparoscopic procedures are curative LADG and HALTG is expected to become more widely adopted as a treat ment for gastric cancer and may change the surgical treatment for patien~ with gastric cancer.

LAPAROSCOPIC COLORECTAL CANCER SURGERY IN 129 PATIENTS Junji Okuda, M.D., Maseo Toyoda, M.D., Shinsho Mofita, M.D., Tetsuhisa Yamamoto, M.D., Keitaro Tanaka, M.D., Kanji Nishiguchi, M.D., H!roshi Kawasaki, M.D., Hirokazu Okano, M.D., Nobuhiko Tanigawa, M.D., Department of General & Gastroenterological Surgery, Osaka Medical College, Takatsuki-City, Osaka, Japan

The purpose of this study was to demonstrate our indication and surgical procedure of laparoscopic curative surgery for coloreotal cancer and to evaluate its efficacy.

Based on our clinicopathological analyses of conventinally resected col- orotal cancers at our department, we've applied laparoscopic bowel resection with paracolic lympadenectomy(D1) to mucosal('lqs) cancer difficult to be resected endoscopleally, with paracolic and intermediate lymphedenectomy(D2) to elevated type of submucosal(T1) cancer, and with additional lymphedenectomy around the origin of major vessels(D3) to depressed type of T1 cancer as well as T2,T3 cancer, located in the colon or rectum. EMR appears to be the optimal medality even for large mucosal tumors. However, in case the tumor could not be resented completely by EMR including piecemeal fashion, laparoscopic-assisted bowel resection with D1, especially using micro-instruments(2mm in size), might be feasible not only of curative intent but also for better quality of life. The conventional oncologic principles can be maintained in laparoscopic surgery using laparoscopic type of "No-touch isolation technique", which could lead to prevent the port site recurrence.

Through August 2000, we did laparoscopic resection on 129 cases (D1:25, D2:41, D3:63). With respect to adequate resection with lymphadenectomy, laparoscopic surgery was comparable with open surgery. in a laparoscopic group, blood loss was less and first flatus was passed earlier. The overall morbidity rate and mortality rate after lapasroscopic surgery were 11.6% (major:6.2%, minor:5.4%) and 0%. The mean follow- up time is 25 months. Recurrence was identified in three patients with Stage Ill cancer (liver metastasis:2, peritoneal seeding:l). There have been no local or port site recurrences so far. In conclusion, laparoscopic surgery could play a signiFy.ant role in the treatment of colorectal cancer.

OFFICE ULTRASOUND BY GENERAL SURGEONS AIDS PATIENT CARE AND MANAGEMENT

Michelle M Olson. MD and Keith N Apelgren, MD Department of Surgery, Michigan State University, East Lansing, Michigan

General surgeons utilize ultrasound (US) in caring for patients with breast 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 needle aspiration or biopsy. The purpose of this abstract is to illustrate the utility of this technique in the management of a variety of office surgical problems.

Over the previous 2 years, the 7.5 or 10 MHz US probe has been used to le physical examination in many patients r inc ludin 9 me following:

Patient Problem Ultrasound Finding Outcome CS

i EM

i WD

JO

i WP

MJ

Soft tissue mass, left lilac crest Left groin mass s/p lymph node biopsy Rectus hematoma

Foreign body in foot

Vague density 4.1 cm deep Cystic mass

Mixed-density mass, scant fluid Localization

US guided core biopsy done US guided drainage of.semma Operative drainage

Easy removal

Bullet fragment in Localization Easy removal beck, 2 mos later Neck mass near Solid lesion Needle biopsy in mandible office

As we have gained experience, we find more uses for US in the office setting. The technique aids accurate and complete aspiration of a cystic mass and accurate placement of a biopsy needle. Based on our experience with the above patients and others, we conclude that general surgeons should become competent in office uttrasonography and utilize the techniqul more often.

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LAPAROSCOPIC MANAGEMENT FOR ENTERAL BLEEDING Hiroaki Omori,M.D.,Hiroshi Asahi,M.D.*,Yoshihiro Inoue,M.D.,Takashi Irinoda,M.D.,and Kazuyoshi Saito,M.D., Critical Care and Emergency Center and Department of Surgery I*, Iwate Medical University, Morioka, Japan

Introduction and purpose: Enteral bleeding is a relative rare condition among lower G.I. bleeding and is usually accompanied with massive bleeding requiring transfusion, because it takes a long time to make accurate diagnosis. Therefore prompt urgent diagnosis and therapy are needed and open surgery is usually necessary. However, several papers regarding with laparoscopic resection of Mecksi's diverticulum or.bleeding tumor of small bowel were recently reported. In this study, we assessed the outcome of enteral bleeding retrospectively and evaluated indication of laparoscopic management for enteral bleeding. Patients and results: Patients who had accurate diagnoses of enteral bleeding preoperatively were 5 cases from January 1997 to August 2000. All had emergency arteriography in which 3 had extravasation of contrast media and I had tumor stain. One case with no abnormal findings in arteriography had tube enterography and a big enteral diverticulum was detected. Each diagnosis of 5 cases is Meckers diverticulum, leiomyoma, enteral mural aneurysm, lilac pseudo-aneurysm related retroperitoneal abscess, and Crohn's disease. Open surgery was selected for 2 cases (lilac aneurysm and Crohn) who had poor conditions due to shock and laparoscopic surgery was selected in the other. It was difficult for detecting bleeding site in case with enteral mural aneurysm and converted to open surgery. On the other hands, it was easy for detecting each lesions in cases with Meckers diverticulum and leiomyoma and wedge resection of ileum and partial enterotomy were done by laparoscopy-assisted fashion, respectively. Each operative time was 70 and 100 minutes and oral intake was started at 3POD and 6POD, respectively. Two cases required open surgery and 1 case with conversion w e r e obliged to have artificial ventilation for ARDS. Condusion: It was concluded that Meckers diverticulum and benign tumor of small intestine without shock were good candidates of laparoscopic management for enteral bleeding.

A L A P A R O S C O P I C F O R E G U T D I S O R D E R P R O G R A M INCREASES S U R G I C A L RESIDENTS' EXPERIENCE IN FLEXIBLE U P P E R E N D O S C O P Y Raymond P. Onders M.D., Depar tmen t of Surgery, Univers i ty Hospi ta ls of Cleveland and Case Western Reserve University School of Medicine, Cleveland, Ohio

Background: There is some concern that the endoscopic training of surgical residents has been decreasing or being performed by non-surgeons. The aim of this study is to see if the addition of a laparoscopic foregut disorder program increases surgical residents' exposure to upper endoscopy.

Methods: The setting is the division of general surgery in one of three training hospitals for a university based surgical residency. A five-year retrospective review from 1995- 2000 of billing and operative procedures done by the division was performed. The first two years were compared to the last three years after the division began a laparoscopic foregut disorder program with specifically trained faculty.

Results: From 1995-1997 the division averaged 56 flexible upper endoscopic procedures. From 1997 to 2000 the division averaged 158 procedures a year. This is a 180% increase. During the same time period there was only an increase of 50% in the number of colonoscopies. Surgical residents are involved in all of the division's operative procedures.

Conclusions: The development of a minimally invasive foregut disorder program can increase resident's experience and training in flexible upper endoscopy. There has been no decrease in referrals for foregut procedures even with the increased surgical endoscopic practice.

LAPAROSCOPIC VERSUS OPEN SPLENECTOMIES IN THE NEW MILUNEUM: SHOULD OPEN SPLENECTOMIES STILL BE DONE? Raymond P. Onders M.D., John J. Jasper M.D., Department of Surgery, University Hospitals of Cleveland and Case Westem Reserve University, Cleveland, Ohio

Background: Laparoscopic splenectomy (LS) is rapidly becoming the procedure of choice for surgical correction of hematologic disease refractory to medical management. This study was undertaken to compare operative time, blood loss, length of stay and morbidity for patients undergoing open splenectomy (OS) vs LS for hematologic disorders at a single institution at the dawn of a new millenium.

Methods: In the last 30 months of the 1990's, 20 patients underwent LS and 20 patients underwent OS for treatment of hematologic disorders with decision for the type of surgery based only on the referral pattem and insurance status of the patient.

Results: The two groups were comparable in indications (40% for ITP in each group), age (59 for LS, 48 for OS), ASA classification (2.7 for LS, 2.5 for OS) and splenic weight (482 g for LS and 5,33 for OS). The postoperative hospital stay was significantly longer for OS patients than for LS patients (7.3 +- 1.0 days vs 2.5 +- 0.4 days, p < 0.0001). The operative time was shorter for OS than for LS (159 +- 14 min vs 169 +- 10.5 min, p=. 75). Blood loss was leas for LS than for OS (382 +- 116 ml vs 477 +- 107 ml, p=. 55). One of the patients who underwent LS required conversion to open surgery (5%). Accessory spleens were found in two OS patients (10%) and two LS patients (10%). One complication was observed in the OS group (5%), none in the LS group.

Conclusions: For similar groups of patients the laparoscopic technique affords patients a decreased hospital stay, a reduction in blood loss and comparable operating times. There is also improved cosmesis and more rapid convalescence. Patients should be informed of the option of laparoscopic splenectomy to make a true informed decision prior to surgery.

ROBOT-ASSISTED LAPAROSCOPIC ANTI-REFLUX SURGERY Soji Ozawa, M.D., Toshiharu Furukawa, M.D., Masahiro Ohgarni, M.D., Go Wakabayashi, M.D., Masaki Kitajima, M.D., Department of Surgery, School of Medicine, Keio University, Tokyo, Japan

Recently "master-slave" robot systems for endoscopic surgery have been developed. We have been using the da Vinci Surgical System (Intuitive Surgical, Inc.), which consists of a surgeon's console, a patient- side cart, a high - performance vision system, and proprietary instruments, since March, 2000. The purpose of this study was to clarify its clinical usefulness.

We performed 14 operations for benign diseases with the da Vinci Surgical System. We used it for anti-reflux surgery in 6 cases because many suturing steps are required for laparoscopic Nissen fundoplication (4 cases) and laparoscopio Heller and Dor procedure (2 cases). After laparoscopic mobilization of the lower esophagus and the gastric fundus or Heller procedure, the patient-side cart of the da Vinci Surgical System was placed on the left side of the patient, and a 3D camera and EndoWrists, which are proprietary instruments, were set up to it.

The entire suturing step (Nissen / Dor fundoplication) was successfully performed using the da Vinci Surgical System in all patients. The average time (183 seconds) required to tie 4 knots in one suture with the da 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 insert a needle into the crural structure, the stomach, and the esophagus, not only in the proper direction but to the proper depth, and it was also very easy to tie knots. There was no morbidity or mortality related to this procedure.

In conclusion, surgery with the da Vinci Surgical System was feasible, safe, and useful. If a wide variety of instruments, including an ultrasonically activated scalpel and a wide view 3D camera, were available, and if feedback of tactile sensation were provided, it would be a much more promising system.

NEEDLESCOPIC FUNDOPLICATION David E. Pace M.D., Patrick M. Chiasson M.D., Joseph Mamazza M.D., Christopher M. Schlachta 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 needlescopic fundoplication with conventional laparescopic fundoplication.

Between January lg9g and June 2OO0, thirty eight needlescopic fundoplications (using instruments 3 mm or less in diameter) were performed by three surgeons. Short term outcomes of these patients were compared to a matched cohort of patients who had undergone conventional laparoscopJc fundoplication. Statistical analysis was performed using the student's t test and Fisher's exact test where appropriate.

Patient age, weight, gender, and the number of patients who had previous abdominal surgery were similar between groups. The average operative time (127 vs 143 min, p--0.13), average blood loss (48 vs ,54 ml, p=0.30), and average length of hospital stay (1 .S vs 1.8 days, p=0.10) were non-significantly shorter for the needlescopic group. There were no significant differences in intra-operative (5.1% vs 2.6%, p=l.0) complications. Conversion to open laparotomy did not occur in either group while two needlescopic cases were transformed to laparoscopy because of body weight and habitus. Postoperatively, there were no significant differences in rates of early dysphagia (7.9% vs 7.9%), heartbum (0% vs 2.6%, p=l.0), bloating (13.2% vs 5.3%, 10=0.43), or other complicaUons (5.3% vs 5.3%) between groups.

This series suggests that there is no disadvantage to performing needlescopic fundoplication with the cosmetic benefit of smaller incisions.

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LAPAROSCOPIC SPLENECTOMY: DOES THE TRAINING OF LAPAROSCOPIC FELLOWS AFFECT OUTCOMES? David E. Pace M.D., Patrick M. Chiasson M.D., Christopher M. Schlachta M.D., Joseph Mamazza M.D., Eric C. Poulin M.D., The University of Toronto Centre for Minimally Invasive Surgery, Toronto, Ontario, Canada

The training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy.

Data was obtained from a prospectively collected computer database of patients who underwent laparoscopic splenectomy by one of three surgeons from August 1994 to November 1999. Outcomes of the last 25 cases, which were performed by fellows under supervision, were compared to 25 cases performed by surgeons just prior to the introduction of fellows. These surgeons had already performed over 20 laparoscopic splenectomies. Patients with spleens larger than 20 cm were excluded from the study. Statistical analysis was performed using the student's t test and the Fisher exact test.

Patient age, gender, preoperative platelet count, and splenic size were similar between groups. Average operative time (151 min vs 178 min, p=0.055), average blood loss (214 ml vs 162 ml, p=0.40), intra 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 hospital stay (3.3 days vs 2.5 days, p=O.13), and post operative complication rate (4% vs 8%, p=-1.0) were similar between cases done by staff surgeons and cases done by fellows under supervision. There was one death in the last 25 cases done and no deaths in the other group of 25 cases. There was a non-significant trend towards longer operative time and shorter hospital stay in cases done by fellows.

Laparoscopic fellows can safely and effectively perform laparoscopic splenectomy under the supervision of an experienced laparoscopic surgeon.

RESULTS OF PNEUMATIC PAPILLA DILATATION DURING LAPAROSCOPIC CBD EXPLORATION FOR DUCTAL STONES. Alessandro M Paganini, MD, PhD, FACS, Francesco Fellctottl, MD, Andrea Tambudni, MD, Mark> Guerrieri, MD, Roberl~o Campagnacci, MD, Ernanude Lezoche, MD. Clinica di Patdogia Chirurgica, University of Ancona, Italy.

In patients with mu~ple CBD stones undergoing laparoecopic CBD exploration, pneumatic papilla dilatation may be performed after Illhottipey to facilitate removal of stone fragments. Aim of the present study is to evaluate the results of pneuma~ papilla dilatation dunng single stage labaroscopic treatment of gallbladder and ductal stones.

From January 1991 to August 2000, 2894 patients unden~ent laparescoplc chdecyste~y at our institution. Associated choladochdil~ads was present in in 301 cases (10.4%). A successful laparoscopir CBD exploration was performed in 297 cases (98.6%). We divided the patients in two groups: Group A (42 pa~ente, 11 males, 31 females, mean age 53.3 years, range 12-87 years), palJen= undenNent papilla dilatation after CBD exploration; Group B (25g paints, 100 males, 159 females, mean age 64.2 years, range 23-94 years) patients did not undergo papilla dilation.

Group A Group B P Tra~cho ledochotomy expl. 33/g 138/95 Transcystic/T.tube drainage 11/9 74/92 Hyp~mylasamla 8 (19~) 0 p<0.001 Other minor complica~ona 2 (4.8%) 13 (5.1%) 1:=0.874 Major complications 2 (5.4%) 7 (2.7%) p=0.742 Mortality 1 (2.4%) 0 p=0.326 Residual stones 2 (4.8%) 12 (4.7%) I)=0.763 Reourrsntsfonea 2 (4.8%) 3 (1.1%) 10=0.352

Air.ugh in Group A we observed a significant higher incidence of hyperamilasemia as compared to Group B, no statistical difference exists between group= in terms of morbidity, mo~ity, residual and recurrent CBD stones. We cor~ude that pneuma~c papilla dilata'don during laparoscopic explot~on of the CBD is a safe and effective procedure.

RESULTS OF LAPAROSCOPIC ADJUSTABLE SILICONE GASTRIC BANDING (LASGB) FOR MORBID OBESITY. Alessandro M Pacanini. Md, PhD, FACS, Francesco Fdidot~, MD, Macio Guerded, MD, Andrea Tamburini, MD, Emanuele Lez~he, MD, FACS. Ctinica di Patdogia Chirurgica, University of Ancona, Italy.

LASGB is a noninvesive simide and reversible gest~c re~dve procedure for the treatment of morbid obedty which avoids problems of stoma size encountered with nonadjustable gastric banding. Aim of this study is to report the results of laparoscopic adjustable gastric banding for the treatment of morbid ol~ty.

From June lgg5 to August 2000, 63 patients (11 males, 52 females, mean age 37.4 years, age range 19-56 years) undehvent LASGB for morbid obesity at our l ~ o n . Mean Body Mass Index (BMI) was 44.5 Kg/m2, (range 35.1- 63.1), and preoperative asaodatnd morbidity were: hypercholesterolemia (2), diabetes (2), choldithiar~s (7), esteo-a~ropathy (14), hyper~nsion (6) and endocnne d~o~em (3).

No batlant was converted to open surgery. Mean operative time was 131.4 min. (range 80.270 min). Major comprca~ons were an esophageal perforation in 1 case (1.6%), requiring reobara~on on postoperative day 1, and severe arythmia followed by sudden de~t in a 45 years old male pa~ent with setvera obsltuctJve respiratory insuffciency and hypertension who died 12 hours after an uneventful operation for respiratory failure. All remaining patents were ambulating freely and were assuming a semisolid diet within 24 houls after the opera~n. Subcutaneous pert and banding complicalJons requiring recperatJon were observed in 11 (18%) and 3 (5%) cases, respac~ely, and included: port denubitus of the sldn (1), port deconnec'don from the .~licone tube (2), port disl~aceme~t (8), banding displacement (2) and dilatalJon of the gastzic pouch (1), requiring band recnoval in the latter three patients. At an average follow-up of 33.9 months (range 7-62 mon~a) mean BMI decreased to 27.7 Kg/m2 (range 20.9-35.8 Kg/m2).

On the base of tt~ above mentioned results we conclude q~tat LASGB for the ~eatment of morbid obedty in selected patients is feasible, safe and effeddve in obtaining prolonged weight reduction

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A NEW COMPOSITE MESH FOR LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIAS Tom Paluch, MD, Mark Milford, MD, Mark Schumacher, MD, and Mike Clar, MD, Kaiser Foundation Medical Center, San Diego

Laparoscopic techniques are now widely accepted for the repair of Type II, or paraesophageal hiatal hernia. Initial enthusiasm was tem- pered by a recurrence rate higher than that seen in open surgery. We report the use of a bi-component or composite mesh for repair of Type II hiatal hernias. From 1994 to 2000, 52 patients (27 female, 25 male) aged 36 - 88 yrs underwent primary laparoscopic repair of a paraesophageal hemia. All underwent sac excision, primary crural re-approximation, mesh repair, and fundoplication with fixation of the wrap to the diaphragm and mesh. Repair in the first 22 patients utilized a simple polypropylene mesh fixed to the esophageal hiatus with silk suture and the endoscopic hernia stapling device. Since early 1997. all repairs utilized a composite mesh developed by the authors which is composed of a 'darted' PTFE teflon cuff secured to the nee-hiatus with polypropylene suture. The mesh was then secured to the hiatus and the fundoplication secured to the hiatus and diaphragm in the same manner as in the first 22 patients.

The groups were similar with respect to mean age, BMI, and ASA class. There were no significant differences operating time, complication rate, or LOS between those repaired with simple mesh -vs- those repaired with composite mesh. There were no conversions or esophageal leaks in either group. There were 4 recurrences in the group repaired with simple mesh. There were no recurrences in the composite mesh group.

Preliminary results with the use of a composite mesh for repair of paraesophageal hemias suggest a lower recurrence rate. Larger numbers of patients will be required to determine whether this diminution is statistically significant.

A HYPOXIC PNEUMOPERITONEUM INITIATES THE METASTATIC CASCADE IN COLON CANCER CELLS Paraskevas K Paraskeva FRCS, David Peck PhD,/Era Da'zJ FRCSI Imparial College School of Medicine, St Mary's Hospital London, United Kingdom.

Tumour cells when rendered hypoxic have an enhanced abllibj to form metastases. The carbon dioxide (C02) pneumopedtoneum used in laparo~___opic surgery as v,~tl as alternative gases such as Helium (He) cause hypoxic conditions. The metastat~ process begins when tumour cells detach and migrate. These interactions are under the control of several families of adhesion molecules particularly the cadherins and integdns, and a number of proteolyt~c enzymes such as the urokinase plasminogan activator (uPA). The changes in expression of components of the metas~c ~ in

human colon cancer cells when exposed to CO= and He pneumoparitoneums were examined. The human colonic cancer cells SW1222 were exposed to an in vitro pr~umopadto~um of Air (control), CO2 or He at 3 mmHg for 4 hours at 3TC. Cells were then detached and incubated wi~ primary antibodies against, E-Cadherin, CD44, uPA receptor (uPAR) and I~1 integrin, a secondary FITC-anti-mouse IgG was added to the cells that were analysed for surface receptor expression by flow cytometry (FACScan, Becton Dickinson). The results are the mean fluorescent Intensity expres____~J asa percentage of the conlz'ol and standard enor of ti'ze mean.

I E-Cad n l IS1 �9 I I C02 44%+/- 3" I 80%+/'1" 200%+/-7* I 80%*/-0.5

I I He 68 %+/-2* 1" = P < 0.05 vs Cont~, "= P < 0.01 vs Conbol (Dunnett)

All of these receptors have pivotal roles within the process of metastasis and these changes will enhance metas~c potential as a small change in expression has large functional significance. This could provide a mechanism to explain how viable tumour cells detach from a pdrnary and establish metastatic fed.

IMPROVEMENT IN THE LAPAROSCOPIC VIEW USING HISTOGRAM EQUALIZATION A. Park M.D., W. Charash, M.D*., Ph.D., M. Shaw, Ph.D., Depts. of Surgery, University of Kentucky and * Boston University

PURPOSE: Video images obtained during minimally invasive surgery suffer from limitations in illumination that result in color distortion and degradation of image quality. Real time histogram equalization applied to the video signal can result in a better image. The subjective improvement in the image quality is correlated with an edge detection technique to quantify the improvement. METHODS: Video of a laparoscopic procedure was obtained using standard MIS equipment and was analyzed in real time using a digital signal processor. The signal was subjected to a histogram equalization algorithm on the processor board and fed back to a monitor. The processing speed was fast enough so that the surgeons could detect no delay between the processed view and the actual surgical scene. Several images were captured in both processed and unprocessed form. The images were analyzed using a Sobel edge detection algorithm and the increase in the number of edge pixels of each form was computed. The increase in the edge pixels was compared to the subjective image quality. RESULTS: Twenty images were analyzed. In all cases histogram equalization resulted in an improved image. The more dramatic the subjective improvement in image quality, the greater the increase in the number of edge pixels detected, indicating that the subjective assessment of quality was reflected in an increase in the number of features seen. The results ranged from a 41% increase in edge pixels for images that were judged only slightly better in quality to over a 5400% increase in edge pixels where a dramatic increase in image quality was obtained.Detailed data will be presented as well as examples of the processed images. CONCLUSION: Histogram equalization of an image using a proprietary algorithm and digital signal processing results in an operative view where features can be more easily discemed. The resulting clarity of the operative image translates into subjective improvement of the surgical experience.

COMBINED LAPAROSCOPIC/ENDOSCOPIC APPROACH FOR DUODENAL WEB RESECTION Eduardo Parra-Davila MD, J.Arturo Almeida MD, Morris E.Franklin MD, Jose Munoz MD, Jeffrey LGlass MD, Robert Michaelscn MD, TEXAS ENDOSURGERY, San Antonio, Texas

Congenital duodenal obstruction is uncommon. In general the lesion becomes evident in the newborn or in early years in life, although in a few cases if may manifest in the adult pa~ent (20). We report a case of a 27 year-old female with Down's syndrome and duodenal obstruction by a duodenal web in whom endoscopic treatment was not feasible. We review different treatment options for this rare anomaly and describe an innovative approach by resecting the duodenal web utilizing laparoscopic endoluminal surgery. Duodenal webs are the third leading cause of digestive tract obstruction in childhood (3). Congenital duodenal obstructions are rare in the adult population. Duodenal webs account for less than 2% of the obstructions but the true incidence is difficult to estimate because more than half of the cases are reported later in life (11). Patients with Down's syndrome have an increase incidence of duodenal anomalies. Duodenal webs result from incomplete recanalization of the duodenum during the early weeks in life (2). Webs consist of mucosa and submucosa and rarely have muscular layer (11). Most webs are proximally to the ampulla of Vater (3). The reason why some of these congenital anomalies may only become manifest later in adult life is unexplained. Some suggest that chronic inflammation with superimposed acute edema may suddenly change a tight but asymptomatic lesion into an obstructing and symptomatic one. The role of endoscopy in the management of duodenal webs has been mainly diagnostic to confirm barium studies of the gastrointestinal tract. With the progress of technology and the increase ability of the endoscopists techniques to cut and ablate the lesions are feasible. The development of laparoscopic surgery has provided a different approach to gastrointestinal surgery. The improvement of lens and instrumentation has lead to the emergence of Laparoscopic Endoluminal Surgery (LES).

LAPAROSCOPIC ESOPHAGOMYOTOMY FOR ACHALASIA UTILIZING ULTRASONIC COAGULATION SHEARS Steven C. Patching, M.D.,Horacio Asbun, M.D., Helmuth Billy, M.D., Donald Waldrep, M.D., Department of Advanced Laparoscopic Surgery, Sutter Medical Center, Sacramento, CA

Our center reports on 18 esophagomyotomies performed from November 1996-August 2000; in all cases ultrasonic coagulation shears were utilized in performing the esophageal myotomy. The shears were used to develop the plane between the muscularis and the mucosa, then the device was applied to divide the muscular layer. A Dot fundoplication was then performed in 17 patients. One patient underwent a Toupet fundoplication. Intraoperative endoscopic examination of the esophagus and the lower esophageal sphincter was used in all cases.

94.5% (17/18) of patients had complete resolution of their preopera- t ive dysphagia. Pat ient ages range between 17-78 years. Complications included a small mucosal tear in one patient, treated by laparoscopic suture repair at the original surgery. One patient experienced persistent dysphagia requiring reoperation. One patient reported occasional postoperative heartburn. There has been no mortality. Average hospital stay is 2.3 days. There were no conversions to open surgery.

Successful laparoscopic esophagomyotomy requires meticulous division of the muscularis and the lower esophageal sphincter. Application of ultrasonic coagulation shears appears to be a safe and effective alternative to electrocautery myotomy, potentially reducing the chance of electrothermal injury to the mucosal layer.

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COMPARISON OF LAPAROSCOPIC VERSUS LAPAROSCOPIC HAND-ASSISTED DONOR NEPHRECTOMY Emma J Patterson, MD, Michel Gagner, MD, Jonathan S. Bromberg, MD, Sandy Florman, MD, Richard Knight, MD, Lewis Burrows, MD, and Michael Edye, MD., Divisions of Laparoscopic Surgery and Transplantation, Mount Sinai School of Medicine, New York, New York

Many transplant centers now prefer hand-assisted laparoscopic donor nephrectomy (HALDN) to the totally laparoscopic technique (LDN). Possible advantages of the hand-assisted technique include rapid manual hemostasis and improved tactile sensation that facilitates dissection, retraction, and exposure. Vascular control and extraction of the kidney may also be faster.

This is a retrospective comparison of data from all LDN and HALDN at Mount Sinai (MS) between October 1996 and April 2000. In June 1999 the technique at MSH changed from LDN performed by one surgeon (ME) to HALDN by another surgeon (MG). Results are as follows (mean + SE):

Outcome Laparoscopic (117) Hand-Assisted (40) Operating time (m) 257 +/- 5 184 +/- 0.2 * Blood loss (ml) 286 +/- 33 108 +1- 15 * Renal vascular bleed (%) 5.1 0 Conversion to open (%) 3.4 0 Warm ischemia time (s) 257 +/- 8 101 +/- 9* LOS (days) 2.4 +/- 0.07 2.9 +/o 0.13 * 30-day graft survival (%) 94% 92.5% Median 30-d Creatinine 1.5 mg/dl 1.5 mg/dl

Hand-assisted laparescopic donor nephrectomy is associated with shorter operative times, less blood loss, shorter warm ischemia times (WIT), and slightly longer hospital stays. It is therefore beneficial to utilize the incision throughout the operation that is necessary for intact organ 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 WITH 45-DEGREE ANTERIOR FUNDOPLICATION Emma J Patterson, MD, Doron Katz, Marina Kurian, MD, Barry Salky, MD, Mount Sinai Medical Center, New York, New York.

Over recent years, laparoscopic Heller myotomy has become the standard treatment approach for achalasia. However, considerable controversy still exists regarding the addition of an antireflux procedure. The purpose of this study was to evaluate patient outcomes following laparoscopic Heller myotomy with a novel 45-degree anterior fundoptication.

Sixty-two patients underwent laparoscopic Heller myotomy between April, 1993 and July, 1999. There were 26 females and 36 males (56%), with a mean age of 46 years. Thirty patients (45%) had prior treatment for achalasia. The preoperative mean resting LES pressure was 34.5 mm Hg. Using a standard five-port technique, a six centimeter anterior myotomy was performed, and the adequacy of the myotomy was confirmed by intraoperative endoscopy. The anterior gastric fundus was sutured to the left edge of the myotomy.

The mean operating time was 112 minutes. There were three operative complications: one pneumothorax and two mucosal lacerations (3%) which were repaired laparoscopically. The mean postoperative length of stay was 34 hours, and all but four patients were discharged within 48 hours. At a mean follow-up of 25 months, 92% of patients were satisfied with the results of surgery: 84% were "very satisfied" and 8% were =somewhat satisfied". Good to excellent relief of dysphagia (less than weekly symptoms) was achieved in 67% of patients. 86% of patients had less than weekly regurgitation, and 89% of patients had less than weekly regurgitation.

Laparosoopic myotomy with a 45 degree anterior fundoplication provides good symptomatic relief of dysphagia. Medium-term follow-up reveals that symptomatic reflux is uncommon. Correlation with objective measures of reflux via 24-hour pH and manometry is still necessary.

SALVAGE OF LEAKING RECTAL ANASTOMOSIS: THE ROLE OF LAPAROSCOPY Miguel Pera MD, Salva Delgado MD, Juan C. Gamia- Valdecasas MD, Antoni Castelis MD, Josep M. Pique MD, Manuel Pera MD, Ernest Bombuy MD, Xavier Gonzaiez MD, Antonio M. Lacy MD., Service of Gastrointestinal Surgery. Institut de Malalties Digestives, Hospital Clinic, University of Barcelona, Spain

The conventional management of a clinicel anastomotic leak with peritonitis is to take down the anastomosis with exteriorization of the proximal bowel end.However, salvage of leaking rectal anastomoses has been reported in some cases, with or without reoperation.The aim here is to report our experience in the laparoscopic management of rectal anastomotic leaks.Between August 1998 and August 2000,112 patients underwent treatment for rectal cencer.Mean age was 68.3 years (67 males/45 females).Fffty-eight patients underwent preoperative radiotherapy.Surgical procedures included transanai excision in 13 patients (11.6%), rectal amputation in 17 cases (15%),Hartmann operation in 10 patients (8.9%), and anterior rectal resection with anastomosis in 72 patients (64.3%).The celorectal anastomosis was below 6 cm in 62 (86%) patiants.All anastomosis were double-stapled except 2 handsswn coloanal.The operation was performed laparoscopically-assisted in 58 cases and open in 14 patients.Conversion rate in laparoscopy was 22.4%.Thirty loop ileostom~es were done (41.6%).Among the 72 anastomoses,10 clinical anastomotic dehiscenses occurred (13.8%).Five of these 10 patients had a diverting stoma that minimized the symptoms.Conservstive therapy was a success in 3 cases, and reoparation was necessary in the other 7 patients.Among the patients reoperated, the anastomosis was taken down in only 2. Five patients with peritonitis were succesfully managed b~ peritoneal lavage and creation of a diverting loop stoma using either sig- mold(2), or transverse colon(l) or ileum(2).Threa of these 5 cases had previ. ous laparoscopic-assisted rectal resection and were reoperated by laparoscopy.No complications resulted from the use of laparoscopy in the early postoperative period.There was no mortality.Four of the 5 divertin~ stomas created to treat the leak were closed between 2 and 3 months afte reoperation.Saivage of anastomoses with a leak can be performed in the majority of cases (80%),and laparoscopy should become a therapeutic option in patients who had previous laparosoopic rectal excision.

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A TECHNIQUE FOR GASTRIC INTUBATION IN PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PLACEMENT Paul E Perkowski, MD, Alan B Marr, MD, Department of Surgery, Louisiana State University Health Sciences Center and Overton Brooks VA Medical Center, Shreveport, Louisiana

OBJECTIVES The majority of patients referred to surgeons or gastroenterologists for per-

cutaneous endoscopic gastrostomy (PEG) tube placement are those with malignancies of the aerodigestive tract, or disorders in swallowing. These disorders often make gastric intubation during PEG placement more difficult. We present a technique to assist in re-intubatlon of the stomach during PEG procedure. METHODS

We identified 34 patients referred to the General Surgery service for PEG placement at the Veterans Affairs Medical Center. Each patient had a disorder that may have potentially made gastric intubation difficult (e.g., stroke, head and neck or esophageal cancer). The procedure was done under intravenous sedation in most cases. The flexible video endoscope was inserted in standard fashion to begin the case. Difficult intubations were assisted with a nasogastric tubs used as a stent. The gastrostomy tubs was then placed using the pre-assembled Ponsky PEG kit.

Preparations were made to pull the gastrostomy tube through the orophar- ynx and esophagus into the stomach using the guidewire. The snare, which was still threaded through the gastroscope, was attached to the PEG tubs 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 the stomach. Correct PEG tube placement could then be confirmed prior to termination of the procedure. RESULTS

The procedure was 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 that the technique saved time and potential morbidity to the patient. CONCLUSIONS

We suggest that this procedure may assist in percutaneous endoscopic gastrostomy placement in patients with potential for more difficult gastric intubation due to near-obstructing malignancies or disorders in swallowing. The technique could be done with less morbidity and faster operating times.

L A P A R O S C O P I C A P P R O A C H TO T H E M A N A G E M E N T OF TORSION OF APPENDICES EPIPLOICAE Yaron Perry M.D, Petach ia Re i ssman MoD., D e p a r t m e n t of Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel

Appendices Epiploioae may be involved in several intraabdominal pathologic processes include torsion and primary inflammation. Clinical and biological features have a small specificity.

We are presenting here a 55 years old patient with right lower quadrant abdominal pains, which started on the day of admission with temperature of 37.9c. His past medical history was significant of Ischemic heart disease and hyperlipidemia.

On physical Exam He had right lower quadrant tendemess and guarding.

He was taken to the opera t ing room and on exp lo ra to ry laparoscopy he was found to have a torsion of cecal appendices epiploicae with necrosis at its tip and some reactive fluid surround it. The appendix was mild hyperemic but not inflamed. The appendices epiploicae was excised laparoscopically and appendectomy was done.

The patient had uneventful recovery and was discharged 24 hours after surgery.

One of the differential diagnosis of acute appendicitis is torsion of appendices epiploicae, in our case this pathology was treated laparoscopicelly with good outcome and with no complications. The laparoscopic approach eases the diagnosis and the surgical technique.

PRACTICAL BENEFITS OF TELEMEDICINE S. Perretta, R. Campegnacci, F. Feliciotti, A.M. Paganini, M. Guerrieri, A.Tamburini and E.Lezoche Istituto di Sdenze Chirurgiche Universit~ degli Studi di Ancona. ITALY Ente Nazionale Idrocarburi (ENI). ITALY

Telemedicine has gained a wide acceptance dispelling the skepticism surroundig this new technological tool. Aim is to report a case in which telemedicine proved to be of practical benefit.

A six years old female from Congo suffering from fatigue, dispnea and mild precordial pain was referred to our telemedicine service (INCAS telemedicine project supported by Ente Nazionale Idrocarburi). Her symptoms had been underevaluated by the local doctor and treated as chronic pulmonary infections. After worstening of the patient's conditions, the child was referred to the telemedicine service. Chest X- Ray, EKG,and cardiac ultrasound were performed. The local practitioner involved in the INCAS project suspected a cardiac atrial septal defect (ASD). The exams were sent by satellite and terrestrial ISDN line to our Department and analized by a consultant cardiologist of a pediatric cardiological Unit. Who confermed the presence of the atrial septal defect liable to surgical treatment. In a very short time the child was transferred to our local Cardiologic Hospital. The ASD measuring 1,5 cm was repaired by a pericardial patch. The postoperative course was uneventful and brillant. The patient was discharged after two weeks in excellent clinical conditions and repatriated. A four months follow up shows the complete resolution of symptoms.

Atrial septal defects are among the most common congenital cardiac lesions and can be safely repaired by surgery. If underavaluated they can lead to severe complications. In this case Telemedicine allowed to easily diagnose and to successfully tret a clinical problem otherwise difficult to manage in an african country breaking barriers related to distance and underdevelopmenL

LAPAROSCOPIC RYGB - SHOULD IT BE CONTRAINDICATED FOR THE SUPER OBESE? Richard Perugini, M.D., Kent Keroher, M.D., Demetrius I itwin, M.D., Stephen Baker, M.Sc., John Kelly, M.D., Department of Surgery, University of Massachusetts Medical School, Worcester, MA

Laparoscopic roux en-Y gastric bypass (LRYGB) is well recognized as an effective therapy for the treatment of morbid obesity. The laparoscopic approach should lead to superior outcomes with respect to pain, recovery, 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 substantial subset of patients who would otherwise greatly benefit from the mini- really invasive approach, we performed our initial series of LRYGB without using excessive BMI or weight as contraindications

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 the morbidly obese. Patients were then divided into Group I (BMI<50), and group II (BMI>50) and were compared with regards to time required for surgery, postoperative length of stay, complication rate, need for readmission and need for reoperation. Results were evaluated with two-tailed T-test (time of operation), Mann-Whitney U test (pest-operative length of stay), and Fisher test (rate of complication) with significant p-value considered >0.05.

LRYGB was attempted in 37 consecutive patients between 7/99 and 9/00. The groups ranged in size from BMI of 42 to a BMI of 74, with 8 patients with 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 LRYGB. The time required to perform LRYGB was similar between groups I and II (mean+-st.dev. 225+-77 rain. vs 228+-60 min.). Post-operative length of stay (median, 25-75% equal 3 days, 3-4 vs 4 days, 3-4), major complication rate (1/14 vs 3/23) and total complication rate (5/14 vs 8/23) were not different between groups.

LRYG8 can be accomplished in super-obese patients without any increase in operative time, pest-operative length of stay, and comphcation rate.

Evaluatiou of the Safety aud Efficacy of Early Chest Tube Removal After Video-Assisted Thorascopir Surgery (VATS). Stcvm W. P e ~ D.O., P, obett Caccavale, M.D., J.P. Bocage, M. D., W. Peter Gels, M.D. lkparane= of Surguy and Minimally lnvmive Training Cug=, St. Peter's University l.lmpital, New Bnmswick, New Jersey. Introduction: Chest tubes afer thoracic surgm'y have traditionally resulted in prolonged hospital stay and morbidity. In this study we have designed a mechanism to eliminate prolonged ches: tube drainage with the benefit of curly hospital discharge. Methods: From Javuary 1999 through July 2000, 245 consecutive patients refcn'~ for diagnostic and/or therapeutic lung resection underwent video-assisted tho'.ra.'scopic surgery (VATS) with lung resection. Patients were placed in three ~agories for chest tube removaL 1) Removal within 1-2 hrs following surgery. 2) In hospital management of air leak with removal of cbest tube prior to discharge. 3) Discharge home with chest tube/Heimlich valve with removal as an outpatient. Chest tubes were removed when there was no air leak, expansion of the lung was demonstrated, and drainage was minimal. Results: Charts were available for review for 237 of the 245 patients. This included 111 males and 126 females ranging from 16 to 89 years. Resections included 133 wedge resections, 16 segmental resections and 86 Iobectomies. The final pathology was benign in 97 cases and malignant in 140 cases. Of the 235 patients, 126 had chest tubes removed within I-2 hours following surgery. Eighty-four patients had chest tube management with removal during their hospital stay. Twenty-seven patients had a persistent leak, which was managed with chest tube/Heimlich valve'as an outpatient. In group !, patients had an average length of stay of 1.2 days with only 4 patients requiring chest tube reinsertion. The average hospital stay for patients in group 2 and 3 were 1.6 days and 1.7 days respectively. Conclusion: Clearly this data indicates that creative and movstive management of chest tubes following VATS lung resection allows an unprecedented shorter hospital stay.

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C O N V E R S I O N F R O M L A P A R O S C O P I C TO O P E N CHOLECYSTECTOMY AT A RURAL TEACHING HOSPITAL - - A STABLE RATE Todd Petty, MD, Matthew Indeck, MD, Department of Surgery, Geisinger Medical Center, Danville, PA

Introduction Laparoscopic cholecystectomy is recognized as the gold standard for treatment of gallstone disease, and is now commonly a junior resident case at teaching institutions. This study seeks to determine whether the conversion rate from laparoscopic to open cholecystectomy has changed over the last 8 years at our institution.

Methods This is a retrospective study of all patients undergoing laparoscopic cholecystectomy -- and those requiring conversion to an open procedure - from January 1993 to August 2000 at Geisinger Hospital - a rural, referral teaching hospital. These were then divided into two groups for com- panson - 1993 to 1996 (Group 1), and 1997 to August 2000 (Group 2).

Results During this time period, there were 1703 cholecystectomies initiated laparoscopicaUy, of which 100 required conversion to open. This is an overall conversion rate of 5.9%. Group 1 (n=814) had a conversion rate of 6%. Group 2 (n=889) had a conversion rate of 5.7%.

Conclusions The overall conversion rate of 6% falls well within reported rates in the literature. The conversion rate has not significantly changed at our institution over this eight year period. Although the staff surgeons gain experience with each procedure, the majority of these operations are performed 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 TREATMENT MODAUTY THE SURGEON FEELS THE MOOr COMFORTABLE WITH, PW. Plais'~r. Ph.D.G.C. Huitema,M.D., J.J.GM. Gerritsan, Ph.D., W.BJ. Masttxx)m, Ph.D. Dept. Surgery, Medisch SpectnJm Twente, Enschedo, The Nethedands.

Conventional cholecystectomy (CC) has been performed with great ~___,,':ce~__s for over a cantury. L a p a ~ cholecystectumy (LC), however, is now generally considered the gold standard. Still, in some randomized controlled trials mini-choleoystectomy (Me) proved superior to LC. The discussion on what vestment modality is best, may, therefore, not yet been considered dosed dosed. CO, LC and MC are all being performed in our hospital, the method chosen largely depending on the surgeon's experience and preferance and the patient's preference and charactens~. We retrospectively analyzed our results in 419 patients (111m/308f, mean age: 53.4 • 15.4 years) electivety cholecystoctomized in the period 1994-1999.

LC M.~ CC Number 57 89 273 Mean operating time (min) 60+_.27 43+18 ~ 61:1:37 Mean hospitalization time (day) 4.6.J:3.8 = 4.7:1:1.9' 6.5• Minor complications (%) 1.1 6.7 9.8 Major complication@ (%) 1.1 2.2 2.2 Oeeth (%) 0.O 1.1 0.4 [a=signi~;a'~'y less than CC (1~0.001); b--significantly less than LC (p=0.01); requimg ~ (i.e. ERCP or r e o ~ e.g. for hemorrage or indsional hernia)]

Our dsta c o n ~ that LC and MC have shorter ho6pitalization times than CC and that MC requires ~ least opiating time. Considering major complications and death, we think it is justified to state that patients are most Ixobal:~y ~__J3d best by ~e type of cholecysted~ ~e surgeon feels the most comfortable with. Surgeons, well equipped and confidant to treat gallstone disease by one type of operation or the other, should not be forced to perform treatment modalities he or she feels inexpedenced or unconffortable with. Eventually, this will be in the patie~'s best interest.

IS IT SAFE TO LEARN LAPAROSCOPIC COLON SURGERY (LAP) WITH ILEOCOLIC RESECTIONS FOR CROHN'S DISEASE (CD)? Lis.a S. Porilz, M.D., Martin Fdedlich, M.D, and Helen MacRae, M.D., Department of Surgery, University of Toronto, Toronto, Ontario

With concerns about port site recurrences and difficult Crohn's mesentery, it is recommended that one begin their LAP experience with benign, non- inflammatory cases. There ere very few such cases, making it difficult to accrue experience. The following is a review of one surgeon's initial LAP experience with ileocol[c resection for CD. Methods: A retrospective review of all LAP ileocolectomies by a single surgeon without prior advanced laparoscopic experience was done. The patients were divided into two equal groups of 28 (1: 1/97-2/11/99, 2: 2/17199-6/00), to compare eady and late experience. Results:

Group First 28 Second 28 Age 31.4 • 2.03 31.3 • 2.3 OR Time 166.4 • 8.58* 129.9 + 6.26* LOS (days) 5.86 :t: 0.34 6,36 :t: 0.61 Inc (cm) 5.2 :!: 0.24 4.08 • Conversion 28%= 4%=

means + standard error *p<O.O05 by t-test, * p=.025 by Fisher exact test

There were no deaths. Complex cases included: phlegmon/abscess (11), entero-intestinal fistula (13), enter-vesicle fistula (3), extensive adhesions (4), additional small bowel disease (4), and repeat ileocoleotomy (6). Complications occurred in 9 patients, 4 in the group I (anastomaotic bleed, enteretomy, intra-abdominal seroma, and port site hematoma) and 5 in the group 2 (wound infection, prolonged ileus, partial small bowel obstruction, anastomotic bleed, and phlegmon,). Conclusions: LAP ileocolic resectiov for CD, even with complex disease, is a safe way to begin LAP surgery, il one accepts a high initial conversion rate. With experience, OR time ant conversion rate decrease.

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ENDOSCOPIC EXTRAPERITONEAL REPAIR OF A GRYNFELI"r HERNIA. Ro(df R.Postema, H.D. t~ and HJaap Bonier, H.D. Ph.D. 1, Department of Surgew ~ and PediabJc Surgery ~, University Hospital Rotterdam, Rotterdam, The Netherlands.

Lumbar hernias are uncommon. There are three types of lumbar hernia: congenital, acquired and Indsional hernias. The acquired hernia can appear in two forms: the inferior (Petit) type and the supedor type, first described by Grynfeltt in 1866. We report a case of endoscopic extrapedtoneal repair of a Grynfeltt hernia using a prosthetic mesh graft.

A 46 year old woman presented with a painful swelling in the le~ lumbar region which had caused her Increasing discomfort over several months. The diagnosis of Grynfeltt's hernia was made and she was operated upon.

The patient was placed in a left sided decubltus position. Accas to the extraperib:~l space was gained by Inserting a 10 mm inflatable balloon trocar Just antedor to t ~ mldaxlllary line between the twelfth rib and the superior iliac crest through a muscle splitting incision into the extrapedtoneal space. Alter the balloon trocar had been removed a blunt tip trocar was Inserted and worldng space was maintained by Insuffiation of C02 to a pressure of 12 mm Hg. Using two extra 5 mm trocars above and below the 10 mm port In the mid-axillary line the hernia could be reduced. A 6xl l cm polypmpylene mesh graft was Introduced through the 10 mm trocar. The graft was tacked with 5 mm spiral rackers, avoiding bony sl~u~res and nerves. The three portsite openings were sutured with 4-0 nonabsorbable Interrupted sutures. OperalJve Ume was 30 minutes with neglegible blood Ices. The patient could be discharged the next day afl:er requiring only minimal analgesics, Two years after the operation she is doing well and there is no sign of recurrence of the hernia.

This rare lumbar hernia which is prone to complicaUom oould safely be treated In a minimally Invasive manner using the extrapedtoneal approach. This obviates opening and dosing the peritoneum and can therefore reduce operative Urea and possibly postoperative complications.

PORTAL VEIN THROMBOSIS: AN UNUSUAL COMPLICATION OF LAPAROSGOPIC CHOLECYSTEGTOMY. Ourania A. Preventza, M.D., Fahim A. Habib, M.D., Shun C. Young, M.D., David Penney, Ph.D., William Oppat, M.D., and Vijay K. Mittal, M.D. Department of Surgery, Providence Hospital & Medical Centers, Southfield, Michigan

Complications following laparoscopic cholecystectomy are encountered infrequently due to the increasing proficiency in laparoscopic surgery. The occurrence of portal vein thrombosis following a laparoscopic cholecystectomy has not been previously described and forms the basis of this report.

A 32-year old, healthy female on oral contraceptives underwent an uneventful laparoscopic cholecystectomy for symptomatic gallbladder disease. Sequential compression devices and minMose-unfractionated heparin were used prior to the procedure. The patient was discharged home on the first post-operative day without complaints. She returned one week later with nausea, bloating, and diffuse abdominal pain. Ultrasonography of the abdomen revealed thrombosis of the portal vein and the superior mesenteric vein not seen in the preoperative ultrasound. Computed tomography of the abdomen and pelvis confirmed this finding and showed a wedge-shaped infarction of the right liver lobe. The patient was anticoagulated with intravenous heparin. An extensive coagulation work-up revealed elevation of the IgG anticerdiolipin antibody. A percutaneous ~'ans-hepatic portal vein thrombectomy was performed. A post-procedure duplex ultrasound of the abdomen demonstrated recannalization of the portal venous system with no flow voids. Anti- coagulation therapy was continued and the patient was discharged home therapeutic on oral warfarin and with resolution of her ileus.

This case demonstrates an unusual complication of laparoscopic cholecystectomy. It may have resulted from the use of oral contraceptives, elevation of the IgG anticardiolipin antibody, unrecognized trauma, and was accentuated by the pneumoperitoneum generated for the laparoscopic cholecystectomy. Our case report provides insight and poses questions regarding peri-operative measures for thromboprophylaxis in young females on oral contraceptives undergoing elective laparoscopic abdominal surgery.

LAPAROSCOPIC BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH: THE EARLY EXPERIENCE Theresa Quinn MD, Michel Gagner MD, Christine Ren MD, John de Csepel MD, Subhash Kini MD, Paolo Gentileschi MD, Daniel Herron MD, William Inabnet MD, Alfons Pomp MD., Division of Laparoscopic Surgery, Mount Sinai School of Medicine, New York, NY

Biliopancreatic diversion with duodenal switch (BPD/DS) is an excellent operation for weight reduction in the patient with super obesity (BMI [body mass index] > 50 kg/m2). The purpose of this study was to evaluate our experience with BPD/DS using a laparoscopic approach.

We performed 62 laparoscopic BPD/DS at a single institution over a one- 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 median hosp'aal stay 4 days (range, 3 - 200 days). Twenty-six percent of patients had previous abdominal surgery including two cases of failed bariatdc surgeries. Minor complications such as wound infection and ud- nary retantion occurred in 14%. One patient required admission for dump- ing and malnutrition. Major complications (6%) included anastomotic leak, staple line bleeding, Dv'r and splenic injury. There were three deaths (5~176 all of which occurred in patients with a BMI >60 kg/m2. Late complications (5%) included incisional hemia and bowel obstruction. We calculated the mean percent excess weight loss (-~SD) postoperatively: 3 weeks: 15% +- 6 (39/62); 3 months: 33% +-11 (34/62); 6 months: 46% +-15 (19/62); 9 months: 60% +-18 (13/62); and 62% +-11 (4/62) at one year. Twelve of 23 patients (52%) who had required medication for diabetes or hypertension were medication-free postoperatively. One operation was converted to an open procedure. No patient required a revision.

Laparoscopic BPD/DS is feasible and effective, and can be performed on patients with previous abdominal surgery. Half of the patients no longer require medication for diabetes or hypertension. Mortality occurred in 3 of 22 patients with a BMI > 60 kg/rn2. These patients may have a relative contraindication to laparoscopic BPD/DS.

EEA STAPLER HEMORRHIODECTOMY: A NEW TECH- NIQUE OF EFFECTIVE REDUCTION OF HEMORRHIODAL MUCOSAL PROLAPSE BY CIRCULAR SURGICAL STAPLER: A CASE STUDY Prasanta Raj, MD FACS, Gregory Eason, MD, George Castil lo, MD, Timothy Barnett, MD, Lavonne Urban, BA, Fairv iew Hospital - Department of Surgery - Cleveland Clinic Health System

The treatment of grade III or IV hemorrhoids can be a challenging problem, especially in the face of circumferential anal mucosal prolapse. The use of standard techniques of hemor- rhoid repair in the face of mucosal prolapse may lead to recurrence and anal stricture. The ideal repair would restore near normal anatomic planes, maintain sphincter function and intact sensation.

Proper anatomic repair can be performed by use of a circular surgical stapler with minimal postoperative discomfort. Several details must be ensured to provide satisfactory repair: 1) suture ligation of hemorrhoidal pedicles at their apex, 2) adequate dissection of the mucosa off the internal sphincter in the anal canal, leaving the muscle intact, 3) placing the pursestring such that the proximal dissected mucosa is centered properly around the anvil of the stapler while incorporating the distal internal sphincter, 4) firing the stapler above the perianal-ano- dermal junction.

A satisfactory repair of mucosal prolapse and treatment of hemorrhoidal disease can be obtained while reconstructing anal anatomy with the circular-stapling device. This will maintain normal sphincter function, intact sensation and because the anastomosis is above the dentate line should result in minimal post-operative pain.

LAPAROSCOPIC HERNIA REPAIR IN A COMMUNITY BASED VIDEO- SCOPIC SURGICAL CENTER Chun (Chris) Rhim,BA, Charles Mixter, MD, S.D. Schwaitzberg, MD, Center for Videoscopic Surgery, Exeter Hospital, Exeter, NH and the Department of Surgery, New England Medical Center/Tufts University School of Medicine, Boston, MA

Objective: Repair of inguinal hernias by the laparoscopic methods has been somewhat controversial since the introduction. The aim of this study is to report a large case series of outpatient laparoscopic hernia repairs and to evaluate the results in term of recurrence, conversion, complication and retum to work.

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) including femoral and sliding hemies were operated upon in a community-based videoscopic surgery center by a single surgeon using the Laparoscopic Transabdominal Preperitoneal (TAP) method with a polypropylene mesh (no slit) onlay All cases were done in an outpatient basis. Complications, recurrences, conversion and return to work data were recorded.

Results: The laparoscopic TAP was successful in all 483 patients who underwent 633 hernia repairs, days There were 5 recurrences (0.8%) with a mean follow up of 30 months. The overall complication rate per hernia repair was 3.3%. There were 6 admissions after outpatient discharge (hematoma, postop bleeding requiring reoperation, pain, drug reaction, urethral bleeding, urinary retention) 16 complications were managed on an outpatient basis (post-op bleeding (2), prolonged post-operative pain (6), hematomas (1), urinary retention (1), port-site hernia (1), balanitis (1), epi- didymitis (1), shoulder pain (1), infected mesh (1), and intestinal obstruction (1)).The average Return to Work (RTW) was 7.5 (4.5-29)days. "Sedentary light duty" patients had the shortest R'FW of 5.7 (1 -24) days and "heavy labor" patients the longest with 9.4 days (1-36).

Conclusion: Laparoscopic TAP hernia repair method is associated with a low recurrence and complication rate with average return to work data that compares favorably with open techniques reported. These data suggest that Laparoscopic TAPP hernia repair is suitable for both for unilateral and bilateral hernias.

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RISK FACTORS OF GALLSTONE DISEASE IN THE LAPAROSCOPIC ERA. William Richardson, MD, Knstine Carter, MO, Boyd Helm, MD, Luts Garcia, MD, Richard Chambers, MSPH, Bronya Keats, PhD; Alton Ochsner Medical Institutions and LSU Health Sciences Center, New Orleans, Louisiana.

Introduction: Risk factors for gallstone disease are well known, but have not been looked at recently with better ultrasound technology and in the laparoscopic era.

Methods: We compared a group of 100 consecutive patients who had undergone ultrasound showing no gallstones (NGS) to a group of 100 consecutive patients who had their gallbladder removed for gallstone disease (GS). Data was obtained by questionnaire and chart review. Ultrasound was performed for. al0dominal pain-58, cirrhosis.10, liver enzyme elevation-6, and other-19. Data is presented as mean+SD, and significance was determined by independent T test or Chi squared test.

Results: The mean age for the GS was 51 • 15.9 and for the NGS 50 • 16 (p=NS). Fifty nine percent of GS were female and 52% of NGS were female (p=NS). The body mass index was 32 • 8 for GS and 28 • 6 for NGS (p=0.013). Cholesterol in GS was 196 + 39 and in NGS 200 • 42 (10=0.945). Cholesterol level greater than 200 also did not reach a significant difference between the two groups. In GS, 74% were Caucasian and in NGS 64% were Caucasian (p=NS). Parity in GS was 2.6 • 2.1 and in NGS 2.1 • 1.8 (p=NS). Menarche was 12 :i: 1 in GS and 12 :l: 1 in NGS (p=NS). 17 (24%) of GS breast-fed at least one child and 8 (12%) of NGS (p=0.03). 37 (52%) of GS took oral contraceptives for more than a year and 17 (22%)of NGS (,o=0.0005). For GS primary relatives having gall bladder surgery was 0.68:t:1 and for NGS was 0.35t0.6 (p=0.02).

Conclusion: Body mass index, breast-feeding, oral contraceptives, and 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 MALIGNANT POTENTIAL VIA UP REGULATION OF MATRIX-METALLO- 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, Academic Surgical Unit, Imperial College School of Medicine. St Mary's Hospital London, UK.

Background: Certain surgical strategies, including carbon dioxide (C02) insufflation in laparoscopy, have been demonstrated to induce a hypoxic environment. Patients with hypoxic cancers have a worse prognosis than those with an adequate oxygen supply, particularly in head and neck cancers and cervical tumours. The undelying mechanism has not been elucidat- ed. Expression of Matdx-Metalloproteinases (MMPs) have been correlated with enhanced tumour aggression, we investigated the induction of MMPs in tumours in response to hypoxia. Methods: Colonic (SW1222) and breast (MDA-MB231) adenocaminoma cell lines were exposed to a hypoxic environment of helium or left in normal growth conditions(Control). Media from cells was removed after exposure to normoxia, hypoxia, and reoxygenation for 24 hours after a 4 hour exposure to hypoxic conditions. Gelatin zymography was carried out to determine total activity of MMP-9 and MMP-2. Activity of MMPs correlates with density of the gel bands. Gel bands were analysed using densitometdc analysis. Results: The results are expressed as mean densitimetric readings and SEM (arbitrary Units) SW1222: CONTROL- 0* 0# HYPOXlA- 70 +/- 0.7* 51 +/- 0.6# MDA-MB231: CONTROL- N/A* 27 +/-2# HYPOXlA- N/A* 44 +/-1.2# A Key: MMP-2:* MMP-9:# MDA-'~MMP 9 Control Vs Hypoxia - P < 0.05 Conclusions: These results indicate that oxygen levels play an important role in malignant progression by virtue its effect on MMP expression and therefore the invasive capacity of tumour cells.

LAPAROSCOPIC LATERAL L4-L5 DISC EXPOSURE. Michael Rosen MD, Fred Brody MD,Isador Liebcrman MD.Cleveland Clinic Foundation, Cleveland, OH.

The anterior laparoscopir approach requires precarious dissection around the lilac vessels to expose the IA-L5 level. Furthermore, a retroperituneal endoscopic approach to the LA-L5 level requires a technically demanding dissection to access the LS-SI disc space. A unique lateral laparoseopic approach to the LA-L5 disc space allows concurrent access to the LS-SI space while avoiding major dissection around the iliac vessels. This paper describes this novel lateral approach and reviews the initial clinical outcomes.

Between January 1999 and April 2000, 5 patients underwent laparoscopic lateral L4-L5 disc exposure at the Cleveland Clinic Foundation. All charts were reviewed retrospectively. Mean value~standard deviation were determined for patient demographics and operative characteristics. A standard five port laparoscopic technique is used. The sigmoid colon is retracted medially with an endoloop. The retroporitoncum is entered and the ureter and left lilac artery arc retracted medially while the psoas is retracted laterally. Fluoroscopy delincatas the L4-L5 disc space allowing discectomy and cage insertion. Postoperatively, subjective patient satisfaction was obtained and radiologic evidence of fusion was assessed.

All 5 patients were males with a mean age of 47.4_+7 years and a BMI of 3_0!-6 kg/m ~. Four patients had an L4-L5 and LS-SI fusion and one patient had an LA-L5 and L3-1A fusion. Mean operative time was 349~-32 minutes with a mean blood loss of 210+_74cc. There were no intraoperative complications, no convcrsious, and postoperatively all patients were ~ on a clear liquid diet on POD#1. The mean length of stay was 3.4_+0.9 days. Patients returned to work in a mean of 12+7 weeks. All patients had evidence of fusion on their radiologic follow up. Four patients were pain free while one patient required intermittent narcotics at one year follow up.

For multilevel fusions including the L4-L5 disc space, the lateral laparoscopic exposure is a safe and efficacious procedure allowing simultaneous access to multiple disc spaces while avoiding the sympathetic chain, ureter, and major vascular structures. The lateral approach affords excellent exposure for accurate depioymen! of the appropriate orthopedic hardware.

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LOW PRESSURE LAPAROSCOPY IS ASSOCIATED WITH LESS INCREASE IN ICP AND LESS DECREASE IN RENAL BLOOD FLOW. Dannv Rosin M.D., Oscar Brasesco, M.D., Javier Varala, M.D., Arul Chidembaram, M.D., Alan A. Saber, M.D., Seong You, M.D., Raul J. Rosenthal, M.D., and Stephen M. Cohn, M.D. Department of Surgery, Cleveland Clinic Flodda, Fort Lauderdale, Florida, and Department of Surgery, University of Miami School of Medicine, Miami, Florida.

Increased abdominal pressure is associated with both an elevation of the intracranial pressure (ICP) and impaired renal function. These adverse effects are important in clinical situations, among which are severe abdominal trauma and laparoscopic donor nephrectomy. It was hypothesized that the secondary elevation of intracranial pressure leads to release of vasoconstrictors, which may affect renal function by decreasing the renal blood flow (RBF). We investigated the effect of using laparoscopy on simultaneous measurements of ICP and renal blood flow in a pig model.

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 measured using a Camino 0"M) monitor, and RBF was measured using a doppler probe placed on the renal artery. Results were analyzed using two- way ANOVA and paired t-test.

No significant change from baseline was observed in ICP and RBF when the abdominal pressure was 5 mm Hg (p=0.37 and 0.63, respectively). However, both ICP and RBF were significantly affected by increasing the abdominal pressure to 15 and 25 mm Hg (p<0.05L

Low pressure laparoscopy may reduce the adverse affects of pneumoperitoneum. The mechanism may involve prevention of significant elevation of ICP. It may be advisable to use low pressures in laparoscopic donor nephrectomy, to reduce the incidence of graft malfunction.

BEDSIDE LAPAROSCOPY IN THE ICU. Danny Rosin, M.D., Yael Haviv, M.D., Joseph Kuriansky, M.D., Eran Segal, M.D., Oscar Brasesco, M.D., Raul J. Rosenthal, M.D. ,Moshe Shabtai, M.D., Amram Ayalon, M.D., Department of Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida, Department of Surgery B and Intensive Care Unit, Sheba Medical Center, Tel Hashomer, Israel.

Patients in the intensive care unit may suffer from life threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as symptoms are often masked and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries a significant morbidity and mortality. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these diffcultJes.

We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in 4 patients, over a 4 months period, and successfully completed ,n all four. Tne findings were. I) I, urbid ~uid consister,t w;U= a v;scus perforation in a patient with unexplained sepsis after cardiac surgery. 2) sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura. 3) a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure. 4) abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patient 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 dies several days later.

Bedside laparoscopy in the ICU is feasible, informative and accurate. It has 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 AN ELECTROTHERMAL BIPOLAR VESSEL SEALER. ~eyen S. Rothenbem. M.D.. John T. Bealer, M.D., Ned Cosgdff, M.D., The Hospital for Infants and Children, Presbytedan SL Luke's Medical Center, Denver, Colorado.

Advanced thoracoacopic surgery requires a method of obtaining reliable hemestasis to ensure successful outcomes. The recent introduction of bipolar vessel-sealing technology has made it possible to seal adedes and veins up to 7 mm in diameter safely and effectively through a 5 mm port. Chronic animal studies have demonstrated the effectiveness of the vessel- sealing device on both the pulmonary vasculature and pulmonary parenchyma.

From September 1999 to February 2000, 5 patients, ranging in age from 11 months to 18 years, underwent video assisted lobe resections, (4 left lower Iobectemies, 1 dgM upper Iobectomy), using the bipolar vessel-sealing system as an adjacent method for hemostasis and vessel occlusion. Major vessels that were effe<~lvaly sealed by the system include the infedor pulmonary vein and branches of the main pulmonary admy.

An procedures were completed successfully without complication. There were no failures of the device to achieve hemostasls, and no apparent injudes to surrounding tissues." In all procedures, the vessel-sealing device dissected tissue very well and there was no difference in surgical blood loss when compared to traditional techniques. Thoracescopy was performed completely through trocar sites using the 5 mm vessel-sealing device. Mini- thoracotemy was not required in any of the cases. Spedmans were morselized and brought out the 12 mm trocar site. Hospital stays ranged ~rom 1to 3 days.

Iniial experience whh the laperoscopic bipolar vessel-sealing device in thoracoscopic surgery indicates that it is effective for dissecting and permanently sealing vessels commonly encountered in thoracoscopic lung reseotlons.

LAPAROSCOPIC EXCISION OF A SYMPTOMATIC URACHAL CYST IN AN INFANT Noel C. Sanchez, M.D., Harsh Grewal, M.D., Department of Surgery, University of Kansas School of Medicine- Wichita, Wichita, Kansas

Introduction: The urachus is the obliterated allantois, and extends from the dome of the bladder to the umbilicus. Symptomatic urachal anomalies are rare; a patent urachus has been observed in 2% of adult autop- sies. However, these anomalies account for only 0.0015% of hospital admissions. The diagnosis of symptomatic urachal anomalies requires a high index of suspicion. We report a unique case of laparoscopic excision of a urachal cyst in a lO-month old boy.

Methods: A lO-month old boy presented with a swollen, tender, and erythematous umbilicus. In addition, there was a tender supra-pubic mass. Incision and drainage of this 'urachal abscess' was performed through the umbilicus. A computed tomographic scan performed postoperatively revealed a tubular cystic structure in the antedor midline between the umbilicus and bladder, consistent with a urachal cyst. This was excised laparoscopically four weeks later. Two 3-mm ports in the right and left upper abdomen, and one 5-mm port in the epigastrium were used. The cyst was dissected off the abdominal wall with electrocautery and ligated with an endo-loop at its junction with the bladder. Post-operatively, he was dismissed the next day, and was asymptomatic on follow-up.

Conclusion: Traditionally, urachal anomalies have been treated by open excision to prevent complications of infection and possible malignant change. This is associated with significant post-operative pain, morbid~, and prolonged convalescence. Laparoscopic excision minimizes the morbidity of definitive therapy and is cosmetically superior. However, laparoscopy in young children and infants is not widely practiced. Our case is unique in that laparoscopy was used for the definitive treatment of a symptomatic urachal cyst in an infant. In summary, we believe that laparoscopic excision of urachal anomalies can be safely performed in infants and children.

ASSESSMENT OF HEPATIC METABOLIC RESPONSE IN RATS AFTER LAPAROSCOPIC AND OPEN SURGERY Markus Sch&fer, M.D.1, Beate Richter, M.D.2, Carsten N. Gutt, M.D.2, Stephan Kr&henbShl, M.D.1, Lukas Kr&henb0hl, M.D.1, Dep. of Visceral and Transplantation Surgery, University of Z(~rich, Switzerland 1, General and Vascular Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany 2

Patient's stress response is an inevitable physiologic consequence of every surgical procedure, whereby it has been assumed, that laparoscopy minimizes the surgical trauma and thus patient's stress response. The purpose of the current study was to assess the hepatic metabolic response of diagnostic laparoscopy compared to open abdominal exploration in a small animal model. Male Sprague-Dawley rats were randomized into 3 groups (n=28 each). Group A underwent a diagnostic laparoscopy (LS) using a CO2- pneumoperitoneum with a pressure of 6 mmHg. Animals of group B had a 5 cm taparotomy (LP) and underwent open abdominal exploration. Group C served as control group (CON) and animals only had anesthesia. Animals were characterized by their body weights, daily food intakes, hepatic glycogen contents, activities of alkaline phos- phatase (AP), aspartate aminotransferase (AST), alanin aminotransferase (AL'r), bilirubin, bile acids and glucose in plasma. Body weight gain and food intake did not differ among the 3 groups. Hepatic glycogen contents were significantly decreased after LS and LP compared to CON for 8 days postoperatively (-32%), whereas plasma glucose, bile acids and glucose remained unchanged. AST was 3-4 fold increased after LS and LP compared to CON for 8 days postoperatively. Both surgical interventions (LS and LP) induced a hepatic metabolic response which could be confirmed by a decreased glycogen content. Plasma glucose levels were maintained demonstrating that glucose homeostasis is not severly altered.

ADVANTAGES OF A STANDARDIZED LAPAROSCOPIC COLECTOMY FOR SIGMOID DIVERTICUUTIS. Anthony ~1. Sene(]ore.M.D.. Hans-Joachim Duepree, M.D., Victor W. Fazio, M.D., Dept. of Colorectal Surgery, Minimal Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio.

The indications for elective sigmoid colectomy for diverticulitis are deady defined however, lapamscopic sigmoidectomy has failed to become routine. Concerns remain regarding prolonged operative times, extensive use of instrumentation, and limited reductions in hospitalisation. The purpose of this report is to compare a standardized approach to laparoscopic sigmoid colectomy to open colectomy for diverticular disease in one institution.

All patients requiring elective stgmoid colectomy for sigmoid diverticulitis from 3/1999-7/2000 were analysed. Data collection inctuded age, gender, type of procedure (LAP vs OPEN), estimated blood loss (EBL), length of hospital stay (LOS), intra- and postoperative complication, reedmission-rate (<30 days), and return of bowel function. The converted patients were included in the LAP group for calculations of OR time and LOS, based on intent to treat. Standardization of the instrumentation resulted in an increased acquisition cost for instruments of $425.00 in the LAP group.

A total o! 59 patients were eligible for evaluation (LAP:3 t/OPEN:28). There were no significant differences between the groups with respect to age (LAP: 51.8• vs OPEN: 82.0~:1.8 years), M/F ratio (LAP 15118 vs OPEN 11/17), or OR time (LAP: 109.3+7.3 vs OPEN:101.4• min). The LAP group had signi- ficanUy shorter lengths of stay (LAP: 3.2• vs OPEN: 6.3-/0.4 days), estimated blood loss (LAP:148.0:I:20.4 vs OPEN: 280.~36,8 ml), and return of bowel function (flatus: 2.481021 vs. 4.43~.78 days, bowel-movement: 3.4• 0.37 vs. 5.69• days). Conversion to open was required in 4 patients (12.9%) due to obesity, trocar.site bleeding or severe adhesions. Re-admission occurred in 1 LAP (3.2%) patient for small bowel obstruction compared to 3 OPEN patients (10.7%) however the difference was not statistically significant.

The results indicate that a standardized approach to laparoscopic-assisted resection for sigmoid diverticulitis reduces LOS, resource utilization, even with a low but acceptable conversion rate.

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ADVANCES IN LAPAROSCOPIC CLIP DESIGN: THE PREFORMED CLIP S.D. Schwaitzberg MD, D Rifkin MD, W. A.Amold MD, R.J.Connolly, PhD Center for Minimally Invasive Surgery, Dept of Surgery, New England Medical Center, Boston, MA

Introduction: With over 600,000 laparoscopic cholecystectomies performed 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. The most commonly applied ligating clip is the crush type clip delivered 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 surgeon confidence in the retention strength of any single clip. This concern is borne out by the fact that the single greatest cause of bile leakage is clip slippage. Method: Pre-formed, titanium spring ligation clips (Smm applicator), were tested for transverse and longitudinal holding force on simulated vessels and compared with published results for conventional crush clips from 2 manufacturers (10mm applicator) and crush clips (5 mm applicator) Results: Transverse holding force in Grams 10mm crush clip A 235 10mm crush clip B 185 5mm crush clip A 206 5mm preformed clip 566

Axial holding force in Grams 10mm crush clip A 416 10mm crush clip B 488 5mm crush clip A 279 5mm preformed clip 816

Conclusion: The new clip design was found to demonstrate significantly better holding forces and significantly more consistent application than the crush clips with 25% of the crush clip falling below 147 grams and only 2% 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.

A COMPARISON OF COSTS AND OUTCOMES AMONG PRIMARY AND REOPERATIVE LAPAROSCOPIC FUNDOPLICATIONS= F. Serafini, M D, William Nlelds, MS, M. Bleomston, MD, E. Zervos, MD, M Murr, MD, M. Albdnk, MD, Eli Lemer, MD, A.S. Rosemurgy, MD. Department of Surgery, University of South Rorida, Tampa, FL.

The morbidity, efficacy, and costs of lapamscopic reoperative antireflux operations have not been established. This study compares cost and outcomes of laparoscopic reoperaUons to initial antireffux procedures.

30 consecutive patients undergoing laparoscopic fundoplication revisions were compared to 60 random patients undergoing primary laparoscopic fundoplication undertaken between 1995 and 1999. Patients were of similar age (52ys + 18.3 vs 49ys • 15.0,1o=0.4) and severity of GERD (DeMeester score 31:1:10.6 vs 70:1: 64.1,p=0.4). Patient satisfaction was queried using scales (1 for worst, 10 for best) via written questionnaires that included relief from symptoms, need for antJreflux medications, and capability of returning to precp activities. Data are presented as mean • STD.

Fundoplication was completed laparoscopically in 26 (86%) patients and in 60 (100%) patients undergoing revisional and primary fundoplicatJons. Blood loss, hospital stays and costs are summarized in Table 1. No deaths occurred, but with ravisional operations major morbidity (18%) resulted in 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 zfter primary ft ndoplications (9 • 1.9 vs 6 +3.7) (p=0.0~)07).

Blood Ioss(ml) Hospital stay(days) Hospital Costs ($) Lap Redo 116+ 197.8 3 (2 - 90) 34~734:1:49,289.4 Lap Primary 41• 35.8 2 (1 - 21) 10,575:1:4238.5 P value 0.005 0.001 0.001 Longer hospital stays, increased morbidity, and higher hospital costs

occurred after recperative laparoscopic antireflux surgery. With extended follow up, patients were less pleased after reoperative fundoplications because of operative morbidity and recurrent symptoms. Revisional operations are possible but with increased morbidity, increased cost, and greater likelihood of symptom recurrence.

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LAPAROSCOPIC CELIAC PLEXUS NEUROLYSIS IN A PATIENT WITH INTRACTABLE PAIN ASSOCIATED WITH CHRONIC PANCREATmS Thomas E. Serena, M.D., Warren General Hospital, Warren, Pennsylvania, Gannon University, Erie, Pennsylvania

Background: We report a case of laparoscopic celiac ganglionectomy with alcohol neurolysis of the celiac plexus. The disabling intractable pain caused by chronic pancreatitis frustrates patients and physicians. Medical therapy consists of addictive narcotic analgesics which do not have Ion- gacting efficacy (1). Open abdominal procedures such as resection of the celiac ganglion are associated with significant morbidity. These have been largely replaced by percutaneous techniques (2-4). However, there are also complications with percutaneous neurolysis and pain relief is not always achieved (5). More recently thoracoscopic splanchnicectomy has been proposed as an alternative treatment, but requires a hospital stay of 3-5 days (6).

Case Report: A 39 year old Caucasian male with intractable mid-epigastric abdominal and back pain caused by alcoholic pancreatitis presented to my office in the early part of 1998. Not having had a drink in two years, he now feared he was becoming addicted to narcotic analgesics used to treat his pain and was unable to work. He had not tolerated a previously attempted percutaneous procedure (neurolysis was not performed). We performed surgery in March 1998. We visualized the celiac plexus using a 10 mm. 30 degree laparoscope. The celiac ganglion was resected wi~ the aid of the Harmonic scalpel (Ethicon, Cincinnati, OH). Alcohol neurolysis was achieved using a modified laparoscopic needle passed through a 5 mm. port. Dehydrated Alcohol (American Regent Labs) was injected in the area of the celiac plexus for therapeutic neurolysis. The procedure took less than 30 minutes to complete and was uncomplicated. He was discharged on the day of surgery receiving almost immediate and complete pain relief. At his two year follow-up he had some mild abdominal discomfort, but he was narcotic free and gainfully employed.

Conclusion: Laparoscopic celiac plexus neurolysis and/or celiac 9an- glionectomy may be another option for selected patients with intractable pain caused by chronic pancreatitis.

AN UNUSUAL LATE COMPLICATION OF LAPAROSCOPIC NISSEN FUNDOPLICATION: AN INTRAWRAP HERNIATION Thomas E. Serena, M.D., Gary L. McAfoos, M.D., Warren General Hospital, Warren, Pennsylvania

Background: We report an unusual complication of Nissen fundoplication occurring nearly two years postoperatively. In the past decade the treatment of gestroesophageal reflux disease (GERD) has been revolutionizeq by minimally invasive surgery. Laparoscopic Nissen fundoplication provides symptomatic relief in >90% of patients. In most series, postoperative corm plications occur in <10% of patients (1-3). Mortality is infrequent. As the procedure becomes more commonplace one would expect to find previously unknown complications.

Case Report: The patient is a 38 year old Caucasian male with severe, refractory GERD complicated by GERD-induced asthma. His past history is remarkable for Ehlers-Danlos syndrome. Preoperative manometry revealed only a decreased LES pressure. His 24-hour pH studies demonstrated a composite score of 48 on the Johnson-DeMeester Table. He underwent an uneventful laparoscopic Nissen fundoplication in March of 1998 resulting in excellent relief of his GERD symptoms. Twenty-two months postoperatively the patient presented complaining of worsening post-prandiai discomfort and [eft upper quadrant pain not relieved by narcotic analgesics. Ultrasound revealed a cystic mass in the area of the proximal stomach and distal esophagus containing both air and fluid. Percutaneous CT-guided aspiration of this collection was unsuccessful. Upper GI endoscopy demonstrated no evidence of bleeding, obstruction or other abnormality. At surgical exploration we found that a portion of the greater curvature of the stomach which was not part of the wrap had herni- ated between the esophagus and the fundoplication. This hemiated stomach was incarcerated in this intemal hernia. Two small perforations from the CT-guided aspiration were repaired easily. The hernia was reduced and the fundoplication redone. The patient did well and was discharged on the fifth postoperative day. At his six-month follow-up he was free of reflux symptoms.

Conclusion: As laparcscopic fundoplication is performed more frequently, we e x ~ to see unique complications.

ESOPHAGEAL MANOMETRY PERFORMED BY SURGEONS AT A RURAL COMMUNITY HOSPITAL Thomas E. Serena, M.D., Sartaj Ahmed, M.S., Gary L McAfoos, M.D.

Background: Esophageal manometry can be performed by laparoscopic surgeons. The popularity of laparoscopic Nissen fundoplicetion in the treatment of esophageal reflux disease (GERD) has spread from academic centers to community hospitals. While most community hospital operating rooms are outfitted with all the necessary equipment to perform these procedures, in many rural areas the necessary preoperative diagnostic studies are not available. It is considered the standard of care to perform esophageal manometry on all patients considered for laparoscopic anti-reflux procedures (1,2). In our community esophageal manometry could only be obtained at a tertiary center three hours distant.

Methods: A solid state three channel manometry catheter (Sandhill Scientific, Denver, CO) was used for all procedures. The data collection and analysis were performed by the surgeon with the aid of Sandhill Scientific's Bioview computer software.

Results: We present the results of 79 esophageal manometries performed by laparosoopic surgeons at our institution between January 1998 and June 2000. The rnajority (77/79) of these studies were performed as part of the preoperative work-up for patients with GERD considering antireflux surgery. The average time to complete the study was one hour with times decreasing as experience with the procedure increased. 78% were read as normal. 16% identified only a decreased lower esophageal sphincter pressure. 4% were found to have achalasia and one patient had a motility disorder. Thirty patients subsequently underwent laparoscopic anti-reflux procedures (90% Nissen fundoplications/10%o Toupet fundoplications). There have been no complications related to esophageal motor dysfunction to date.

Conclusion: Laparosoopic surgeons can safely perform preoperative esophageal manometry studies in patients undergoing work-up for laparoscopic anti-reflux procedures. This is particularly pertinent for surgeons in rural communities in which these studies are not readily available.

LAPAROSCOPY IN FULMINANT ULCERATIVE COLITIS Neal E. Seymour, M.D., Robert L. Bell, M.D., Department of Surgery, Yale University School of Medicine

To establish the role of laparoscopy in the treatment of severely active ulcerative colitis (UC), laparoscopic subtotal colectomy was undertaken in 12 patients with pocdy controlled colitis on aggressive immunosup- pressive therapy as a preliminary step to restorative proctectomy. Methods: Records of 12 patients who underwent laparosoopic subtotal celectomy with ileostomy were reviewed. Results: Courses of medical therapy varied, but 9 patients were receiving inpatient treatment at the time of surgery, or had recently had inpatient treatment. 2 patients had failed cyclosporin treatment and had resumed prednisone (> 40 mg/day). Profound weight loss or biochemical evidence of malnutrition was present in 9 patients (67=/o) and 6 (50%) were on TPN preoperatively. 4-port access was used in all cases. Postoperative complications occurred in 3 cases (abscess, rectal bleeding, ileostomy diarrhea). Postoperative length of stay was 5.4 +/- 0.4 days compared to 8.8 +/- 1.8 days(p < 0.05) for a group of 6 patients who had undergone open subtotal colectomy for the same indications. Systemic steroids were withdrawn in all patients, although 2 required hydrocortisone ene- mas for rectal disease. 11 patients underwent proctectomy and pelvic pouch construction within 4 months of the laparoscopic procedure. The first 3 patients had protective loop ileostomies, but the remaining 9 patients did not. There were no anastamotic leaks, and all patients have excellent pouch function at 1-24 month followup. Conclusions: Laparoscopic subtotal colectomy with ileostomy is associated with early hospital discharge in acutely ill patients with UC. Relatively high morbidity is likely related to these patients' compromised status at the time of surgery. Subsequent pelvic pouch construction was facilitated by the absence of a large abdominal incision and of peritoneal adhesions. Laparoscopic subtotal colectomy, followed by proctectomy with pelvic pouch construction an d eliminat=on of ileostomy is an excellent alternative to conventional 2- and 3- staged surgical treatment of fulminant UC.

ULTRASONIC TROCAR-EVALUARION OF INFLUENCE ON TUMOR GROWTH Kazuvuki Shimomura MD. Yukio Fujino MD, Tsuyoshi Suzuki MD, Tomonori Ohsawa MD, Yasuo Idezuki MD, Department of Surgery, Saitama Medical Center, Saitama Medical School, Saltama, JAPAN

Recently we developed ultrasonic (US) trocar for laperoscpic surgery to prevent complications at the time of insertion like abdominal wall bleeding or organ injury by its hemostatic and forceless insertion as we previously reported. This time we evaluated effect of US trocar on tumor growth at insertion site in comparison with usual disposable trocar. (Method) Male DomTu rats (n=30, body weight 200-250 gr) were used. Under intramuscular anesthesia, AH1 30 tumor cell (5 x 10(6)) were injected into in t raabdonminal space after 5 t rocarswere inserted. Pneumoperitoneum (30rain, 10mmHg)was maintained in expe r imen ta l group and just kept for 30rain wi thout pneumoperitoneum (0mmHg) in control group. On POD 9, all animals were killed for evaluation of port site tumor recurrence. (Results) Under 0 mmHg the rate of trocer site implantation was 10128 (35.7%) in US trocar, and 6126 (22.7%) in disposable trocar, respectively. And under 10mmHg pneumoperitoneum, 10 136 (27.7%) in US trocar and 14/36(36.8%) in disposable trocar, respectively. Between US trocar and disposable trocar, there was no significant difference about the rate of tumor recurrence at tocar insertion site regardless of intraabdominal pressure. ( Conclusions) Ultrasonic trocar did not enhanced tumor growth at trocar insertion site in comparison of disposable trocar.

CYSTIC FIBROSIS AND GASTROESOPHAGEAL REFLUX DISEASE: CAN LAPAROSCOPIC NISSEN FUNDOPLICATION REDUCE HOSPI- TAL RECIDIVISM AND PULMONARY MORBIDITY? T Shope, M.D., T Singh, M.D. Department of Surgery and S Beagle, M.D., J Rosen, M.D. Department of Medicine, Albany Medical Center, Departments of Surgery and Medicine, Albany, New York

INTRODUCTION: Gastroesophageal Reflux Disease (GERD) is a common associated problem for Cystic Fibrosis (CF) patients. As the life expectancy for patients with CF lengthens, more of these patients will be at risk for the complications of the disease. Successful treatment of GERD should reduce morbidity in CF patients.

OBJECTIVE: To evaluate the impact of laparoscopic Nissen fundoplica- lion (LNF) on hospitalization rates and pulmonary complications of adult CF patients with GERD.

METHODS: A case series analysis of four adult patients with CF and dec- urnented GERD who underwent LNF was performed. Patients hospital and outpatient medical records were evaluated for evidence of pulmonary morbidity and need for hospitalization.

RESULTS: #Hospitalized #Hospitalizations Steroid Use

Pulmonary Symptoms* PreL.NF** 3/4 8 4/4 Significant Post LNF*** 2/4 5 1/4 Improved *Includes cough, dyspnea, and sinusitis. **In the year prior to their LNF. ***Follow-up 5-18 months. 4 Post LNF hospitalizations and the need for Post LNF steroids were for 1 patient who had repeated technical failures and documented recurrent reflux. For the periods when this patient did not experience reflux symptoms, he did not require steroids. The remaining admission was for Aspergillus infection refractory to outpatient manage- merit.

CONCLUSIONS: GERD is a common comorbid condition in the CF population. Recurrent tracheal acidification, and the resultant chronic inflammation, which occurs with GERD, cause increased pulmonary morbidity and need for increased medical care in this at risk population. Successful LNF should eliminate gastroesophageal reflux and therefore reduce pulmonary morbidity and hospitalization in adult CF patients. Further evaluation and long term follow-up is needed in this population and should be in the pediatric population.

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CLINICAL EVALUATION OF COMMON BILE DUCT REPAIR BY TITANIUM CLIP Kazuvuki Shimomura MD. Yukio Fujino MD, Masanobu Hosino MD, Deijo Hashimoto MD, Yesuo Idezuki MD, Department of Surgery, Saitama Medical Center, 8eiteme Medical School, Saitama, JAPAN

Recently common bile duct (CBD) explorat ion ieo f ten performed laparoscopically. However suture repair of common bile duct is sometimes difficult technically, and T-tube insertion tends to prolong hospital stay up to 3 weeks. In order to simplify closure technique of CBD and avoid T-tube insertion for shorter hospital stay, we applied VCS titanium clip to repair CBD in clinical cases. We evaluated efficacy and safety of this method. (Method) Before c losing CBD, we performed intraoperative cholangiogram to neglect outflow obstruction of papilla Vater. After lithotripsy, we applied VCS clips ((~ 3ram) to

repair CBD. As we can expect pressure tolerance of clip- repaired CBD up to 50 mmHg according to our preceded pig experimatal data, we applied clips every 0.5 mm -,, 2ram. No bile drainage was attempted to place. (Results) We have 4

clinical cases( 3 male, 1 female). Size of CBD exploration was 5 ram, 10ram, 10mm and 20mm, respectively, mainly according to the size of largest stone. And the number of applied VCS clip was 10, 20, 10 and 10, respectively. Days of postoperative stay was 5, 3, 4, and 5. There was no bile leakage and CBD stanosis. Average period of observation was 2.5 months. ( Conclusions) VCS clip was useful to simplify CBD repair technique and suggested possibility to reduce hospital stay as short as basic laparosccpic cholecystectomy.

LAPAROSCOPIC MANAGEMENT OF RECURRENT POST TRAUMAT- IC SPLENIC PSEUDOCYS-E CASE REPORT Jonathan Smith, MD, CPT, MC; Anthony Laporta, MD, COL, MC; Department of General Surgery, Evans Army Community Hospital, Fort Carson, Colorado

Introduction: Pseudocysts of the spleen are rare but usually arise after blunt abdominal trauma. The purpose of this review is to present the case of a recurrent post traumatic splenic pseudocyst, three years after initial injury, and its laparoscopic management.

Methods and Procedures: The patient is a 22 year old female who three years prior to presentation to our facility, received blunt abdominal trauma during sports related activities. Three months after the initial injury, she developed a splenic pseudocyst, which was managed by laparoscopic marsupialization. Three years later, she developed a large left upper quadrant mass, but was otherwise asymptomatic. A preoperative CT was obtained which documented a 24 cm splenic cyst with significant mass effect. She then underwent laparoscopic exploration, cyst decompression, and splenic cystectomy. Several intraoperative pho- tographs were taken. 1600 cc of green fluid were obtained. A 7mm Blake drain was placed within the cyst cavity and was discontinued on post operative day 4. She also underwent CT on postoperative days 1 and 10, which did not demonstrate cyst recurrence.

Uterature review shows that these cysts are rare. Most pseudocysts arise after splenic trauma from liquefaction of splenic hematomas. Several treatment options exist to include percutaneous drainage, marsupialization, cystectomy, and spleneotomy. Extemal drainage and marsupialization have an unacceptable rate of infection, bleeding, and reaccu- mulation, and are inadequate modalities of treatment. Splenic preservation is preferred, however splenectomy may be necessary for uncontrol- lable hemorrhage or possible malignancy. Small cysts may effectively be managed with percutaneous drainage, however, cystectomy is the pre- ferrod management for larger cysts.

Conclusions: Splenic pseudocysts are a rare complication of splenic trauma. We present the case of a recurrent posttraumatic splenic pseudecyst managed by laparascopic cystectomy. Several methods of treatment exist, however splenic preservation is preferred.

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TASK DECOMPOSITION OF MINIMALLY INVAS1VE SURGERY FOR OBJECTIVE EVALUATION OF LAPAROSCOPIC SKILLS. Massimiliano Solazzo M.D. * Jacob Rosen Ph.D. A Blake Hannaford Ph.D. A, Mika N. Sinanan M.D., Ph.D. *, Dmitry Oleynikov M.D. *, Carlos A. Pellegrini M.D. * �9 Dcpamnent of Surgery, Box 356410, University of Washington Medical Center, SeaR]c, WA, USA ^Department of Electrical Engineering, Box 3.52500, University of Washington, Seattle, WA, USA.

Lapazoscopic skill evaluation of general surgery residents is usually a subjective process, carried out by senior surgeons in the operating room using fuzzy criteria. The aim of this study was to develop and assess an objective laparoscopic surgical skill scale using Hidden Marker Models (HMM) based on hapdc informations, tool/tissue interactions and visual task decomposition. Eight subjects (six residents at different training levels: 2xR1, 2xR3, 2xR5 and two experts surgeons: 2xES) performed laparoscopic choleoystectomy on pigs following a specific 7 step protocol. During surgery, they used an instrumented grasper equipped with force/torque if/r) sensors able to measure forces and torques at the hand/tool interface and synchronized with a video of the operative maneuvers. Fourteen types of tool/tissue interactions, each associated with unique F/r signatures, were defined from frame-by-frame video analysis. The statistical distances between HMMs representing expert surgeons and residents were significantly different. Major differences were: (i) F/T magnitudes (ii) tool/tissue interactions used and transitions between them (iii) time intervals in each tool/tissue interaction and overall completion time. The greatest differencr in performaaco was between El and g3. Smaller changes were seen as expertise increased. This obJeCtive learning curve indicates that the laparosoopic surgical residents acquire a major portion of their skill between the first and the third years of their 5 years of training.

LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER USING THREE TROCAR TECHNIQUE: OUR EXPERIENCE AND PRELIMINARY RESULTS 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 Department, Manerbio Hospital, Manerbio (BS), Italy; Center for Videoendoscopic Surgery, University of Washington Medical Center, Seattle, WA

INTRODUCTION: The aim of the current study was to assess the feasibility 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 left colon and rectal cancer underwent complete laparoscopic or laparoscopic assisted colectomy using only three ports of entry instead of the 4 ports usually required. W'rth the patient in normal supine position a 10 mm. t]'coar is inserted in the midline 3 cm above the umbilicus, a 10 mm trcoar is placed just above the pubis, 2 cm on the left far from the midline and a 10 mm. tzocar is inserted 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- ere inserted through the trocar placed in the right midclavicular line, allowing the surgeon to perform the procedure autonomously by utilizing the remaining two ports. RESULTS: All the 24 procedures were completed laparoscopic~ly: 5 left colectomies, 7 sigmo=d resections, 11 anterior resections and 1 Hartmann's procedure. In 18 patients we completed a full laparoscopic colectomy with intracorporeal anastomosis, whereas in the remaining 6 we performed extracorporeal anastomosis. We used a 6 cm minilaparotomy for specimen retrieval. There were no intraoperetive complications and 3 (12.5%) postoperative complications requiring reoperation: 2 intestinal occlusions due to adhesions and 1 anastomotic fistula. The average number of lymph nodes harvested in resected specimens was 16 (range 6-26) and the mean distance of the tumor from margins 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). CONCLUSIONS: Three trocar laparoscopic colectomy is a reliable and safe technique in which most of the procedure is performed by one surgeon assisted 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 SKILLS IRRESPECTIVE OF PRIOR TRAINING T. Sweeney MD D. Rattner MD Department of Surgery Massachusetts General Hospital and the Harvard Center for Minimally Invasive Surgery Boston MA

INTRO: This study compares the performance of a set of standardized surgical skill tests using conventional laparoscopic instruments (CLI) and a robotic surgery system (RS)in subjects with differing surgical expertise. The 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 medical students(n=10). Each subject performed a set of 4 tests: bead drop into a container, object transfer, suture placement and intracorporeal knot tie. .Each test set was performed using CLI and the Zeus RS(Computer Motion Inc, Goleta CA). RS test sets were performed with both a standard television monitor and a 3 dimensional visual system. Performance of each test was assessed by both time and error rates. Residents and students, but not attending surgeons were randomly assigned to receive VR training prior to performing the test set. A 2 tailed Hest was used for comparison of means of paired samples. Significance was assumed at 10<0.05. RESULTS: 91% of subjects completed all tests. Combined data from each test cohort demonstrated that CLI were faster and produced lower error rates than RS for both bead drop and suture tests (p<O.02). RS was faster and produced lower error rates than CLI for object transfer and was faster than CLI for knot tying using the standard television monitor(p<O.O3).The 3 dimensional visual system resulted in no improvement in either speed or error rates. Subjects who received VR training prior to testing showed no consistent improvement in performance though reduction in error rates approached statistical significance. CONCLUSIONS: The Zeus RS provided no advantage over CU for simple repetitive tasks such as bead drop and simple suture placement. For complex tasks such as knot tying and object transfer, RS was superior to CLI. MIST VR training and the 3D visual system did not significantly improve skill test performance.

L A P A R O S C O P I C S P L E N E C T O M Y F O R C H R O N I C R E L A P S I N G T H R O M B O T I C T H R O M B O C Y T O P E N I C PURPURA(TTP) : L O N G - T E R M RESULTS Amir Szold, MD, Boaz Sagi, MD, Andre Keidar, MD, and Ami ram Eldor, MD, Endoscopic Surgery Service, Depar tment of Surgery B' and Depar tment Hematology, Tel Av iv Sourasky Medical center and the Sackler School of Medic ine, Tel Av iv University, Tel Aviv, Israel

Object ive: To test the ef f icacy and safety of laparoscopic sp lenectomy (LS) for the t reatment of the chronic relapsing form of Thrombot ic Thrombocy topen ic Purpura (TTP).

Methods: We performed LS in nine pat ients wi th refractory or relapsing TTP. The operat ive as wel l as the ear ly and late post operat ive course and compl icat ions were recorded.

Results: The mean durat ion of LS was 70 minutes (range 35-180). There were no ser ious b leeding compl icat ions during or a f ter surgery . C o n v a l e s c e n c e was rap id and the mean hospital stay was 2.5 days (range 1-9). The patients were fo l lowed up for a med ian of 29 months (range 1-60 months). Eight pat ients are in remission with no relapse of TTP. One pat ient wi th fami l ia l TTP had mul t ip le re lapses before and after the surgery.

Conclus ion: LS for refractory or relapsing TTP is safe and associated wi th low morbid i ty and fast recovery. It is effec- t ive in the long- term p reven t ion of TTP re lapses in most patients, and it should probably be cons idered ear ly in the course of chronic, re lapsing I-FP.

PLACE OF LAPAROSCOPY IN GASTRIC AND DUODENAL ULCER PERFORATION MANAGEMENT Hossein Takeh M.D., Philippe Boute M.D., Patrick Philippart M.D., Patrick Emonts M.D., Pierre Mendes da Costa M.D., Department of Digestive and Laparoscopic Surgery, C.H.U. Brugmann, Brussels, Belgium

The aim of this retrospective study is to evaluate the place of laparoscopy in gastric and duodenal ulcer (GDU) perforation management. From 1994 to 1999, 32 patients were admitted for GDU perforation. There were 20 males and 12 females. The mean age was 59 years. 7 patients had received non steroidal anti inflammatory drugs(NSAI) and 3 others cortisone. 11 other patients have suffered from chronic GDU. All patient presented an acute abdomen and 4 were shocked. 8 patients had ASA score 4 - 5 at operation. The perforation was gastric in 13 patients and duodenal in 19. Plain abdominal X ray failed in 50 % of cases but computed tomography detected the pneumoperitoneum in all cases. 7 patients were treated by laparotomy, 21 by laparoscopy (3 conversions) and 4 by Taylor procedure (nasogastric tube aspiration, H2 receptor antagonist and antibiotics). Mortality rate was 18.7 % (50 % in laparotomy group and 5.5 % in laparoscopy group). The total morbidity rate was 43 % (50 % general and 50 % local complications). The mean intensive care unit and hospital stay were respectively 4.6 and 16.6 days.

The morbidity and mortality are both very high in GDU perforation with general peritonitis. The laparoscopic treatment of GDU perforation is a feasible and safe procedure. In our experience, 64 % of patients were treated successfully by laparoscopy with a very low mortality (5.5 %).

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THOFIACOSCOPIC ESOPHAGECTOMY IN THE ELDERLY. Masashi Harushi Osugi M.D., Hiroaki K]hoshita M.D., Masayuki

Higashino M.D." Second Department of Surge~/, Osaka City University Medical School, Department of Gastroenterological Surgery, Osaka City General Hospital"

We have reported that thoracoscoplc esophagectomy and lymphadenectomy contributed to preserve pulmonary function (Surgical Endosc, 11(2),p184,1997). Because esophageal cancer Is commonly seen in the elderly, feasibility of thoracosooplc surgery for elderly patients with esophageal cancer was studied.

Twrdu patients with squamous cell carcinoma of the esophagus older then 75 years old were subjected. All patients were fitted for our indications of thoracosoo~ esophagectuny; 1) the patient is able to tolerate the single lung ventilation, 2) no diffuse pleurel adhesion, 3) the esophageal lesion less then T3. In 9 patients, the esophagectomy end medlastinal lymph node dissection were performed thoracoscoplcally (T group), and other 14 patients were done through right conventional thoraootomy (C group). CUnicopathologicel features and postoperative course In both groups were compared.

There were no difference in age, gender, pathological staging, location of tumor, preoj~,h-a.tive respiratory tundJoo (%VC, FEVI.0%, MVV%), Hugh- Jones classif'c, ation between two groups. Nine patients in C ~roup and 8 patients in T group were associated with preoperative complication, such as diabetes mellitus or hypertension. There were no significant difference in duration of intmthoracic procedure (C group ; 173 minute vs T group ; 204 minutes) end amount of bi(xxI loss during intrathoracic procedure (C group ; 208 g vs T group ; 231 g). The number of dissected rnediastinal nodes was 27 nodes and 31 nodes in C and T group, respectively. The changes of peripheral blood leukocyte count and C-reactive protein level were not stgnifcently difference during preoparatlon to two weeks after surgery in two groups. There was no hospital death related surgery. The most frequent postoperative complication was pneumonia in both groups. The inddence of postoper~ve complications was 64% end 56% in C and T ~roup, respectivdy, which was not significantly different. Accumulative sunnvel rate was 51% and 88% at I year after surgery, and 34% end 33% at 2 years after surgery in C and T group, respectively.

Thoracoscopic esophagectomy was feasible for the elderly patients with esophageal cancer.

LAPAROSCOPIC STOMA CREATION: IS THERE A LEARNING CURVE? Kazuo Takeuchi, MD, Brooke Gudand, MD, Oded Zmora, MD, Nelli Mizrahi, MD, Seong You, MD, Lucia Oliveira, MD, Alon Pikarsky, MD, Eric Weiss, MD, Juan Nogueras, MD, Steven Wexner, MD, Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida

The aim of this study was to compare our early to our latter experience with laparoscopic stoma formation.

We retrospectively reviewed all patients with laparoscopic diverting stomas without intestinal resection from 1992 to 2000 who were then divided into an Early Group: 1992-1996 and a Late Group: 1996-2000.

73 patients of a mean age of 51 (22-89) years (37 females; 20 males) were reviewed. 36 patients were in the early group and 37 in the latter. 29(40%) patients had previous abdominal surgery. Average length of the procedure was 80 (30-330) minutes. 14 patients in the early group had previous abdominal surgery and an average operative time of 117 minutes while 22 patients had no previous abdominal surgery and an operative time of 55 minutes. In the latter group, 15 patients had previous abdominal surgery with an operative time of 94 minutes, and 22 patients had no prior abdominal surgery with an average operative time of 77 minutes. 7 patients were converted to open laparotomy (5 in the early group due to extensive adhesions (n=3) and intestinal injury (n=2); 2 in the latter group due to extensive adhesions). 5 patients required reoperation (2 in the early group for intraabdominal abscess and torsion and 3 in the latter group for lys=s of adhesions, torsion, and trocar site hemorrhage). Length of hospitalization in the early group was 6.2 days and 8.2 days in the latter group (2 patients had an extended stay due to non-surgical conditions).

Although conversion rates decreased with increasing experience, operative time, length of stay, and complications requiring reoperation did not improve. Thus, laparoscopic stoma creation appears not to have the steep leaming curve as other laparoscopic colorectal procedures.

ROBOTIC LAPAROSCOPIC SURGERY: EARLY LESSONS LEARNED Mark A Talamini MD, Kurtis Campbell MD, Cathy Stanfield NP, Chandrakanth Are MD, The Johns Hopkins University School Of Medicine, Department Of Surgery

Robotic systems are now available and approved for use in the US for surgery below the diaphragm. The daVinci Robotic system offers significant expansion and enhancement in the ability to perform minimally invasive procedures by providing six degrees of freedom plus grasp in two robotic wrists, motion scaling up to 5 to 1, tremor elimination, and stereo- scopic high detail vision. After engaging the system, the surgeon sits at a console near, but physically separated from the patient, and controls the stereo-laparoscope, an energy source, and two robotic arms by means of a controller for each hand and foot pedals. Ten patients underwent robotic assisted laparoscopic surgery, consisting of 4 Nissen fundoplications, 3 cholecystectomies, one exploratory laparoscopy, one laparoscopically assisted bowel resection, and one Heller myotomy and Toupet fundoplication. There were no intra-operative complications. One patient was converted to open cholecystectomy due to extensive inflammation in the right upper quadrant. One patient had a post-operative gastric leak from the non-robotic portion of the procedure. Average time to engage the system during surgery was 7.4 min. (9.5 for lap Nissens) and average system time was 104 min. (132 for lap Nissens). In most cases, one or two additional 5 mm auxiliary ports were used for additional retraction. In the authors' judgment, 3 cases could not have been successfully completed laparcscopically without robotic assistance (extensive adhesiolysis necessary for bowel mobilization, difficult crural closure during laparoscopic Nissen, and ability to exhaustively examine the small bowel during exploratory laparoscopy). Success with robotic laparoscopic surgery depends upon existing experience in laparoscopic surgery, adequate training regarding robotic technical issues, careful port placement, an anesthesia team willing to accommodate the system, and team coordination during procedures. Robotic systems expand the scope and difficulty of laparoscopic operations, and offer the future promise of at-distance surgical intervention.

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LAPAROSCOPIC GASTRECTOMY WITH REGIONAL LYMPH NODE DISSECTION FOR GASTRIC CANCER. Shinya Tanim~ra, M.D., Masayuki Higashino, M.D., Yosuke Fukunaga, M.D., Department of Gastroanterological Surgery, Osaka City General Hospital, Osaka, Japan

Recently a minimally invasive operation for gastric malignancies has been advocated. Here we have performed laparoscopic gastrectomy with regional lymph node dissection using hand-assisted laperoscopic surgery (HALS) on 83 cases of gastric cancer from March 1998 to August 2000; distal gastrectomy in 78 cases, proximal gastrectomy in 2, and total gestrectomy in 3. The dissection of all group 1 and group 2 lymph nodes defined according to the general rules of the Japanese Research Society for Gastdc Cancer was completely carded out in the distal gastrectomy cases. Reconstruction after distal gastrectomy was made by Billreth 1 method in 67, and by Billroth 2 method in 11, respectively. Billroth 1 reconstruction was applied intracorporeally to the former 29 cases using the double stapling method with a conventional circular stapling device, and in the latter 38 cases 'the quadrilateral (square) stapling technique' with a laparescopic linear stapling device was employed to prevent postoperative anastomotic bleeding and stanosis. The average duration of operation of 78 distal gastrectomy cases was 230 rain, which was significantly longer than that of conventional open surgery. The average blood loss was 132 ml which was significantly less than that compared with an open gaslmctomy. Postoperative complications from anastomosis resulted in leakage in one patient, bleeding in one patient and stenosis in one patient; all complications were treated conservatively. Postoperative pedods of walking flatus, oral feeding, and discharge were 1.1 days, 2,7 days, 3.3 days, and 13.7 days, respectively, which were all significantly sooner than those of conventional open gastrectomy patients. This technique is not only less invasive, but similarly safe and curative compared to an open gastrectomy.

SAFE AND EFFECTIVE LAPAROSCOPIC APPROACH FOR COLON DIVERTICULITIS WITH DENSE ADHESION Keitaro Tanaka, M.D., JunjiOkuda, M.D., MasaoToyoda,M.D.,SinsyoMorita,M.D., Tetsuhisa 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 College, Japan

In case of colon diverticulitis with dense adhesion, the medial aprcach, which means initial mesenteric dissection followed by mobilization of the bowel, appears to be useful for safe and easy identification of the ureter and gonadal vessels before mobilizing the inflamed bowel from the lateral side.

(Case 1) 72 y.o. male with both mid-rectal cancer and ascending colon diverticulitis. After laparoscopic rectal resection, we performed laparoscopic-assisted right colectomy for ascending colon diverticulitis. The right mesocolon was dissected from medial to lateral. The third portion of duodenum was identified and swept free of the mesentery. After confirming right ureter and gonadal vessels, ileocolic vessels were divided. Despite dense adhesion caused by diverticulitis, mobilization of dght colon was safely accomplished without inadvertent injury of right ureter, gonadal vessels and duodenum. The inflamed bowel was resected extracorporeally and anastomosis was created.

(Case 2) 68y.o male with sigmoid colon diverticulitis. We found the sig- mold colon with dense inflammatory adhesion caused by diverticulitis, We incised the rectosigmoid mesocolon to the medial side of the inferior mesentedc artery. Dissection proceeded medial to lateral. After sweeping down the gonadal vessels and ureter from the mesentery, the lateral attachment of sigmoid colon was detached laterally. The anal side of the colon was transected with an endoscopic stapler. After completion of mobilization, left colon was extracted from the left lower enlarged wound and the oral side of the colon was resected outside. Anastomosis was performed intracorporeally using double stapling technique.

Medial approach by laparosccpy is thought to be feasible for the ~eatment of both side diverticulitis especially with dense adhesion.

HAND ASSISTED LAPAROSCOPIC SPLENECTOMY FOR SPLENOMEGALY. A comparative analysis with conventional lap. splenectomy. Eduardo M' Targarona, Carmen Balagu~, Gemma Cerd~n, Juan Jose Espert, Antonio Lacy, Jose Visa, Manuel Tdas. Service of Surgery. Hosp. S Pau. UAB, and Hosp Clinic. Barcelona. Spain

Laparoscopic splenectomy (LS) is an accepted technique for cases with normal spleen but the difficulty of LS increases with splenomegaly. Recently, some devices have designed to assist laparescoplc procedures with the hand inserted in the abdomen, while the pneumoperitoneum is maintained. This device permits to recover the tactile feeling and facilitate the mobilization and dissection of the organ. Finally, the organ is recovered through the mingaparotomy. Objective: To compare the immediate results of conventional LS and hand-assisted LS (HAt.S) in cases of splenomegaty. Matsdal and Methods; Between FelP93 and sept-2000, 169 LS were attempted in 2 surgical units. 48 cases had an enlarged spleen, with a final spleen weight �9 700 g. We compare the first 36 patients operated with conventional LS (Group I, LS) with the last consecutive 12 patients approached by HALS (Group II. HALS). Results:

N Age (y) Op t (min) Conversion Transfusion Morbidity Stay ReeperaUon Spleen weight Mortality

Group !, LE Grouo I1. HALS o 36 12 58 (19-82) 62(4476) ns 177 (95-300) 131(85-270) .009 20% 7% ns 40% 25% ns 35% 7% ns 6.3 (3-14) 3.6 (2-7) 05 1/36 (3%) 1112 (7%) ns 1425 (700-3400) 1324(720-3100)ns 0 O

Conclusion: HALS facilitates significantly the surgical maneuvers during LS, while keeping the advantages of a purely ]aparoscopic approach.

COMPARISON OF LAPAROSCOPIC AND OPEN MANAGEMENT OF PANCREATIC PSEUDOCYSTS Michael Tamoff, MD, Fred Brody, MD, Michael Rosen, MD, Jeffrey Ponsky, MD, Department of General Surgery and Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio

Currently, minimally invasive techniques are available for managing pancreatic pseudocysts. Recent reports document successful treatment utilizing laparoscopic techniques. This study presents a compad- son of laparoscopic and open management of pancreatic pseudocysts at a single institution.

A retrospective review was performed of all patients undergoing operative treatment of a pancreatic pseudocyst between July, 1994 and August, 2000 at the Cleveland Clinic Foundation. Patients requiring complex surgical management were excluded (n=25). Patient demographics, intraoperative details and postoperative complications were determined for all patients. Wilcoxon rank-sum tests and Fisher's exact tests were used to compare the two groups.

Seven patients underwent laparoscopic intervention and twelve patients underwent open decompression. The mean operative time was 149.6 +- 49.5 minutes and 226.6 +- 103.2 minutes, and the mean length of stay was 8.6+- 3.1 days and 9.7 +- 9.0 days in the open and laparoscopic groups, respectively. The mean estimated blood loss in the open and laparoscopy groups was 315.2 +- 325.8 cc and 183.6 +- 230.1 cc, respectively. Comparison of these data revealed no significant differences. There have been no postoperative complications or recurrences in the open group. One patient in the laparoscopic group suffered an anastamotic leak and was managed nonoperatively. One patient in the laparoscopic group recurred 8 months postoperatively and underwent open cystjejunostomy.

This study compares open and laparoscopic approaches in the treatment of pancreatic pseudocysts. Failure to perform a wide cystgastros- tomy resulted in the single recurrence. As a result, we avoid a single staple line technique and recommend a large resection of the posterior gastric wall to ensure adequate patency.

AN OBJECTIVE ASSESSMENT OF THE IMPACT OF ADVANCED LAPAROSCOPIC FELLOWSHIP ON PERFORMING LAPAROSCOPIC CHOLECYSTECTOMY Michael Tamoff, MD, Fred Bredy, MD, Michael Rosen, MD, Jennifer Maim, RN, Jeffrey Ponsky, MD, Department of General Surgery and Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio

Recent interest in pursuing minimally invasive fellowships has steadily increased. However, little data exists regarding the technical impact of these advanced fellowships. This study attempts to objectively quantitate the technical impact of an advanced laparoscopic fellowship on surgical performance.

A retrospective review of all laparoscopic cholecystectomies performed by two consecutive laparoscopic fellows at the Cleveland Clinic Foundation was performed. Patients were stratified by anesthesia class (ASA) and preoperative diagnosis (biliary colic or acute cholecystitis). Intraoperative details were recorded including skin to skin time (STS). The fellows performed a total of 77 laparoscopic cholecystectomies with one staff surgeon. Initially, the relationship between STS and each of the variables was assessed with Spearman rank-correlations to determine which variables were significantly related to STS based on univariate tests. Subsequently, stepwise multivariate regression analyses were performed to determine which variables were most related to STS.

STS for procedures performed earlier in the year were longer based on univariate analysis (p<O.05). Although not significant in univariate analyses, after adjusting for calendar time, ASA class was significantly related to STS. In this analysis, STS significantly decreased for ASA classes 3 and 4 as the fellowship progressed (p<O.05). There was no relationship between ASA classes I and 2 or preoperative diagnosis and STS.

This study shows the importance of advanced fellowship training in minimally invasive surgery. Although other variables may contribute to improvement in STS, advanced laparoscopic training at a tertiary referral center provides exposure to complex patients not otherwise encountered in surgical residency. This may account for the decrease in STS in ASA 3 and 4 patients

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A MINIMALLY INVASIVE TECHNIQUE IN BARIATRIC SURGERY TV Taylor, M.D.

Baylor College of Medidne St. Joseph Hospital

Houston, Texas

A minimally invasive technique has been devised and tested for the performance of weight redudng surgery. The method of weight reduction is a modification of the bilio-pancreatic diversion procedure described by Scopinaro. A horizontal indsion about 4cm in length is made immediately medial to the left costal margin. Access to the stomach is easily achieved through this incision, as the stomach is the immediate posterior anatomical relation. The greater curvature of the stomach is delivered into the wound. From a point high on the greater curvature, the stomach is stapled and divided across its width using the 6cm Endoscopic GIA linear stapler/cutter, thus completely dividing the stomach. A second horizontal incision about 4 an in length is made to the nght of the umbilicus and infenody lateral to the rectus sheath. This incision allows the small bowel to be delivered into the wound so that accurate measurement prior to stapling can be carried out. Through this incision the small intestine and its mesentery are divided 250cm from the ileo-cecal junction using the Endoscopic GIA. The endoscopic linear vascular stapler can then be placed behind the wound so as to divide suffident mesentery for mobilization. A Roux-en-Y anastomosis of the proximal defunctioned intestinal segment is made 50cm from the ileo-cecal junction again using the Endoscopic GIA device. The proximal end 0fthe 250cm of divided ileum is then passed retrocolically to reach the upper incision where it is anastomosed to the stomach by the linear stapler cutter. The small incisions are dosed. Management is then identical to that used alter laparoscopic bilio-pancreatic by-pass.

COMPARISON OF TECHNIQUES OF CREATION OF GASTROJE- JUNOSTOMY IN LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY Teixeira, M.D., Ashutosh Kaul, M.D., Luis Jacome, M.D., Thomas Cerabona, M.D., Dominick Anuso, M.D., Dept. of Surgery, New York Medical College, Valhalla, N.Y.

Roux-en-y gastric bypass has been shown to an effective procedure in the treatment of morbid obesity and laparoscopic Roux-en-Y gastric bypass (LRYGB) has been demonstrated to be a safe and effective altemafive. The creation of the Roux-en-Y gastro-jejunal anastomoses has remained an issue of contention with many alternative techniques and modifications reported in literature. The purpose of study was to critically analyze our experience of three different techniques of creation of the gastrojejunal anastomoses. Three different techniques of creation of gastrojejunal anastomoses were compared. These included use of EEA stapler (29 cases); use of Endo GIA stapler (20 cases) and hand sutured anastomotic technique (23 cases). Brief description of different techniques will be provided followed by a critical analysis of our results. Patients were stud- led for intraoperative time, blood loss, complications, weight loss, length of stay and wound problems. Significant differences were found in between these groups and they will be highlighted. Hand sewn anastomoses required more advanced skills, took a longer time but had better control of stoma size, lower wound infection rates and avoided stapler costs. Endo GIA anastomoses were more reproducible and took less time. Use of EEA resulted in higher incidence of wound infection and has a potential for oral-pharyngeal and esophageal trauma. We believe that Hand Sutured anastomotic technique provides for a safe gastro-jejunostomy avoiding all problems asseQated with stapled anastomoses. It provides a better control of stomal size, avoids stapler costs, eliminates the potential for oral-pharyngeal and esophageal trauma, and potentially decreases wound infection.

THE D~-.-NOSS OF CONG~Nn'~L ESOPHAGEAL STENOSS BY ULTRASOUND SONOGRAF'~. : ~ z ~ T . ~ m m , . . ~ : xa~o ~h~a, MD.', Kazurcci Fun.l~, MD. ~, Sabine Ka~ M.D. ~, Tattoo Eronoto, MDJ, Tsuyo~ Takahashi, MD/, Akira ~ M.D. ~, G~ro Kamda, MD. ~, ~Depem~ert of Sug~y,

Sa~r~ra Hosp~ g.a-~aw~ .~r~

Cor~r~ ~ =a~ow(CES) ir~__,-~,__ throe types of pJe'x~ =x',c~ namely ~d~cUord~ remna~ fi~mucular ~ and ~,,,;~,~,-,;,~ dartragn~ z s dmo~ �9 premem~ crB~noN ~e ~ of CES at a pa~t We pe~rmed per~ =~,~,,,~eal ~ to ~reet an k~rt w~ CES ~er ~e ck~o~ bX ~ ~=ound r (EUS).

A 10~onCH~ Japanese git p ~ wi~ post ~ ~al ~ i l i ~ had a I - ~ ~ con0er~ e~=~W~ a ~ m a~d a ~ ma~omW~m ~ e ~ r

~ reve~ed esq:t~eel dro.dar ~-~ locad 18cm from arl indsor, lout

9 a s ~ relax ~ (GERD) v~s not noWcL EUS shov,~l g~e v~l of

not r my e~ - ,~ r GERD. md pressure d'~e lower esopt',~_._ _ r ~ ~ normal rungs B~oon ~ ~ d~e steno~ salient ~ not e~ec~z The paJert ~as cla~..:_,~._ J as I-~v~ng a lil~rnusoJar r type of CES, and ~-,~-,~rt su~e;y. P - ~ e~T,i'1~m co'6,med ~he c ~ d CES c~e ~o

EUS ws ulJized ~ cr~ ~ a ty10e or CES. This case serves Io ~rnon~ale

�9 at EUS rr~ be able not ody t~ da~x~e a type of CES, but abo ~o d§ m ~r ra~ ~r It may ~ p~_~'~ ~o ped~rm s gxxacocq~ suge~ for CES, v~d~ ~ dacron.___ _ of aty~e by EUS.

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A COMPARISON OF T-TUBE INSERTION VERSUS SUTURE CLOSURE FOLLOWING LAPAROSCOPIC BILE DUCT EXPLORATION Sheena E. Tranter, MB ChB, Michael H. Thompson, M.D., Depar tment of Surgery, Southmead Hospital, Bristol, England

Exploration of the bile duct at open operation is conven- tionally followed by insertion of a T-tube. The aim of this study is to compare the effectiveness of T-tube insertion with direct suture closure of the duct following laparoscopic exploration.

Comparison has been made between 29 patients undergoing laparoscopic common bile duct exploration (LCDE) with T-tube insertion and 43 patients in whom the duct was directly sutured. All data were collected prospectively.

Both groups were comparable in terms of age, sex, common bile duct diameter and pre-operative LFT's. The use a T-tube was associated with a significantly higher incidence of post-operative complications (32% vs 14%; p=0.001) including 5 cases (17%) of T-tube related complications and 4 cases (14%) with retained stones requiring endoscopic sphincterotomy. The introduction of direct suture closure resulted in a statistically significant reduction in hospital stay (5 vs 3 days; p=0.001).

Direct suture closure of the bile duct is a safe and effective technique following LCDE resulting in a reduced incidence of biliary morbidity and a shorter hospital stay.

THE FREQUENCY OF SPONTANEOUS PASSAGE OF BILE DUCT STONES AND RELATION TO CLINICAL PRESENTATION Sheena E. Tranter, MB. ChB., Michael H. Thompson, M.D., Department of Surgery, 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 passage and relate it to the clinical presentation of the bile duct stone.

Prospectively collected data was studied on a total of 991 consecutive patients undergoing laparoscopic cholecystec"tomy with or without laparoscopic common duct exploration (LCDE). Comparisons were made between 123 patients with common bile duct stones (CBDS); 496 patients who had no previous or current evidence of duct stones and 372 patients who had good evidence of previous duct stones but not present at the time of chloecystectomy. The evidence used for previous duct stones included a good history of jaundice, a raised serum amylase, abnormal pre-operative LF'F's and/or a dilated common bile duct. We have assumed that this group underwent spontaneous passage of bile duct stones.

49% of patients undergoing laparoscopic cholecystectomy had a history of previous or current CBDS: 74% of these passed the ductal stones spontaneously prior to operation. Patients presenting with pancreatitis had an 82% chance of passing their stones spontaneously. Those presenting with jaundice had only a 58% chance of spontaneous passage; the remainder in each group required LCDE or endoscopic sphincterotomy (18%: p=0.001; and 42% NS respectively). All patients with cholangitis had CBDS at the time of operation.

The majodty of patients (almost 3 in 4) with CBDS pass their stones spontaneously. Four out of five patients with pancreatitis passed their 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 REMOVAL OF COMMON BILE DUCT STONES Sheena E. Tranter, MB. ChB., Michael H. Thompson, M.D., Department of Surgery, Southmead Hospital, Bristol, England

Impacted bile duct stones are difficult to remove laparoscopically. The aim of this study is to assess intra-operative endoluminal lithotripsy as an adjunct to the management of difficult common duct stones.

Comparison has been made between 51 patients undergoing laparoscopic common bile duct exploration (LCDE) without available lithotripsy (Group A) and 76 patients where it was used if required (Group B). All data were collected prospectively.

Group A patients experienced conversion to open operation in 12 cases (6 for gallbladder inflammation and 6 for impacted stones) and post-operative sphincterotomy in 5 cases, resulting in 31% failed LCDE's. In contrast, conversion was only required in 11 cases when lithotripsy was available (Group B); 9 due to gallbladder inflammation, 1 due to bleeding from the cystic artery and 1 due to the large number of stone fragments produced by lithotripsy, too many for laparoscopic removal. There were no complications from the use of lithotripsy and none of the cases in this Group required post-operative sphincterotomy. The introduction of lithotripsy resulted in a statistically significant reduction in the failure rate of stone removal(31% to 9%; p<0.001) and a reduction in hospital stay (5.1 to 3.8 days; p<0.001). There was one missed stone in each group.

Lithotripsy is a safe and effective adjunct to the laparoscopic removal of common bile duct stones. Rates of conversion and sphincterotomy for failed laparoscopic duct clearance are sig- nificanUy reduced with a shorter hospital stay.

MANAGEMENT OF BILE DUCT INJURY DURING AND AFTER LAPAROSCOPIC CHOLECYSTECTOMY. Konstantinos G. Tsalis M.D., Emmanuil Ch. Chdstoforidis M.D., Charalampos A. Dimitriadis M.D., Dimitrios S. Botsios M.D., John D. Dadoukis M.D. D' Surgical Department, "G. Papanikoiaou" Hospital, /uistotelion University of Thessaloniki, Greece.

Bile duct injury is perhaps the most feared complication of laperoscopic cholecystectomy. The aim of the present investigation was to analyze the outcome of Isparescopic biliary tract injury.

Twelve patients with bill duct injury after iaparoscopic cholecystectomy were treated. Eight of them were referred to our institution for further treatment. The follow-up was complete and focused on clinical outcome and biochemical analysis.

Results: Five patients had minor biliary tract injury with leakage. In all of them the biliary tract injury was recognised postoperatively. Two of these patients were managed by ERCP-stent placement. The other 3 patients underwent an open laparotomy and bile duct ligation.

Seven patients had major biliary tract injury. In two patients biliary injuries were identified at the time of laparoscopic cholecystectomy and the procedure was converted to a laparotomy. At the time of conversion primary suture repeire with T-tube drainage of the injured bile duct was performed. These patients developed stricture formation after 2 and 6 months respectively and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, biliary tract injury was recognized postoperatively. In this group one patient died because of lately diagnosed biliary peritonitis. During a median follow-up time of 52 months, neither clinical nor biochemical evidence of biliary disease has been found up to this writing.

Laparoscopic biliary tract injury has a high morbidity and mortality rate. Late recognition of the biliary tract injury remains a problem.

HAND-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY: ASCENDING THE LEARNING CURVE Ruth vanDoorn MD, Willem Bemelman PhD, Laurens deWit PhD, Janto Surachno PhD, Cees Kox MD, Olivier Busch PhD, Dirk Gouma PhD., Departments of surgery and nephrolo- gy, Academic Medical Center, Amsterdam, The Netherlands.

Introduction Laparoscopic approach in live donor nephrectomy is gaining more acceptance. Potential advantages of laparoscopic donor nephrectomy (LDN) as compared to the open technique include rapid patient recovery, better cosmetic results and increased living donation. Crucial shortcomings are the learning curve. A longer operation and warm ischemia time may compro- mize the graft function. The hand-assisted approach might exclude these dis- advantages.

Methods Ten hand-assisted LDN of the right kidney were performed. Patients were postioned in the French position. Through a 7.5 cm Pfannenstiehl incision the cecum and ureter were mobilized. A 'handport' (Omniport TM, Advanced Surgical Concepts, Co. Wtcklow, Ireland) was placed. Two 10-11 mm trocars were inserted subumbilical and in the epigastric region. A pneumoperitoneum (12 mmHg) was estabhshed. The right kidney was mobilized and the ureter was transected, followed by transection of the renal artery. The renal vein was transected by a vascular endostapler. The kidney was removed through the handport and was directly perfused.

Results The median age of the donor patients was 42 years (29 - 57) and the median body-mass-index was 22.4 (19.4 - 32.6). There were no conversions. Median operation and warm ischemia time were 140 minutes (120 - 400 rain.) and 2.5 (1 - 4.5 min.) respectively. Blood loss was negligible. Postoperative morbidity included 1 unnary tract infection. One patient with a long operation time (400 min.) suffered from femoral nerve neuralgy. All but one patient returned to a normal diet within 48 hours. Opiates were needed for a maximum of 48 hours. The median hospital stay was 8 days, due to the .social relation between donor and recipient. There were no ureteral complications. In 1 recipient there was initial loss of graft function due to unknown causes, which eventually required graft removal. In all other recipients the graft func'don was normal.

Conclusions Hand-assisted LDN significantly reduces operahon and warm ischemia time even at the beginning of the learning curve.

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LAPAROSCOPIC VENTRAL HERNIA REPAIR; INITIAL EXPERIENCE Daniel G. Vanuno, M.D.,Ioannis Raftopoulos, M.D., Marcia Edison, Ph.D. Joubin Khorsand, M.D., Phil Lasky, M.D., Santiago Horgan, M.D., Department of Surgery, University of Illinois at Chicago.Metropolitan Group Hospitals. Chicago, Ininois., Lutheran General Hospital, Chicago, Illinois, Illinois Masonic Medical Center. Chicago, Illinois

Conventional repair of large ventral hernias is often associated with a prolonged recovery time. The use of mesh has reduced the recurrence rate, but the morbidity is still significant when wide fascial dissection and lysis of adhesions are required. The objective of this study is to investigate the efficiency of the laparoscopic approach in treating large ventral hernias.

We retrospectively reviewed the records of the first 50 laparoscopic ventral hemia repairs done at two major community teaching hospitals over the past 6 years. The size of the hemia defect ranged from 9 to 660 cm2. The sample was divided into two groups based on the hernia size, using the mean of 114 cm2 as a cutoff between the groups. A one way analysis of variance (ANOVA) showed no statistically significant difference (p<.05) in length of hospital stay, retum to normal activities, retum to work and recurrence rate between the two groups, after a mean follow up of 17.5 months. However, the larger hemias required significantly longer operative time (p<.02) and pain control medications (p<.047).

These results suggest that the size of the hernia, though a factor in the time needed to conduct the hemiorraphy and in the amount of pain medication needed in the post-operative period, does not have a significant impact in the length of hospital stay, the time to reasume normal activities or early recurrence rate.

These supports the fact that the laparoscopic approach minimizes the significant difference in recovery time that we see when large ventral hernias are approached with the open technique. Laparosoopic ventral hemiorraphy is an attractive altemive and should be strongly considered for the repair of large ventral hernias.

PERCUTANEOUS CHOLECYSTOSTOMY IS AN EFFECTNE TREAT- MENT FOR HIGH-RISK PATIENTS WITH ACUTE CHOLECYSTITIS. 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 Medical University, UKRAINE.

In elderly pa in ts emergent cholecystectomy for acute cholecysttitis (AC) is a high risk procedure. Of 750 patients (range: 14-93 years) who underwent laparoscopic cholecystectorny, had acute cholecystitis; 476 (63,5%) of them aged over 60 years. This reports of our experiences of percutaneus cholecystostomy (PCS) in the treatment of AC in a well defined high.risk patient group.

From October 1998 to July 2000 are 138 consecutive high-risk patients underwent PCS by means of a transhepatic (n=130) or transperitoneal (n=8) access mute. In 112 patients (81%) ultrasound control was used for puncture guidance, in the 18 (13%) - the procedures were performed under laparoscopic control, and 8 (6%) - underwent open dreinage procedure. Eigth (6%) patients had acute severe medical problems, such as respiratory distress and cardiovascular shock. Ninety-one (66%) patients had chronic severe underlying diseases. Ultrasound PCS was successful in 106 (95%) from 112 patients, 6 patients after unfortunate attempted ultrasound PCS omergency performed PCS under laparoscopic control. Ultrasound-signs of gallbladder inflammation reduced on 3-4 days (96%). Three (2,1%) patients died from the evolution of their underlying diseases and 2 (1,4%) patients died from sepsis befor interval operation. Forty seven patients (34%) underwent interval cholecystectomy. Laparoscopyc cholecystectomy was attempted in 46 patients and was successful in 43, with 3 conversions to open cholenystectomy,

Percutaneus cholecystostomy is a safe, effective trea~ent for high risl( patients with AC. Cholecystostomy can be followed by laparoscopic cholecystectomy at later time if the patient's conditions permits or by expectant conservalJve management in patients who have a very high mortality risk with surgery.

CONVERGENCE OF QUALITY OF UFE OUTCOMES OF LAPAROSCOPE AND OPEN ANTIREFLUX OPERATIONS. Vic Velanovich, M.D.; Saroj K. Chowdhry, Aisha Violette, R.N. Department of Surgery, Henry Ford Hospital, Detroit, Michigan.

Ba..ckqround: Short term analysis of laparoscopic and open antirel]ux surgery (ARS) have been shown to have equivalent symptomatic symptom relief, but better quality of life (QL) outcomes in patients treated laparoscopically. However, no data exists comparing long- term QOL results. Methods: All patients treated with ARS from July 1996 to June 2000 were interviewed for satisfaction, symptom seventy using a standardized questionnaire and QOL using the generic QOL instrument, the SF-36. Patients were divided into 3 groups:/, L ,7~.: 1-2 yrs, and > 2 year follow-up. Results: A total of 144 ARS were done (107 laparoscopic, 37 open). There were no difference in satisfaction rate between the lap and open group in any foUow-up period, nor were there differences between follow-up period. Similady, there were no differences between groups nor follow-up pedods for symptom severity. However, QOL scores were better in the lap patients <1 yr follow up, but in the subsequent follow up pedod, these differences appear to converge. Conclusion: Lap ARS produces similar improvement in >2 yrs. However, the QOL advantage of lap ARS appears to be of short duration.

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LAPAROSCOPIC VERSUS OPEN PYLOROMYOTOMY: A COMPARISON AND COST ANALYSIS Ashley H. Vernon, M.D., William D. Hardin, M.D., Charles S. Baldwin, M.D., Walter S. Cain, M.D, Keith E. Georgeson, M.D., Division of Pediatric Surgery, Department of Surgery, Universi ty of Alabama, Birmingham, Alabama

INTRODUCTION: Them have been numerous reports reflect- ing ear ly exper ience compar ing laparoscopic and open pylommyotomy in the treatment of infantile hypertrophic pyloric stenosis. We performed a retrospective study of 301 cases over the past 42 months. METHODS: From January, 1997 through July, 2000, 301 pylommyotomies were performed, 129 lapamscopic and 172 open. Of the latter group, there were 148 performed through a right upper quadrant incision and 24 through a circum-umbilical incision. RESULTS: The groups were similar in terms of sex, age and weight. The procedure time was less for the lapamscopic group (23.4 mins) compared to the open group (28.6 mins) (p--0.0001). The postoperative length of stay was shorter for the lapamscopic group (33.3 hours) compared to the open group (41.3 hours) (p=0.002); although this did not result in a cost benefit. The cost per patient for the laparoscopic group was significantly higher than for the open group, $4339 vemus $3886 (p=0.01). The complications were similar for both groups with five perforations in lapamscopic group and four in the open group. CONCLU- SIONS: Laparoscopic pylommyotomy is equally safe and effective as open pylommyotomy in the treatment of hypertrophic pyloric stenosis. The lapamscopic procedure has obvious cosmetic benefit, but the challenge now is to reduce cost.

THREE.DIMENSIONAL COMPUTERIZED AXIAL MANOMETRY (CAM) OF THE CANINE LOWER ESOPHAGEAL SPHINCTER WITH AND WrrHOUT

FUNDOPLICATION. Leonardo Ville=as, MD; Miguel Garcia-Oria, MD; Robert McRae; Ross McMahon, MD;

Sandhya Lagno, MD. PhD; Erik M Clary, DVM, MS; W. Steve Eubanks, MD. Endosurgical Research Group, Duke University Medical Center, Durham, NC.

Introduction Morphological charact~zation of the surgically manipulated lower esophageal sphincter is important for understanding the treatment options for gastroesophagesl reflux disease (GERD). This study presents a reproducible extensive method of manomeUic evaluation using three-dimensional (3D) CAM imaging of the canine lower esophageal sphincter (LES), before and after fundoplication, performed in the awake dog. Materials and Methods: 6 dogs equipped with a cervical esophagnpoxy underwent esophageal cannulatiun using the Seldmger technique. Control manometry with a 12Fr catheter containing 8 concentrically positioned channels was performed area" 24hs with the awake dog. The dogs were then divided in three treatment groups: Niasen fundoplication (n=2), Dor fundoplication (n=2) and Heller myotomy (n=2). Manometric studies were repeated 4 weeks following the main surgical procedure. Results: Vector volume (VV) was increased 105% with Nissen and 250% with Dor fundoplication, reflectin~ increases in LES length and pressures.

LES Length LES Mean LES Max LES (cm) Pr.(mmH 8) Pr.lmmHg ) 3DVV(mm ~)

Control 2.24 26.6 64.1 6878.4 Nissen 3.15 33.1 83.9 14088 Dor 2.50 49.9 113.1 24090 Hdler 1.75 6.78 31.1 415.5

The 3D CAM morphology of the fundoplicatien per manomet~c studies showed the presence of a high-pressure zone posteriody at the level of the wrap in the Niss~ and on the fight in the Dor fundoplication. Hdler myotomy resulted in a reduction of LES pressures and vector volume. Conclusion: Manometric and 3D vector volume studies can be used to evaluate the morphology of the LES and can provide recognizable patterns in various fundoplication models and following a Heller myotomy. This information, in conjunction with patient symptoms and 24-hour pH studies, may provide a more thorough understanding of the efficacy and failure patterns of fundoplication techniques.

THE MANOMETRIC COMPONENTS OF THE LOWER ESOPHAGEAL DOUBLE HUMP

ALEXANDER KLAUS, MD, FRANK RAISER, MD, JAMES M. SWAIN, MD, RONALD A. HINDER, MD

Mayo Clinic Jacksonville, Department of Surgery, 4500 San Pab[o Road, Jacksonville, 32224 FL

Obiective of the study: The lower esophageal sphincter manometry of patients with hiatal hernia often displays a double hump configuration. It seems that this is due to gastric bemiation above the high pressure zone of the crur~ This study examines this manometric phenomenon in patients with hiatal bemia and relates it to the lower esophageal antireflux barrier. Methods: Manometric and 24-hour pH studies of 68 consecutive patients with suspected gastroesophageal reflux disease were analyzed to obtain information regarding the double hump and acid reflux. Results: The findings of a manometric double hump correlated well with the presence of a hiatal hernia greater than 5cm. The mean pressure of the lower and upper high pressure zones was 12.~1.3 mmHg and 16.0~1.4 mmHg respectively. The overall 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 constant (2.5~.2 vs. 2.2_+0.1, p--0.2). Resting pressures at the respiratory inversion point were significantly lower (4.9i-0.9 mmHg) than those measured at either high pressure zone (12.~1.3 mmHg and 16.0-2:1.4 mmHg). The location of the respiratory inversion point was seen most commonly at the superior margin of the distal high pressure zone. Double hump patients with a negative acid reflux score were found to 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 represent the cmral and muscular components of the lower esophageal sphincter. Descriptive information regarding the double hump phenomenon is given, and the importance of the crural component of the lower esophageal sphinct~ in preventing acid reflux is stressed. This information stresses the importance of crural closure during laparoscopic antireflux surgery.

FIBRIN SEALING IN MINIMALLY INVASIVE SURGERY H:W. WACLAW- ICZEK, M.D., Landeskrankenanstalten Salzburg

For the application of the two component sealant in minimal invasive surgery a special adaptor for the trocar was designed in combination with a thin plastic catheter, which can be placed next to the wound surface which has to be sealed.

Indications and Results:

1) FS (2 ml) was used in laparoscopic cholecystectomies (LC) when intraoperatively diffuse bleeding from the liver bed occurod and/or severe distur- bances of the blood coagulation in scope of liver cirrhosis, sepsis or acute acute choecystitis were observed. This method was necessary in 84 out of 2.832 LC (4%). In only 3 of these cases a rebleeding occured which had to be reoperated.

2) FS was also applied in very selected cases with liver (n-=2) and spleen (n---3)traumas laparoscopically to achieve hemostasis. These lacerations were then coated w~ a collagen fleece additionally. In none of of these patients postoperative complications occured.

3) Another excellent indication for FS is the additional sealing of laparoscop'r.~ly sutured or stapled perforations and anastomoses of the gastrointestinal tract(i.e, perforated duodenal ulcer, bowel injuries, colon resection etc.) to avoid postoperative insufficiency. The postop, leakage rate in our series amounted 1.9 % (1/46).

4) Also in video assisted thoracic surgery (VATS) FS was used in patients suffering from recurrent pneumothorax in order to form adhesions of the pleura after apical lung resections and so to avoid recurrences. In all these cases (n=41) the FS method was sucassful.

Conclusion: Rbrin sealing is a simple, safe and most effective method to achieve hemostasis and better wound healing also in minmal invasive surgery, The postoperative morbidity and mortality can be reduced.

TOTAL LAPAROSCOPIC RESECTION OF COMPLICATED HEPATIC VASCULAR TUMORS Donald J. Waldrep M.D., Helmuth T. Billy M.D., Steven C. Patching M.D., Sacramento Advanced Laparoscopic Surgery Associates, Sacramento, Califomia

Introduction: Although minimally invasive surgical techniques have been described for hepatic resection, reports of laparoscopic excision of complicated hepatic vascular tumors are rare. We describe total laparoscopic resection of symptomatic hemangiomas in four patients, including an intrahepatic 5 cm segment VIII lesion abutting the right hepatic vein and vena cava.

Methods and Procedures: Four females were referred for surgical resection of symptomatic hemangiomas. The surgical team included two surgeons with extensive advanced laparoscopic experience. All patients underwent a total laparoscopic excision via a 4-trocar approach.

Results: All patients were female and ranged in age from 35 to 47 years. Preoperative symptoms of intermittent severe abdominal pain and nausea were present from 3 to 16 months prior to referral. Surgical evaluation included ultrasound, HIDA scan, esophagogastroduodenoscopy, CT, MRI, and angiography. Involved segments included II/111, IV, V, and VIII. Tumor size in greatest diameter ranged from 2 cm to 6 cm. All resections were completed laparoscopically. The Pringle maneuver was performed in three patients. Vascular isolation was completed for the segment VIII lesion by control of the intrahepatic right hepatic vein. Dissection was performed with an ultrasonic aspirating device in one patient and harmonic shears in the remaining three. Operative times ranged from 40 to 516 minutes. No patient underwent conversion to laparotomy. Estimated blood loss was less than 50 cc in three patients and 1500 cc for resection of the segment VIII lesion. One cholecystectomy was performed. Hospitalization was 1, 3, 3, and 5 days, respectively. The only complication was a postoperative urinary tract infection. Follow-up has ranged from 3 to 13 months. All patients have had complete resolution of symptoms.

Conclusions: The well-established postoperative benefits of minimally invasive surgery may be achieved in total laparoscopic excision ot large hepatic vascular tumors.

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LAPAROSCOPIC MESH RECONSTRUCTION OF SEVERE ABDOMI- NAL WALL ATROPHY FOLLOWING OPEN ANTERIOR EXPOSURE FOR LUMBAR SPINE SURGERY Donald J. Waldrep M.D., Helmuth T. Billy M.D., Steven C. Patching M.D., Sacramento Advanced Laparoscopic Surgery Associates, Sacramento, California

Introduction: The benefit of employing minimally invasive surgical techniques to repair complicated abdominal wall hernias has been astab- fished. We present three patients referred for repair of severe unilateral atrophy of the abdominal wall. We believe this is an as-yet-undescribed complication of open anterior extraperitoneal exposure of the lumbar spine.

Methods and Procedures: Three patients had recent lumbar spine surgery pdor to referral. All complained of subsequent left abdominal wall distention and pain. Abdominal wall mesh reinforcement was performed laparoscopically in each patient.

Results: Three females, ages 56, 60, and 76, underwent spine surgery four, twelve, and five months prior to referral, respectively. Symptoms of left abdominal distention and pain began three days to five months after spine instrumentation. Defects were 16 to 20 cm in the longest diameter. A total laparoscopic 2- or 3-trocar technique using 3 mm or 5 mm, and 10 mm trocars was employed for mesh reinforcement of the left abdominal wall. Operative time averaged 58 minutes (42 -70). Hospital stays were 0, 1, and 3 days. There were no operative or postoperative complications. The patients have been followed for 3, 8, and 17 months. All patients had resolution of preoperative symptoms, with no further enlargement of the defect. One patient underwent laparoscopic exploration five months postoperatively, revealing complete incorporation of the mesh by the peritoneum with no mesh migration.

Conclusions: Severe abdominal wall atrophy is a rare but disabling complication of anterior extraperitoneal exposure of the lumbar spine. Minimally invasive techniques provide an excellent altemative to tradition. al procedures, such as open mesh reconstruction or the use of muscle flap transfer.

MICROLAPAROSCOPIC FUNDOPLICATION Donald J. Waldrep M.D., Helmuth T. Billy M.D., Steven C. Patching M.D., Sacramento Advanced Laparoscopic Surgery Associates, Sacramento, California

Introduction: Technical improvements in lapamscopic instrumentation 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. We present a series 38 consecutive laparoscopic fundoplications performed with 3 mm endosurgical instrumentation.

Methods and Procedures: Between February 1999 and August 2000, 38 consecutive patients underwent laparoscopic fundoplication using a five- ~ocar approach (three 3 mm and two 5 ram).

Results: Of the 38 patients (23 male and 15 female) presented, 9 had a history of previous abdominal surgery. Three-millimeter instrumentation was employed except when limited by available technology (in the LUQ in order to accommodate 5 mm harmonic shears and in the RUQ to accommodate the 5 mm liver retractor). Procedures included Nissen fundoplication in 34 patients, Toupet fundoplication in 3 (including one revision of a previous Nissen), and one esophagomyotomy with Dor fundoplication. In all antireflux procedures, the short gastric vessels were divided harmonical- ly, a beugie was employed, the crura approximated, and the wrap was sutured to the esophagus. Operative time averaged 110 minutes (55-145). No patient required conversion to standard laparoscopy or laparotomy. Eight patients were discharged home from the recovery room, 27 were discharged 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 included 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 previously published reports while providing identical outcomes.

ACCURATE DETERMINATION OF INTACT SPLENIC WEIGHT BASED O1~ MORCELLATED WEIGHT. R. Matthew Wal~h, M.D,, Bipan Chand, M.D., Jason Brodsky, M.D., Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, R. Todd Heniford, M.D., Carolinas Medical Center, Charlotte, North Carolina.

Comparisons of splenic size based on splenic weight is difficult after laparoscoplc splenectomy (LS) which results in a morceitated spedmen. Wq report results of direct compedson of moroeliated and intact splenic wts.

Porcine spleens were harvested via a midline lapamtomy and an intact splenic wt obtained which served as the control. The spleen was then place( into an impermeable retrieval bag and returned to the peritoneal cavity. A separate 10 mm indsion was made through which a utedne forceps mechanically morcellated the spleen. This design most faithfully recreates the morceflation process at LS in humans. The aggregate wt. of the fragments was compared with intact splenic wt. Intact and morcellated wts. were obtained from 58 porcine spleens. A linear regression analysis with 95% prediction limits are given in Rgure 1. For a given morcellated wt. achieved at L$, an actual intact wt. can be determined by the following formula: Intact wt. (gins) = morceliated wt. (gins) x 1.34 +44.92.

~gure 1

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.

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CURRENT INCIDENCE OF BILIARY TRACT LEAKS FOLLOWING LAPAROSCPIC CHOLECYSTECTOMY. Jeffrey L. Ponsky, M.D., Department of General Surgery, Cleveland Clinic Foundation, Cleveland.

Biliary leaks following laparoscopic cholecystectomy (LS) were felt to be the most common bitiary complication when the operation was introduced.. The current inddence and types of biliary leaks following LS performed by expadenced surgeons is unknown and is the subject of this report.

A prospective database is maintained of all biliary complications following LS. From January, 1995 through July 2000 a total of 5 biliary leaks were identified following a total of 1696 LS performed (incidence 0.3%). There were two cystic duct leaks, two leaks from a duct of Luschka, and one was a tiny lateral common duct leak presumed to be a thermal injury. The number of LS has increased yeady since 1995 (183, 241,321,341, and 371, respectively) with one leak occurring in 1998, two in 1999, and two in 2000. Four of the five were operated for chronic cholecystitis, one for acute cholecystitis. The mean time of presentation was on the third post.operative day (range 1-5 days)

Four patients were suspected to have a biliary injury due to persistent pain and underwent computed tomography and biliary contrast studies. Two had collections amenable to percutaneous drainage, and all four had leak of contrast at ERCP (3) or PTHC (1). Three of these patients were successfully treated with endobiliary stents. One patient failed stenting and required two laperotemies for persistent intra.abdominal sepsis from which she succumbed. The one remaining patient was explored for an acute abdomen of the third postop day and the lateral common duct thermal injury was treated successfully by T-tube insertion.

In summary, blliary leaks are currently uncommon. The cause of the leak is vadabie and not necessarily from the cystic duct stump. Control oftho leak with drainage and stenting is crucial, yet may not ensure success.

BI-LEVEL POSITIVE AIRWAY PRESSURE FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE PLACEMENT IN PATIENTS WITH AMYOTROPHIC LATERAL SCLEROSIS. Department of General Surgery, Edk Pioro, M.D., Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio.

Amyotrophic lateral ,sclerosis (ALS) is a progressive degenerative motor neuron disease that causes dysphagia and pulmonary failure. A percutaneous endoscopic gastrostomy (PEG) tube may forestall pulmonary failure from malnutrition. Bilevel positive ailway pressure (BIPAP) is a device that can support pulmonary function during PEG insertion to avoid acute respiratory failure.

From January, 1999 through July 2,000, 769 patients with ALS were evaluated at the Cleveland Clinic, and 13 (2%) were referred for PEG. There 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 average amount of weight loss was 18.2 (0-33) pounds. Seven (54%) of patients were on home BIPAP. All received pulmonary function tests pdor to PEG; the mean FVC was 127 (.41-2.2) liters, representing 42 (25-68)% of predicted volume. FEV.1 averaged 0.92 (0.5-1.67) liters, which is 39.5 (17-54) % of predicted. Pnor to endoscopy, all received topical pharyngeal anesthesia and intravenous sedation, Demero125.50mg and Versed 1-2rag. A complete EGD was performed in 12, and 10 (77%) had double endoscopy. The mean length of time for procedure was 9.6 (5.13) minutes. The mean pre- procedure room air oxygen saturation was 95.5 (86-100)%. All received supplemental oxygen (2.10 liters), BIPAP settings ranged from 6-25 cm H20 end inspiratory pressure/2-5 cm H~O end inspiratory pressure. The lowest mean oxygen saturation during the pmcedurs was 92 (85.98)%. One patient had stndor post-procedure, none required intubation. At a mean follow-up of 8.3 (1.5-17) months, 8 (62%) have succumbed, all to respiratory failure at a mean of 8.5 months post-PEG. All had maintained or gained (2-61bs) weight.

BIPAP is a useful adjunct to PEG placement in patients with ALS and ma~ed pulmonary compromise.

RETAINED GALLBLADDER/CYSTIC DUCT REMNANT CALCULI AS A CAUSE OF POST-CHOLECYSTECTOMY PAIN. R. Matthew Walsh, M.D., Jeffrey L Ponsky, M.D., Department of General Surgery, John Dumot, D.O., Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio.

Pain following cholecystectomy can be a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants which present with recurrent biliary symptoms.

Over the last six years, six patients have been referred for evaluation of recurrent biliary colic orjaundico. There were four men and two women ranging in age from 35 to 70 years. All six had biliary pain similar to symptoms that preceded cholecystectomy, two had assodated jaundice and one pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median of 8.5 yrs). Four had undergone laparoscopic cholecystectomy and two open cholecystectomy; none having had an operative cholangiogram. Five of six had a diagnostic endoscopic retrograde cholangiography (ERC) with obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscoplo ultrasound after eight negative radiographic exams. Three underwent laparotomy and resection of a retained gallbladder and cystic duct. Two were treated with extracorporeal shock-wave lithotdpsy (ESWL) one of which also required endoscopic biliary Holmium laser lithctdpsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic.

In summary, retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and an heightened suspldon may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder.cystic duct junction at cholecystectomy and by routine use of cholangiography, A vadety of therapeutic options can be employed to obtain a successful outcome.

TEP WITHOUT BALLOON DISSECTION OR MESH FIXATION Carl J. Westcott, MD., Frank Chase, MD., Department of Surgery, Wake

Forest University School of Medicine, Winston-Salem, NC.

Laparoscopic hernia repair is cdtidzed on the basis of cost, operative times, and complications. OR times have been shown to decrease with experience, and eliminating disposable equipment can bdng down expenses. Presented is a senes of totally extra-pentoneal hernia repairs (TEP) performed without mesh fixation, or balloon dissection. These are compared to a group of traditional TEP repairs. Variables examined were direct OR cost, procedural times, and complications.

35 patients underwent a no tack-no balloon TEP. 42 TEP repairs by 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 averaged 70 rain for unilateral and 76 rain for bilateral The experimental group averaged 66 rain and 82 rain, respa~vely. There was a significant learning curve for manual prepedtoneal space creation as it relates to OR times. Unilateral balloon-less OR times decreased from 83.1 rain for the first 10 procedures to 63.7 rain (p=0. 03) for the last 10. Groin hemetoma, cord swelling, recurrence rates, residual discomfort and conversion to TAPP did not differ between groups. Costs per case were significantly decreased in the experimental group. Recurring equipment costs for a bilateral repair averaged $516 vs. $76, and unilateral repairs averaged $481 vs. $41. Total hospital savings for the experimental group (n=35) was $13,604 compared to traditional TEP.

TEP hernia repair expenditures can equal the cost of insufflation tubing and Ititer over and above that of open mesh inguinal hemiorraphy. Alter a short learning curve the proposed changes do not affect operative times or short term recurrence rates in these small groups. Complication rates are not affected and the threat of stapler or tacker complication avoided.

PERSISTANCE OF PNEUMOPERITONEUM AFTER LAPAROSCOPIC SURGERY Warren D. Widmann, M.D., Elizabeth Teigen, M.D., Ned Dykes, D.V.M.,, Lawrence Crist, M.D., Lauren= Willekes, M.D., $haun Calhoun, D.O., Eric H. Liu, M.D., Alycia Lungs Columbia Universe, College of Physicians and Surgi~ons, 177 Ft. Washington Avenue, NY NY; Departments of Surgery and Radiology, University of Medicine and Dentistry of New Jersey, Morristown Memorial Hospital: 100 Madison Avenue, Morristown, NJ

This study was performed to d=termine the extent and duration of pneumoperltoneum post-laparoscopic surgery.

Five 140-150 lb. swine were studied alter standard laparoscopic and laparoscopic assisted cholecystectomy, and open cholecystectomy.

On plain film and CT imaging examination, there is little remaining pneumoperitoneum by 36 hours postlaparoscopy. The time resolution of pneumoperttoneum is expectedly longer post open surgical procedures.

Finding more than small amounts of pneurnoperitoneum greater than 36 hours after laparoscoplc and laparoscopic assisted procedures is suggestive of a source other than residual CO 2 pneumoperitoneum e.g. bowel perforation or bowel =mstamotlc leakage.

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CARNEY'S SYNDROME: LAPAROSCOPIC RESECTION OF A GAS- TRIC STROMAL TUMOR(GIST) IN A 17-YEAR OLD GIRL Jason Paul Wiltshire, M.D., Phillip D. Price, M.D., Department of Surgery, Mt. Carmel Medical Center, Columbus, Ohio

Carney's syndrome is a rare condit ion consist ing of leiomyomas/leiomyosarcomas of the stomach, pulmonary chondromas, and adrenal paraganglionomas. A case is reported of a 17-year old girl suspected of Camey's syndrome who underwent laparoscopic resection of a gastric tumor.

JS was admitted to our hospital with a severe anemia in February, 1998. Extensive workup including colonoscopy, esophagogastroduodenoscopy, and upper intestinal contrast studies revealed an ulcerated gastric mass which was histologically identified as a gastrointestinal stromal tumor after local laparoscopic resection. Further histologic evaluation by Mayo Clinic Pathology Department and J.A. Camey, M.D., confirmed the uncertain malignant potential of the tumor consistent with the syndrome. CT evaluation of the chest and abdomen revealed no evidence of the tumor tdad. Consultation with the patient and family was performed, at which time further surveillance was elected versus total gastrectomy.

The patient tolerated her initial procedure without incident and left the hospital on postoperative day 6. Regular endoscopic evaluation including an endoscopic ultrasound of the stomach post-resection revealed no further evidence of recurrence at 24 months of follow-up.

Recurrence and malignancy is typical of Camey's syndrome GISTs. They tend to occur in families and young women. Local resection is followed by local recurrence in the majodty. Total gastdc resection is the procedure of choice when the patient is known to have Camey's syndrome and develops a GIST or has a malignant GIST. Patients who are at suspicion of Camey's syndrome with a gastric stromal tumor of uncertain malignant potential are adequately resected locally with regular endoscopic follow-up and evaluations for the other components of the syndrome. Laparoscopic resection is effective and safe in this situation.

CORRELATION BETWEEN ESOPHAGEAL EXPOSURE TO ACID AND ESOPHAGEAL MOTILITY. Eleftherins S. Xenos, MD, Depadment of Surgery, Lincoln County Mernonal Hospital, Troy, MO.

Objso~ve: Factors that predispose to gas~oescphageal reflux =nclude dacre~sed resting pressure of the lower esophageal sphincter( LES ), transient relaxation of the sphincter, abnormal esophageal acid clearance, dllatabon of the ga~oesophageal junc~on, delayed gastric emptying. This study evaluated the relationship between esophageal acid expesure and manometric indicators of esophageal motility.

Methods and procedures: 46 patients underwent esophageal manometry and 24- Iv pH testing for evaluation of symptoms suggestive of reflux. Patients with scisroderma, previous surgery of the cardia, achalesia and esophageal stenosls were excluded. Medication affecting esophageal motility and gast~c acid production were discontinued 7 days prior to the study. The esophageal manomelr/study was performed using the station pull ~ough technique. LE$ pressure and length, percentage of penstaltic, hypotens~ve and uncoordinated swallows of the esophageal body and, distal esophageal pedstals~ and wave amplitude were measured. The DeMeester score was used to quant~te esophageal acid exposure during the 24-hr pH study.

Results: 17 patients had DeMeoster score<14.4 (group 1) =ndicating physiologic reflux and 29 patients had De Meester score >14.4 (group 2) indicating pathologic reflux. There was no difference between the age and gender characteristics between these two groups. There was no statis0cally significant difference between the LES pressure (20-+15 mm Hg for group1 Vs 15_+7mm Hg for group 2, p=0.19) and length (3_+1.3 crn for group 1 Vs 3.3+1.2 cm for group 2, p=0.38). Similarly, the percentage of distal esophageal peristaltic waves was not different between the two groups Patients with pathologic reflux had greater percentage of hypatensive swallows (p=0.0017) and a greater percentage of combination of hypotensive and uncoordinated swallows (17_+25 % for group 1 Vs 32_+24% for group 2, p=0.05). Also the amplitude of the distal esophageal perista~ waves was smaller in the patients with abnormal DeMeester score (8822 mmHg for group 2 Vs 116_.51 turn Hg for group 1) but the difference did not reach statistical significance (p-0.0a).

Conclusions: Pelients with abnormal exposure of the esophogus to acid appear to have impaired motility of the body of the esophagus with fewer normal peristaltic swallowing waves. They also exhibit smaller contraction amplitude of the distal esophagus. In this study LES pressure and length were not found to be significantly different between the two groups.

APPLICATION OF LAPAROSCOPIC COLECTOMY USING THE RETROPERITONEAL SCOPY Yamada Hideo,M.D.,P_j, Ochiai Takenori,M.D.,,Q..j, Okazaki Yasunaga, M.D.,Pi, Michihiro Kawada ,M.D.,P_i, 1) Dept. Of Surgery, Sakura national hospital, Chiba, Japan ,1) 2 nd Dept. Of surgery, Chiba university, Chiba, Japan

Generally, it is thought that the technique of a laparoscopic colectomy as the treatment for the colo-rectal cancer is difficult. Therefore, it takes a long time at the operation time of a laparoscopic colectomy. To shorten the operation time and to assume a steady operation, we developed a laparoscopic colectomy which used the retroperitoneal scopy. The advantage of this technique is as follows. We can dissect the retroped. toneum in a short time. We can obtain excellent view. And, we can see the blood vessel and ureter. We will show our operation method of anterior resection. We insert the scope into the abdominal cavity. And, we observe the organs, liver, colon and others. Next, we insert the balloon from a left side of abdomen to the retroperitoneum. We e~pand the balloon and expand the retroperitoneum. We remove the balloon. Next, we flow the carbon dioxide in to the retroperitoneum. And we do retrepedtoneal scopy. We can see the dght and left common lilac artery, the right and left ureter, Abdominal aorta, and IMA under the retropedto- meal scopy. We are not disturbed view by other internal organs such as small intestines and can see these vessels easily. Next, we inserl the scope into the abdominal cavity. Aorta and IMA can be easily observed by incising the retropedtoneum at the dght side of the mesocolon sigmoideum. We ligate and dissect IMA. Next, we dissect the left side of the retropedtoneum and cut the colon. We do anastomosis. Laparoscopic assisted colectomy is done to the cancer of Cecum, Ascending colon, and Tranverse colon. We have performed laparoscopic colectomy for the colo-rectal cancers on 230 cases since 1994. The transition of the operation time is seen. The operation time has been shortened by using the retroperitoneal scopy. Present operation time is 120_}31 minutesin laparoscopic colectomy using retropedtoneaJ scopy. The postoperativus complication in this technique is not seen. Neither the hemorrhage nor the ureter trauma, etc. We will present the technique of the taparoscopic colectomy and our results.

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HAND-ASSISTED LAPAROSCOPIC SPLENECTOMY FOR SPLENIC TUMOR: A CASE REPORT. ~ d ~ , Takushi Monden,M.D., Mnsakatsu Kinuta,M.D., Yoshlaki Nak~mo,M.D., Takushi Tono,M.D., Shigeo Matsui,M.D., Takashi lwazawa,M.D., Toshiyuki Kanoh,M.D., Jun Okamura,M.D., Department of Surgery, NTT ~8,~st Osaka Hospital, Osaka, Japan

Splenic tumor, such as a hemangioma, lymphangioma, hamartoma, hemangic6areoma, malignant lymphoma, metastatic caranoma et al. is very rare and it is difficult to d i ~ preolm'atively whether it is malignant or not. The technique of hand-assisted laparocoplc splenectomy (HAts) was dcvdct0ed mainly for benign hematologic disease, such as idiopathic t h r o m ~ n i c purpura or heredit=y spherocytmis. We report a case of metastatic splenic tumor, r e m ~ by HALS. The patient is a 38-~r-old woman who undenvcut a hysterectomy, b i la t~ ~ y , omentectomy by diagnosis of fight ovarian carcinoma (stage lllc) three yems ago. The solitary tumor formation of 3.0cm in the spleen was noticeable in a CT scan and MPJ. Ne/~r aacites, reU'Ol~-itoneal lymph node swelling, nor other metastatic lesions was observed in the ixeolmmive examinations. HAtS was decided to perform, because we could not diagnose whether this tumor was malignant or not, ~mmy or metastatic, l.~oeroso~c p~edures were ped'ormed with the surgeon's left hand through the 7cm skin incision and lafamscopic coagulating shears. We ckl not use the metal clips to cut the vessels. The splenic vessels were divided using vascular stapl~ By the palpation of the left hand, the swollen regional lymph node was also n:sec~. The duration of surgery, and intra-operative blood loss was 178minutes, ~ 22g respactivdy. She could walk amend at the l'u'st post-operative day, discharge at the t0th post-opaneive day. The pathological diagnosis of splenic tumor aod the swdlen regional lymph node was metastatic serous papillary =leux:mcinuna from ovarian cancec The totally latxu'oscoplc surgery, for splenic malignancies is now discussed to he a good indication or not, because the other malignant lesions including regional lymph node, pancreas and stomach =m not be dL,~c~__ by only an inspection with lapsrow.opy. On the contra~, HALS is safe and a good indication for splenic tumor, _beca_,_,_,_,~ the 1 ~ resection of the malignant lesions may he expected by both the inspection with laparoscopy and ~pation of the tumor like a open surgery.

OUTCOME OF LAPAROSCOPIC COLORECTAL SEGMENTAL RESECTIONS IN ELDERLY PATIENTS Seong Yeop You, M.D., Alon Pikarsky, M.D., Sung Won Chun, M.D., Pascal Gervaz, M.D., Eric G. Weiss, M.D., Juan J. Nogueras, M.D., Anthony M. Vemava III, M.D., Steven D. Wexner, M.D., Department of Colorectal Surgery, Cleveland Clinic Ronda, Fort Lauderdale, Flonda

Background: Application of laparoscopic colorectal segmental resections to elderly patients is steadily increasing. The aim of this study was to evaluate the outcome of laparoscopic colectomy in the elderly.

Methods: All patients, who underwent laparoscopic-assisted segmental resections between August 1991 and September 1999, were divided into two chronological groups: below 65 years of age (Group I) and 65 years and above (Group II). All operations were performed by one surgeon. Statistical analysis was performed utilizing Fisher's Exact test for qualitative data, Mann-Whitney test for continuous non-parametric variables, and Student t-test for continuous parametric variables; p value of <0.05 was considered statistically significant.

Results: There were 88 patients in Group I and 101 in Group II. There were no differences in gender between the two groups (10=0.15) and the procedures were well stratified. Operations performed included dght hemicolectomy: 55 and 63, left hemicolectomy: 5 and 8, sigmoidectomy: 29 and 30 in Groups I and II, respectively. There was no difference in the incidence of previous abdominal surgery between the two groups. The most prevalent indications for surgery were neoplasia in Group I and Crohn's disease in Group I1. Significantly more patients in Group I1 than in Group I had higher (111 and IV) ASA scores (19~ vs 50%;p<0.0001). There were no statistical significances between the two groups relative to the incidence of conversion (11% vs 15%;IO==0.52), intraoperative complications (6% vs 7%;p=0.77), postoperative complications (37% vs 43%;p---0.66), operative times (169 vs 175 min.; 10=0.55), estimated blood loss (182 vs 213 ml; p--0.57), time to return of bowel function (4.2 vs 4.6 days; p=0.17), or length of hospitalization (6.8 vs 7.4 days; p=0.17).

Conclusion: Despite higher ASA scores in eldedy patients the outcomes were comparable to those in younger patients.

EXPERIMENTAL ASSESSMENT OF AESOP, ENDOASSIST, IMAGTRAC AS SURGICAL CAMERA HOLDERS Yunus Yavuz,M.D., Eirik Skogvoll*, M.D.,Ph.D., Brynjulf Ystgaard**, M.D., Ronald Marvik, M.D., National Center for Advanced Laparoscopic Surgery, *Department of Pediatrics, **Department of Surgery, Trondheim University Hospital, Trondheim, Norway

Surgical robots have been introduced to provide more precise and steady control of camera. We aimed to compare commemially available robotic camera holders Aesop (manual, voice and memory modes, Computer Motion,USA), Endoassist (Armstrong, England),lmagtrac (Olympus, Japan) with the conventional human control. A single examiner conducted the study in surgical training boxes with standard laparoscopic equipment. Unear (upwards, downwards, side- ways and diagonal) in and out, and complex three dimensional movements were assessed by using standardized distances and tests. The time required to achieve each task was measured assuming that the more precise and accurate the movements of the robot were, the shorter the time it would take to perform the tasks. Linear regression analysis and Mann-Whitney test with Bonferroni corecction was used accordingly. In all type movements human control provided the best camera control. In linear movements, Aesop manual control and Imagtrac were the quickest among all; whereas voice and memory modes of Aesop and Endoassist were relatively slower. Conceming in and out movements Imagtrac was the most effective and closest to human control (p<0.05). In complex three dimensional movements the memory mode of Aesop was supenor to other types (p<0.05) and it was followed by manual control of Aesop and tmagtrac.

The human control of the camera is still the best option regarding to time required to achieve each movement; whereas the quality of vision is poor due to movements of the scope. On the other hand, among the robotic systems the manual mode of Aesop and Imagtrac were efficient and precise compared to the other robotic arms.

LAPAROSCOPIC COLORECTAL SURGERY: EARLY AND LA'I-FER EXPERIENCE Seong Yeop You, MD, Chien Yuh Yeh, MD, Sung Won Chun, MD, Pascal Gervaz, MD, Jonathan Efron, MD, Eric G. Weiss, MD, Juan J. Nogueras, MD, Anthony M. Vemava III, MD, Steven D. Wexner, MD, Department of Colorectai Surgery, Cleveland Clinic Flonda, Fort Lauderdale, Flonda

Background: The aim of this study was to compare early and more recent results of laparoscopic colorectal surgery to assess any differences in indications or procedures as well as any changes in results.

Methods: All patients who underwent elective laparoscopic colorectal surgery were prospectively entered in a laparoscopic database. Group 1 included individuals operated upon between August 1991 and December 1995 while Group II included January 1996 to September 1999.

Results: 364 patients underwent elective laparoscopic surgery including 175 patients in Group I and 199 patients in Group I1. While them were no differences between the two groups relative to gender, patients in Group II were significantly older [50.3+19.5 (range 15-89) years; p<0.001]. In addiUon, significan T more patients in Group I than in Group II had undergone total abdominal colectomy or restorative proctocolecto- my (17% vs 2%;p<0.01) for either mucosal ulcerative colitis (19% vs 2%;p<0.01) or constipation (7% vs 2.5%;p<0.05). Conversely, the number of patients who underwent nght hemicolectomy increased from Group I to Group II (24.5% vs 39.7~ mostly due to an increase in terminal ileal Crohn's disease (18.8% vs 26.6%). Despite the fact that there was an increase from Group I to Group II in the number of patients who had adhesions (25% vs 51%;p<0.001), the conversion rate decreased (22% vs 14%;p<0.01) as did the intraoperative complication rate (16% vs 4.5%;p<0.01) and the operative time (181 vs 154 min; p<0.01).

Conclusion: Increasing experience in laparoscopic colorectal surgery may have lead to better case selection with the performance of less total abdominal colectomias and restorative prectocolectomies and more segmental nght colectomias. Thus, despite an increasing need to perform enterolys~s, both the conversion rate and the intraoperative complication rate decreased as did the operate time.

INITIAL PATIENT SERIES WITH A ROBOTIC ASSISTED NISSEN FUNDOPLICATION James A Young, MD, William H H Chapman, III, MD, Robert J Albrecht, MD, Victor B Kim, MD, L Wiley Nifong, MD, W Randolph Chitwood, Jr, MD, East C a r o l i n a Un ivers i t y , The Brody Schoo l of Med ic ine , D e p a r t m e n t of Surgery , Greenv i l l e , Nor th Carolina

Objective: The FDA has recently approved clinical use of the da Vinci robot for general abdominal surgery. We will present results from our initial series of ten patients. Methods: Patients with indications for elective Nissen fundoplication were offered the option of a robotic procedure. Exclusion criteria included patients with large hiatal hernias, multiple prior abdominal surgeries, and severe dysmotility. Operat ive t imes and detai ls are compared to standard laparoscopic Nissen fundoplication. Results: Five patients have undergone Nissen fundoplications using a robotic assisted technique, the remainder are scheduled in the coming weeks. Robotic operat ive t ime averaged 1.4 hours (range 1.2 to 1.8 hours). To date, no conversions or complications have occurred in either group. Patient satisfaction has been high in each group. Conclusions: Robotic Nissen fundoplication is a feasible al ternat ive to the standard laparoscopic technique. We have found the robotic system easily understood and its operat ion quickly learned. While the optical system has improvements over conventional laparoscopy, tactile feedback is lacking. Continued development of computer assisted technology and instrument refinement should improve the technique.

ENHANCED ADHESION OF TUMOUR CELLS TO MESOTHELIUM FOLLOWING EXPOSURE TO PNEUMOPERITONEUM. P. Ziprin FRCS, D.Peck PhD, P.F. Ridgway AFRCSI, A. Darzi FRCS FACS, Academic Surgical Unit, Imperial College School of Medicine. St Mary's Hospital London W2 1NY. United Kingdom

Background: Exposure to a carbon dioxide pneumoperitoneum used in laparoscopic surgery can increase the occurrence of peritoneal metastases; for this to occur cells must attach to the mesothelium. We therefore analysed the effect of a carbon dioxide pneumopedtoneum on tumour cell / mesothelium interactions and mesothelia] cell surface expression. Methods: Pdmary cultures of human peritoneal mesothelial cells (HPMC) were derived from omental samples. Monolayers of HPMC ceils were exposed to either an in vitro carbon dioxide (CO2) or helium (He) pneumoperitoneum for 4 hours or left under normal growth conditions (control). Colonic (SW1222) adenocarcinoma cells ability to adhere to the monolayer was assessed. In parallel w~ these study alterations in mesothelial cell surface expression of avB3 and av integrin were analysed. Results: Figures are expressed as mean % of control

Adherance to mesothelium CO2 141 +/-10 He 136+/- 8

Expression of av133 CO2 200 +/- 20 He 198 +/- 16

Expression of av CO2 122 +/- 7 He 111 +/-2

(Adherence, avB3 & av expression - CO2 & He Vs Control, P < 0.05 ('T'ukey-Krarner))

Conclusions: Exposure to either a carbon dioxide or helium pneumoperitoneum causes an increase in the ability of tumour cells to adhere to mesothelium. This indicates a mechanism of how the operative environment influences tumour growth.

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LAPAROSCOPIC VS OPEN REPAIR OF INCISIONAL HERNIAS USING A MESH. A CASE CONTROL STUDY Hans Zengerink MD, Bait Appeltans MD, Henk ten Cate Hoedemaker MD Department of surgery, Academic Hospital Groningen, Groningen, The Netherlands

Introduction: Laparoscopic repair of incisionai hernias using a mesh is an attractive alternative to conventional open repair for larger defects. Many advantages are reported, but studies comparing the laparoscopic method with the open technique are rare. Goal of this study was to prove these reported advantages. Methods: The first 25 laparoscopic hernia repairs performed in our clinic were compared with 25 historic controls that were operated using an open technique. Only open repairs using a pdmary closure of the hemia with a madex onlay were used as controls. They were matched for age, sex, BMI and ASA status. The hernia sizes were comparable, as was theil operative history. Results: Conversion to conventional repair was necessary in 2 patients of the laparoscopic group. In the laparoscopic group the mean operating time was significantly longer (93 min vs 72 min). On the other hand the mean hospital stay was significantly shorter (6.1 vs 7,4 days; p=0.044). There were more short and long term complications in the open group. ThE number of recurrences was higher in the open group (4 vs 1). Howevel the mean follow up in the laparoscopic group is only 9 months. Conclusions: Our findings confirm the earlier mentioned advantages of the laparoscop. ic approach. It also confirms the disadvantage of a longer mean operative time. Another problem concerns the much higher operative costs. Ou~ plan is to perform a prospective randomized study to compare these ; methods. In this study we will also compare whether the total costs of th~ laparoscopic repair are lower than of the open method due to a shortel hospital stay and a lower recurrence rate.

INTRAOPERATIVE LOWER ENDOSCOPY IS A USEFUL TOOL I1~ LAPAROSCOPIC COLECTOMY Oded Zmora, MD, Adam Dinnewitzer MD, Alon Pikarsky, MD, Jonathan Efron, MD, Eric G Weiss, MD, Juan �9 Nogueras, MD, Steven D Wexner, MD, Department of Colorecta Surgery, Cleveland Clinic Rodda, Fort Lauderdale, Florida

Objective: Assessment and localization of colonic pathology may bE more difficult in laparoscopic surgery as palpation of the specimen is diffi cult, and perception may be distorted. Therefore, the aim of this stud~ was to assess the use of intra--operative lower endoscopy for evaluatJor of the colon in laparoscopic colorectai surgery.

Methods: A retrospective chart review of the patients who underwen segmental colonic resection with primary anastomosis was perfon'ned t( determine the rate and charactedstios of the use of intraoperative Iowe endoscopy. The results were compared to a group of open colectomie., matched by surgeon and procedure.

Results: 233 patients had laparoscopic segmental colon resection an( anastomosis between 1991 and 2000. Intaoperative lower endoscop,. was used in 24% (n=57) of these patients, compared to 18% in the opel matched group. In the laparoscopic group, intaoperative Iowe endoscopy was performed in 42% (n=101) of the patients in whom tht pathology was located in the sigmoid colon or rectum, compared to 119 of the patients with pathology proximal to the sigmoid colon, or encom passing the entire colon. The main indication for intaoperative Iowe endoscopy was to assess or localize the pathology in Co4~ rule out syn chromous pathologies in 8%, and asses an anastomosis in 27% However, 42% of the patients had more then one intaoperative Iowe endoscopy during their laparoscopic case. The information gathered fron intaoperative lower endoscopy was judged to directly influence the ope; ative decisions and management in 71% of the patients and provide reassuring information in the rest of the cases.

Conclusions: Lower endoscopy is a useful tool for the intaoperatiw assessment of colonic pathotog;es and anastomoses in Japaroscopi, colon resections. These results suggest that surgeons performing laparc scopic colorectai surgery may benefit having the expertise of performin! lower endoscopy.

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THE ECONOMIC IMPACT OF FLEXIBLE ENDOSCOPY IN A LARGE, GROUP PRACTICE SETTINGKeith A. Zuccala, M.D., Jeffrey L. Ponsky, M.D., Department of Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

Purpose:There has been confusion and debate regarding the value added by the incorporation of f lexible gastrointestinal endoscopy into a general surgery practice. The purpose of this study was to assess the economic impact of f lexible endoscopy performed by general surgeons in a large group practice setting. Methods:Total practice size was 11 surgeons, 3 of which performed flexible endoscopy on a regular basis as well as traditional surgical cases. Based on a retospective review of bi l l ing records for the ca lender year 1999, the total amount billed for all surgical procedures was compared to bil l ing for f lexible endoscopy. Two of the three endosurgeons performed colonoscopies and EGD's in addition to their open and laparoscopic surgeries, while the third performed ERCP as well. Results:There were a total of eleven surgeons in the practice, three of whom performed endoscopy in addit ion to other surgical procedures. The total percentage of billed income for the department attributable to endoscopy was 12.2% The three endosurgeons contr ibuted 29% to the total gross billings of the department. Conclusion:Flexible endoscopy can contribute significantly to the income of a surgical practice.

THE DURATION OF HEMODYNAMIC DEPRESSION DURING LAPARO- SCOPIC CHOLECYSYECTOMY Randall S. Zuckerman, M.D., Michael Gold, M.D., Matthew Jones, B.S., Tara Erb, M.A., Steven J. Heneghan, M.D.,Departments of Surgery and Research Computing, Bassett Healthcare, Cocperstown, New York

We previously prospectively evaluated the effects of pneumoperitoneum and patient position on hemodynamics during laparoscopic cholecystectomy and found that patient position had no effect on Cardiac Index (CI), Stroke volume (SV) and Left Ventdcular End Diastolic Volume (LVEDV). Analysis of that data showed that the adverse hemodynamic changes associated with anethesthesia and pneumoperitoneum were short lived with values tiending towards baseline during the operative peried. The purpose of this study was to examine the duration of negative hemodynamic effects during laparoscopic cholecystectomy.

Thirty-eight patients undergoing laparoscopic cholecystecomy by a single surgeon were enrolled in the study. Hemodynamic data was collected via a trans-thoracic bioimpedance monitor (IQ, Renaissance Technology). Baseline readings of were taken prior to establishing pneumoperitoneum. Data was the collected continuously over the course of each case. Patients were compared to their baseline value. Data was analyzed every 5 minutes with the paired t-test used to determine statistical significance.

Baseline was defined as the point prior to insufflation. With insufflation 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 LVEDV from 111.46 ml to 102.68 ml ( p = 0.003) At 5 minutes, all values were further depressed. At 10 minutes all values were no longer significentiy different from baseline with CI 2.78 L/min/rn2 (p = 0.76), SV 67.42 ml (p = 0.14) and LVEDV 102.26 ml (p = 0.179). Values reached those at baseline at 15 minutes and did not waiver for remainder of each case or the next 35 minutes.

Patients undergoing laparoscopic cholecysteotomy undergo significant hemodynamic depression with pneumoparitoneum. These hemodynamic changes are short-lived and loose their statistical significance at 10 minutes from the time a patient undergoes pneumoperitoneum.

Surgical Endoscopy - Springer

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